Getting to Why

One of the most common concerns we hear regarding IME’s is that “the doctor didn’t explain why…”  Frequently the issue centers around the doctor’s opinion that a particular mechanism of injury did not or could not have caused the claimant’s condition.  For example, a doctor may conclude that a particular accident was not of a sufficient magnitude to have caused an acute rotator cuff tear and that the MRI findings demonstrate a wholly preexisting, degenerative process.  Most claims professionals and attorneys would be happy with this opinion, but only if the opinion did not end there.  We all want to know why the doctor reached her conclusion.One of the reasons doctors do not explain themselves in greater detail is that they live their entire professional lives interacting with other doctors and health professionals who do not require further explanation.  If an orthopedist tells a referring internist that an accident was not of a sufficient magnitude to have caused an acute tear, the internist generally will not require additional information to understand why the doctor reached that conclusion.  The orthopedist conveyed the relevant information and the internist can adjust her assessment accordingly.  Unfortunately for those of us in the medico-legal world though, medical opinions do us little good unless doctors explain why they reached them.In our rotator cuff example, the doctor likely had sound reasons for her opinions.  Perhaps the claimant did not complain of shoulder pain at the scene of the accident.  This, any orthopedist will tell you, would be highly unusual in an acute rotator cuff tear because acute tears are painful.  The tendons forming the cuff are enervated and when a complete tear occurs the nerves in and around the tendon are also torn.  This causes pain, which is the body’s natural protective mechanism to keep the person from continuing to use the joint in a way that could cause further injury and impede healing.Perhaps the claimant was a seat-belted driver whose vehicle was merely sideswiped.  The claimant did not report shoulder pain at the scene and did not hit her shoulder or have force transmitted to the shoulder through an outstretched arm.  Most orthopedists will tell you that a minor collision that does not involve direct impact to the shoulder or indirect transmittal of force through an outstretched arm cannot physically cause a rotator cuff tear.  If the shoulder is not hit or the arm is not outstretched, the rotator cuff tendon complex is essentially relaxed.  In this state it cannot be torn.  It is like a rubber band:  if you stretch a rubber band until it is taut you can break it when additional force is applied.  However, if you attempt to break a rubber band that is relaxed, nothing happens.So how can we get the doctor to explain why?  The simplest way to get an explanation is to ask for it.  We understand that certain questions need to be asked in a certain way, such as the Llewellyn questions in Wisconsin worker’s compensation cases (definite breakage, precipitation, aggravation, and acceleration beyond normal, or mere manifestation); however, tailoring causation questions to the mechanism of injury at issue will often get the doctor to answer why she reached her conclusions.  Take the rotator cuff example above:    The claimant alleges an acute rotator cuff tear arising out of a motor vehicle accident.  You have reviewed the file and just don’t think the accident could have caused a rotator cuff tear because the mechanism of injury doesn’t seem right and the MRI reports suggest the tearing was of a longstanding, degenerative nature.  In addition to the typical questions, you might want to ask the doctor a specific question regarding the MRI findings:  “The reading radiologist on the November 2nd MRI report states that there is fraying of the supraspinatus tendon that appears to be of a degenerative nature.  Please comment on whether you agree with the reading radiologist and if so what aspects of the MRI images suggest a degenerative versus an acute tear.”  You might also want to ask the doctor a specific question regarding the lack of shoulder complaints immediately after the accident:  “In her description of the accident and the development of her shoulder problems, the claimant does not mention shoulder pain immediately after the accident and first reports shoulder pain two weeks later.  What is your opinion on whether the claimant’s report of injury and the onset of shoulder pain is consistent with suffering an acute rotator cuff tear arising out of the motor vehicle accident?”We know that there are no silver bullets in obtaining independent medical examinations.  The doctors who are asked to examine claimants give an objective opinion based on the history described and the other facts available to them.  Nevertheless, targeted questions can go a long way in getting the in depth explanation behind an opinion that helps bolster the IME doctor’s credibility.  When preparing the cover letter to the IME doctor, consider whether there is anything unusual about the claimed injury.  If the mechanism of injury doesn’t seem right, point that out to the doctor and ask her to comment specifically on the mechanism of injury and why it would be unlikely to cause the alleged injury.  In many cases, you will receive a more detailed and individualized answer than you would if you only asked standardized questions.For more information on Medical Systems go to www.MedicalSystemsUSA.com

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