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11/22/2016 in News

As you know, we at Medical Systems strive to practice the highest degree of honesty, truthfulness, reliability and fairness in every aspect of our work and our client relationships. It’s what you have come to expect from us and we continue to seek out and deliver our best work because our relationships matter to us. We continually practice quality measures through every aspect of our process; from hiring the best people, consistently focusing on ethics and excellence, and routinely practicing “quality control” reviews of work produced to ensure the best work is presented. This work ethic has, and will continue to be our commitment to our customers, our doctors and our staff.

You know we produce quality work, but you may not know we constantly put ourselves through a checks and balances system throughout our work process to deliver the best results. This is true from the very beginning of scheduling to the quality assurance of end result reports. It is important to all of us that you are receiving the very best work product we are capable of giving because our relationships with you, our doctors and our staff are held in highest regard.

When it comes to the quality assurance with doctor reports, we work meticulously to preserve the integrity of the reports and the doctor’s opinions because we know getting it right builds trust. Our detailed quality control system involves review of work product by the doctor and multiple Medical Systems personnel to assure the highest degree of quality is maintained to produce the results our customers need and rely on.

Providing you with honest, truthful, accurate IMEs is our top priority and our continued commitment. We pride our reputation for accurate, reliable work product and work hard each and every day to make sure we’re getting it right and earning your trust. Earning that trust is the driving force for all of us at Medical Systems to do our best. We will always put ourselves to the test in order to deliver results that are fair, truthful and reliable. Because at the end of the day, we know you count on us to get it right. Our commitment is to do everything we can to deliver quality results because we value you and all our relationships.

The IME report can serve several functions, but there is one thing common to every IME: the doctor makes the difference.

So how do you choose the best doctor for your case? The reason for seeking the IME will be an important consideration. If causation alone is the issue, then you may want an expert who is skilled at analyzing mechanisms of injury or physical job demands analysis. Let’s say it is indisputable that the examinee needs a knee replacement and the only issue is whether repetitive job activities contributed to the claimant’s knee condition. In this case, you may want an occupational medicine specialist who has experience with job demand analysis and has studied the effects of repetitive activities on the development of osteoarthritis.

On the other hand, if the reasonableness and necessity of treatment is a major issue in the case then you will want to have a specialist qualified to address treatment. Let’s say a lumbar fusion has been recommended but seems likely to fail for some identifiable reason. In this case you will want a spine surgery specialist who can credibly explain the reasons why the proposed surgery is likely to fail and is thus contraindicated.

Once the purpose of the IME has been identified, what are other considerations in determining the best expert? Several strategies can be used. First and foremost is the requester’s experience. Each claims and legal professional will have her own idiosyncrasies and practical experiences when it comes to IME experts. This combination of experience and preference is the chief guide most claim professionals do and should use in choosing an expert. You don’t want to reinvent the wheel: if you had a good experience with an expert on a similar claim in the recent past, you probably don’t need to expend mental energy and productive time searching for another expert. Use the one you already know.

Unfortunately, we run into unique or otherwise unusual situations for which an expert is not immediately obvious to the claim or legal professional. In this case, the investigation should start closest to home and gradually expand outward. Thus, the next step would be to consult one’s colleagues. In any claims department or law firm, the chance of encountering a wholly novel claim is relatively small, which means someone in the department or the office has probably dealt with a similar situation in the past. Consulting with peers is an efficient way to find the right doctor for an unusual claim. This step, when it is successful, has the built in advantage of having evidence to support the decision. For example, if a complicated neurological condition such as syringomyelia is alleged to have arisen from an accident, the appropriate expert may not be immediately obvious. Most orthopedic spine specialists and even the majority of neurosurgeons are unlikely to have experience with this condition. Nevertheless, in a large claims department or a law firm there is a decent possibility that someone has encountered a similar condition in a prior claim and used an IME. If a similar claim exists and the IME was good, then the query should probably be over.

If a survey of one’s peers still does not give the claims professional a satisfactory recommendation for an IME specialist, one may wish to consider the nature of the case and contact an attorney. In most claims, the ultimate disposition would be a trial, whether in an administrative or court setting. Hence, there will be issues to consider that relate to the possibility that a claim will not settle and will end up before a judge, jury, or administrative law judge. In this case, an attorney can provide valuable guidance with respect to qualified experts that will be credible in the particular litigation forum. An expert that might be well-suited for a personal injury claim could be ill-suited for a worker’s compensation claim or vice-versa. Practicing attorneys with whom you have a relationship can be an enormously valuable resource to use when deciding on what IME expert to use.

Your IME vendor can also be an excellent source of information regarding what doctors specialize in or have a clinical interest in a particular condition. Your IME vendor should have the tools necessary to identify the right expert. The best vendors actively recruit doctors to offer the widest range of specialists possible. In addition, when the best vendors vet their experts, they identify and note each expert’s specialties and areas of clinical interest to make the choice easier for you. The best vendors also schedule countless IME’s for many different clients, so there is a good chance that the vendor has run into a similar condition in the past and can recommend a physician based on the earlier case. Finally, the best vendors will be sensitive to your requirements and will tailor any recommendations so that the doctors put forward will prepare a report that meets your requirements.

At Medical Systems we strive to be a resource for you. We have a wealth of knowledge and experience that we put at your disposal. If you have a claim, chances are we’ve seen one like it before. We know what’s worked in the past and we share that information with our clients. And we get to know our clients so that we can match the expert that not only has the right experience but also meets your specific needs, be it turnaround time, style of writing, or type of analysis. While there are no guarantees, we will do our part to ensure that you choose the best and most qualified expert for your claim.

Choosing the medical expert is a critical decision in the life of your claim or case. This is true in every case, but can be especially true in some situations where you may be bound to your selected expert through the entire case. Regardless, be sure to consider all the issues on your case, the medical questions, and the purposes of the report, and also use all available resources to ensure that your choice of medical expert is the best possible option. 

A command of the facts is essential to managing claims effectively.  Equally important is the ability to understand what the facts mean in context.  Deer hunting is still a popular pastime in Wisconsin.  As such, one avenue for investigating whether a person’s condition is as disabling as they claim is to find out if they hold a deer hunting license.  The idea being that a person who is able to hunt for deer is probably less disabled than they claim.  The inference is strongest in the case of hunting with a bow and arrow because compound bows require significant strength to use and their shorter range (compared to a gun) generally requires the hunter to climb into a tree stand to hunt.  Deer are also heavy, which would make it difficult for a lone hunter to deal with the animal after a successful kill.  You will note that several assumptions are required to make the leap from the premise “claimant possesses a deer hunting license” to the conclusion that “the claimant is less disabled than alleged.”

The assumptions need to be teased out before the fact of possessing a hunting license can be used to infer less disability than alleged.  Take the following hypothetical:  a relatively young person who is right-handed alleges a disabling work-related right shoulder injury (rotator cuff and SLAP tear) that prevents him from returning to his former occupation that requires he be able to lift up to 100 pounds to his waist occasionally and 15-25 pounds above his shoulder frequently.  In the course of the investigation, the claims professional discovers that the employee obtained a license enabling him to hunt deer in Wisconsin with a crossbow.  The claims professional considers this to be a red flag and evidence that he is not as disabled as he claims.  She sets up an independent medical examination and informs the expert of this fact, expecting it to be significant.

The question we must consider is whether the employee’s crossbow hunting license is in fact evidence that he is not as disabled as he alleges.  The first thing we need to know is a bit about crossbow hunting in Wisconsin.  Until 2014, the only persons who could obtain a crossbow license to hunt deer were persons with a physical disability that prevented them from being able to use a vertical (and typically compound) bow.  This should immediately give us pause in our analysis since it suggests that the employee’s license very well may have been obtained because his right shoulder condition prevents him from using a standard vertical compound bow.  This possibility is bolstered when one considers that the draw weight (how many pounds of force are required to draw the string back) on a compound bow for an average-sized man will be around 60 pounds.  For a right-handed shooter this puts a tremendous amount of stress on the right, or draw-hand shoulder. 

But what about dealing with a deer that has been shot and killed?  Wouldn’t that be physically difficult?  It is true that most whitetail deer killed in Wisconsin will weigh over 100 pounds, with some bucks tipping the scales at well over 200 pounds.  Obviously field dressing, dragging a deer out of a field or woods, and lifting into a vehicle would require significant effort.  However, we are again making assumptions about what physical activity the employee is doing.  We must consider the possibility that the employee uses a four wheeler to get to his hunting location, as many hunters now use four wheelers.  We must also consider the possibility that a hunter with a four wheeler also has a power lift on the vehicle to help get the carcass off the ground and onto the four wheeler.  In addition, we must consider the possibility that the employee hunts with other people and will have assistance if he makes a kill.  The point is that we cannot infer from the employee’s license to hunt deer with a crossbow that he will engage in physical activity exceeding his alleged level of disability. 

The above scenario demonstrates the importance of not only knowing the facts of a claim but also of knowing what those facts mean.  Without a clear understanding of what the facts mean, one can misinterpret how the facts effect the claim.  In the above scenario, it is possible that the claim could be considered suspect based on the assumption that a person seeking a hunting license is probably less disabled than they claim to be.  However, knowing a bit more about hunting suggests the fact that a person who claims to have a disabling shoulder injury and seeks a crossbow hunting license is probably behaving consistently with the alleged disability.  Not drawing out the most reasonable inferences from the known facts could very well compromise one’s ability to effectively administer a claim.  Investigate carefully, but know what the facts turned up in the investigation really mean.

Rope fraying

The language we use to describe various medical conditions impacts how the conditions are viewed in the medicolegal context.  Some of the common culprits include “tear,” “herniation,” and “edema.”  The everyday understanding of these words suggests to readers of medical reports that they are the result of acute injuries rather than the normal result of aging.  Take for example the word “tear,” which is frequently used to describe the condition of tendons, ligaments, and meniscuses.  To the ordinary reader, if some says that they “tore” a tendon or have a tendon “tear,” the immediate image is something akin to paper being torn.  In many tendon “tears,” nothing could be further from the truth.  Instead, many tendon “tears” are actually degenerative in nature, resulting from the normal effects of time and aging on the body.  Medical experts and claims professionals should be more precise in describing such conditions so that it is clear to the ordinary reader that the condition is degenerative rather than the result of an acute injury.

How can this be done?  A good example is found in a Wisconsin Labor and Industry Review Commission decision.  There, the Commission quoted Dr. Paul Goodman:

MRI scan reports and common medical lingo frequently utilize the words 'tear' when describing the disruption of tissues and structures found on diagnostic imaging or at times of surgery. However, for the most part such language is misleading, manipulating the mind of the reader to understand that some sort of traumatic event is responsible for the 'tear' or 'torn' rotator cuff, event in the absence of any objective evidence of trauma having occurred. In the examinee's case, although her diagnostic reports indicate such language, I find it better to use the word 'disruption' which avoids a traumatic connotation. Over time, tendon structures deteriorate, breakdown, and become disrupted as a usual and normal consequence of the aging process. This is what has occurred in the examinee's case. No injury per se is medically determined.

The proof that this careful attention to language matters:  the Commission concluded the employee’s condition was not work-related and dismissed her claim.

“Did the accident (or exposure) cause the condition?” is usually the crux of most IME reports.  We expect the expert to answer “yes” or “no” and explain why and how she came to that conclusion.  The worst answer is some variation of “I’m not sure.”  This is enormously frustrating.  The person asking the question rightfully expects to receive a definitive answer and “I’m not sure” is tantamount to no opinion.  As a practical matter, “I’m not sure” functions only marginally better than having no report at all.

We have all seen variations of “I’m not sure” in IME reports.  But what can be done to avoid it?  A carefully worded cover letter specifically explaining the standard that the writer is asking the expert to meet can help.  One simple way to explain the expectations for answering basic causation questions is through a coin flip analogy.  Every physician understands that a coin flip is a 50/50 proposition, meaning that whenever a coin is flipped the likelihood that it will come up heads is exactly equal to the likelihood that it will come up tails.  It is easy to explain that you are asking the expert to determine whether the likelihood that the accident (or exposure) caused the condition is greater than a coin flip based on the available information.  If so, then the causation question should be answered “yes.”  If the likelihood that the accident (or exposure) caused the condition complained of is equal to or less than a coin flip, then the causation question should be answered “no.”  The vast majority of experts will understand this analogy and it often helps prevent them from equivocating on causation.

Experts also are prone to conflating medical diagnostic impression and causation in an IME report.  The diagnostic impression as reflected in chart notes is often blurry and by necessity uncertain.  This is why chart notes frequently reflect more than one diagnostic impression.  For example, a person who presents with carpal tunnel-like symptoms my carry a differential diagnosis of carpal tunnel syndrome versus cervical spine nerve root impingement versus shoulder impingement.  The doctor will keep the competing diagnoses in the chart until tests are performed to rule out (or confirm) causes.  It would be unwise to establish a definitive diagnosis in the clinical setting if there is not definitive medical evidence supporting one diagnosis over the others, even if the doctor believes, based on the available evidence, that one diagnosis may be more likely than the others.

This is the precise issue that experts performing IMEs must overcome.  Again, the cover letter can help them.  An effective way to help doctors move away from the medical diagnostic impression model is to explain to them that answering the causation question ‘yes’ or ‘no’ neither precludes the accident (or exposure) as a cause nor fixes the expert’s opinion for all of time.  Definitively answering the question is the equivalent of stating that based on the available information, it is more likely than not that the accident (or exposure) did not cause the condition.  This opinion does not preclude other causes or state that is 100% certain with respect to the cause of the condition.  The opinion also does not lock the expert into her opinion in the future.  The opinion is based on information available at the time the opinion was rendered.  If additional information becomes available in the future, the expert should be assured that it is permissible and expected that her opinion will conform to the new information, even if that means her opinion on causation does a 180° flip.  Explicitly explaining the nature of the opinion expected, its limited effect, and the possibility of changing it in light of new information will help the expert be more comfortable with stating a definitive opinion on causation.

Taking these steps in the cover letter can go a long way toward eliminating ambiguous, vague, or equivocal opinions on causation in IME reports.  We don’t expect perfection out of our experts, but we do expect that they will provide clear answers to the questions that we ask them.  Helping the expert understand exactly what those expectations mean will help her fulfill them.  

Low back problems are a necessary evil of being human due to our anatomy and physiology.  This is of great importance in many medicolegal claims in which an injury or repetitive stress exposure is alleged to have caused low back problems, thereby attempting to shift responsibility for the costs imposed by low back problems from the individual and his or her health insurance (if applicable) to the liability policyholder/employer and the liability/workers compensation insurance carrier.  The high prevalence of low back problems in the general population makes differentiating between idiopathic problems and those caused by an accident or repetitive stress exposure extremely difficult.  It is also complicated by the fact that the idea of a manifestation of a preexisting condition is at odds with our folk understanding of temporal proximity and causality, i.e. if two things happen near in time, we tend to assume they are causally related, with the first thing causing the second thing.

Human beings perform many cognitive tasks exceptionally well.  Accurately assigning causation is not one of them.  In particular, we are prone to making a priori assumptions about how things work and then confirming our assumptions (confirmation bias) post hoc (post hoc ergo propter hoc fallacy).  Low back pain is a notable example:  we often associate low back pain with lumbar disc pathology discovered on post-injury MRI despite the fact that we know from the medical literature large percentages of the general population have similar MRI findings but no low back pain.  We make the assumption based on our assessment of human anatomy and physiology that lumbar discs work in a certain way and when they are compromised it must cause discernible effects such as low back pain.  We then see evidence of compromised lumbar discs in persons who complain of low back pain following an injury or exposure and we leap to the bias-confirming post hoc conclusion that the pathology or compromised condition is causing the pain.  So strong is this impulse that we ascribe causation even though we are well-aware of the medical literature demonstrating that disc pathology is an exceedingly poor proxy for low back pain.  The coup de grace of this faulty reasoning is the post hoc association between disc pathology and pain:  physicians will regularly conclude that a specific event or long term exposure caused a herniated disc despite the person being in a population cohort in which it is at least as likely than not that herniated disc was present before the injury or exposure.  The only reasonable way one could reach this conclusion is with a pre-injury MRI showing there was not a herniated disc.

The problem with this sort of faulty reasoning is that it can lead to treatment that is extraordinarily expensive but ineffective.  In a low back pain claim with post-injury evidence of a herniated disc, the treatment is often a discectomy/laminectomy with or without fusion.  If the herniated disc was not causing the pain, the surgery will have been unnecessary.  While the placebo effect will almost certainly result in some short term improvement, the long term outcomes are likely to be, at best, no different than they would have been with conservative therapy because the treatment will have been aimed at discal pathology that was benign.  The triers of fact in the medicolegal systems will, however, require the workers compensation or liability carriers to absorb the costs of surgery, including non-medical costs that are recoverable under the different systems (such as indemnity payments in worker’s compensation or wage loss and pain and suffering in personal injury), because they are likely to believe the opinion that the herniated disc is the problem.  This belief is based on the folk (mis)understanding of cause and effect.

There is an expression in statistics that has been borrowed by cognitive psychologists:  regression to the mean.  It simply holds that unusual states, events, or findings tend to be temporary and regress over time to the average or status quo.  This is true with many non-malignant medical conditions as well.  This is both profound and somewhat dispiriting because it means that most of these conditions will get better over time regardless of treatment.  It is hence a fallacy to ascribe efficacy to treatment or causation based on recovery following treatment when a condition simply regresses to the mean because it would have regressed to the mean regardless of treatment.

Much attention has been paid to this phenomenon in the context of overusing antibiotics.  Most people who go the doctor for upper respiratory infections wait to seek treatment until the condition has been present for some time.  They then go to the doctor, ask for antibiotics, take antibiotics, and recover from the condition.  These persons then assume that the antibiotics caused the improvement.  The problem with the assumption is that most of these persons almost certainly had viral infections that simply got better according to the natural course of the condition.  ANTIOBIOTICS DO NOT AFFECT VIRUSES AT ALL.  The fact that the condition improved after starting antibiotics was due to the simple fact that the person started the antibiotics at about the time the condition would improve on its own.  The antibiotics had nothing to do with the condition improving because ANTIBIOTICS ARE 100% INEFFECTIVE AGAINST VIRUSES

The same holds true for many persons with low back pain who undergo surgery to remove a herniated disc.  Low back pain usually stabilizes over time after an acute exacerbation regardless of treatment.  Given enough time, it is highly likely that the person would have gotten better or at least recovered to the same extent regardless of the treatment received (including no treatment).  The fact that the person improved after surgery does not indicate that the surgery caused the improvement.  Instead, the relation of surgery and improved low back pain is almost certainly coincidental.  We regress to the mean.  That the surgery occurred and improvement subsequently happened is not evidence that the surgery was effective or that the herniated disc was causing the low back pain.

How do we know this?  The medical literature is replete with evidence to that end.  Take for example the study, “Influence of Low Back Pain and Prognostic Value of MRI in Sciatica Patients in Relation to Back Pain.”  The study was undertaken to evaluate the correlation between MRI findings and outcomes in patients with sciatica alone versus patients with sciatica and back pain.  As the authors note, “it remains unclear to what extent morphological changes seen on MRI in sciatica patients are associated with back pain, rather than being a representation of irrelevant differences between individuals.”  The study found “that herniated discs and nerve root compression on MRI were more prevalent among patients with predominantly sciatica compared to those who suffered from additional back pain.”  Interestingly, patients with sciatica and low back pain but without a herniated disc or nerve root compression fared worse after one year than those patients with a herniated disc or nerve root compression.  And “remarkably large disc herniations and extruded disc herniations were … equally distributed between the two groups,” causing the authors to conclude that “the worldwide accepted mechanical compression theory therefore seems not to offer a sufficient explanation for the cause of the disabling back and leg symptoms in sciatica.” 

Other studies demonstrate similar findings that call into question our ability to assign causation of low back pain to herniated discs and nerve root compression.  The well-known twin study demonstrates the difficulty in linking specific activities with low back pain.  As the authors in that study report, “disc degeneration appears to be determined in great part by genetic influences. Although environmental factors also play a role, it is not primarily through routine physical loading exposures (eg, heavy vs. light physical demands) as once suspected.”  As noted above, other studies have found that large portions of the general population have disc pathology on MRI, but no low back pain.  Still other studies find low back pain in the absence of disc pathology on MRI.  Despite this evidence, triers of fact routinely base liability decisions on medical opinions that conclude an injury or exposure caused a herniated disc based on a post-injury MRI (which is almost impossible to conclude from a rational, evidentiary perspective in the absence of a pre-injury or exposure MRI) and that the herniated disc is causing low back pain (which runs contrary to the received scientific evidence).   

What does this mean for medicolegal claims?  It suggests that every claim for injury- or exposure-related back pain based on post-injury MRI scans demonstrating a herniated disc should be carefully scrutinized.  In addition, worker’s compensation and liability carriers should take every opportunity to educate triers of fact regarding the lack of a causal nexus between herniated discs and low back pain.  Independent medical examiners should point to the relevant literature to begin convincing triers of fact that there is no evidentiary link between low back pain and herniated lumbar discs.   In this regard, insurance carriers can look to how the relationship of carpal tunnel syndrome to repetitive keyboard use evolved over time.  When these claims first started arising, triers of fact in worker’s compensation accepted the link based on treating physician opinions seemingly without question.  This was based on the fact that claimants reported experiencing symptoms while using computer keyboards.  The medical literature did not support this association.  Independent medical examiners began citing to research finding the opposite:  that repetitive keyboarding is not a risk factor for or a cause of carpal tunnel syndrome.  In at least some jurisdictions, the triers of fact and treating physicians eventually listened and stopped finding a relationship between repetitive keyboarding and carpal tunnel syndrome. 

A similar shift ought to occur in the context of herniated discs and low back pain.  While this does not suggest that low back pain itself is unrelated to an injury or exposure, it would radically reduce costs because it would limit surgery for herniated discs to cases where there is discernible nerve impingement causing motor and sensory deficits rather than in cases of low back pain alone.  Although human beings are not very good at accurately assessing causation, we can learn to go against our instincts if there is high quality evidence denying causation and experts willing to hammer that point home.  It is time to hammer home the point that disc pathology on MRI is poorly correlated to low back pain and limit expensive surgical procedures the efficacy of which is not supported by the medical literature.  The simple fact of the matter is that costs for treating a condition that cannot be reliably related to an accident or repetitive stress exposure should not be borne by a liability or worker’s compensation carrier (especially when the condition is poorly correlated with the alleged health effects).

8/5/2016 in Blog Categories, News

We have written about the potential to use stem cells to regenerate articular cartilage in this space before.  Now researchers at Washington University in St. Louis have grown articular cartilage using a person’s own stem cells in a moldable 3D synthetic scaffold.  The development is exciting because the scaffold can be molded around the shape of an arthritic femoral head, thus potentially replacing a person’s damaged articular cartilage with healthy cartilage.  If this potential treatment becomes a reality, it could offer an alternative to total hip replacement surgery.  This would be particularly beneficial for patients under 50 years of age with advanced hip arthritis since most prostheses last less than 20 years and replacing a prosthetic hip carries with it greater complications than the original replacement.  While the research is preliminary and has not yet been tested in animals (let alone humans), it is exciting and worth following, especially considering the fact that 322,000 hip replacements are performed annually in the United States alone.

7/29/2016 in Blog Categories, News

What do a 2,200 year-old Egyptian mummy and many Americans have in common?  Sedentary lifestyles.  And the effects are not pretty in either case.  Scholars who examined the mummy using CT scans determined that the man suffered from osteoporosis and tooth decay despite only being 30-40 years old when he died and having lived at a time when both ailments were rare.  They believe his poor health is explained by the fact that he was a priest, which allowed him to be sedentary, avoid manual labor in the sun, and eat a carbohydrate-heavy diet. 

A recent study published in the European Journal of Preventative Cardiology and reported on in numerous news outlets demonstrates how perilous the effect of a sedentary lifestyle is even today:  researchers concluded that the effect of being unfit “on mortality was a strong predictor in our population, second only to smoking.”  So deleterious were the effects of unfitness that researchers found men who were fit but suffering from high blood pressure and high cholesterol were less likely to die prematurely than men with normal blood pressure and normal cholesterol who were unfit. 

The study involved 792 men who were followed for 45 years starting when they were 50 years old.  Researchers measured the participants’ maximum oxygen uptake capacity, known as VO₂ max, to establish baseline fitness.  VO₂ max is a useful proxy for fitness because it is partly influenced by genetics but increases with increasing aerobic fitness.  The men were divided into three groups:  low VO₂ max, mid VO₂ max, and high VO₂ max.  The men were followed every 10 years, with analysis of cause of death among participants who passed away.  Researchers concluded that the mid VO₂ max group was 21% less likely to die of premature causes than the low VO₂ max group and that the high VO₂ max was 42% less likely to die of premature causes than the low VO₂ max group.  The results remained even when controlling for blood pressure and serum cholesterol.  Lead author Dr. Per Ladenvall summarized the findings thus:

We found that low aerobic capacity was associated with increased rates of death. The association between exercise capacity and all-cause death was graded, with the strongest risk in the tertile with the lowest maximum aerobic capacity. The effect of aerobic capacity on risk of death was second only to smoking.

The findings should give us pause to consider how we approach health care and maintenance.  Rather than relying on pharmaceutical or surgical interventions to control the effects of unfitness, perhaps we ought to insist on interventions that increase fitness.  If being unfit causes premature death and disease, it would seem wise to treat the cause rather than the effects.  As a corollary benefit, the treatment for being unfit, i.e. being physically active, is certainly cheaper than treating the effects, i.e. weight-loss surgery, prescription statins, diabetes medications, blood pressure medications, cardiac bypass surgery, joint replacement surgery, etc.  No doubt increasing fitness in the general population would also have a positive effect on medico-legal claims, since some injuries would likely be prevented and recovery from those that occur would be better in a fit population than an unfit one.

Employment-related meniscus tears are among the more common worker’s compensation claims.  The reasons are myriad but are influenced by the fact that most people develop degenerative meniscus tears as they age and the mechanism of injury for an acute tear merely involves twisting the knee, which can occur in even the lightest and most sedentary occupations because all workers who are not wheelchair-bound walk which means all workers are at risk of twisting their knee in a slip, trip, or fall at the workplace.  Setting aside the possibility that such an event is idiopathic, if a worker seeks medical treatment for knee pain following an industrial event and a meniscus tear is discovered on an MRI the treating physician usually relates the tear to the event.  Standard treatment in most such cases is usually surgical excision of the loose or torn meniscal tissue, more commonly known as a meniscectomy.  The assumption driving the surgery is that the meniscus tear is causing the knee pain and resecting the tear will eliminate the pain.  The problem with this scenario is that most meniscus tears are degenerative and there is no high quality research demonstrating that meniscectomy is an effective treatment for degenerative meniscus tears.  In fact, when researchers recently studied the question they found that exercise was equally effective as meniscectomy to treat knee pain in the presence of a degenerative meniscus tear, according to results published in the British Medical Journal (“BMJ”).

In the worker’s compensation setting, the argument is often made that an industrial event extended a preexisting degenerative meniscus tear in order to justify the surgical intervention (and coverage of the procedure under a worker’s compensation insurance policy).  The cost of meniscectomies to the worker’s compensation system is substantial.  The medical expenses alone are significantly higher for surgery than for conservative care.  In addition, meniscectomies often result in some permanent partial disability.  For example, a meniscectomy in Wisconsin carries with it a 5% minimum PPD rating to the lower extremity at the level of the knee and under the AMA Guides a meniscectomy typically results in at least a 1% impairment rating.  Surgery also typically necessitates a period of temporary total disability in non-sedentary workers.  The findings of the BMJ study should give every employer and worker’s compensation insurer pause and an editorial advocating systemic prohibition of using arthroscopy to treat knee pain that appears in the same issue should spur change.

First, a few things about the study itself.  The BMJ study is a level 1, properly designed randomized controlled trial.  This is the highest category of medical studies and is considered to produce the best and most reliable evidence available.  The BMJ study was conducted in Norway and was a randomized control trial with two parallel intervention groups of 70 patients per group.  One group received exercise alone and the other group received partial meniscectomy alone.  The participants were 35-60 year old persons of both sexes with a 2+ month history of unilateral knee pain without a major trauma but with a verified medial meniscus tear verified on MRI and no worse than grade 2 arthritic changes on x-ray.  The study found that there was no difference in outcomes between the two groups at 3 months and 24 months post-intervention.  The meniscectomy group reported better function and greater participation in sports and recreation at 12 months post-intervention, but the effect was gone by 24 months.  The authors could “not exclude the possibility that the greater placebo effect from surgery on patient outcomes” may have “mask[ed] the ‘real’ difference in treatment between the groups,” which they postulated could explain the temporary effects observed in the meniscectomy group.

More striking even than the study findings is the accompanying editorial.  The authors of the editorial call for a systemic level rule to prevent unnecessary knee arthroscopies from being performed to treat knee pain.  As they note, in the last decade:

A series of rigorous trials, summarized in two recent reviews and meta-analyses, provide compelling evidence that arthroscopic knee surgery offers little benefit for most patients with knee pain.  The latest nail into what should be a sealing coffin appears in a linked paper by Kise and colleagues (doi:10.1136/bmj.i3740):  a rigorous comparison between exercise alone and arthroscopic partial meniscectomy alone (without any postoperative rehabilitation) in adults with degenerative meniscus tear.  The authors found no between group difference in patient reported function at the two year follow-up…

The editorial authors note there has never been high quality research supporting meniscectomy in an older population with degenerative meniscus tears, but that the procedure was extended to this population based on unverified assumptions:

With no support aside from biological rationale, the indication crept from locked knees in young patients to all patients of all ages with knee pain and meniscus tears of any sort; tears which, on magnetic resonance imaging, have proved poorly associated with symptoms. 

The conclusion they reach is both astonishing and harsh:

We are at the point where any careful scrutiny, by, for instance, public health administrators or officials of an insurance company, would conclude that the estimated two million arthroscopic partial meniscectomies undertaken globally each year at a cost of several billion US dollars is potentially nothing but medical waste. Because frontline practitioners and local commissioners have not responded appropriately to the evidence, it follows that system level measures that result in more appropriate use of scarce medical resources are necessary—and perhaps urgently required.

In short, the authors believe the evidence against arthroscopy to treat knee pain is so strong and the evidence for it is so weak that health systems as a whole should stop paying for these procedures.  Such a rule would have a significant impact on worker’s compensation claims where meniscectomies are routinely performed to treat degenerative meniscus tears.

Choosing the right IME doctor can be challenging, especially in complex claims or those with unusual injuries.  Numerous factors influence the decision-making process.  However, two of the most important factors include familiarity with the injury or condition at issue and knowing the precise claims at issue.  These factors are particularly important because many injuries or conditions can be treated by different specialists and it can be difficult in these cases to figure out which specialist is truly the most qualified and credible for the claim at hand.   In simple terms, merely knowing the diagnosis is not enough.

For example, an orthopedic surgeon may amputate toes in a diabetic foot infection claim, but if the cause of the infection is themain issue an endocrinologist, infectious disease specialist, or podiatrist may be better able to write a detailed, credible report as to what caused the infection.  The reason is simple:  orthopedic surgeons do not treat diabetic foot problems unless amputation is required.  The treatment of diabetes, infection risk, and diabetic foot infection management are handled by other specialists.  On the other hand, if permanent impairment is the main issue then an orthopedic surgeon may well be the best expert to use because they are uniquely qualified to evaluate the effects of surgeries they perform.

A similar situation arises in the context of moderate to severe traumatic brain injury.  A neurosurgeon will typically treat the initial injury, but once the condition has stabilized and requires no further surgical management care is usually transferred to a rehabilitation specialist (or more than one).  Once rehabilitation and recovery are complete, care is transferred again, often to a neurologist and a psychiatrist.  In addition, neuropsychologists are often involved in the rehabilitation and recovery process to assess mental functioning.  If the main issue in the claim is the extent of permanency and the type and nature of future care, a neurosurgeon would be of limited value.  However, if the issue is the appropriateness of care in the critical post-traumatic period, a neurosurgeon would obviously be the most qualified expert.  Yet another iteration may involve questions over the extent of mental impairment, in which case a neuropsychologist would be the most qualified expert. 

Facial injuries involving the eye can be difficult also.  The initial treatment may involve an ophthalmologist and a plastic surgeon.  Once the emergency treatment is completed, care may be transferred to a different ophthalmologist for treatment and management of long term vision issues.  Severe ocular injuries can precipitate neurological issues as well, especially headaches.  Sinus and nasal problems can also be present.  In such complicated cases, the actual issues must be examined to assess which experts to use.  For example, in a penetrating eye injury where the patient claims he cannot return to work an ophthalmologist may not be the best choice where the failure to return to work is unrelated to vision loss.  In penetrating eye injuries, the loss of intraocular pressure can precipitate headaches with position changes.  If the claimant was a laborer who routinely has to bend over or look up, a neurologist may very well be the best expert to assess whether the work conditions would in fact precipitate headaches that would prevent the claimant from returning to his employment.  Again, knowledge of both the injury and the actual claim being made are necessary to make the best doctor choice.

Choosing the right doctor is often vexing.  Making the most informed doctor choice not only requires knowledge of the type of injury or condition, but also the precise issues or claims being made in relation to the injury or condition.  To make an informed doctor choice, it is important to recognize that the seemingly obvious specialist might not actually be the best choice depending on what exactly is at issue.  Hence, being familiar with both the injury or condition and the precise issues involved in the claim are necessary to make the best doctor choice.

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