The Essentials of IMEs: A Conversation with Diana Kraemer

In this comprehensive episode of ‘Fit for Duty,’ Dr. Larry Earl, president of the National Association of Occupational Health Professionals, hosts neurosurgeon Dr. Diana Kraemer to explore the critical role of Independent Medical Exams (IMEs) in the occupational health field.

The discussion delves into the significance, process, and intricacies of IMEs, covering scenarios that necessitate these evaluations, and shedding light on the perspectives of healthcare professionals and employers. Key topics include ethical and legal considerations, the impact of biases, maintaining objectivity and impartiality, and effective communication in advancing patient cases.

The episode also addresses the nuances of headache diagnoses, particularly migraine misdiagnosis, and evaluates emerging trends in technology such as AI and big data. Practical insights on diagnosis, treatment recommendations, and dispute resolution are provided, emphasizing state-specific regulations, Functional Capacity Evaluations (FCEs), and the importance of considering biopsychosocial aspects in patient treatment.

Key topics include:

00:00 Introduction to Fit for Duty

00:54 Exploring Independent Medical Exams (IMEs)

01:56 Understanding the IME Process

10:44 Challenges and Ethical Considerations in IMEs

14:44 Addressing Bias and Legal Issues in IMEs

18:13 Common Challenges and Solutions in IMEs

20:50 Disagreeing Respectfully in Medical Opinions

21:58 Impact of IME Findings on Treatment Plans

22:51 Diagnosing and Managing Carpal Tunnel vs. Radiculopathy

23:27 Challenges in Returning to Work Post-Injury

25:38 Evaluating Risk, Capacity, and Tolerance

27:56 Writing Effective IME Reports

29:12 Addressing Disagreements in IME Results

31:02 Undiagnosed Migraines and Misdiagnosis Issues

34:00 Navigating Work Comp and Medical Care

38:04 Emerging Trends in IME Technology

40:32 Conclusion and Future Topics

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Transcript

[00:00:00] host: Hello and welcome to Fit for Duty. I'm Dr. Larry Earl, your host and the president of the National Association of Occupational Health Professionals. Today, we'll unravel the intricacies of occupational health, examining OSHA regulated exams, workers compensation cases, drug testing, and strategies for injury care.

[00:00:19] host: We'll also [00:00:20] look at prevention strategies and the role of total person health analytics in occupational health. In uncovering root causes of workplace health issues, highlighting successful interventions that have made a real impact on employee health and well being. Fit for Duty offers a comprehensive approach to occupational health, empowering [00:00:40] organizations to build healthier and more productive workplaces.

[00:00:43] host: Join us as we break new ground, dismantle barriers, and move forward. and seamlessly connect theory with practice.

[00:00:54] host: In this episode of Fit for Duty, we welcome back Dr. Diana Kraemer to explore independent medical exams [00:01:00] and their significance in occupational health. Join us as we unravel the complexities surrounding IMEs, the pivotal roles they play in resolving cases, and how they can bridge gaps between employers and employees.

[00:01:14] host: Dr. Kramer brings her insights as a seasoned neurosurgeon Shedding light on the nuances of [00:01:20] conducting IMEs with objectivity and integrity. Whether you're a healthcare professional, employer, or simply curious about the intricacies of occupational health, this episode promises valuable perspectives and informed discussions.

[00:01:39] host: Okay, and we are [00:01:40] on with Dr. Diana Kraemer. Welcome back. Thanks so much for joining us again here on Fit for Duty.

[00:01:47] guest: Larry, it is good to see you again. I enjoy doing these with you.

[00:01:50] host: Yeah, absolutely. I do as well. Uh, let's jump right into IMEs today. Can you just explain, first of all, what an independent medical [00:02:00] exam, an IME is?

[00:02:01] host: Why is it important to occupational health?

[00:02:05] guest: The IME is an examination that's performed when there is a question to be resolved in an injured worker's case. Um, the IME can be either positive or negative. Um, [00:02:20] and my goal when I'm doing an IME is to figure out what the, Issue is it's not, it's still being contended has not resolved and is, uh, keeping that worker from getting the best outcome.

[00:02:34] host: And when are, what kind of scenarios are we usually talking about? Uh, is it always at the [00:02:40] end of, of a case when the, uh, treating physician is sort of, uh, frustrated patient's not better? Or are there other times when we would also request an IME and who, who does it? Who, who's requesting it?

[00:02:53] guest: Yes, that's a good question.

[00:02:55] guest: Um, most of the patients we [00:03:00] see have an injury, get better, and go back to work, whether it's with accommodations or not. Um, there is a small percentage, 10 15 percent of cases, Um, that don't resolve and this is that 80 20 rule where, uh, 20 percent of the cases take 80 percent of the [00:03:20] resources. And that includes, that's not just money, it's money, time, patients, our ability to, um, our empathy.

[00:03:29] guest: Because when we have these refractory cases that aren't getting better, um, it makes us feel bad. Um, [00:03:40] everybody's frustrated.

[00:03:41] host: Yeah. We feel inadequate.

[00:03:43] guest: Yes. Um, our patients think we're inadequate.

[00:03:47] host: Yeah.

[00:03:49] guest: Sometimes. The IME can essentially, the doctor can, Can request one. The insurance company can request one.

[00:03:58] guest: Rarely plaintiff, [00:04:00] if there's an, uh, an attorney injury, personal injury, uh, attorney involved, they can request one in basically their request is to solve a log, log jam. And that log jam can be diagnostic. It can be treatment. It can be administrative, it can be legal, [00:04:20] and the IME can be another set of eyes.

[00:04:23] guest: Now the challenge for many of us is our natural reaction to feeling like somebody else is going to interfere, opine on our case, when we [00:04:40] are more intimately aware of. What's going on with the person? We're sitting in a room with a patient. Why should Dr. Kramer be butting in on, on my care?

[00:04:50] host: Yeah, although I, you know, I, I know myself when I've asked for IMEs and when other docs that I speak with about this, sometimes there's [00:05:00] also a relief.

[00:05:01] host: Oh, I can really get another opinion and hopefully some direction on what I can now do with this case because I'm frustrated. I don't know what else to do.

[00:05:11] guest: And I, I agree with you. There are times when I just see things differently. I'm a neurosurgeon. I get a lot of, um, [00:05:20] I am ease for Ahmed situations, arms, legs, not working, neck pain, refractory, uh, post concussion.

[00:05:29] guest: And 1 of the things I can do as a neurosurgeon and be is be a support to the, to the Ahmed doc where exactly where I may just, you know, the 4 [00:05:40] things that sort of, you know, are in the back of your mind, I can put together into a diagnosis. So sometimes as a IME, um, first of all, I'm probably going to have a lot more records than you ever had.

[00:05:54] guest: I'm going to have stuff beforehand. I'm going to have stuff from other doctors that didn't make it in your clinic note. [00:06:00] And I'm going to have this big perspective and I'm going to be able to see everything you did, everything that happened over here that you didn't really know about. Um, and I'm also going to be.

[00:06:09] guest: have another specialty to look at it. So for example, I mean, I may be able to say that whiplash injury and then they had tingling in [00:06:20] their fingers afterwards and the surgeon wants to do a two level fusion but on physical examination the person has carpal tunnel and they've not had an EMG, you know, and sometimes.

[00:06:35] guest: We just don't see the forest for the trees.

[00:06:38] host: Yeah. [00:06:40]

[00:06:40] guest: Uh, and, and that's normal. Can I do that? Sometimes I can just redirect the, the landscape.

[00:06:47] host: Helpful. What's the typical process of an IME? Can you walk us through how that usually happens?

[00:06:57] guest: It's well, it's changing over time in our post COVID [00:07:00] days, but for a clinical examination, let's say I've been asked to see somebody, the first important thing.

[00:07:06] guest: So I will get a case. I will get it assigned to me. I will make an appointment with that person. I will review the records. Then I sit down and I, the way I like to do is, I just try to put the person at ease [00:07:20] because by definition for the most part, somebody is telling them to be there and they don't necessarily want to be seeing me.

[00:07:27] guest: So the first thing I think in doing a good IME is getting the person comfortable. Leaning forward and saying, well, this happened, you know, and, um, getting that, giving the sense that I am listening and I'm [00:07:40] here to try to move the thing, move the case forward. Um, so I have an appointment with a person. I sit down and listen to them.

[00:07:49] guest: I do a directed, uh, history and physical to the problem, but I also do have kind of a broader psychosocial screen in the background. And then I do a directed [00:08:00] examination and. For my neurosurgical neurological evaluation, maybe a little bit better than a typical clinicians, my cardiac examination is probably a whole lot worse.

[00:08:13] guest: But, um, my neuro exam is, I may pick up things that somebody else doesn't see. And then [00:08:20] I'm able to synthesize all this. So I say, Do the examination. Thank the person for coming in. Um, let them know that we're receiving a report and then try to write my report in a neutral way that expands opportunities, shuts appropriate doors to be shut, and [00:08:40] helps move the case along.

[00:08:43] host: Yeah, great points. You touched on this a little bit in terms of, uh, your background and qualifications. What type of Uh, you're, you're a neurosurgeon, uh, is it always super specialty person that needs to [00:09:00] see all OCMED work comp cases?

[00:09:03] guest: No. And I think a lot of times, um, uh, OCMED is great for seeing OCMED cases.

[00:09:10] guest: There can be, for example, for an occupational medicine, a lot of times the question is fit for duty or return to a safety sensitive work, where, you [00:09:20] The IME can support the doctor, uh, the treating doctor in coming to a safe decision. There are times when it's a real conundrum about whether or not you should allow someone to go back to a particular type of work.

[00:09:35] guest: So in terms of the, the whole construct of [00:09:40] risk, capacity, and tolerance, it may be helpful to have an IME help you support or refine your clinical impression. That just, that's very broad. So clearly as a neurosurgeon, I see, you know, the It's kind of the far, [00:10:00] one far spectrum of neurosurgical disease and injury, but I see a lot of backs and necks, concussion, headache.

[00:10:08] guest: So this strange, very specialized and very generalized situation, but many IMEs are, Ortho, OcMed, [00:10:20] um, sometimes internist, PM& R, and so you don't have to have a subspecialty interest and I think OcMed docs are valuable for being IMEs for their generalized overview and their ability to examine all body parts, which I'm [00:10:40] technically not qualified to do.

[00:10:42] host: Yeah. Let's talk about some of the legal and ethical. issues surrounding IMEs. What should occupational health professionals be aware of?

[00:10:53] guest: Uh, I think it's important as an, from an ethical issue to understand [00:11:00] that the IME evaluation is fundamentally different than a clinical, a treating evaluation.

[00:11:07] guest: relationship. I never take my MD hat off. However, my role as an IME is different. My role is to be independent, [00:11:20] whatever that means. It's to try to be objective. It's to try to take a different slant on things. The, the history taking is different for my patient in my office versus a claimant. or somebody being examined because there's no [00:11:40] positive word other than Mr.

[00:11:41] guest: or Mrs. Jones for anybody I'm sitting across from. Um, we'll get to that in a minute. The physical exam is different in that if you're, if I'm, for example, doing an impairment rating exam, I am required by AMA guides to do different examination [00:12:00] techniques or parts of an exam that I would not do for clinical exam.

[00:12:04] guest: Circumferences, range of motion,

[00:12:06] host: measurements. Yeah.

[00:12:08] guest: All of those things are different ethical issues, whether or not I can tell the person what's wrong with them. There's an important ethical [00:12:20] guideline that, um, I include in my conversation, my introduction to a person. The MA guides ethics for independent medical evaluations.

[00:12:31] guest: States that if you find something of concern, not only should you inform the person, but if requested you should help them [00:12:40] obtain Care that that is within the guidelines of your non treating role as a physician and there's been more than one or two or even three times when I've sent someone to the ER and Where we tend to see that the most would be for most doctors would be Um [00:13:00] would be hypertension if somebody walks in with a blood pressure 210 over 100 in your office and okay yeah you got to take care of that.

[00:13:08] guest: But a lot of times I see some pretty crazy stuff and I say we really need to get you to the ER now.

[00:13:14] host: Yet you're not in, you're not entering into a physician patient relationship with [00:13:20] any of these exams even in those cases.

[00:13:22] guest: Yes, I am. I am not treating the person. Okay. I am, uh, a referee. Um, but if, you know, if the building is on fire, it's my job to, to intercede in my [00:13:40] role as the physician.

[00:13:42] host: And what if you feel there's a misdiagnosis? Are you then making a diagnosis? And is that considered? A physician patient relationship.

[00:13:51] guest: It is not. So, that's one of the strengths of being, uh, an IME is that if I'm doing my job right, I may [00:14:00] come up with diagnoses that have not been previously made. And it's important.

[00:14:04] guest: If we are not treating a person for the right thing, the chances are going to get better and go way down. That's one of the things I like doing most as an IME, is looking at what's in front of me, looking at the records, adding [00:14:20] neurosurgical examination, history, different viewpoint, and going, well, maybe it's not, you know, neck strain, whiplash with cervical radiculopathy.

[00:14:29] guest: Maybe we should put wrist splints on that person.

[00:14:32] host: Yeah. Yeah. You mentioned the carpal tunnel example. Absolutely.

[00:14:36] guest: Yeah,

[00:14:37] host: yeah, very good. Um, [00:14:40] you know, we talked a little bit before the session about. Impartiality and objectivity, and we just mentioned it, but you said sometimes there are biases. Can you explain what you mean by that?

[00:14:54] guest: Yeah, uh, in a nutshell, anybody who says they're not biased is biased. [00:15:00] We all have biases. We have biases, intrinsic, external. It isn't, it's just who we are. We all have them. And I think the best way to start to address bias is to understand that you have it. And there's, there's actually literature to that effect that says the best thing to [00:15:20] do to combat bias is to try to acknowledge that it exists.

[00:15:23] guest: Because until you start to internalize this concept that we all have intrinsic biases, it's a, it's really difficult to, to change that. So one of the things I've been, one of the most important, [00:15:40] fascinating areas of bias that I've seen recently is, uh, Something we all, I think we all do, and that is the difficult patient.

[00:15:48] guest: Okay? So if a person is perceived to be a difficult patient, the diagnostic accuracy of their condition goes down. [00:16:00] More likely to make a misdiagnosis or miss a diagnosis in someone who's perceived as difficult. And I think that plays really well into this entire concept of the need for the IME. Is these are the contested cases

[00:16:16] host: and

[00:16:16] guest: maybe we're not getting it right through no fault [00:16:20] of the doctor treating the person, but it can be a communication bias.

[00:16:24] guest: It can be a gender bias. It can be a race bias. I saw a gentleman who was non fluent in English. And I think it affected his care and I [00:16:40] like to think that I helped by focusing more on the neurosurgical objective findings and changing the dynamic.

[00:16:51] host: Interesting. Is there bias also, I know this comes up in medical legal because you're working for one or the other usually, is there plaintiff defense?

[00:16:59] host: What is [00:17:00] bias in a typical IME for a work comp case?

[00:17:04] guest: So the typical answer, so the answer, the standard answer is I'm being paid for my opinion or am I being paid for my time? The opposing counsel will be, is inferring that I'm being paid for my opinion and [00:17:20] what I'm trying to do is be paid for my time.

[00:17:23] guest: And that's it. The bottom line is that someone is paying me, and I think going to the sense of intrinsic bias of saying, Oh, it doesn't matter who's paying me. I mean, that doesn't pass the sniff path test. You know, there's, there's an, [00:17:40] there's a string there. There's a connection where I try to go with this.

[00:17:46] guest: And what I try to communicate is that is two things. One, my reputation is more important to me. Yes. Being an accurate, not fair, because that's in the eye of the beholder, an accurate evaluator, [00:18:00] and to give the impression that my reputation is more important and being able to come back another day and evaluate another case based on my credibility is important.

[00:18:13] host: What are some of the common challenges you face when performing IMEs? How do you address those? Just talk about a couple [00:18:20] of them. How do you handle discrepancies between findings of an IME and other medical reports? We talked about misdiagnosis. Um, sometimes there's been another IME that's already been done.

[00:18:31] host: Maybe you disagree with that. How do you handle all that?

[00:18:34] guest: I handle it respectfully. Okay. And with new and, and with neutral [00:18:40] language. My job is to give an opinion, try to be ethical and accurate. Um, my job is to put the person at ease. You know, my goal is to get somebody who from this to this during an [00:19:00] examination, I want them leaning forward.

[00:19:02] guest: I want them telling me what's going on. I will frequently dictate the case, the history in front of them. You know, did I get this right? And they're going, yeah, yeah, or no. You, you know, it was after not before or, and they're, they're leaning forward and they're helping me get this history [00:19:20] and it can be a, it can solve problems.

[00:19:23] guest: The challenge. So first of all, the challenge is, is that somebody made them come in. Okay. This, this is. The second challenge is I am seeing things through a different lens, and there can be multiple opinions, not [00:19:40] from one doctor, from multiple doctors, and I have to integrate all of those. The exam may be inconsistent, and I think it is very important not to try to throw shade on the exam or the examinee during the examination, but just to say, Mr.

[00:19:59] guest: Jones [00:20:00] had, you know, Had, you know, had difficulty standing up and, uh, had to use his hands on the chair two times, but then whatever you just describe it, you describe that the actions in the room in neutral language, when you make a diagnosis, you [00:20:20] know, would you say, I see this, you know, you in neutral terms.

[00:20:25] guest: When I make treatment recommendations, I make them in neutral terms. If I go into the examination with the concept that I'm trying to move a case forward and resolve dispute, it solves a [00:20:40] lot of those, those tension points.

[00:20:45] host: So you don't really have to address, Oh, I disagree with this. Just stating matter of factly what your findings are and you don't really dwell on that.

[00:20:54] guest: I respectfully disagree with Dr. Jones opinion [00:21:00] based on my, I see this, this, this, and this.

[00:21:04] host: Okay.

[00:21:05] guest: And I don't have to call him a, you know, a cone nosed bug.

[00:21:10] host: But you will call it out.

[00:21:12] guest: I just, I, you know, I see this differently. I respectfully disagree. And then I'll give four reasons if I'm doing my job right, or I'll [00:21:20] just say, I see that this person has, you know, has this based on these four things, and these are sufficient to explain.

[00:21:30] guest: his symptoms, he does not need this diagnosis of, okay, let's go back to our person with carpal tunnel. I don't have to say, I don't think he needs surgery. [00:21:40] Okay. I don't have need to say, why would you operate on our, do neck surgery on a person with carpal tunnel? All I need to say is on my physical examination, I see physical, I see signs of carpal tunnel.

[00:21:52] guest: I recommend nerve condition tests and wrist splints.

[00:21:56] host: Uh, that really leads into the next question, right? How can the findings of [00:22:00] the IME affect the patient's treatment plan or return to work timeline? So that's what you're talking about.

[00:22:07] guest: One of the founding principles of the guides is correct diagnosis.

[00:22:13] guest: Um, and it's amazing how often we are incorrect and it is amazing how [00:22:20] more often we're incorrect in dealing with a difficult patient. population. So I think fundamentally when doing an IAME, I'm trying to get back to the correct diagnosis. And that does not mean that I'm trying to outguess or rearrange the attending physicians.[00:22:40]

[00:22:40] guest: Diagnoses, I'm looking for alternative diagnoses, additional diagnoses, refinement of diagnoses, different options. Go back to our radiculopathy versus carpal tunnel. Classic example. Um, sometimes just having a different [00:23:00] set of eyes in a problem can completely change the case. There may be times when I say this person absolutely cannot go back to driving a truck, you know, so let's move on.

[00:23:10] guest: Let's get them retrained.

[00:23:13] host: Yeah. So, uh, and that leads into the next question about why What impact do [00:23:20] IMEs have on the employer employee relationship could affect the actual job assignment, right?

[00:23:27] guest: Yes, you, you and I have talked about this before about the institutional barriers to return to work and as an Occupational Physician, you know way more about those than I do.[00:23:40]

[00:23:40] guest: Getting a person back to work by the time they get to an IME is difficult You Because they're already weeks to months out, maybe years out, um, from the injury and have probably, may not have worked for a long time. One of the things that I think, [00:24:00] so kind of the easier answer to that is, trying to move the case to an IME faster, which is very difficult to do.

[00:24:09] guest: That's really out of my hands and out of the treating doctor's hands. The second one is resolving work disputes, returning return to work. For example, [00:24:20] I see patients who've had low back fusions, where the fusion's intact, there is bony fusion, and that person is given a lifting, uh, a lifting, um, Precaution, but they can't lift over 35 pounds.

[00:24:37] guest: And some of my mentors have said to me, [00:24:40] well, they're better now they're fused. Why would you think that that fusion where there's bony union would require a limitation, lifting limitations. And I have to admit that. I used to limit someone who's had a fusion to no lifting more than 35 pounds, and it [00:25:00] took some education on my part to kind of think of those dynamics differently.

[00:25:05] guest: Now would I have everyone, you know, would I do that across the board? No, this is the, this is the finesse of what we do. What's the conditioning of that person? What's their overall body mass? What's their general? you know, how long have they [00:25:20] been laying in bed? What's their pain tolerance? So, getting back to that risk capacity tolerance, um, equation, that can be, that can help the IME move a case forward to resolution, can support the OCMED doc.

[00:25:38] host: How often do you recommend [00:25:40] an FCE in those cases? Or do you, do you always have them? We don't always have them ahead of time, right?

[00:25:47] guest: I do not always have them. Um, and this gets to, back to that risk capacity tolerance equation again. When I, and, and this is fundamentally [00:26:00] important, it's a massive concept here, sorry.

[00:26:02] guest: When we are talking to our patient, we are talking to them in terms of tolerance. What can you do? What do you feel you can do? When I'm evaluating a patient, I am evaluating them in terms of risk and [00:26:20] capacity. Risk, is it safe for you to do the job? Will you hurt yourself? Will you hurt somebody else? Two, capacity.

[00:26:27] guest: Do you have the medical capacity to do that job and why? You have the strength. Do you have, can you bend? Can you lift? Can you raise your arm? Do you, would you be [00:26:40] able to do better with physical therapy? Because physical therapy is really about improving capacity for doing it well. I'm thinking in terms of risk and capacity.

[00:26:50] guest: As an IMB, but also as a doctor, whereas our patient is talking to us in terms of tolerance.

[00:26:57] host: Yeah. It hurts when I do that. [00:27:00]

[00:27:00] guest: Hurts when I do that. You know, I can do

[00:27:02] host: it, but it hurts. Yeah.

[00:27:06] guest: So that, that's the fine part. So when I'm, when I'm looking at a person, I'm trying to do it objectively, I will say, You know, it is absolutely unsafe for [00:27:20] a person who has dizziness to look up to be on a, you know, be at heights or epilepsy be at heights around moving equipment.

[00:27:28] guest: That's easy. Um, but the kind of the finer point is what can that person do? What's safe, okay, what can they do physically, but then [00:27:40] tolerance, well, can their, can their workers tolerate them having a seizure in the, in the, on the middle of, you know, in the office. So, different types of risk capacity and tolerance all go into the equation.

[00:27:56] host: When the treating doctor receives your IME report, what do you [00:28:00] hope they're going to accomplish with that?

[00:28:05] guest: I try to write my reports in such a way that it helps the treating doctor. I'm trying to write a report that moves the case forward. I'm trying to write a report that resolves [00:28:20] the case and leads to a better outcome for the patient. If I were treating a doctor though and somebody else, you know, my patient went out for an IME and this IME report comes back, I may not see those subtleties.

[00:28:38] guest: So what I'm hoping for, [00:28:40] when I, first of all, I'm hoping my report gets read.

[00:28:47] guest: Secondly, I'm hoping that someone thinks some of the ideas are worthwhile.

[00:28:56] guest: And thirdly, I'm hoping that [00:29:00] the receiver understands that I wrote the report with some sort of grace to facilitate care.

[00:29:12] host: And what if they disagree with the results of the IME?

[00:29:19] guest: You know, a lot of that [00:29:20] is a, is actually a systems question. In most states, the treating provider has the presumption of correctness or is concerned concerning, is considered correct over a medical legal provider or an expert. Um,

[00:29:39] host: so they're using [00:29:40] that as a piece of another piece of information, but they're making the decision.

[00:29:44] guest: Yes, um, sometimes the, you know, the claim will be closed or kept open based on what I say. So that sword can cut many different ways.

[00:29:56] host: And it varies by state, right? We have patient choice [00:30:00] states where they can order their own IMEs and we have other states where pretty much only the adjuster or sometimes the treating physician is ordering the IME.

[00:30:12] guest: I will say it's unusual for me to, to get a report back. There are times when we can get [00:30:20] into this, uh, we can lose some objectivity with our patients sometimes. Which is a good thing because we are normal. Okay, and there are times when I'll get I'll see the same person back for an IME Or I'll see or I'll see I'll do an [00:30:40] IME When somebody else has given an opinion and the treating doctor says, this person doesn't want to know what they're doing, you know, the Siamese completely wrong and maybe the treating doctor is correct, you know, or maybe the treating doctor is just got his, his or her heels dug in and [00:31:00] there are.

[00:31:01] guest: different issues. Where I see this a lot is, um, people with headache, neck pain and headache, and they've had multiple rhizotomies, needle branch, they've had multiple injections, ablations, and their headaches keep coming back. And [00:31:20] I'm like, um, maybe we should stop putting needles in their neck. And maybe we should like look for a headache diagnosis.

[00:31:28] guest: And it's amazing how much resistance I get to that concept.

[00:31:33] host: Interesting.

[00:31:34] guest: Yeah.

[00:31:36] host: Yeah. Then you want to go back to your other biopsychosocial [00:31:40] aspects, right? Go get a massage or try a chiropractic or try something completely different.

[00:31:45] guest: One in five women has migraine. Half of women, one in ten men, half of, half of us don't know we have migraine.

[00:31:55] guest: We've been diagnosed with something else, or we haven't been diagnosed at all. [00:32:00] And 30 percent of us have been told we, it's from our necks. So, and that's, that's, 30 percent of the people that meet international classification of headache disorders, diagnostic criteria for migraine, when they come into a headache center of [00:32:20] excellence, have been given a diagnosis of cervicogenic pain.

[00:32:25] host: So there's a lot of undiagnosed migraine out there.

[00:32:29] guest: And if you think about the person who is, just take Whiplash and I'm taking whiplash because people can, it's both personal injury and it's also [00:32:40] uh, med because somebody's driving and they get rear ended and their head hits the back of the, the um, the headrest and they go in and they've got headache and neck pain and they're severe, severe headache, red flag for migraine, um, severe headache.

[00:32:58] guest: They go to Cairo, they get better, [00:33:00] they get better, they get better. They flare severe neck pain, severe headache. I'm thinking migraine. Okay. Yeah. And good point. I'm the person. I'm the person who's just seen him have 20 Cairo visits. So I'm getting all those records retrospectively and I can say better, better, [00:33:20] better flair, better, better, better flair.

[00:33:23] guest: And then they've gotten a little narcotic and they've gotten, um, maybe some butalbital, um, and they're getting chronic daily nonsteroidals and maybe a little soma. And all of a sudden you've taken that person with a treatable headache disorder and you've pushed them [00:33:40] into, um, chronic daily headache with medication.

[00:33:44] guest: Yeah. With overuse. Multipharmacy. Now how are you going to undo that? So that's one place where I think the, the IME can give you, it's a huge place the IME can give you a different set of things to think about. [00:34:00]

[00:34:00] host: Yeah. And that's such a problem because then when you're making that assessment, that is essentially ending the work comp case, right?

[00:34:09] host: It's not, the migraine is not a work comp issue. So all those doctors that loaded up all those drugs now are not going to be. Necessarily [00:34:20] seeing that patient anymore could open some additional issues.

[00:34:23] guest: That entire problem of, well, your work comps, so you're in this box, but if you're medical, you're in this other box.

[00:34:30] guest: And that's very difficult.

[00:34:31] host: It is.

[00:34:32] guest: So how do you, you know, is, so that whole concept of how do you detangle a headache? [00:34:40] Maybe it is related. Maybe it is. There's migraine and post traumatic headache. That's where an artful answer can make a huge difference. If we treat you for your post traumatic headaches and get you back to your migraine baseline, you will be better off.

[00:34:54] guest: But the person who's sitting there in a dark room every day with chronic daily headache, you're not doing anybody a [00:35:00] favor. were comp related or not by not moving that forward with correct diagnosis.

[00:35:08] host: So you would still recommend a treatment plan that would move that person humanistically and compassionately through that process?

[00:35:18] guest: Yes, and and [00:35:20] and that's Very complicated because it breaches, it kind of has a foot in both the worker's comp and the preexisting. Um, it's complicated because people don't are afraid of treating migraine. It's, you know, the, you know, it's hard to get a person to necessarily do some of the [00:35:40] medications.

[00:35:40] guest: People don't understand the nutraceuticals and I realize I'm getting off on a tangent. It's a real, there's an artful answer. My point is there's an artful answer. when doing an IME towards moving the case forward. And sometimes that's within workers compensation. Sometimes it's [00:36:00] getting it out of workers compensation.

[00:36:03] guest: Sometimes it's sending a person back to work whether they want to or not. Sometimes it's keeping somebody out of work whether they want to or

[00:36:11] host: not. Yeah. Yeah. And I think those are some of the areas where I hear from physicians, treating physicians, [00:36:20] that, uh, Where they may have disagreements is, you know, they're saying this is pre existing every every patient I send for an IME I get back.

[00:36:29] host: Oh, this is pre existing But you're saying well, there's a way to transition that care Properly and as I said compassionately to make sure they still get the [00:36:40] care they need.

[00:36:41] guest: Yes, and well also saying Right to what you said that on higher comp set of this was pre existing Okay, so when is it pre existing, when is it aggravated, when was it pre existing, asymptomatic, and now made symptomatic, so that concept of lit up, and this gets back to that conversation [00:37:00] we've had about causation before.

[00:37:02] guest: You know, if I don't know why something got broken, it's gonna be really hard for me to fix it. So when the person, when the IME comes back and says this is pre existing, it may be a way of saying that not everything that, not all the symptoms that [00:37:20] occur after an accident are necessarily related to that accident.

[00:37:25] guest: And how do you sort that? And how do you take that? Well, this is all pre existing from the treating physician's point of view, who's been the person in the room. You know, I've seen him once, this person's seen him all the time. How can the [00:37:40] causal assessment, the causation of the injury help with diagnosis and appropriate treatment?

[00:37:48] guest: And I think that is actually a huge conflict between the IME and the clinician, because IMEs have a different sense [00:38:00] of causation.

[00:38:03] host: Good. Thanks for that. Uh, just a couple of minutes left, I just wanted to touch on what are some of the emerging trends in technology, there's a lot of technology out there now that we can use for, uh, evaluating our reports and report writing and, and all those sorts of things.

[00:38:19] host: What do you [00:38:20] feel like are the most interesting IMEs or medical legal work?

[00:38:26] guest: So AI is going to be huge, um, and we could talk about AI, but by the time we get done with the sentence, it would have, you know, moved on past us. One of the big things is going to be integrating AI intelligently. Um, [00:38:40] AI is full of mistakes.

[00:38:42] guest: And whether I am having, when I, when I am doing an IME, there is no substitute for me being in the records myself. I, you and I see paper differently in a medical chart than [00:39:00] anybody else. We can read through, you know, there are maybe hundreds of words on a medical chart, but you and I are looking for the three words in the musculoskeletal examination, or did they actually put a stethoscope on the heart, or is that still?

[00:39:18] guest: Is that [00:39:20] text, is it standard language and they, you know, you can't trust that exam. That's all something you have to see on the page. So no matter how good this technology gets, it's not going to replace you and I as the clinicians. So [00:39:40] my concern with AI is not that it's going to do a better job because it's going to be faster.

[00:39:45] guest: It's going to make things easier. It's going to streamline things. It's not going to take away my need to do my job. That's one. The second one I think is actually very important is big data and claims. [00:40:00] and patient claims. And the big data and the AI is going to, if we're lucky, identify the at risk patient earlier.

[00:40:11] host: Yeah, you mentioned that before.

[00:40:13] guest: And it may be

[00:40:14] host: sooner. Yeah.

[00:40:16] guest: Maybe we, if we're lucky, that [00:40:20] system will identify the at risk person, set up a different paradigm, help the treating doctor. and avoid having to go to an IME.

[00:40:31] host: Great point. Well, I think we're going to have to leave it there. Another fascinating discussion with the wonderful Diana Kramer.

[00:40:39] host: Thank you [00:40:40] so much for being with us today. And, uh, we will cover additional topics on IMEs in subsequent sessions.

[00:40:48] guest: I look forward to seeing you again, Larry.

[00:40:50] host: All right. Take care. Bye [00:41:00] now.

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