by Brian L. Grant, MD
We at MCN speak about quality in examination and review services and hear similar speech from others including competitors. The term “quality” is but a homily or empty rhetoric unless it is defined and clarified. We also believe that some may have been led astray when they allow quality to be defined along standards that lose sight of the inherent values of the medical profession. We believe that adherence to quality standards is neither negotiable nor fluid or subject to market forces. From time to time we observe within our company or learn from other quarters certain practices that we can’t endorse and ought not be endorsed or practiced by others. By raising the matter publicly we call attention to standards that should be expected by clients who order review services, by doctors who perform them, and by companies that facilitate them.
The below memo was sent to MCN consultants. We share them with you and invite you to pass them on. Or if readers have additional standards or take issue with any we have raised, we would enjoy hearing from you:
December 6, 2011
To: MCN Consultants
From: Mark Doyne MD and Brian Grant MD, Medical Directors
Regarding: Examination conduct, standards and physician demeanor
As medical directors for MCN, we review complaints that periodically arrive from claimants regarding their examinations. Every one of these is reviewed individually and each physician is given the opportunity to respond. We are passionate about the integrity of MCN examinations and expect that all MCN consultants share our values and practice accordingly. Given the nature of our work, a complaint should be reviewed in the context of the nature of the issues raised, including the possibility of there being other motivations for a given complaint among other factors. We do not take complaints at face value at all times. We review the specifics and may conclude that a complaint may lack merit. Sometimes we may choose to investigate with a call to the claimant and review the consultant’s response to the complaint. Other times we have chosen to briefly survey other claimants who have been evaluated by the consultant via phone calls to them and an audit of the corresponding reports.
Certain types of problems, when representing a pattern, will and have resulted in termination of a consulting relationship with the company for specific consultants. We believe that adherence to appropriate standards should be inherent in the profession and are obvious requirements to perform quality reports. As such, they may be beyond the scope of MCN or others to teach, and when basic standards are not adhered to, this is a serious matter.
We expect consultants performing medical reviews, whether for MCN or others, clients requesting such examinations, and competing companies to adhere to basic standards of conduct and practice.
Some of the points below have been conveyed in past memos. We are restating them as a reminder, and for the benefit of new consultants. We call upon the industry, including clients, physician consultants and MCN’s competitors, to enforce adherence to these standards, embracing them in intent and practice. We also welcome your comments and additional ideas.
Our standards (as expected of all who perform medical reviews) include but are not limited to the following:
Sufficient Time Must Be Spent with Claimants. We expect that the consultant devote sufficient time for a thorough review of records, history and physical or mental status assessment of the claimant. It is NOT appropriate to book exams in increments of less than thirty minutes. We have heard stories of companies in certain regions of the country where four to six or more exams scheduled per hour are not uncommon. Some consultants find it of benefit to review the records in the presence of the claimant. If time has been spent away from the claimant reviewing the records, however, it might be a good idea to share this fact and show those records to the claimant. Actual face time with claimants should be sufficient to perform an appropriate history and examination without creating a perception by the claimant of being rushed. It is impossible to perform a thorough history and physical of a typical injury claim in less than thirty minutes and often more time is required.
Reports Must Be of Sufficient Length. A report should be several pages or more in length, have sufficient depth to answer the questions of the client, and reflect a thoughtful, individual review of the specific case. There should be documentation of what has been reviewed. We remind you that it is not necessary to extensively quote records that have been reviewed. Some consultants issue reviews that are unnecessarily long. It should generally suffice to state the nature of the record, date, person who generated it, and a brief reference to the conclusions. The goal is to be certain that you have reviewed the document and considered it in your conclusions. If need be, one can refer to the original document at a later date.
Each Case Must Be Evaluated on Its Individual Merit with Every Examination a Unique Event. Other than a preliminary disclosure paragraph used at times, MCN does not employ any standard language in reports. We expect that consultants likewise will individualize each report in their own words. Held to the light, no two reports should ever appear the same or close to the same. Clinical boilerplate is not permitted for MCN examinations. Normal findings, if conveyed numerically, should reflect normal range and not a standard value.
Report Findings Must Be Objective and Evidence-Based. Our clients want quality, objective reports, regardless of claim impact. They want reports that are based upon data, not merely a claimant’s self-report. They use IMEs and medical reviews because they want incisive and critical medical thinking. If they wanted a report to repeat the claims of the claimant in the absence of data, they would have no need to spend the time and resources to ask for an IME and would merely accept what the claimant says. The reader of the report (more often than not a non-clinical individual) should be able to understand the reasoning behind the conclusions.
Consultants Must “Stay in the Box.” This means answering each question you are asked, not answering questions you are not asked, and staying within your area of clinical expertise. These are simple concepts, but too often not honored.
Reports Must Be Issued in a Timely Manner. A good examination ceases to be good if the consultant is late on initial report submission, signatures, clarifications, and other actions that delay report issuance. Our clients are often working under time constraints. Delays rarely add value and quality may be diminished with the passage of time as specific details can fade. We rely upon consultants being timely to meet our mutual commitments.
Claimants Must Be Shown Respect During all Interactions. Remember that some claimants are nervous, apprehensive, and often unsophisticated when they report for an examination. They deserve a response to questions and an explanation of procedures as well as appropriate respect for modesty and personal boundaries. Curtness, over-familiarity, and criticism of the claimant or their treating physicians are all to be avoided. Demonstrate respect for claimants as you would want your own friends or family members to be shown respect if they were to be sent for an examination. And write a report that you would respect if issued by a colleague.
Treatment Is Never Offered During an Independent Medical Evaluation. Never offer treatment or comment on current or past treating doctors: Please remember that your credibility depends on being regarded as neutral, objective, and not vested clinically. From time to time a claimant may request that a reviewing doctor assume treatment, and there have been situations when a reviewing doctor has offered his/her own services or even issued a prescription. Offering any sort of treatment, however, should never occur. If there is an urgent medical matter observed during an evaluation, stabilization and referral to an appropriate physician or emergency facility should be undertaken.
Testing Should Only Be Performed as Necessary. Additional diagnostic testing should be only performed when necessary to answer questions posed to the examiner. In many cases testing must be authorized by MCN or the client. In our experience the need for additional testing is relatively infrequent because numerous diagnostic tests have typically been performed prior to the IME, with the results readily available in the medical records.
We are proud of our work at MCN. We have been in the business of performing medical judgment services for almost twenty-seven years and strongly believe in the value of our services to society and the integrity of the company and our consultants. We call upon all involved in requesting and providing such services to adapt and enforce standards that reflect the best of medicine and respect for the dignity of claimants.
Thank you for your support and quality consultations. If you have any questions or comments, feel free to contact Brian Grant at firstname.lastname@example.org or 206.447.3449. Mark Doyne may be reached at email@example.com or by phone at 214.762.0784.