Importance of medical records for an IME

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As an IME one is called upon to conduct an assessment which contains elements beyond those of a specialist referral consultation from a general practitioner or other medical specialist.That is not to say that the latter is less important than an IME however the requester must understand they are DIFFERENT.

A neurosurgical referral(or treatment) consultation focusses on making an accurate diagnosis  with history, examination and investigations and advising same and differential diagnosis and formulating treatment options and plan.It does NOT require  assessment of causation ( medically and legally defined) nor does it require determination of apportionment between various events.Similarly it does not require WPI assessment and apportionment analysis.

An IME assessment +/- WPI assessment usually DOES require determination of causation, apportionment analysis and estimation WPI with apportionment between events. Differential diagnosis and treatment options may be required depending on matters such as the stage of the claim and jurisdictional issues. An IME who makes a determination of causation with or without apportionment knows that his/her opinion is likely to be of legal significance to a tribunal or court and certainly will affect the claimant , insurer and employer/3rd party e.g. in a medical negligence case or accident/wounding case.The IME is required to explain reasoning  and methodology used in reaching these important conclusions usually retrospectively and at times many years after subject events with surgery/ies in between. 

The experienced and highly trained IME attempting to give the best and most evidence-based opinion in these matters must display the evidence upon which he/she relied upon and the scientific methodology used. In the US the judge may throw out an opinion not meeting this standard ( Daubert principle).

An IME seeking to identify causation/apportionment is advised to view contemporaneous medical records in such circumstances as this is an exercise in determining diagnosis at the time of the injury/ies (event/s) and not at the time of consultation as he/she is doing when treating a referred patient for treatment. Many years may have passed.Many operations may have occurred. Many diagnoses may have been given to the claimant. There may have been a number of events.The claimant may not have an accurate recall due to the passage of years. HENCE, the responsible IME will seek out the best records i.e. evidence to consider along with the claimant's history, examination findings and imaging /investigations.After all, one way or another the IME may be cross examined by opposing counsel or be called upon by a medical regulator, to defend his/her opinion. Often the opposing counsel or regulator will be briefed with a differing opinion from another IME or specialist.

The IME who can explain his/her opinion regarding causation , apportionment and WPI with reliable evidence and a logical and scientific argument on his/her analysis will be the one best serving the court or tribunal.

The 'best' records are the most contemporaneous to the event. In many cases these are not provided for unclear reasons yet the IME is called upon to make his/her 'best findings as a reliable IME'. But what can be said of the efforts of the briefer in such a situation that does not cause offence? Similarly no radiology films are provided with expectation of diagnosis , causation and apportionment with no medical records and no incident reports. An IME making CONCLUDED findings does so at his/her peril and such reports may be disregarded by a discerning decision maker who may ask if the contemporaneous medical records, incident report and radiology films are/were readily available might I not conclude that this IME report is unreliable and cursory to say the least?

This is the standard expected of an expert in matters of medical negligence and is the standard expected in personal injuries matters. The court/tribunal recognises that the IME /expert report may be crucial in the outcome of a contested matter and the outcome may well be irreversibly damaging to another party and will seek an assessment with logical sequential reliable and reproducible scientific evidence -based reasoning and not a one page report with no discussion on the contemporaneous records etc. A bruise may be fleeting and the enquiring and responsible IME will seek out the records .Similarly neurological symptoms and signs that appear at a time remote to the  subject incident/s may not be causally related to the incident for a variety of reasons. 

An IME may provide an opinion based on history, examination, viewed tests and provided briefing and give findings with stated limitations i.e. not concluded opinions, with identification of material which he/she deems to be required and agrees to provided a supplementary ( or in some jurisdictions, a supplemental ), report for a further fee upon provision of missing information, records, films etc. 

UCPR 2005-Schedule 7 Rule 31.23 3 (k) requires an expert under the Expert witness code of conduct, to advise' if the opinion is concluded because of insufficient research or insufficient data or for any other reason'. This is repeated in 31.27 (2) and (3).

Readers interested in the importance of appropriate and reliable briefing and IME recommended methodology may wish to refer to the following resources which are WIDELY available , or undergo examination and training as a Master Certified Independent Medical Examiner (Master CIME) by the American Board of Independent Medical Examiners(ABIME);

1.'AMA Guides to the Evaluation of Disease and Injury Causation', Edition 2, 2015 Edited by J. Mark Melhorn et al. page 146 and pages 150 to 153

2.'Writing and Defending Your IME Report :The Comprehensive Guide', Edited Steven Babitsky Esq et al 2004 pages 87,89.90 and 190-199.

3. 'AMA Guides to the Evaluation of Permanent Impairment', Editions 4, 5 and 6.

The opinions stated herein are those of the author and references are provided and individual IMEs are advised to seek their own advice and practice standards.

The author is a senior specialist neurosurgeon who was awarded Master CIME in 2017 and holds 6 Fellowships in Surgery having graduated MB BS (1st Class Honours) from University of Queensland in 1980.