Guide for independent medical examination reports

Introduction

An injured worker can be compelled under Victorian workers compensation legislation (the legislation) to attend an independent medical examination.

The resulting independent medical opinion is to assist the Scheme to make claims management decisions affecting an injured worker

WorkSafe Victoria approves a pool of qualified medical practitioners who have each been assessed for suitability by meeting the selection criteria for their specialty band signed a standard WorkSafe IME Agreement covering the services they are to provide.

This Agreement includes Service Standards for the conduct of the examination and the preparation of the report. WorkSafe Victoria requires all reports to meet these standards relating to format, content, accuracy, consistency, and absence of bias.

Once an IME submits a report to the requestor, it is eligible for quality audit at any time against these standards by peer review. If reports are determined not to meet the standards, an IME's WorkSafe approval to accept referrals may be revoked.

It is in the interests of all IMEs to be familiar with WorkSafe Victoria's service standards and WorkSafe's expectations to ensure the right outcomes for injured workers in Victoria.

Writing for your audience to understand

Why good writing matters

Information is clear if you understand who your target audience is and whether the information can be understood. This can pose a real challenge, because there are many audiences for an Independent Medical Report who may differ in background knowledge, literacy skills, and other characteristics that affect how easily they can understand the information you present.

Be consistent and well organised

Consistent report format is essential to ensure maximum clarity and usability of the information being provided. This is particularly important if this information is subsequently scrutinised in a medical panel, dispute conciliation, or a court of law.

To enhance clarity for all potential users of your report, it is recommended that it is structured and written in a manner that is easily understood by the intended readers. The ability of a reader to understand the information depends upon many factors including:

• The simplicity of words and sentence structure
• The clarity and cohesiveness for explanatory text
• The readers’ background knowledge and culture perspective.

While it may be necessary to use relevant medical terminology in reporting findings and medical conditions, plain English is encouraged for commentary, explanations, conclusions, and summaries. Keeping your language and writing style consistent will help the reader follow and comprehend the material.

Use familiar words

It is important to use words that are familiar to the readers and as simple as possible. Use words that your readers would use themselves.

Use active voice

Many reports use passive sentence structures that can sound impersonal and be hard to understand. Readers prefer text in an active voice. Active voice is simpler and more direct. You can write vast majority in an active voice, which makes it much easier for readers to understand and act upon the information.

For example, in an active sentence the person or thing responsible for the action comes first "the doctor refers the patient to a specialist". In a passive sentence, the person or thing acted on comes first and the actor is added at the end, introduced with the preposition "by", "the patient is referred by the doctor to a specialist".

Using the passive voice can sometimes lead to a sense of confusion, especially when trying to determine who is responsible for the action.

Format of the report

Having a consistent report format is essential in providing all potential users to easily understand its content. The following structure will guide you in compiling your report.

In the introduction section

• The purpose of the examination and the identity of the report requestor
• Injured Worker information including, name, claim number, the employer, date of injury and date of birth
• A list of all materials provided to you and sighted by you in preparing your report

In the body section

• The body of the report should contain a concise yet comprehensive history of the events leading up to and including the injury/ies.
• The subsequent work and medical history and other relevant personal, occupational, and medical history, Relevant findings, both positive and negative, from your physical (and/or mental state) examination.
• The results of any relevant investigations provided to you by the agent, or organised by you subsequently after consultation with the requesting agent.
• The nature and significance of any other opinions/reports/assessments made available to you and;
• Specific answers to each of the questions asked by the requesting agent.

Note: A short explanation should be provided if a question is not answered or is considered inappropriate or irrelevant.

In the concluding section

It is important to include a concise summary or concluding comments highlighting the most important issues in your report, particularly in the case of extensive and/or complex reports.

Your personal signature is essential to verify that you have read and checked your report and certified its veracity.

Content of the report

The content within the structure of your IME report is formed by the history and the findings from your examination. The following information will assist you in meeting WorkSafe’s expectations when composing the content of your report. Further information on consistency of content and answering specific questions asked by the requesting agent are dealt with in later sections of this handbook.

The history

The history is available from materials provided by the agent and the injured workers own responses during examination. Where independent corroborating or conflicting information exists or is elicited, this should be reported.

For most reports the following history is essential:

• The events leading up to and causing the reported injury.
• The injury itself – mechanism, nature, severity, etc.
• Subsequent medical attention, care, investigations, treatment, procedures, complications, etc.
• Effects of the injury/ies on capacity for work (current functional status), including current work status.
• Current symptoms and/or disabilities.
• Current treatment.

Additional history which may be relevant in certain circumstances includes:

• Pre- and post-injury personal, work, or medical factors which may have had or may be having an impact on the injury and/or on the consequences of the injury.
• Handedness (usually in the event of limb or shoulder girdle injuries).
• Level of education, other training, etc.
• An occupational history, i.e pre-injury employment and work capacity.

Investigations

A review of investigations presented, if any

The Examination

Every independent medical examination report must be based upon an actual medical assessment of the patient conducted.

Report negative findings as well as the positive

In the case of psychiatry, every independent medical examination must include a mental state examination.

Your physical and/or mental state examination serves a number of purposes:

• To document the nature and consequences of the injury;
• To assist with the assessment of functional capacity and the nature and magnitude of any impairment/disability;

Constituent evidence-based findings and conclusion

Conclusion and recommendations

It is important to ensure that the conclusions and any recommendations are evidence-based and consistent with the findings of the injured worker’s history and examination.

Inconsistent report information can mislead the readers, prompt unnecessary supplementary requests, and bring the basic capabilities of the professional into doubt when the report is scrutinised.

Your report should have elicited a thorough and relevant history, and performed a high-quality, targeted examination. Your role is to use this data to formulate an understanding of the worker, the injury, and its consequences in light of your specialised medical knowledge, experience, and expertise together with your understanding of the workplace.

The conclusions and recommendations are the most important aspect of any independent medical examination, reflecting where your particular expertise is most directly brought to bear on the case.

You should seek to demonstrate the consistency of your answers with your findings and their basis in evidence by referring specifically to the relevant findings and the appropriate evidence. This will support the conclusions and recommendations contained in your answers.

Insufficient evidence to make a clinical opinion

Conversely, if you cannot support your conclusions or recommendations by the findings, or if your conclusions or recommendations are not consistent with current medical knowledge and evidence, you should give serious consideration as to whether you should be making those conclusions or recommendations at all. It is better to indicate that you are unable to answer the question, or that there is insufficient information available to provide an answer, rather than venture an opinion which is unsupportable.

Presenting symptoms or signs outside your field

Sometimes a referral may be made outside of your speciality, or presenting relevant factors on which you are not qualified to provide advice.

If at any time you consider there are symptoms or signs that are beyond your area of expertise, you should not include an opinion in your report on that matter. You should simply note them as another particular factor and that you are unable to provide an independent medical opinion on that matter as it is outside your area of expertise.

Before submitting your report, confirm for yourself that the key service you have agreed to provide – a sound, independent, evidence-based professional opinion – is not compromised by missing information, unsustainable links between evidence and opinion, or internal inconsistencies.

Presenting symptoms or signs not related to the referral

If, during an examination, you find a condition that does not relate to the request, normal ethical requirements still apply. If the condition clearly does not relate to the worker’s claim the matter should be raised with the injured worker and the injured worker encouraged to raise the matter with their treating health practitioner. If you think you need to discuss the matter with the treating practitioner, obtain the worker’s consent in writing to do so.

You must not, of course, discuss treatment with the injured worker. You should not raise the condition with the report requestor or include it in your report.

Answering the question asked

This is the crux of your report – answering, to the best of your ability (with regard to the history you have elicited, your examination findings, your review of any additional information available, and the best available medical knowledge) the specific questions posed by the requesting agent.

In answering the requesting agent's specific questions, best practice is to state the question in your report and then proceed to answer that question, and only that question.

For Example: Was employment a significant contributing factor to the injury?

Answer: "I consider that this worker's employment has not been a significant contributing factor to her injury. I have reached this conclusion having regard to the sedentary nature of her work, the duration of her symptoms, examination and X-ray findings demonstrating osteoarthritis consistent with her age. That is, it is my considered opinion that the changes are age-related degenerative changes which would have occurred whether or not she had undertaken this employment."

Providing additional, un-requested answers or opinions

Normally you should not need to provide any separate assessment, opinion/s, or conclusions, if you have answered all the questions asked by the requesting agent.

However, you may feel there are circumstances in which one or more unsolicited responses may be appropriate, indeed necessary, e.g. you consider the questions posed to be insufficient or inadequate in a particular case, i.e. unable to reflect adequately the complexities of the case or the full breadth of the situation.

Whether you wish to proceed directly to provide unsolicited conclusions or recommendations, or whether you feel it more appropriate to contact the requesting agent to seek direction, will depend to a considerable extent upon your personal approach to your role, your prior experience, logistical realities, etc.

Responding to inappropriate, irrelevant or repetitive questions:

In some circumstances the requesting agent’s questions may seem inappropriate, irrelevant, or repetitive. This is clearly a difficult situation, and one which has the potential for misunderstanding.

However, attempting to answer questions in which you have little confidence, or which lie outside your area of special expertise can be frustrating, irritating, and pointless. On the other hand, just omitting to answer questions, or re-framing them in a way which you consider makes more sense, is contrary to the implied contract you have with WorkSafe Victoria and its requesting agents.

Ideally it would be better if you were able to clarify the situation with the requesting agent before finalising the report. However, this may not always be possible, and there may be situations where it is reasonable to list the question, explain your concerns regarding that question, and indicate how you have chosen to proceed.

Avoiding bias

As an IME you are being engaged by the requesting agent not as their agent, nor to act as the claimant’s personal doctor, but to provide a fully independent professional medical assessment of the case.

It is very important that an independent medical examination and its associated report are just that, i.e. independent and impartial. Note also that it is not the role of an IME to determine or comment on liability, but to provide a medical opinion to assist others in their determination of liability.

Bias, either consciously or subconsciously, most commonly arises from one of three sources:

Taking the injured worker's "side"

This may occur because:

• You feel sympathetic to the claimant's circumstances;
• Because you accept at face value what the claimant tells you about their workplace, their accident, and the consequences of the accident; or
• Because of a professional commitment to "act in the best interests of your patient".

These factors may be compounded by the usual working presumption doctors quite correctly normally operate within: that their patients tell the truth about their injuries/illnesses – a presumption which may not be justified in circumstances where the patient stands to benefit from being less than forthcoming with the truth.

Taking the requesting agent's "side"

This may be due to the natural tendency one has to provide a sympathetic service to the person or organisation paying for the service (particularly in a fee- for-service culture), or it may be due to a more or less well informed suspicion of some WorkCover claimants and the nature of some of their injuries and/or claims.

However, the content of your reports must always be in accordance with the terms of your Agreement, which explicitly requires that the opinions you provide in your report be quite independent of the Authority, authorised agents, or self- insurers.

You have a contractual obligation to protect this independent status and are required to notify the Authority immediately in the event of any real or perceived attempt by an employee of the Authority, a self-insurer, a worker, or worker’s representative to influence your report in any way.

Professional bias

This may be demonstrated through certain diagnoses, models of causation, and/or treatments, either as a result of one's particular specialty training, or arising from a somewhat idiosyncratic view of some aspect/s of medical practice.

The best defence against unconscious bias is a deliberate, conscious awareness of the issue of bias, its types and its origins, and a determination to minimize its effects on your work.

The best defence against conscious bias is to write your report and subsequently to read it through, asking yourself the following three questions:

• Could what I have written be biased in any way?
• Could what I have written create a belief or perception of bias in others who might read it, even if no such bias exists?

If the answer to either of these questions is 'yes', or 'maybe', can I rewrite it in such a way as to remove that bias or perception of bias?

Be the best IME

"Getting the job done" includes such organisational issues as timeliness, efficiency, presentation standards, accuracy, etc.

While there are many ways to deliver a well-written, well presented, accurate report on time, the following are some "tips" to assist those who don’t always find their performance in these matters is up to the standards they, and others, would wish.

Use a checklist

If you are performing independent medical examinations regularly, you might wish to use a report checklist. This would normally include all those components of the report which are more or less standard for each report, such as your usual preamble, section headings, signature, even basic history and examination proformas which can be tailored to each case.

Ensure the availability of all the provided documentation

Letters, results, reports, etc are available before starting the interview and the examination of the claimant. You may decide to read these documents before starting to enable you to develop an initial understanding of the case – or alternatively choose deliberately to "start fresh", i.e. with no preconceived ideas, in which case you will need to read the documents after initially seeing the claimant, but before they leave (in case you need to confirm or corroborate any information or findings arising from the documentation).

Contacting the claimant direct after an examination is not an acceptable avenue for seeking private information.

Read the requesting agent's questions

Before commencing (and if necessary again during the interview and/or examination) to ensure that you gather the information which will be necessary to answer the specific questions you have been asked.

Make concise notes

Notes should be made of your findings as you go, particularly key positive and negative findings on both history and examination, and any contradictory findings which could influence your assessment and conclusions. This will assist you in writing your report at the end of the clinical encounter with the claimant, and also ensures that if for some reason you are unable to write your report immediately, or if the report is mislaid or lost, you have a contemporaneous record of your key findings for later use.

Recording the examination

Some IMEs prefer to record the interview and examination from which they prepare the report. Some injured workers also want to record the interview for their own records. If a recording is to made , it must be done with the agreement of both parties and made available to either party on request.

Decide your own drafting strategy

Decide your own strategy for how best to prepare first and final drafts of your reports. However it is done, quality results are generally achieved by preparing an initial draft, then revising or editing to a final draft, while ensuring appropriate formatting (and use of some form of 'spell-check' to detect spelling errors, typos, etc).

Re-read your opinion

Ensure the report accurately reflects your findings and conclusions and ask:

Is my report accurate, i.e. containing an accurate medical diagnosis based on appropriate clinical examination presenting an evidence based approach to evaluating symptoms and findings;

Is my report independent, impartial, limited to relevant information and not disclosing personal information except where it bears on the work injury;

Are you satisfied that the medical opinion provided is consistent with and agrees with your clinical findings.

Personally sign the report

Ensure the report is signed and record that you have signed it on your own copy. If the report is forwarded without your signature, record the reason for it not being signed and ensure that a signed copy is forwarded as soon as possible.

Transparency

As per WorkSafe's updated IME processes, a copy of your report will be made available to the treatment providers. It is envisaged that the detailed information and opinions you provide will support them in the management of their patients. Your report is also likely to read by the injured worker.