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The 10 worst mistakes IME examiners make
By Steven Babitsky, Esq.

The Independent Medical Evaluation (IME) reports that physicians prepare are playing an increasingly important role in workers’ compensation cases, personal injury litigation, and long-term disability claims.

Each year physicians prepare hundreds of thousands of IME reports, which are read and utilized by judges, hearing officers, and plaintiff and defense attorneys to decide and settle claims.

Physicians are frequently called upon at depositions, hearings, or trials to support, justify, and defend each and every word of their IME reports. With this in mind, we turn to the 10 biggest mistakes physicians make in writing their IME reports.

No. 1 mistake: Not answering the questions asked. Physicians frequently do not answer the questions posed by the referring client. These physicians either opine in areas they were not requested to address or do not answer questions posed by the client.

Solution: Get a clear understanding of the questions the referring client wants answered.

No. 2 mistake: Expressing opinions outside their area of expertise. Physicians make the mistake of straying from their areas of expertise and expressing opinions in areas in which they are not truly an expert.

Some examples include opining in areas outside of their medical discipline and specialty and using legal and other terms for which they do not know the definition.

Solution: Stay in your sandbox (area of true expertise) and check your reports for words and terms you cannot define.

No. 3 mistake: Not listing the medical records reviews. Doctors mistakenly refer generally to the medical records they reviewed. These physicians open themselves to endless questions about what records they did and did not review.

Solution: Explicitly list and precisely describe all of the medical records and other documents you reviewed prior to preparing your IME report.

No. 4 mistake: Not taking a detailed history. Physicians frequently do not document an accurate history in their IME report. This can and will lead to many questions at deposition, hearing, or trial about the inadequate or incorrect history and how that affects the validity of the physician’s opinions.

Solution: Include a thorough, well-written, and accurate history as a part of your IME report.

No. 5 mistake: Not documenting the results of a physical exam. Physicians often perform a detailed physical examination, but make the mistake of not thoroughly documenting the exam.

Remember the old medical maxim, “If it is not documented, it was not done.”

Solution: Check your IME report to make sure all of the tests performed and all of the findings made are clearly and accurately documented in the report.

No. 6 mistake: Not properly wording an opinion. Physicians frequently perform a complete review of the medical records, an extensive physical examination, and a draft detailed IME report that fails due to poor wording.

Solution: Remember that the main reason for your examination and report is to express your opinion in a legally sufficient and defensible manner. Familiarize yourself with the legal terms of art for expressing your opinions which usually are based upon a reasonable degree of medical certainty or based upon a reasonable degree of medical probability.

No. 7 mistake: Not properly proofreading reports. Physicians frequently do not carefully proofread their IME report before it is finalized. Each mistake reduces the value of the report and calls into question the precision of the IME physician and the validity of her opinions.

Solution: Take the steps necessary to catch and correct all misspelled words, transcription errors, and grammatical mistakes before your IME report is finalized and released to clients, attorneys, judges, and hearing officers.

No. 8 mistake: Expansive and overly friendly transmittal letters. Physicians can, and often do, ruin an otherwise excellent examination and IME report by including an overly friendly or detailed cover letter to the client. This letter will be used by opposing counsel to show or imply bias.

Solution: Write a short (one-sentence) cover letter. Make it objective and devoid of any extraneous information.

No. 9 mistake: Improper formatting. Physicians often spend many hours on their review of the records, examination, and dictation of the IME report with little or no thought concerning how the report is to be formatted. An IME report which is not properly formatted is very difficult to read and is of little value to the client.

Solution: Use topic headings, 11-point or larger font, and short, concise paragraphs to properly format your IME reports.

No. 10 mistake: Using hedge words. Physicians often inadvertently use hedge words, such as “it seems,” “I think,” “I believe,” “it appears,” “it could,” or “apparently,” in their IME reports. These hedge words lessen the impact of their findings and conclusions.

Solution: Use precise, powerful, and persuasive language in your IME reports and avoid using hedge words.

If you avoid these 10 mistakes as an IME, your credibility will increase and you will be more effective in the courtroom.

Image Steve BabitskySteve Babitsky, Esq., is the president of SEAK, Inc. and is the co-author of Writing and Defending Your IME Report: The Comprehensive Guide. For further information, visit www.seak.com or call 508-548-9443.

 

   
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