Specialists in physical medicine and rehabilitation (PM&R) can expect to be called on to make formal assessment of the disabilities of their patients. This chapter summarizes the information needed to address the patients’ health care needs through acquisition of the conceptual foundation and terminology of disablement and application of the same to the practices of impairment rating and disability determination.
Terminology and Conceptualization of Disablement (eSlides 5.1, 5.2, and 5.3)
The medical model still serves as the fundamental basis for Social Security disability determinations and physician-rating schedules that remain largely anatomically and diagnostically based. A “biopsychosocial model” of disability is now the preferred model and has gained wide acceptance when disability is conceptualized. The biological component refers to the physical or mental aspects, or both, of an individual with a given health condition; the psychological component recognizes personal beliefs, coping strategies, and emotional and other psychological factors that may affect functioning; and the social component recognizes contextual, infrastructural, and other environmental factors that may also affect functioning in any given case. The World Health Organization introduced the International Classification of Functioning, Disability, and Health (ICF), which underlines the interactive (i.e., nonlinear) relationships between the impairment and the potential functional consequences of impairment with respect to the individual’s personal and social sphere, and contextual factors that may mitigate or amplify these consequences.
Americans with Disabilities Act and Implications (eSlides 5.4, 5.5, and 5.6)
According to the Americans with Disabilities Act (ADA), disability is “a physical or mental impairment that substantially limits one or more of the major life activities of such individual, a record of such impairment or being regarded as such impairment.” “Title 1” of the ADA (Employment) recognizes employment as a major life activity and views disability within the context of performance of the essential functions of an employment position with or without reasonable accommodation . Reasonable accommodation can include structural modifications of the work site to improve accessibility, availability of modified duty options, and acquisition of adaptive equipment or devices to enable an otherwise qualified worker with a disability to perform the essential functions of the job. Accommodation under the ADA is a fundamental social environmental modifier mandated by statutes to mitigate the disabling consequences of impairment in the workplace, in terms of accessibility related to activity limitations and participation restrictions. However, the employer is ultimately responsible for determining reasonable accommodation . It is not the responsibility of the disability-evaluating physician to determine the essential functions of a job, devise accommodation, or determine reasonableness of any accommodation proposed by the employer.
Relating Impairment to Disability and Compensation Formulas
All the major current disability systems are designed with the intent to compensate individuals financially for losses due to their qualifying disablement. The impairment rating represents the keystone to any disability determination for the following several reasons:
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It serves as a standard reference point in terms of linking a specific diagnosis to an associated percentage of physical and functional loss in compensable injury claims.
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It enables the impaired individual to exit the system of temporary disablement at maximum medical improvement (MMI).
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It provides a diagnosis-based classification of severity to segue to alternative systems for the management of long-term disablement.
Social Security Disability Insurance and Supplemental Security Income
Social Security Disability Insurance (SSDI) provides benefits to individuals who have worked in a qualified job for at least 5 of the 10 years before onset of disability, paid into the Social Security system, and subsequently become disabled before age 65 years. Eligibility for SSDI requires that the disability prevents the affected individual from engaging “in any substantial gainful activity (SGA) … for a continuous period of not less than 12 months.” Supplemental Security Income (SSI) provides income for medically indigent people who are blind, disabled, or older (>65 years). Eligibility is determined according to a means test and does not require a work history. SSI also requires that a “medically determinable impairment” be established.
Federal and State Workers’ Compensation Systems (eSlide 5.7)
In the United States, four major federal workers’ compensation programs provide wage replacement benefits, medical treatments, vocational rehabilitations, and other benefits to injured workers (or their dependents) who experience a work-related injury or an occupational disease. At the individual state level, each state has enacted a workers’ compensation law. The PM&R physician can be involved in four situations: (1) initial evaluation and treatment of the injury, either as an approved and designated attending physician or as an authorized consultant; (2) overseeing rehabilitation, including return-to-work or stay-at-work issues; (3) determination of any residual impairment (permanent) or disability (work restrictions); and (4) estimation of long-term care needs in catastrophic injuries (e.g., limb amputations, spinal cord injuries, and major multiple trauma), including participation in life care planning.
Impairment Rating Guides for Physicians With Attention to Guides, Sixth Edition (eSlides 5.8, 5.9, and 5.10)
The American Medical Association’s Guides to the Evaluation of Permanent Impairment is a standardized and objective reference and reporting guide for physicians and other professional stakeholders. It is the preferred reference for the US Department of Labor and for many domestic personal injury claims. The sixth edition has adopted the ICF terminology, definitions, and conceptual framework of disablement, defining impairment rating as a “consensus-derived percentage estimate of loss of activity reflecting severity of a given health condition and the degree of associated limitations in terms of activities of daily living.” As such, the AMA Guides has adopted metrics sensitive and specific to medical (i.e., anatomic and physiologic) aspects of organ system disease, as well as functional aspects (mobility and self-care) of losses that can occur; both an ADL-based functional history and ordinal measures of ADL assessment serve as important modifiers of the final impairment rating, when applicable.
Four key issues guide the physician in evaluation of patients’ reports:
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What is the clinical diagnosis?
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What difficulty does the patient report (symptoms, functional loss)?
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What are the examination findings?
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What are the results of clinical studies?
Independent Medical Examination: Elements and Reporting Requirements
An independent medical examination (IME) is a one-time evaluation performed by a physician for the purpose of, answering a series of interrogatory questions posed by the referring party to achieve claim settlement. The opinions set forth by the independent medical examiner must be expressed in terms of medical possibility versus probability. The physician examiner is expected to provide the specific diagnosis for each and all allowed conditions relevant to a specific claim, and to help determine both medical and legal causation . Medical causation is biological in nature and is established through scientific analysis of sufficient rigor to demonstrate a cause-and-effect relationship with a high degree of certainty. Legal causation is determined on two bases: first, if an injury would have occurred independent of the alleged act or omission, the cause in fact has not been established; second, if a given risk could not have been reasonably anticipated, the alleged act cannot be considered as the proximate cause of an injury. In summary, legal causation is mainly a question of “foreseeability.” An actor is liable for the foreseeable but not the unforeseeable consequences of his or her act. The workers’ compensation systems vary from state to state in terms of their causation and work-related rules.
Maximum Medical Improvement Determination (eSlide 5.11)
The physician examiner is required to provide a final statement that includes an estimate of when MMI occurred or is expected to occur. From a rehabilitative perspective, a claimant should not be considered for MMI as long as expectations for continuing functional improvement are being met by demonstrable and ongoing performance gains. When functional progress is no longer evident or tenable and a sufficient (typically 6 months) healing period has transpired, MMI is generally thought to have occurred. Deterioration that might normally be expected with the passage of time does not preclude MMI determination. The physician should also address issues of future medical management and follow-up anticipated to be necessary to maintain MMI for a given condition.
Disability as Return-to-Work Restrictions (eSlides 5.12, 5.13, and 5.14)
The PM&R physicians can be asked to provide a patient status report and return-to-work/fitness-for-duty form. If treatment is ongoing and transitional work is available, the physician might recommend modified duty in terms of restrictions on the allowed number of hours of work and the permissible activities in terms of frequency or degree of material handling tolerated during the healing period. If no modified duty options are available or applicable, the physician may be required to render a temporary total disability determination until MMI is reached. Because the probability of returning to work decreases precipitously as time out of work increases, the physician should make every effort to return the claimant safely to a transitional work setting as soon as possible. In cases when transitional return-to-work options are not available, work conditioning and work hardening may be preferable and viable alternatives to forced inactivity and should be considered whenever feasible and medically necessary. At the point of MMI, the physician must also render a final opinion on permanent restrictions applicable in going forward. The functional capacity evaluation can be used to help establish a performance baseline and treatment goals for the injured worker to monitor recovery and establish a new performance baseline when treatment has been completed. A job description can provide a useful list of the essential functions of the job in question; a job site evaluation can validate the essential functions listed in the job description with respect to critical physical demands and relative amounts of time spent performing specific activities within each function. Ergonomic analysis can help quantify the job’s physical demands and enable accommodation in terms of job redesign or workplace modification. Finally, employer and claimant willingness and ability to comply with recommended accommodations can also be addressed. Physician examiners should avail themselves of these assessment tools to ensure that the prognostic inferences derived and sanctions imposed are founded on valid, empirical, and functionally based data to the fullest extent possible.
Legal and Ethical Considerations
Expert Witness Testimony (eSlide 5.15)
The opinions set forth in an IME and the resulting formal report comprise expert witness testimony that must validate or refute the presence and severity of injury toward, and resulting in disability to, any claimant. This occurs within a legal infrastructure from which the claimant maintains certain legal rights and entitlements and may derive significant monetary gain.
Physiatrists and other practitioners in the field of disability medicine performing IMEs and giving expert testimony should be aware of not only the legal liabilities in the overall practice of their subspecialty but also the additional malpractices and civil liabilities entailed with exposure to the practice constraints under which IMEs and expert witness work is performed. Physicians attracted to disability assessment and inclined to serve as independent medical examiners are encouraged to attend several of the high-quality training programs offered in the United States for independent medical examiners and expert witnesses, with the goal of empowering them with greater knowledge, skills, and abilities necessary to practice as an independent medical examiner or expert witness in the field of disability medicine. IME physicians or expert witnesses can be successful despite these challenges if they remember several key principles, including intellectual honesty, professionalism, and respect for the judicial process at all times. An ethical and objective examiner who performs a thorough evaluation, deals with the plaintiff (or claimant) in an empathetic, unbiased manner, and avoids advocacy has a lesser risk of getting entangled in the allegations of wrongdoing.
Conclusion and Ethical Considerations
The PM&R physician must remain committed to preserving patient autonomy as a member of the treatment team and also maximizing functional recovery and reducing or eliminating dependency to the fullest extent possible on the treating system and caregivers, including the disability system itself. The patient, as a claimant, may otherwise choose to behave in a manner that is counterproductive to these goals and thereby appear noncompliant.
The physician must also remain cognizant of the paradox of compensable injury—that financial compensation can discourage return to work and thereby promote disability. Undue prolongation of an open claim might further serve to legitimize disability in the claimant’s mind and can inhibit the likelihood of functional recovery and return to work.
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