The Independent Medical Examination: When is Enough, Enough?

TASA ID: 2379

  
Certainly, patients know how they feel about this: the need for more care is obvious, "doc: I am still in pain!" Pain is an important feature of my own clinical decision-making process.  But what else is there to consider when making a decision regarding future treatment?

The short version is “Symptoms, Signs and Improvement.” (The longer version is “are you treating the patient, or the insurance carrier,” but that will be covered in another article!)  When all three are present, more treatment is likely to be recommended.

Symptoms 

This is simple: what is the patient reporting to me in response to being asked about his or her pain? Which body parts were injured in the car or work accident?  Is there still pain in that area now?  Constant or intermittent pain?  Any time of day which tends to be worse (first thing in the morning, after work, at night)?  Does the pain ever radiate down the arm or leg?  If so, is it pain, weakness, numbness or tingling?  What makes the pain worse?  What makes it better, even for a short time?  Are they improving overall?

You would be amazed how rare it is that a patient, when asked directly what helps to reduce their pain, even temporarily, reports that their chiropractic treatment is helpful!  

About half of the patients I see for IMEs report very little pain, so continued care is unlikely.  I do like to see that they have been given a form of non-supervised home exercise program of stretching and rehabilitation.  Unfortunately, if I have one primary complaint about the chiropractic care these patients receive, it is that there is no home program at all.  Either the treating doctor is ignorant of what is needed to really improve the clinical outcomes (and make no mistake, home rehabilitation is crucial to a good outcome), or they just do not seem to care, even when they can bill for this training.      

Signs

Signs are the objective findings of my examination: chiropractic, orthopedic and neurological, using standardized upper and lower quarter screens as the basis for my examination, after performing a consultation.  If the only signs are spasm and reduced ranges of motion, I may or may not recommend further treatment.  In many cases, the patient is very de-conditioned and/or overweight, so that spasm and reduced ranges of motion would be expected without any accident having occurred.  The addition of positive orthopedic test results, however, will be likely to lead to a recommendation of more care.  The reported symptoms now have an objective basis of evidence.

Improvement

Half of the patients do report ongoing pain patterns, but also report that they are not getting better with their treatment, or have hit a plateau in their improvement.  With these patients, even if they report pain, and also have objective findings on examination, I am unlikely to recommend more chiropractic treatment, because I cannot understand the value of doing “more of the same” when it is not working.  If there is one thing I would love to ask such patients, who often continue treatment three times per week for months on end, with no improvement whatsoever, it is why they continue to do “more of the same.” They are certainly more patient than I am, when I am having medical treatment of any kind. Unfortunately, they are also losing precious time and timing, making a full recovery ever less likely.  After an accident, the first 90 days is when the most recovery is likely to be made, before a chronic condition sets in.  Waiting for six months to “see if it gets better” with a treatment that is not helpful is a poor choice that patients often make, with no help from their treating chiropractor to avoid it.

I will occasionally recommend a different treatment, such as massage therapy, but physical therapy and orthopedic evaluations fall outside my scope of practice in New York and New Jersey.  I will usually still recommend a non-supervised home rehabilitation program.    

At bottom, many of these patients would respond to either a different form of treatment from the same practitioner, or from a new practitioner, but many chiropractors loathe to “lose the patient” through a referral, even when it may help the patient, or lead to some nice cross-referrals from other doctors.  I do recommend that patients tell their doctors when they feel they are not getting better, because some doctors will try a different therapy, and may then find the patient improving.  

I usually recommend further treatment when I see all three of these together - Signs, Symptoms and Improvement.  De-conditioning and pre-existing conditions, such as old accidents and disc disease or arthritis, must always be considered in the overall clinical picture.  These are likely to lead to a slower recovery time, and more positive examination findings.  My report recommendations, however, must be focused on the effects of the current accident being treated, and where the patient is at the time of my examination which is, ultimately, a snapshot of the patient’s current status and progress.  When there is real progress being made, and a full professional program of treatment and rehabilitation is present, more treatment is warranted.  Otherwise, if treatment is not corrective in nature, then I will say that “enough is enough!”

This article discusses issues of general interest and does not give any specific legal or business advice pertaining to any specific circumstances.  Before acting upon any of its information, you should obtain appropriate advice from a lawyer or other qualified professional.

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