Treating Physician vs Independent Medical Evaluator

Who is in the better position to evaluate, the treating physician or an independent medical examination (IME) physician? A treating physician has a patient-advocate role because he or she has a doctor-patient relationship with the patient/claimant. Unlike the treating physician, an IME physician does not have a doctor-patient relationship, and can, therefore, provide an impartial evaluation necessary to assess the extent to which the patient/claimant is impaired or disabled from functional activities of daily living.

Fundamental Principles of Independent Medical Examination

An independent medical evaluation (IME) is a specialized examination or evaluation best performed by a physician who has special training and experience in assessing issues unique to an IME. IMEs must be independent, and opinions should be consistent and impartial and based on evidence-based medicine. An IME includes the essential elements of a medical assessment, including a history, a physical examination (usually), and review of records and studies, followed by clinical impressions or diagnoses, and then by recommendations. The medical assessment may include other practitioners, eg, psychologists and chiropractors. Depending on the referral request, the IME typically discusses disability (the definition depends on the local jurisdiction) based on deficits in the person's activities of daily living. In the IME, the evaluator may be asked to consider claims issues that include causation, apportionment, impairment, work ability, appropriateness, and costs of medical care and/or future needs. The physician who performs the examination does not provide care to the individual and provides medical opinions about issues associated with the case. Impartiality, objectivity, and an understanding of medicolegal issues are required of the evaluator. IME reports are not confidential and likely will be read by many stakeholders in a claim. Accordingly, nonmedical personnel should find it easy to read and understand the IME.

Disability Evaluations

Mental health professionals frequently participate in the disability application process. Standards and requirements for a finding of disability may vary considerably from one context to another. A disability carrier may request that a mental health professional perform an independent medical examination. This chapter discusses the concepts of work capacity, functional impairment, and disability as they apply to disability evaluations performed for the most common types of disability insurers (Social Security, workers’ compensation, and private insurers), as well as work-related evaluations involving the Americans with Disabilities Act, fitness for duty and return to work, and disability in the context of litigation. Ethical issues in performing disability evaluations are addressed, including differences in the roles of the treating clinician and the independent forensic evaluator and management of situations where the evaluator’s opinion differs from that of the claimant and the claimant’s attorney.

Data Collection

This chapter focuses on data collection as part of the evaluation of disability, with emphasis on the specific methodology for obtaining data from various sources such as written records and documents, self-report data from the claimant, psychological testing and neuropsychological testing, and information from collaterals such as interviews and treatment providers including psychiatrists, psychologists, and psychotherapists. It also describes instruments commonly used in assessing psychopathology and cognitive functioning during disability evaluation. Finally, it considers formal assessment of the claimant's response style as an integral part of the independent medical examination.

A simplified questionnaire for self-assessment of hirsutism in population-based studies

ObjectiveThe measurement of excess body hair is not straightforward. As the modified Ferriman–Gallwey (mFG) score is unsuitable for self-assessment and requires specialist training, a short, self-administered questionnaire to identify hirsutism was constructed and validated for large-scale application, particularly targeting population-based studies.DesignA validation study was conducted to assess a new hirsutism questionnaire.MethodsA total of 90 women aged 35–72 years who were enrolled in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) were evaluated. A self-administered instrument containing four questions was designed to evaluate five body areas: upper lip, chin, chest, lower abdomen, and thighs with respect to the current distribution of body hair and that before 35 years of age. A score of 0–4 was attributed to each region based on drawings provided in the instrument. Test–retest reliability was evaluated by reformulating the initial questions. An independent medical examination was conducted to apply the gold standard, the mFG score.ResultsThe area under the receiver operating characteristic curve was 0.93 (95% CI: 0.87–0.99). A cut-off score of 5 showed the best balance between sensitivity (85%) and specificity (90%), with 88.9% accuracy. Spearman's correlation between current and past body hair score was calculated at 0.82 (P=0.000), and showed a test–retest reliability of 0.49, with a trend toward similar answers regarding changes in the quantity of body hair over time, irrespective of how the questions were asked (P=0.000).ConclusionThe accuracy and internal consistency of this self-administered questionnaire for the identification of hirsutism were good. Therefore, this questionnaire represents a useful tool for self-assessment of hirsutism in population-based studies.