Many who order or perform medical review services including IMEs and peer reviews hold the belief that there is no physician-patient relationship and therefore no responsibility towards the claimant. As readers will see in the article found below this post (scroll down), such a belief may, depending upon circumstances, be quite wrong.
The article, written by Rosemary Gafner, Ed.D. and James E. Schutte, Ph.D. of Medical Risk Management, Inc./Medrisk identifies the limited duty of care and other responsibilities that physicians may have in the course of their work. The cases cited are fascinating and demonstrate that beliefs that one may hold, or even try to put into contractual language, may differ from the findings of a court when presented with case-specific facts. Such circumstances are rare, but they will occur from time to time and it is essential that they be properly managed.
Another way to look at this is putting oneself in the shoes of the claimant, when during an examination, one uses ones medical skills to learn of a life impacting or threatening finding not already known to the claimant. And the cases suggest that delegating notification may not suffice and that it may be best to personally ensure that one’s concerns have been shared – and fully documented.
We urge those who order IMEs and those who perform them to read Gafner and Schutte’s article carefully. If in doubt, inform, document and communicate to all parties, including the referring party, the claimant, treating physicians (subject to consent), and the IME company who organized the evaluation. Document in the report what has been done. If in doubt, consider asking for legal advice from one’s personal attorney or malpractice carrier. Malpractice carriers are quite interested in providing proactive risk management advice rather than defending preventable suits.
As we recently reported in MCNTalk in a case of a tumor being discovered, the outcome can be both professionally satisfying and in the clear interests of the claimant.
We are very grateful to Rosemary and James for permission to reprint their article. Not only will you learn about potential duties to claimants, but about duties to third parties, ex-parte communication errors and other relevant topics. I encourage you to visit their site. And if you wish CME credit, for a fee, by answering questions on the article, you can find the specific unit here: https://www.medrisk.com/medrisk/d0b7bb34-80be-41a6-94d7-57c17fba7812.aspx
Brian L. Grant MD
INDEPENDENT MEDICAL EXAMINATIONS
Many clinics offer or even specialize in medical services that are ordered by, paid for by, and performed for the benefit of third parties. Known as independent medical examinations (IMEs), such services range from pre-employment or insurance physicals and drug screenings to the evaluation of claims for worker’s compensation or other disability benefits to the assessment of injuries claimed by a plaintiff in a lawsuit.
In a normal provider-patient relationship, the physician or other healthcare provider owes a clear and unequivocal duty to act in the patient’s best interest. In an IME, however, the provider also owes a duty to the party paying for the exam, whose interests are often adverse to those of the examinee. While this is not a standard physician-patient relationship, you still owe at least a limited duty of care to the examinee/patient. In addition, as we’ll see, there are several circumstances that can transform an IME into a physician-patient relationship in which there may well be a conflict between your duty to your patient and that owed to the third party. And even in the absence of a provider-patient relationship, you still owe a duty to protect the examinee from harm.
The Concept of a “Limited Duty of Care”
The AMA’s position on a physician’s duty to the examinee during an IME is spelled out in a 1999 opinion published by its Council on Ethical and Judicial Affairs:
“When a physician is responsible for performing an isolated assessment of an individual’s health or disability for an employer, business, or insurer, a limited patient-physician relationship should be considered to exist.” It goes on to state:
“The physician has a responsibility to inform the patient about the important health information or abnormalities that he or she discovers during the course of the examination. In addition, the physician should ensure to the extent possible that the patient understands the problem or diagnosis. Furthermore, when appropriate, the physician should suggest that the patient seek care from a qualified physician and, if requested, provide reasonable assistance in providing follow-up care.”
While AMA positions are not legally enforceable, the courts may refer to them to determine what the medical profession itself considers to be the standard of care in a given situation. Indeed, the courts have repeatedly referred to this AMA position outlining a limited duty of care to decide cases in which claims have arisen out of independent medical examinations.
A case in point is that of Andrew James, 27, a heavy equipment operator whose company had sent him to gastroenterologist Marcus Mason’s clinic for a pre-employment physical. Mason ordered a chest X-ray, and the clinic radiologist who interpreted it observed cardiomegaly—of which James was already aware—and a widened mediastinum, which can be an indicator of lymphoma in men in their 20s. James was not aware of this latter finding.
Mason reported back to the company that the X-ray had been abnormal, but only noted the presence of cardiomegaly, not the widened mediastinum. A few days later, the company informed James that he was in good health, and he was hired.
Six months later, James was referred back to the clinic with complaints of flu-like symptoms and a weight loss of 25 pounds. This time, a chest X-ray revealed a large mass in the mediastinum, and a diagnosis of stage IIB Hodgkin’s disease was ultimately made. The patient died of the disease 8 months later, and his widow sued Mason and the clinic for failing to inform James that he had warning signs of lymphoma during his first examination.
During the subsequent trial, Mason argued that the clinic’s contract with the company stated that the clinic’s only duty was to report the examination findings back to the company, and that it was the company’s duty to communicate those findings to the examinee. The trial court allowed the jury to consider the contract between the company and the clinic to determine whether the physicians’ conduct had been reasonable, and the jury found in the defendants’ favor.
The plaintiff appealed, and the higher court determined that the jury should not have been allowed to examine the contract because it was in violation of the AMA’s position that the examining physician has a non-delegable duty to inform the examinee of any significant findings. Only another physician who has been fully apprised of the findings and agrees to follow up with the examinee can relieve the examining physician of that duty. Therefore, the contract between the company and the clinic was legally unenforceable and void. The verdict in favor of the defendants was reversed and the case ordered retried.
This case raises an important point: It is common for third-party companies, especially those involved in an adverse relationship with the examinee, to contractually relieve or even prohibit the examining physician from sharing any findings with the examinee. Be advised that such a contract would place you in direct violation of medical ethics unless it specifies a physician who will carry out that duty in your place. Therefore, you should never enter into an arrangement of this kind and, if you do, realize that the contract will not protect you against a claim that you failed to advise the examinee of an important health issue. In fact, such a contract might even be used against you in court to paint you as an unethical and irresponsible physician.
The danger of a “limited” physician-patient relationship, as defined by the AMA, is that the mere act of providing someone with medical advice may be enough to create a standard physician-patient relationship. This means that, in fulfilling your limited duty, you run the risk of creating a full-fledged duty of care.
Simply advising the examinee to seek follow-up care will likely not incur such a duty. For example, the courts held that FP Reginald Frankel did not create a physician-patient relationship by informing examinee Agnes Blaine that she had tested positive for tuberculosis during her pre-employment physical. The trial court’s decision, upheld on appeal, was based on the fact that Frankel had simply informed Blaine of his findings and advised her to seek a second opinion from her own doctor.
When you do provide such warnings, however, you must make clear to the patient the gravity of the situation and the need for prompt follow-up, as shown by the case of Joseph Mahan, a real estate agent and part-time model, who underwent a physical exam by internist Derrick Haynes. During the exam, Mahan asked about a 3 mm mole on his left earlobe. Haynes examined the mole and, aware that it could be melanoma, strongly suggested that Haynes see a dermatologist. However, Haynes did not specifically explain the possibility that the mole was cancerous.
Mahan did not see a dermatologist until 6 months later, when the mole was removed and diagnosed as malignant melanoma. He had to undergo extensive ear and neck surgery, which left him unable to find work as a model. Mahan then sued on the allegation that the diagnosis of melanoma was delayed because the internist had failed to adequately warn him about the dangers of not going to a dermatologist immediately. A jury awarded Mahan $730,000. An appeals court upheld the verdict after finding that the physician had a duty to ensure that the patient understood the seriousness of the situation and the potential consequences of not seeking prompt follow-up.
While warning the examinee to seek follow-up care from another doctor generally won’t create a physician-patient relationship, providing medical advice or becoming involved in the examinee’s treatment probably will. A case in point began when orthopedist John Warden examined Don Krug to determine his eligibility for worker’s compensation. Krug complained of back injuries, and Warden suggested physical therapy and even recommended a specific therapist.
Following therapy, Warden again evaluated Krug and determined that his condition had improved to the extent that he was able to resume his regular job without restriction. Krug did so, and his return to work either caused or exacerbated a previously undiagnosed herniated disc, necessitating surgery. Krug then sued for malpractice, alleging that he was prematurely and negligently advised to return to work.
Warden applied for and received summary judgment on his argument that he owed no duty because he had not directly treated the plaintiff. However, an appeals court found that Krug had presented a plausible argument that the doctor had provided him with medical advice, and that Krug had relied on that advice to his own detriment. The higher court overturned summary judgment, ruling that it should be left to a jury to decide whether Warden’s actions constituted malpractice.
Even telling an examinee that he does not need treatment might be construed as establishing a physician-patient relationship. In one case, for example, an orthopedist under contract with an insurance carrier evaluated a worker’s job-related shoulder injury annually for several years. After each exam, the doctor advised both the insurance carrier and the worker that surgery was not indicated.
Eventually, the worker sought an independent evaluation of his injuries, which resulted in surgery on his shoulder. He then sued the orthopedist for malpractice and the insurance company for intentionally delaying needed medical care. The trial court granted the defendants summary judgment, which the plaintiff appealed.
The appellate court upheld summary judgment for the insurance company, finding that they had reasonably relied on the orthopedist’s medical reports in denying payment for the plaintiff’s surgery. As for the doctor’s claim that he owed the plaintiff no duty, the appellate court disagreed. It found that the plaintiff had, to his own detriment, relied on the doctor’s direct advice to him that surgery was not needed. The court overturned summary judgment and sent the case to trial.
Regardless of who’s paying your fees, you should assume that a standard physician-patient relationship exists and proceed accordingly any time you provide the patient with medical advice or other information about the state or progress of his health, especially if you are performing serial exams or evaluations. That’s the best way to protect both the patient’s health and your own legal interests.
Another issue is that, once you initiate treatment, a physician-patient relationship is automatically created and you must respect the patient’s confidentiality going forward. Occupational medicine specialist Greg Herndon discovered this the hard way when he treated laborer Alex Dienst for a job-incurred back injury. Dienst was referred by the company nurse to Herndon, who was under contract with the employer, for treatment.
A company supervisor, noting that Dienst had appeared groggy, called the doctor and requested a drug screen, which Herndon performed with Dienst’s oral permission. When the urinalysis came back positive for marijuana, Dienst was fired.
Dienst then sued the doctor for breach of patient confidentiality. Dienst claimed that he was clearly impaired at the time Herndon requested the urine sample (although Dienst himself claimed that his impairment was from antihistamines), such that he could not have given informed consent for the test. Although a lower court dismissed the claim, an appellate court found that it would have been a violation of patient confidentiality for the doctor to communicate his findings to the employer without the patient’s permission. The higher court also observed that the patient had not signed an advance consent document that would permit the doctor to disclose any of his medical findings to the employer. Ruling that it should be left to a jury to decide whether Dienst had been too impaired to provide consent, the higher court reinstated the case.
Tests or procedures ordered by another doctor can also cause problems unless reasonable care is taken to make sure that the referring physician is made aware of the abnormal report or, failing that, the patient is contacted directly. This point is illustrated by the case in which radiologist Collin Jones evaluated a chest X-ray of nurse Edna Simms as part of her pre-employment tuberculosis screening by a managed care organization (MCO). Jones was himself an independent contractor working with a third-party clinic that provided X-ray services to the MCO.
Jones wrote in his report that the X-ray showed a “small nodule overlying the right sixth rib” and a “patchy consolidated parenchymal pattern superimposing the right third rib anteriorly and interspace.” Jones forwarded his report to the clinic, which then forwarded the report to the MCO. The policy of the MCO was to inform the examinee within 72 hours of any adverse findings. For whatever reason, nurse Simms was not notified of Jones’ report. Approximately 10 months later, Simms was diagnosed with lung cancer.
Simms then sued Jones, the clinic, and the MCO alleging that their failure to inform her of the X-ray report negligently delayed her diagnosis. The MCO, however, had declared bankruptcy and the case against it was dismissed. Jones and the clinic applied for and received summary judgment on the argument that no physician-patient relationship existed and therefore they did not owe an independent duty to make sure that examinees were advised of their reports. Simms appealed, and the state supreme court ultimately determined that Jones did, in fact, owe a duty to make sure that the referring physician was made aware of any adverse findings or, if that physician could not be located, to contact the patient directly.
Also, be advised that just informing the other doctor’s staff of your findings may not be not enough. Consider the case in which the courts held that a radiologist did not discharge his duty by leaving a message with a clerk at another clinic that their patient had a previously undiagnosed wrist fracture. The message did not get passed on to the patient’s regular doctor, and the patient suffered permanent loss of mobility in his wrist because of the delayed diagnosis. The radiologist was subsequently held liable for not informing the patient of his injuries in a timely manner.
To summarize, your best option when an independent medical examination reveals a significant or suspicious finding is to inform the examinee directly, making sure that he is aware of the potential gravity of the situation and the need for prompt follow-up. If you do choose to let another doctor carry out this duty, make sure that you talk directly with that physician and obtain his or her agreement to inform the patient and arrange appropriate follow-up. In either case, document the conversation carefully, making sure to record the time and the date of the exchange, and specify exactly what the other party agreed to do in follow-up.
The bottom line on limited duty of care owed during independent medical exams:
Following the AMA’s position on the matter, the courts recognize that the doctor conducting an independent medical examination owes the examinee a limited duty of care even in the absence of a physician-patient relationship. To honor your duty to the examinee and protect patient safety:
- Be aware that you have a duty to inform the examinee of any untoward findings, and that only another physician who has been properly apprised of your findings and agrees to inform the patient in your stead can assume this duty.
- Any contract with a third party in which you agree not to discuss your findings with the examinee is unethical and unenforceable.
- Advising the examinee of an untoward finding and the need for follow-up with another doctor does not create a physician-patient relationship. However, such warnings must make clear the potential gravity of the situation and the need for prompt follow-up.
- Providing the examinee with direct medical advice will generally create a physician-patient relationship, and providing treatment does so automatically. In such cases, you owe the examinee the same duty as any other patient, regardless of who’s paying your fee.
- When a test or procedure ordered by another doctor results in a normal or abnormal finding, you should contact the referring doctor or an appropriate representative directly to explain your concerns. If the referring doctor cannot be located, you owe a duty to contact the examinee directly. As always, document all such communications.
Other Duties during Independent Medical Examinations
Beyond a limited duty of care, you also owe a duty to conduct your examination in a competent and professional manner so as not to cause undue risk or harm to the examinee’s person or civil rights.
You must respect examinee privacy by not sharing health-related information with anyone other than the entity that has the examinee’s signed permission to access such information. Even in communications with an authorized third party, you can only disclose those findings that are directly pertinent to your examination, plus the results and interpretations of any tests or evaluations that the examinee has consented to. Any findings that are incidental to your examination, especially those that might have been divulged by the examinee in confidence, will most likely be considered confidential. As such, revealing them to the third party constitutes an invasion of privacy and may lead to legal action.
That’s what happened when neurologist Brian Lister was hired by the employer of machinist Thomas Vila to evaluate Vila’s claims of disabling head and back pain resulting from a work-related injury. At the conclusion of the examination, which involved inserting reusable metal electrodes into the examinee’s skin, Vila advised the nurse to be careful in handling and sterilizing the electrodes because he had tested positive for HIV.
The nurse informed Lister of this revelation, and Lister subsequently wrote in his report that Vila’s symptoms were more likely the result of AIDS than of physical injury. Vila’s claim was denied, and he sued the neurologist for invasion of privacy. The trial court dismissed the suit on the basis that Vila had voluntarily disclosed the information during an adversarial medical examination, and therefore had waived confidentiality within the context of his worker’s compensation claim.
Vila appealed, and the higher court considered the fact that the neurologist had not specifically inquired about or tested for HIV as a part of his evaluation. As such, Vila’s HIV status was not pertinent to the examination, and had been volunteered solely within the context of protecting someone else from becoming infected. The court did not consider this to be a waiver of confidentiality, and therefore reinstated the case against the neurologist.
Given that the entire point of a third-part examination is to collect information about the examinee for the benefit of someone else—information that the examinee may not want revealed—it’s a good idea to spell out your intentions in the examinee consent form. The benefit of doing this is shown by the case in which psychiatrist Devon Walker agreed to assess hotel worker Sean Barron at the behest of his employer. Barron had a history of disputes with other hotel employees, including allegations of sexual harassment, and Walker was asked to assess the truthfulness of Barron’s denial of wrongdoing. Initially, Barron complied with the examination under protest. But when Barron refused to complete the full course of psychiatric exams scheduled, the hotel fired him.
Barron then sued Walker for invasion of privacy, alleging that the psychiatrist had subjected him to intrusive, improper, and harassing questions, including queries about his sex life and his parents’ sex life. In his defense, Walker argued that his line of questioning was professionally appropriate for someone accused of harassment.
Walker’s strongest defense, however, was the consent form he had Barron sign before beginning the examination. That form read, in part: “Although [the psychiatrist] is a doctor, we do not have a doctor/patient relationship. What we discuss in the assessment is not confidential or privileged as [it] would be in a therapeutic doctor/patient relationship…At some point, I will be reporting back to your employer.”
Having signed this statement, the court reasoned, Barron had no reasonable expectation that his discussions with the psychiatrist were carried out in confidence. The trial court dismissed the case, which was upheld on appeal.
Ex parte communications carry special legal hazards. Assume your patient has filed a worker’s compensation or other personal injury claim, and has signed a release authorizing you to provide records of his treatment to the company he filed the claim against. You carefully read the release and forward only the specified patient information. Then, as allowed under the provisions of the signed release, a representative of the company calls you to discuss your report.
When you pick up the phone, realize that you are in a precarious position. The legal term for this is an ex parte communication, which means that neither your patient nor his attorney will be present to monitor or challenge what is said. In order to protect your patient’s legal interests, the law limits such communications to a discussion of the contents of your medical report, a copy of which must also be made available to your patient.
You are allowed to explain or elaborate on your report with the third party representative, but you can be held liable if you discuss information not covered by your report, regardless of who brings it up. This is true even if the patient’s actions involve you in the perpetuation of a fraud against the third party.
In one notable case, FP Mark Clarkson treated laborer David Miller for injuries to his back and leg suffered from a fall at work. Clarkson ordered his patient to stay home from work for a week, then report for another examination. Miller complained of the same symptoms at the subsequent visit and was ordered to stay home for another week, followed by a repeat exam. This sequence was repeated weekly, and Clarkson completed a worker’s compensation certification of Miller’s temporary total disability.
After two months, a representative of Miller’s employer went to Clarkson’s office and asked to meet with him about Miller. Clarkson agreed and was shown photos and videos of Miller digging a trench during the time he was supposedly incapable of such work. The FP then wrote a letter to worker’s compensation withdrawing his certification of Miller’s disability. Miller was subsequently fired from his job and his claim for disability benefits was denied.
Miller sued his employer for interfering in the physician-patient relation, and the FP for breach of physician-patient confidentiality. The defendants applied for summary judgment on several grounds, including the fact that Miller had signed a worker’s compensation form stating specifically, “I acknowledge…providing authorization for release of medical information by a physician to my employer or employer representative.” They also pointed to established legal precedents holding that physician-patient confidentiality is waived when the patient’s purpose in seeing the doctor is illegal, such as when the patient provides false statements to obtain drugs.
The state supreme court, asked to review the issues before trial, found that the consent form signed by the patient pertained only to the exchange of medical information and did not allow the doctor and employer’s representatives to conduct ex parte meetings for the purpose of “…persuad[ing] the treating physician to alter his diagnosis, course of treatment or recommendations.” Finding that the privacy of the physician-patient relationship was more important than the employer’s right to protect itself from fraud, the court denied summary judgment and ordered the case to trial.
The lesson here is not that clinic personnel should turn a blind eye toward fraud, but that they should insist that such matters be handled through formal legal channels in which everyone’s rights are protected. In the above case, for example, Clarkson took the word of the employer’s representative that the evidence presented him had been gathered during the period of alleged disability and that the person pictured was actually his patient. What if the evidence had been gathered before the accident, or the person appearing in the video was really someone else? To protect against such injustices, the law demands that the patient and his lawyer have the right to be present when such evidence is presented.
Before meeting with the employer’s representative, Clarkson should have contacted the patient and requested permission for the meeting. If the patient refused—which he most likely would have—it would be up to the employer to call for a formal worker’s compensation hearing. At that hearing, which would be open to all parties, the physician would have been asked to review the incriminating photos and video after his patient had been given the opportunity to contest their legitimacy. At that time, the doctor could have testified as to his belief that the patient was faking disability with little risk of future legal entanglements.
Any time a third party attempts to obtain or offer information about your patient that goes beyond a discussion of your medical report, refuse the request and contact your malpractice carrier for advice.
You must not injure the examinee, as shown by the case that began when orthopedist Arturo Arena was contracted by an oil company to evaluate employee Ann Gorton’s claim of work-related injuries. During the examination, Gorton would later allege, she was negligently “strapped…into an apparatus which caused her body to be contorted and maneuvered in various damaging positions.” As a result, she claimed, she suffered a “total collapse and deterioration” of an earlier spinal fusion at L5, resulting in severe, permanent, and disabling injuries along with mental and physical pain and suffering.
Arena, while not contesting the cause or severity of the injuries, argued that he owed Gorton no duty arising from his examination. A lower court agreed and granted him summary judgment. An appellate court, however, reasoned that this ruling, if allowed to stand, would permit doctors to injure examinees with impunity simply because they had no duty otherwise. Following judicial precedents in other states, the appeals court overturned summary judgment and ordered the case to trial, holding that a “physician owes duty to examinee and may be liable for negligence or professional malpractice for injuries incurred during examination even in the absence of a physician-patient relationship.”
You owe a duty to the third party, irrespective of any duty owed to the examinee, to conduct your examination within the standard of care and to report your findings appropriately. This point is illustrated by the case that began when occupational medicine specialist Jerome Pointer performed a pre-employment physical examination of truck driver Morgan Frost on behalf of Barton Transport Company.
At the time of his examination, Frost suffered chorioretinitis in both eyes, with 95 percent loss of vision in one eye and blurred vision in the other. He also suffered from, among other problems, osteoarthritis of the knees and chronic degenerative disc disease of the cervical and lumbar spine, severely limiting his range of motion. His overall physical condition was so bad that he had been declared 100 percent disabled five years earlier. Nonetheless, Pointer gave Frost a clean bill of health, stating that his vision, reflexes, and extremities were all normal. Based on this, Barton Transport hired Frost as a driver.
Two days after Frost was hired, he plowed a company truck into the rear end of a station wagon parked in the emergency lane of a highway, killing a child and severely injuring three others, along with their father. The accident happened at night, and Frost was unable to see the car until it was too late to avoid hitting it.
Barton Transport then sued Pointer, alleging that his negligent examination of Frost was the proximate cause of the tragedy. A lower court granted Pointer a directed verdict, stating that there was simply not enough evidence to lead to the conclusion that the faulty examination, which even Pointer conceded had been negligent, was the proximate cause of the accident. But the state’s supreme court disagreed, holding that the evidence was sufficient to support such a conclusion, and that the accident was a foreseeable consequence of the doctor’s failure to conduct a competent examination. The case was reinstated and ordered to trial.
The bottom line on other duties owed during independent medical exams:
Beyond the limited duty of care, you also owe the following duties during an independent medical examination:
- You must respect the examinee’s privacy and not divulge to the third party any findings that are incidental to the purpose of your exam or that were provided to you in confidence. To avoid misunderstandings, it’s a good idea to have the examinee sign a consent form acknowledging and authorizing the types of information that you will be providing to the third party.
- In communications with the third party requesting the exam, you may not discuss matters not included in your original report without the examinee’s permission. This is true even if it appears that the examinee is perpetuating a fraud against the third party. If the examinee refuses to grant such permission, the third party has a right to compel your testimony at a hearing, at which time you may speak freely.
- You must not subject the examinee to undue risks or injury.
- Irrespective of any duty owed the examinee, you owe the third party a duty to conduct the examination competently and to provide the third party with a professionally reliable report relevant to the purpose of the exam.
NOTE: the authors often receive requests for final disposition of the cases that are remanded back to the trial court after appeal. In most cases, when the physician defendant loses an appeal, the parties thereafter enter into a confidential settlement agreement that legally prohibits both sides from discussing the case with others. Even when the case is decided by jury trial, the outcome is not published by the courts unless an appeals court agrees to review the verdict. While every reasonable attempt is made to learn of the final outcome of the cases presented, this information is usually not available. However, the lessons to be learned from the case law decisions still stand, regardless of the final outcome of the cases themselves.
Also, the names of the parties in the cases have been changed to protect undue embarrassment to the involved parties. If you want details on a case, review the cited case at a law library.
One final word: The information presented in article is for general educational purposes only and should never be construed as legal advice. If you need legal advice on a specific risk management issue, always consult with your malpractice carrier or your own attorney.
 Council on Ethical and Judicial Affairs, American Medical Association, Opinion E-10.03 (AMA Opinion), Patient-Physician Relationship in the Contest of Work-Related and Independent Medical Examinations. Current Opinions, December, 1999.
 Rhodes v. Button, 764 A.2d 433 (N.J. 2001).
 White v. Southside Hospital, 721 N.Y.S.2d 678.
 Moore v. Preventive Medicine Medical Group, 223 Cal.Rptr. 859.
 Heller v. Peekskill Community Hospital, 603 N.Y.S.2d 548.
 Hickey v. Travelers Ins. Co., 558 N.Y.S.2d 554.
 Crocker v. Synpol, Inc. 732 S.W.2d 429.
 Stanley v. McCarver, 92 P.3d 849.
 Siggers v. Barlow, 906 F.2d 241.
 Vilaiak v. Newton, 277 Cal.Rptr. 354.
 Presented without citation in Zarin’s Medical Liability Alert (newsletter) 2007;15(10):10.
 Morris v. Consolidated Coal Co., 446 S.E.2d 648.
 Mero v. Sadoff, 37 Cal.Rptr.2d 769.
 Wharton Transport Corp. v. Bridges, 606 S.W.2d 521.