The American Board of Independent Medical Examiners (ABIME)
This paper reviews the definition and role of independent medical examinations, the need for a certification and credentialing process among examiners, and ABIME’s organizational structure, function, eligibility requirements, and certification process. A number of issues, central to the process of certifying physicians to perform independent medical evaluations, will also be discussed.
Independent Medical Examinations (IMEs)
IMEs are examinations, performed by a physician who is not involved in the person’s care, for the purpose of clarifying medical and job issues. IMEs are performed to provide information for case management and for evidence in hearings and other legal proceedings. IMEs are a component of most workers’ compensation statutes, although the specifics vary by state and country. They are performed at several stages during the cycle of injury/illness, treatment, rehabilitation, and return to work.
The key issues associated with an IME differ from clinical consultations in role and focus. In the workers compensation arena, IMEs may be performed any time there is a dispute, concern, or question regarding the medical treatment or condition of the injured worker. These issues include such topics as:
- diagnosis, proximate causation, and work-relatedness of an illness or injury
- current and proposed medical treatment or diagnostic efforts
- appropriate work and general activity level
- ability to return to work (fitness for duty) and reasonable accommodation
- impairment rating
- stability of the medical condition and status regarding maximal medical improvement
- identification of other nonmedical factors that can have a significant impact on the outcome of the medical condition or treatment
IMEs can help to untangle the complex relationship between pathology (a medical condition or diagnosis), impairment (an anatomic or functional abnormality or loss), functional limitation (a restriction that can be assessed by objective medical assessment), and disability (inability to perform socially-defined activities or roles). For example, the Americans with Disabilities Act defines a disability as “a physical or mental impairment that substantially limits one or more major life activities of such individual, a record of such an impairment, or being regarded as having an impairment.” Major life activities include seeing, hearing, speaking, walking, breathing, performing manual tasks, learning, caring for one’s self, and working. It is essential that IMEs be performed objectively using reproducible techniques and agreed-upon standards.
Several impairment rating systems exist. The “gold standard” for determining a general physical or mental impairment is the AMA Guides to the Evaluation of Permanent Impairment. Specialized systems have been created by the Social Security Administration, the Railroad Retirement Board, and other organizations. Recent publications have added disability duration standards.
IME Providers and Requesting Sources
Those most often requesting IMEs are employers, employees and their attorneys, insurers, disability management, managed care organizations, Workers Compensation Boards, and other bodies that make determinations about impairment and disability. Regardless of the referring source, the evaluation, by definition, should have unbiased objectivity as one of its primary goals, with emphasis placed on reproducible techniques of examination. Furthermore, the opinions given should be based on the most current scientific knowledge, as well as agreed–upon standards of impairment and disability evaluations such as the AMA Guides.
While IMEs are performed by physicians in many different specialties, specialized IMEs can be performed by other health professionals, many of whom are licensed to perform these evaluations. These other disciplines include chiropractic physicians, psychologists, and others.
The Need For Higher-quality IMES
As can be seen by the following survey of attendees at the Disability Case Management Conference, users of IMEs have long expressed dissatisfaction with current IMEs (see Table 1).
|1. Many physicians doing IMEs lack an adequate understanding of disability issues.||33%||56%||7%||4%||-|
|2. Many IMEs are of poor quality.||30%||48%||17%||4%||-|
|3. The use of certified examiners would be of value in improving the quality of IMEs.||65%||27%||6%||-||-|
|4. I would preferentially use a certified independent medical examiner vs. a physician who is not certified.||64%||30%||4%||-||-|
|*Source: Reed PO. Unpublished survey of attendees at Disability Case Mgt Conference. Aspen, CO. Feb. 1996.|
Challenges to the field include:
- poor quality evaluations;
- unavailability of qualified examiners;
- absence of educational performance standards;
- lack of standardized training; and
- no system for determining the competence of examiners.
Inadequate quality of examinations is reflected in many ways. For example, evaluations are often not responsive to client requests for supportable answers. The examiners often fail to understand the critical issues such as case management, medicolegal terminology, and definitions of causation. Assessments may be superficial and reach conclusions that cannot be supported. Biased evaluations may be performed by physicians lacking current clinical competence. Many participants in the area of independent medical examinations have emphasized the need for quality and consistency among examinations.
Several organizations have responded to the need for training in area of impairment and disability evaluation. The ABIME provides a comprehensive educational program. This includes an intensive review of the AMA Guides, examination preparation, and such workshops as report writing and psychiatric impairment.