Originally published December 2000 / Revised July 2011 IS0018-E
There are a number of steps that can be taken to reduce the likelihood of patient dissatisfaction with Independent Medical Evaluation.
An independent medical evaluation (IME) is intended to offer a medical practitioner's perspective of an individual's medical needs or condition in circumstances when benefits, compensation, disability issues or further treatment are being considered or requested by a third party, such as an insurance company. In the context of such evaluations, it is important to ensure that both the individual being evaluated, as well as the party referring the individual (e.g. a lawyer, insurance representative, etc.), are dealt with equitably. Many such evaluations are mandated by legislation.
The importance of IMEs cannot be overstated. For example, the IME and the subsequent reported opinion can provide valuable information that may be used to fairly settle a claim for disability. In some cases, the value of such a claim is calculated based on the impairment noted during the evaluation.
The evaluation and the report can also generate complaints to the evaluating physician and/or the referring party by the person being evaluated or his/her legal representative. IMEs have also been the cause of medico-legal difficulties, notably in the form of College and privacy complaints and, to a lesser degree, legal threats or actual civil actions.
Areas of difficulty experienced by physicians performing IMEs:
College complaints in one or more of these areas:
the doctor's demeanour, (e.g., rudeness, such as "He questioned me as if he was a policeman.") or a "rough" physical examination;
the duration of the evaluation (alleged to be too short);
the type of evaluation (alleged to be incomplete);
the conclusion (alleged to be unfair).
Complaints made to the Human Rights Commission.
Complaints made to the Privacy Commissioner.
Civil litigation alleging battery, defamation and/or breach of the standard of care.
These problems might be avoided by discussing with the third party requesting the evaluation, and the person undergoing it, the nature of the assessment that is required and the terms under which it is to be conducted. Such terms might include the presence of a chaperone (this may not be appropriate in all cases, particularly during independent psychiatric examinations). It is important to note, however, that it would not be advisable to conduct an IME with a representative of the person undergoing the examination as the only witness. A physician may also consider the issue of who, if anyone, should be permitted to attend with the person undergoing the evaluation. In some cases, this may include discussing the issue with the party requesting the evaluation to ascertain their expectations.
It is generally preferable for the third party requesting the IME to first obtain the written consent of the person who is to undergo the evaluation. This might avoid a potentially distressing situation, such as where the individual refuses to proceed with the evaluation or refuses to respond to questions. Even if written consent has been obtained by the third party, the physician should, before beginning the assessment, explain the purpose and the scope of the evaluation, including a review of the terms under which it is to be conducted (see Checklist at the end of this article). It is also important to ensure that the consent remains current. A record should be kept of that discussion along with a copy of the third party's written consent form signed by the person undergoing the evaluation.
Despite these additional explanations, it is possible that the individual may refuse to undergo all or part of the assessment, or may withdraw consent after the evaluation has begun. In these circumstances, the physician should not proceed further with the evaluation.
There is often misunderstanding over who is to receive the report and who is entitled to a copy. It is advisable to clarify this before undertaking the evaluation and after consulting the relevant legislation and any applicable guidelines — some provincial licensing bodies have specifically commented on this issue. Privacy legislation may also specify who is to have access to the report. If a CMPA member has any questions regarding disclosure, she/he may wish to contact the CMPA for advice.
After the IME, the person undergoing the evaluation or that individual's treating physician or lawyer may ask the evaluating physician to respond to questions about the IME. Unless otherwise provided by law or any applicable guidelines, the inquiring party should be advised to request the information from the third party who requested the IME. Any subpoena that may be issued on behalf of the person being evaluated is only a requirement to appear in court. The physician is not permitted to disclose any information about the evaluation until she/he has been sworn in and asked by the judge, in court, to speak.
In conclusion, being prepared before the evaluation, and discussing with the person to be evaluated the physician's role in the process, can go a long way toward avoiding medico-legal difficulties. Physicians should review the checklist before agreeing to undertake an IME. If members have any questions or concerns before, during or after performing an IME, they can contact the CMPA for advice.
When is a patient not a patient?
Patients familiar with the traditional doctor-patient relationship may not understand the physician's role in an IME.
An IME usually does not give rise to a traditional doctor-patient relationship. The doctor has been retained by a third party to perform an evaluation and render an independent opinion. The physician is not there to treat or act as an intermediary. This should be explained to the person who is to be evaluated.
That person is often referenced according to his/her relationship with the third party requesting an IME: a client or insured, in the case of an insurer; an employee in the case of an employer.
Because the independent evaluation is often requested to verify information already supplied by or available from the individual alleging a disability, some may presume that the physician is an adversary. From the beginning, the physician may be viewed as "the opposition." It is therefore particularly important to remain courteous at all times and to support a medical opinion with objective findings.
It is wise for the physician to:
Become familiar with current applicable legislation and College or other guidelines before agreeing to undertake an IME.
Carefully explain to the person undergoing the evaluation the reason for the evaluation and the physician's role. The physician's purpose in an IME is to determine the person's health and functional abilities at the time of the evaluation, not to provide treatment.
Ensure the person undergoing the evaluation consents in writing to all aspects of the evaluation. This includes any audio- or videotaping that may be done.
Make the person undergoing the evaluation aware of who is entitled to the report and where they can direct requests for a copy.
Maintain a professional demeanour at all times.
If appropriate, consider having a chaperone present during the entire evaluation for both males and females. If the physician does not fluently speak the language of the person undergoing the evaluation, it is also wise to arrange for an independent interpreter to be present.
Inform the person undergoing the evaluation if there is a coincidental finding of a possible serious medical problem, even if unrelated to the reason for the IME. The person undergoing the evaluation should be counselled to follow up with his/her own physician. Keep a record of this discussion.