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10 Articles in Volume 6, Issue #3
A Muscular Approach to Headache
Adjuvant Analgesia for Management of Chronic Pain
Breakthrough Pain In Non-Cancer Patients
Case Presentation of Munchausen Syndrome
Electroanalgesic Medical Device
On Knowing
Opioid Malabsorption: Can You Stomach This?
Sedation Safety and Comfort
The American Board of Independent Medical Examiners (ABIME)
The Role of MMPI-2 in Assessment of Chronic Pain

The American Board of Independent Medical Examiners (ABIME)

Since it's inception in 1994, ABIME has been dedicated to the improvement in quality of independent medical and impairment examinations.

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:

  1. diagnosis, proximate causation, and work-relatedness of an illness or injury
  2. current and proposed medical treatment or diagnostic efforts
  3. appropriate work and general activity level
  4. ability to return to work (fitness for duty) and reasonable accommodation
  5. impairment rating
  6. stability of the medical condition and status regarding maximal medical improvement
  7. 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).

Table 1. Response to Survey Questions Asked of IME Users*
  Strongly
Agree
Agree Unsure Strongly
Disagree
Disagree
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:

  1. poor quality evaluations;
  2. unavailability of qualified examiners;
  3. absence of educational performance standards;
  4. lack of standardized training; and
  5. 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.

Educational Organizations

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.

ABIME Structure and Function

The American Board of Independent Medical Examiners (ABIME) was established to enhance the quality of independent medical examinations by creating a voluntary process of standard setting, definition of competencies, and performance evaluation. The ABIME is organized as follows. The small working board of directors spans four medical specialties. An examination committee has five physicians in four specialties, and is assisted by an independent professional examination organization. The Human Resources Research Organization (HumRRO) works with ABIME to define specific competencies, design an examination that is rigorous and fair, prepare and validate a large pool of test items, perform statistical quality control, and insure integrity of the examination. The examination is continuously revised by regular meetings of the examination committee in close consultation with HumRRO.

Requirements for certification by ABIME include:

  1. a current, unrestricted, medical license
  2. a clear record of any disciplinary action for unethical or other offense as imposed by a State Board of Medical Licensure within the last five years
  3. board certification in a specialty recognized by the American Board of Medical Specialties, or the American Osteopathic Association, or documentation that an applicant has been involved in the practice of medicine, including residency years, for a period of five years prior to their submitting an ABIME application
  4. completion of at least 15 hours of continuing medical education (AMA Category I) in impairment rating and independent medical examination within the three years prior to taking the examination. 30 hours of CME in this field is strongly recommended
  5. signed agreement to abide by the ABIME Guidelines of Conduct
  6. satisfactory completion of a rigorous written examination of approximately 100 questions

To encourage awareness of ongoing developments in this rapidly changing area, ABIME certification is valid for a 5-year period. Recertification requirements include passing the current examination or following an alternate pathway consisting of education and completion of CME questions.

The examination was based on an exhaustive analysis of the job tasks of an independent medical examiner. From this job task analysis, the examination committee defined an examination blueprint with five content areas. Questions for each version of the examination are drawn from a large pool, to which new questions are continually being added.

From September 1995 through December 2004; 2,875 individuals completed the ABIME examination. Those certified are awarded certificates valid for five years and are known as Certified Independent Medical Examiners (CIME). Certified Independent Medical Examiners are also eligible to participate in the ABIME National Board of Registry. The Board of Registry publishes a bi-annual National Directory of Certified Independent Medical Examiners. This directory, which is also available online, is available to CIMEs, Workers Compensation Boards, insurers, employers, managed care organizations, and others. The National Board of Registry also publishes the journal Disability and oversees management of the Alternate Pathway Program for recertification. The National Board of Registry Directory is an increasingly valuable resource for those requiring IMEs. CIMEs have also indicated that the directory has led to increased referrals. The directory is available online at www.ABIME.org.

Accomplishments to Date

Since its inception in 1994, ABIME has completed many tasks necessary to accomplish its goals. The organizational entity was created with a board of directors and an examination committee. The Board of Advisors has provided advice and consultation and has helped ABIME develop working partnerships with many employers, insurers, state Workers Compensation boards, federal agencies, national organizations, and professional societies. Response to ABIME has been highly favorable, both from the communities it serves and physicians involved in this field.

Analysis of Issues

Concerns have been raised by some physicians in occupational medicine, who object to a trend to certify limited areas of competency within this specialty. Further, there are concerns from residency program directors who do not want to see the value of residency training in medical specialty board certification undermined. State Workers Compensation boards have sought a comparable credential for health professionals in other disciplines who are licensed to conduct limited functional impairment evaluations. In addition, Canadian provinces have sought an examination process not bounded by U.S. Workers Compensation laws. Each of these concerns are addressed below.

It is vitally important to recognize that ABIME credentialing is not intended to compete with, or appear as, the equivalent of American Board of Medical Specialties (ABMS) medical certification. Clearly, there is an enormous difference between ABMS certification of those who have completed multi-year residency training and other requirements versus ABIME certification of competence in a specific area of performance. ABIME eligibility requirements clearly recognize the importance of certification by ABMS or its AOA osteopathic counterpart. Furthermore, ABIME credentialing is multi-disciplinary and it is open to physicians in many specialties of medicine and osteopathy.

Like all voluntary processes, it will take time for the Independent Medical Examiner credential process to prove itself. At this point, considerable anecdotal information supports the assertion that certified independent medical examiners do, in fact, perform higher-quality assessments.

However, no formal validation studies have yet been published. Many state Workers Compensation boards have now set standards for those performing independent medical examinations. Many boards specify that IMEs can be performed by medical doctors, doctors of osteopathy, doctors of chiropractic, and other licensed health professionals. Some even match the medical condition or organ system to the examiner’s discipline, e.g. specifying that chiropractors can evaluate musculoskeletal problems or perform independent chiropractic examinations. In the future, there may be demand for these other disciplines to follow a similar path as the ABIME, and establish requirements for licensure training, examination, and registration.

The ABIME examination includes many test items related to U.S. Federal and State Statutes and Regulations pertaining to impairment, disability, and Workers Compensation. Within the past few years, an international version of the ABIME examination has been developed which does not test issues specific to American law. The international version has been used in Australia, Canada, China, New Zealand, Malaysia, and South Africa.

Conclusion

As the number of physicians competently performing IMEs grows, corresponding demand will grow to enhance the sophistication of state and national benefit systems. Current challenges include the difficulty in differentiating work and non-work-related events, distinguishing between impairment and disability, defining work ability, clarifying a direct threat to one’s self and others, interfacing with adversarial and often dysfunctional systems, iatrogenic components to disability, and inappropriate diagnostic testing and treatment.

Last updated on: December 28, 2011
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