Confusion still surrounds third-party forms
CMAJ 1997;157:369
From the responses (CMAJ 1997;156:977) to Dorothy Grant's recent article "Independent medical examinations and the fuzzy politics of disclosure" (CMAJ 1997;156:73-5 [full text / résumé]), it is clear that there is still considerable confusion about third-party and formal independent medical examinations (IMEs). There is also confusion about who owns these reports and the duty of the examining physician. I am not surprised by this, because physicians have no training in providing these services.
Grant stated correctly that the number of third-party medical examinations, and not just IMEs, is increasing. There are also increasing demands for the plethora of third-party documents physicians have always struggled with, from sick notes written for employees to clinical-care statements compiled for insurance companies and accident adjusters. Many of these reports function only to sustain a bureaucracy, and some of the greatest abusers are our governments.
Physicians, who are short of time and annoyed by many of these requests, are also ill-prepared to handle them. The "fuzzy politics" of providing a medical opinion to a third party continues to be flawed because the providers (physicians) and the consumers (all third parties) do not understand each other's specific needs. Physicians do not understand rehabilitative medicine or the concept of fitness to work. Too often, they are caught up as enablers of prolonged disability because of the dictum to "do no harm," or they assume they carry the liability for disease that probably does not exist.
As medicine and clinical care move toward service-based practice and clinical practice guidelines, physicians need better training, skills and experience to deal with third-party evaluations. Clinical advice to remain disabled until physicians can prove or disprove a pathologic cause that may or may not be disabling is bad medical advice. Maintaining patients in a sick role until they are abandoned with no diagnosis or treatment is inappropriate. The best advice is to focus on what patients can do instead of what they cannot do. The road back from disability is hard enough without physicians being a barrier to recovery.
Medical training and the clinical practice of assessing and managing disability require a paradigm shift, and physicians can either be part of the solution or remain part of the problem. The people who make decisions about disability claims will go around barriers to assessment and decisions if they have to. I believe that physicians have a large role to play in helping patients convalesce and return to full function.
This letter is an open plea to the CMA to devote more time to debating and taking action on these issues. Most physicians would welcome the CMA's help and guidance.
James D. McDougall, MD
Managing Partner
Viewpoint Medical Assessment Services Inc.
Member
Advisory Board
Physician Manager Institute
Canadian Medical Association
Calgary, Alta.
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