What is an IME?
IME stands for Independent Medical Examination. An IME is:
- A comprehensive review by a health practitioner of a patient's medical condition/s.
- Aimed at evaluating all available medical evidence, addressing relevant issues and providing a report on the current status, including recommendations and advice.
The IME request may be made by a workers compensation insurer, a life insurer regarding income protection, an employer seeking to understand a worker’s fitness for work, legal practitioners, or, for example, Veteran’s Affairs requesting a permanent impairment assessment.
Why are IME’s Needed?
IME’s may be requested when the medical information provided is inadequate, unavailable, inconsistent, or where the claims manager has been unable to resolve the issues directly with the involved parties. There may also be conflicting advice from different treating practitioners.
Alternatively, the treating doctor may not have relevant expertise in the field. For example, the doctor may not know whether work has caused the disc protrusion or the permanent impairment using x or y methodology.
Who are Independent Medical Examiners?
Independent Medical Examiners are healthcare professionals who have experience as a treating practitioner. Their fields of practice include a variety of medical specialisations, such as occupational medicine, orthopaedic surgery, neurology, plastic surgery, rheumatology, etc.
Other practitioners who perform IMEs include physiotherapists, chiropractors, psychologists and neuropsychologists, and dental practitioners.
Most have been in practice for many years, and some organisations require accredited practitioners to have been a specialist for at least five years.
What Do Independent Medical Examiner’s Do?
Their role is to provide an independent review and input.
They take a comprehensive patient history. They have the advantage of seeing the big picture through a point in time snapshot. When a patient is seen on a weekly basis for example, the rate of degeneration may not be as evident as when seen once each year.
They provide an objective picture of the situation. This includes diagnosis, prognosis, appropriate treatment, work capacity, and possibly an impairment assessment.
They look at the situation forensically. Their aim is to reach a scientific conclusion through the assessment of the facts of the case.
In the table below, we outline the differences.
| Forensic questioning | Clinical questioning |
| Goal: to obtain information as reliable and accurate as possible | Goal: to assess and provide treatment of symptoms |
| Fact-finding focus – accurate understanding of events important | Therapeutic focus– Attributions and perceptions of events important |
| Objective, avoidance of biases | Empathy, therapeutic alliance, support of patient |
| IME request or is the client | Patient is the client |
| Consent to obtain outside information and disclose information is obtained and understood prior to proceeding with the interview | Client’s consent required to seek external verification of information and to provide information to outside sources |
| Interviews are formal and restrictive | Interviewing strategies are variable |
| Confidentiality restricted | Traditional confidentiality |
The treating doctor may not go into detail about how the injury occurred as their focus is on the treatment of the injury itself.
The examiners have not previously been involved in the patient’s care. They also don’t provide advice to injured workers about their condition, treatment or claim.
The IME will write a report to the requesting party. Some requesting parties automatically send a copy of that report to the treating doctor, others do not.
They may also be asked to answer specific questions asked by the requesting party. An example might be, ‘How long will Mr FD be off work following his planned shoulder surgery?’
Independence
The independence of IMEs is questioned by some, understandably. If the requester is paying for the review, does this mean they are getting a report ‘in their favour’?
Most reputable organisations know that the opinion provided needs to stand up to scrutiny, such as in a tribunal or court hearing. If opinions are found to be biased, the requesting organisation will spend considerable time and energy only to have the opinion discounted.
If opinions are regularly biased, the refereeing organisation will also lose credibility. While it can and does occur, hopefully infrequently, a reputable IME will be objective.
IME’s don’t have the same established relationship with the patient, and therefore loyalty to the long-standing patient doesn’t get in the way.
How to Get the Most from an IME
Organisations seeking an IME should provide a rich background of the case to the IME. This is important for getting the most out of the assessment.
They should also detail the reasons that the IME has been arranged. Be clear about case management progress and what you want from the IME, versus sending a list of generic questions. For example, Ms X has now had three unsuccessful attempts at return to modified duties. Is a return to her normal job still a realistic rehabilitation goal?
Ensure that questions are simple and easy to read. Complex questions don’t get clear answers.
Inform the IME of any difficulties, for example if the person is very angry or may possibly be violent.
Other activities of an IME
Worksite Assessment
Worksite visits are valuable. Both the worker and supervisor need to be there. The doctor will see the duties performed, and through discussion develop an agreement regarding what is appropriate.
Having a doctor see the duties and their appropriateness can be a powerful way of influencing the GP.
A Review of the File Notes
If you have a good history from the treating doctor or other medical practitioners, a file review may be sufficient. Doctor may focus on researching the topic, if an unusual condition. This may be useful if there is sufficient information on the file, or if it is difficult for the patient to attend.
Research
In some circumstances, it may be valuable to have the doctor specifically research the issue, particularly if the condition or treatment proposed is unusual. This can take considerable time, but may be vital for an important case. This should be discussed with the doctor.
Why opinions may vary
- Some areas have little evidence base, such as work capacity. Different practitioners may have different views about what should be expected of the patient / worker
- Some doctors, such as occupational physicians, have a strong understanding of workplaces and work duties, while other doctors may have a limited understanding of duties
- They can be different interpretations of research. Research on work contribution is of limited quality and can be hard to access. Not all doctors are familiar with relevant research studies.
- The way questions are phrased by the doctor can influence the way they are answered
- Workers who are emotional or distressed may seem to have worse problems
- The way the history is presented can vary
- Workers present differently on different days to different doctors
- Some patients are not good at providing a clear history, eg 19 year old males
- Varying information may available to the assessing doctor. For example, the patient may say that they have had no back problems prior to their injury. The first doctor is provided no extra information, while the second doctor has clinical notes from before the injury showing four consultations for back pain in the year prior to the injury.