The ABCs of IMEs

Over a period of roughly 20 years, I've conducted thousands of independent medical exams, or IMEs, for law firms and insurance companies. When I started, I did it only occasionally, to supplement my practice income. But it gradually grew into a major part of my professional life-and my income.

Much IME work can be routine and even tedious. And it's often less satisfying than the rest of one's practice because it doesn't provide the pleasure of actually treating and helping patients. On the other hand, some cases are very challenging, and present an interesting break from practice routine.

IMEs are usually requested by law firms or insurance companies for workers' compensation claims, or for medical malpractice and personal injury suits. (You don't spend much time in courtrooms, though; most cases wind up before hearing officers or are settled after depositions have been taken.) You do a physical exam of the claimant and review the medical records, just as you do with most patients. But IMEs are part of an adversarial process, so you also have to write an extensive report for which the normal doctor's formal education and clinical experience don't provide much preparation. Here's what you need to know about doing those reports, from one who's had plenty of practice.

IME files come in all sizes, from a few pages that you can quickly review before the exam to a carton that weighs nearly as much as the patient. Fortunately, imposing files often contain plenty of material that you can summarily discard, or at least put aside with the reasonable hope that you'll never have to study it. Such material could include legal and insurance correspondence, engineers' reports, tax forms, authorizations, and numerous duplicate copies.

Some documents, however, can be useful in your review even though they may contain no substantive medical content. Medical bills, for example, may conveniently and succinctly summarize the patient's course of treatment.

Arrange the records in roughly the same order that you plan to use in summarizing them in your report. To make narrative sense, that order should generally be chronological rather than categorical. Describing all of Dr. Smith's contacts with the patient, then all the hospital inpatient treatment, then all the outpatient X-ray reports, and so on, tends to obscure the chronological relationship between clinical events and decisions.

But be willing to deviate from the chronological order to avoid annoying discontinuities in the narrative, or to deal with practical difficulties created by the way most doctors record their notes. For example, if Dr. Smith saw the patient six times and Dr. Jones saw him four times during overlapping periods, summarizing all of Dr. Smith's notes, then all of Dr. Jones' notes might make more sense than trying to interweave the two records chronologically.

Writing the narrative report

There's no standard format for writing medico-legal reports. But the heading should include the name of the case and the file number cited in the cover letter from the insurance company or law firm that has retained you. What follows can start much like a typical consultation note that you might send to a referring doctor: a salutation, the date of the exam (which will probably be different from the date the report is typed or sent), and the name of the patient.

Identify anyone who sits in on any part of the exam, such as a spouse, parent, or companion: "The patient was accompanied by his wife, Maria Rodriguez." If a language barrier prevents clear communication with the patient, say so, and, if necessary, qualify your conclusions accordingly. Or if the patient's spouse or someone else acts as an interpreter, state that also. If you're fluent in the language of a non-English-speaking patient, mention that also, so that a lawyer can't later claim that your assessment is flawed because you and the patient couldn't understand each other.

Introduce your records review with a list of the items you've covered. For example: "The following records and documents were available for review: (1) The summons and complaint. (2) The accident report of June 2, 2005. (3) The office records of Dr. Jones." And so on.