Independent Psychiatric Evaluations

1. Independent Psychiatric Evaluations C Donald Williams MD CGP

2. Course Plan • Define psychiatric IME types and how they differ from other evaluations • Worker’s compensation IMEs • Emphasis because of greater opportunity • Personal injury IMEs • Lesser opportunity—difficult entry—forensic certification helpful • How to conduct the exam • Review a sample exam

3. Workers compensation IMEs • Purpose is to diagnose psychiatric conditions and determine causal relationship to workplace injury • Levels of causal relationship • >51% causal relationship • Pre-existing conditions “lit up” • “2nd injury fund” compensable when Pre-existing condition from prior injury + present injury = permanent disability (other details)

4. Differences from other IMEs • Worker’s compensation—impairment and causal relationship to work injury • Personal injury—Determine the nature and degree of impairment with specific tort cause • Social Security—Impairment of function only • Fitness for duty—Impairment performing the essential tasks of a specific occupation

5. Benefits of IME work • Concentrated practice in detailed civil forensic assessments • Intensive practice in conceptualization, fact pattern analysis, and writing • Opportunity to introduce variety in practice • Work performed outside the constraints of health care insurance structure

6. Qualifications for entry • Board certification (relative-not absolute) • Experience treating injured workers • IME panel membership or reputation with contracting entities to perform solo IMEs • Attorneys • Claims management companies • Ability to author comprehensive reports quickly and efficiently • Willingness to testify at hearings (experience)

7. Challenges of IMEs • Conflict with opposing parties • Can be intensely political • Boundary clarity essential • No treatment relationship (exception when required to testify as treating physician, or a treatment consultation is requested) • Never shade the findings—be consistent between evaluations • “Seeker of truth”—makes litigation more efficient • MAINTAIN TOTAL TRANSPARENCY • Anticipate occasional personal and professional attacks • Be prepared to mount aggressive legal defense • Clear documentation critical

8. To start IME work • Begin with performing SSD evaluations • Be available to treat injured workers • 1-2 years experience desirable • Join IME panels in your state • Contact law firms that specialize in industrial insurance work and provide work samples • Review “Examiner’s handbook” for your state • Practice development requires several years

9. The psychiatric evaluation • Review of medical records • Detailed recitation key to quality evaluations • “Needle in the haystack” common • Discover misstated facts—lack of foundation and consistency in other evaluations • Face to face evaluation of applicant requires between 45-120 minutes, depending on the complexity of the case • Use DSM-IV multiaxial framework

10. Professional conduct • Treat examinee how you would like your relatives to be treated by a professional • Explain your role-”I am not your doctor” • Provide the evaluation requested by referral source and answer their questions, • No value judgments • Harder than it seems on occasion--examples • Countertransference awareness helpful—e.g. fear of being like the claimant

11. The place for templates • Create your own template using the SSA format or a variation • Saves time--promotes efficiency • Record findings under each heading—saving time by not recreating format • Ideal for voice recognition software • Dragon Dictate 8.0 or Via Voice • Use Digital Signal Processing (DSP) USB mic.

12. Confidentiality disclaimer • Statement of Non-Confidentiality:  The limitations on confidentiality imposed by his/her status as a Labor & Industries claimant were explained and accepted. He/she was specifically advised that no doctor-patient relationship was being established and that a copy of this evaluation would be forwarded to his/her attorney, who would utilize it as he saw fit in his representation of him/her in the matter currently before the Department of Labor & Industries. He/she agreed to proceed with the evaluation with this understanding.

13. Assignment letter questions • Your diagnoses for conditions causally related to this industrial injury. • Any treatment recommendations made causally related to this industrial injury. • Whether or not there is any permanent partial impairment causally related to this industrial injury. • Whether one of the causes of this injured worker’s inability to work between February 28, 2003 to present, would be the industrial injury of March 1, 1990.

14. Review a sample evaluation in detail-refer to packet now • Use standard format • Economy of language • Answer the questions posed in the assignment letter

15. Summary • IMEs require discipline and commitment to perform well • Foundation and consistency essential • Templates facilitate efficiency, consistency • Be readily accessible to your referral sources—same day phone call return • Learn from your mistakes—be humble

16. Where to get more information • www.aoop.org has links to AOOP Bulletin and prior meetings • www.cdonaldwilliamsmd.com links to prior courses, publications, and a list of references

17. Your response and questions • Questions • Comments • Criticisms