When The Clinician Becomes Caught in the Contest
Commonly the insurance contest about who is responsible leads to questioning of the physician. You must be truthful in all aspects to maintain the respect of all parties, especially the patient. If you jeopardize your integrity you lose the ability to help anyone. Thus, avoid rating your own patients since it is no more reasonable to evaluate the results of your own care than to be a judge in a beauty contest where your own child is a contestant.
The contest's comes down to 5 areas of information as laid out by 1979 NIOSH Guide to Work Relatedness
: Evidence of disease
, Epidemiology of association
, evidence of exposure
, any other relevant
information and a analysis of the testimony reliability to support a logical conclusions
. Report the medical information about onset according to the patient's story about when and how symptoms began. You do not have to become judge and jury. Only report any the differences in the story that others may have found. Leave the questioning of the individual's integrity to the lawyers and other professionals who are much better trained than physicians in such matters. Also, report the symptoms or diagnosis according to reliable science and avoid insurance company jargon like sprain, strain, repetitive or cumulative, chronic fatigue, fibromyalgia, or some other term that may be commonly used in your community. Unless requested to comment about one of these terms you should stay on firmer more defensible turf. As yet, none have been related to specific patho-physiology that results in predictable prevention or treatment response. If asked to be clairvoyant about limitations, you might provide your own opinion of the original limitations provided by the patient in the initial history before providing a scientific justification for why you would limit the patient in any way. If you use the AHCPR modified NIOSH lifting guide (Work Recommendations
) to guide answers about limitations from a justifiable basis, remind the receiver that the NOISH Lifting Equation is an extremely conservative slant toward safety of the individual and only the product of convention based upon very weak science.
Realize that when evaluating another's patient, the patient expects you to be on the side of whoever pays for the exam. Therefore, do not be alarmed or overly impressed if pain behavior is increased in a single evaluation for insurance company purposes. Nothing keeps you from recommending a home conditioning
to maximize comfortable activity tolerance as part of your evaluation. Nothing keeps you from discussing the predicament and making recommendations about seeking information about options. Unfortunately, though all patients deserve the best physical and helpful recommendations you can make, by the time you are doing an insurance related examination or providing information to the attorneys, the patient's response can be under the influence of many more non-physical than non-physical influences.
Logical Defensible Opinion
We commonly have to provide justification for our own treatment opinions or those recommended by others. The more obvious, logical and defensible our opinion, the greater the chance it will be considered. Common questions include, "Who is responsible for the patients problem?" "Do the symptoms relate to the inciting incident or exposure?" "Are the symptoms logically related to medical evidence and is the medical evidence concordant." A simple acronym "A WISE C?" can help organize the facts needed for consideration before they can be express logical opinion.
"A Wise C?" Is an acronym for "A WISE Correction?" to gather and organize pertinent information:
A – (age): Potential co-morbidity, expected diagnostic study confusion
W (working): Date hire, last worked Full/limited duty – Exposure and hint of debilitation
I (incitation) date- reported & 1st medical Witnessed? Body parts exposed? Dose [load, repetitions, frequency, recovery period] of Exposure
): Prior similar symptoms?, When: Pain?, Numb? Weak?, Stiff? Began & Body part?, Related to Exposure or Care?
Are the Symptoms reasonably the result of the Incident or exposure?
Does the Evidence of Compromised bodily function explain the symptoms?
C (correctable Lesion?): (Imaging)
Is there a Correctable lesion that is concordant with the Evidence of compromise (that explains the Symptoms)? Does the I - S - E - C provide an unbroken cascade of logic?
Summary: A WISE C? Makes more obvious those facts both present and absent that need to be considered.
Logic should flow, like a river, by taking the path of least resistance? But rather than logic, we are trained in the diagnostic approach to seek possibilities as we explore Symptoms by looking for Evidence of Compromised bodily function and if found exploring possible Correctable Lesions. To determine the logic of a diagnosis, we can back track to see if the logic flows along a path of least resistance. Starting at a potentially Correctable Lesion, the question is whether it is the most logical source of Evidence of Compromise and if together they are the most logical source of the symptoms? In other words, does the path of least resistance explain the Symptoms and if so what is the relationship to the Inciting Issue at hand?
A defensible opinion flows logically in an explanation of the cascade I
as being, or not being, the most logical path when examined. Does each finding support the adjacent finding? The best way is to view the relationships is in the flow in reverse order. Clinically charted diagnositic histories are built upon progression in a direction I
If the logic is correct then the flow should logically cascade in the opposite direction according to a path of least resistance from the potential Correctable Lesion back down the cascade (C
) in to establish a truly strong and concordant Diagnosis. For example, does MRI demonstrated correctable lesion (Right sided L4-5 HNP) that explains the evidence of compromise (left sided EMG obvious L5 nerve root compromise) and does that evidence of compromise logically explains the symptoms (right sciatica). If so then do these components the most feasible result from the incitation (Fell two stories, ejected from a jet fighter or incident [lifted 5#] or exposure [worked stocking shelve for three weeks])? A defensible diagnosis allows utilization of organizational tools like the 1979 NIOSH Guide to Work Relatedness
or Bradford Hill Causation Criteria. After expressing your consideration of age and work history before and since the incitation, the organization of the I
issues should make editorializing relative to reliable information much easier and understandable with reference to how only strong concordant findings predict a reasonable surgical outcome (Carragee et al.,'97, Shade et al.,'99 and Hansson & Hansson,'2000 50a-d
, Carragee et al.`06
). Without concordant of "A WISE C?" support from the reliable literature for further invasive diagnostic or corrective attempts related to the incident or exposure is difficult to justify considering the natural history relative to marginally indicated attempts.
Reporting the ease of logic to flow as the most logical cascade (C to E to S to I) most easily justifies opinions of:
1. Expeditious procedure for concordant obvious correctable lesion.
2. Expeditious further work-up for potentially dangerous problem.
3. Treatment of the activity intolerance through self directed conditioning
in caring for patient's who need to make choices according to a desired comfort level.
The relationship to the incitation is obviously an important part of a more complicate causality determinations that in the medical-legal world have become much more complicated. The importance of no relying upon the potential correctable lesion on MRI is made obvious by the work of Carragee
et al.,`06. The Carragee 5 year longitudinal follow up of 200 subjects without low back pain in their prospective cohort found that neither frequency nor severity of event predicted back pain severity or disability, Adverse outcomes were not predicted by structural findings or minor trauma. Having advanced structural changes also did not make subjects more likely
to become symptomatic
with minor trauma
evolving LBP episodes. Neither did an incident of minor trauma or not so minor trauma (fall >3 feet, MVA >30 MPH, lift >60 lbs.) seem to contribute to advancing MRI changes.
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