A Perspective on How to Critically Review Medical Evidence

• Jurisdiction: California,United States
• Author: THE HON. MYRLE R. PETTY
• Publication year: 2016
• Citation: Vol. 29 No. 4

A Perspective on How to Critically Review Medical Evidence

THE HON. MYRLE R. PETTY

San Bernardino, California

Note: The following article and any opinions expressed therein are solely those of the author and are not necessarily the positions of the State of California, Department of Industrial Relations, Division of Workers' Compensation, WCAB, or any other entity or individual. This information is intended to be a reference tool only and is not meant to be relied on as legal advice.

Deficient medical reports are a real problem in our system. They create delays in litigation, in the rating process, and in reaching settlements or final adjudication of disputes. They also result in the incurring of additional costly litigation expense through depositions, supplemental reporting, and a lengthier litigation process. Deficient reports may not be construed as substantial evidence and may be stricken or given very little evidentiary weight.

Some of the significant deficiencies that WCJs commonly see include the following (and this listing is by no means exhaustive or all-encompassing):

• Physicians who are not familiar with the AMA Guides 5th Edition;
• Reports that do not meet the requirements of 8 CCR 10606;
• Opinions that are not supported by the rationale behind them;
• An assumption of causation without a discussion of how the injury occurred, why it is considered industrial, and whether the findings on examination are consistent with the described mechanism of injury;
• Inconsistency within the medical report;
• Incorrect usage of the tables or charts in the AMA Guides, and failure to know which impairments can be combined with others and which cannot;
• Failure to comply with time deadlines for QME and AME reports;
• Lack of diligent proofreading, typographical errors, and obvious use of "canned" report templates that reflect no thought or analysis;
• Failure to list everything reviewed in connection with an evaluation and report;
• Opinions rendered outside the field of expertise of the author (for example, physicians giving vocational opinions and orthopedists giving internal medicine opinions); and
• Failure to include required disclosures and attestations (for example, per L.C. §139.3).

Conversely, the following is a brief outline of the information needed to make a "good" report (and again, this listing is not exhaustive):

• Identifiers (patient name, claim number, date of injury, date of birth, employer, occupation and duties, and anyone who participated in the evaluation and/or report);
• An introduction setting forth the purpose of the report (whether medical-legal, P&S/MMI, supplemental), the role of the evaluator (whether PQME, AME, PTP, consult, secondary physician, etc.), and who requested the report;
• Compliance with 8 CCR 10606 (all reports) and Labor Code Section 4628 (medical-legal reports);
• History of injury that clearly sets forth the mechanism of injury and connects the dots in regard to how the injury occurred, whether findings on examination are consistent with the described injury, and a discussion of why it is or is not considered industrial;
• A detailed...