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Healthcare? Worker’s comp? Auto accidents? Slip and falls? Insurers survive and thrive because of their ability to sort the valid from the invalid, the real from the fabricated, the medical necessity from the medical build-ups. If you’re an adjuster, an SIU specialist, an attorney — any individual who relies on the ability to read medical reports with more than just a passing understanding of what you see — this new JCFR column is for you. Our author is an orthopedic surgeon who proudly “swings both ways.” He’s supported plaintiffs and he’s supported the defense. He has no connection or allegiance to either side. The body, he says, speaks for itself. The trick is in understanding the language it speaks.
And with that introduction, we are bringing you the second installment of the “Ask Doctor Bob” column.
Editor’s Note: We are departing from our usual format this month. Instead of answering reader questions like we usually do, the good Doctor has asked for a soapbox and a microphone in order to get a message out there which he believes needs to be heard. We’ll be back to the usual format for September/October, so keep those questions coming in.
Now Here’s Doc…
There are three perspectives when dealing with injury: the doctor’s, the patient’s and the insurer’s. In a perfect world, the three are all in sync; everyone is communicating, errors are never made and everybody lives happily ever after. We do not live in a perfect world. How do I know this? Because after wearing a stethoscope around my neck and carrying a neurological hammer in my lab coat pocket for so many years as an MD/surgeon, I now wear Bermuda shorts and a flowered shirt as a patient — a Medicare patient at that. I also talk to adjusters and medical reviewers on an ongoing basis. Three perspectives, three worlds.
Here’s how they work — and often collide.
Patient Bob, having chosen Managed Care, was assigned a primary care physician. For simplification, we’ll call my PCP Dr. Primary. Doctor Primary got his first glimpse of me, a glimpse that lasted approximately seven minutes, after he received the intake file prepared by his technical staff. On that chart were notes and numbers gathered by those people who work for Dr. Primary. (Alternatively, Patient Bob could have presented at an E.R. after an accident — and even that information would have been written into the file by intake personnel except in the most serious of cases.). Keep this in mind.
Dr. Primary has written out referral slips for Patient Bob to see and be examined by seven different specialists, each one interested in examining a part of the whole. Their cumulative input establishes baselines that, in turn, combine to present a picture of Bob’s overall health. He IS his medical files. Patient Bob is little more than eight chart numbers and enough duplicative labs to support a small village. There’s Dr. Optometry, Dr. Ophthalmology, Dr. Cardiology, Dr. Urology, Dr. Radiology (actually a few of them), Dr. Oncology, and Dr. Dermatology.
Now we’re going to approach the scary part. What Patient Bob found consistent throughout these doctors’ offices is that the technical staff who gathered the basic information and put it into the computers have too often not been trained correctly, and the result was the production of inaccurate information, which then became a permanent part of the medical file. In the best of situations, the errors made are not life threatening. In the worst of situations, such errors can result in amputation of the wrong limb. Or worse. (“Turn off the respirator on Bed A; he’s DNR. Oops, wrong patient, that was Bed B’s chart.”)
Every doctor believes he has competent people who are gathering information. This valid (or invalid) information is what allows the treating physician to come to a diagnosis. Basically, our medical system is little more than garbage in/garbage out. If the file information that the physician sees is incorrect, it may result in a diagnosis that is incorrect and mandate incorrect treatment. Those are the records that get passed on to adjusters or SIU reps for a decision.
Look at your desk. Human error figures into almost every file that lands in front of you; and that often makes it very important for an adjuster, investigator or underwriter to look for the things that do not fit as well as the things that do fit.
Every participant in the process — doctors, nurses, adjusters, investigators, defense attorneys, judges, and so on — have prepared for their positions through a learning process. Two instructors of the same material may have entirely different presentations. One may emphasize one aspect and downplay another; the second may do the reverse. The result is that the soon-to-be professionals will not be equally trained.
The practice of medicine is not an exact science. It’s an educated guess. It’s a reflection of the teachers who have provided the knowledge and guidance and the lessons learned by the then student. Early program students are taught to take blood pressure. Student A, Student B and Student C may well get three different readings. “A” does not support the patient’s arm and bring it up to heart level, and gets a reading of 150/96. “B” doesn’t wrap the cuff tightly around the arm, so when the pump blows up it shifts and fails to compress the artery. “B” gets a reading of 140/90. “C” let the arm hang down and used an automatic wrist cuff, universally accepted as being inaccurate, and gets a 147/92. If there was a fourth one, a “D,” and if s/he properly applied the cuff, held the arm at the correct level, used the left arm and had good hearing (older doctors can’t hear low frequencies and this, too, can change a blood pressure reading) “D” might well get a 120/80 read and the “give this patient blood pressure medication” flag will not be raised. But if “A” or “B” or “C” records their findings in the chart, the patient, for the rest of his/her life, will be labeled as a hypertensive. This affects obtaining life insurance, health benefits, determination of surgical intervention, certain licensing … in short, someone’s entire life. All because a technician or doctor was improperly trained. Sad, isn’t it?
This fact also became readily apparent to Patient Bob when Dr. Optometrist and Dr. Ophthalmologist produced two radically different prescriptions for corrective lenses. How could this happen? Both exams were done by technicians who may (or may not) have cared, and they were simply doing a job, an inadequate job, in accordance with their own interpretations of their own training. The techs recorded their numerical results in the chart, just a typical part of the work day, Drs. Optometry and Ophthalmology go through their typical routine, just part of their typical day, having been fed information — one wrong and one right — or maybe both wrong, since they both can’t be right. Patient Bob just as routinely orders his lenses (if he even notices the discrepancy, he probably won’t recognize the extent of the difference). Dr. Optometry and Dr. Ophthalmology get paid for their expertise and performing a service, the technicians get paid for their expertise and work, and Patient Bob gets paid — in one of the nastier results — by developing vertigo and falling over because his right eye is being retrained to look at his left ear.
Fitted with his new glasses, Patient Bob undergoes an echocardiogram because Dr. Cardiologist “hears something.” The US performs among the highest number/cost of follow- up diagnostics of any country in the world, followed closely by Australia and Great Britain. Exactly why is this true? The patient is likely to feel very secure and safe with all of the attention, thinking that he is getting such excellent care. Insurers often come to the conclusion that it’s just the good old boy network, building bills and paying for Porsches. Malpractice defense attorneys and the doctors they ultimately must defend like it for its “CYA” appeal. While all of this could be correct to some degree, might the actuality be that the thickness of medical files runs in direct correlation to the percentage of attorneys and the numbers of litigated cases in each country?
Dr. Cardiologist, recognizing that Dr. Radiology’s reading is somewhat alarming and is beyond his expectation based upon his examination, decides to repeat the test. Kaching, ka-ching, ka-ching. Dr. Radiology Number Two reads the second report and sees none of what his predecessor saw. Dr. Cardiologist eventually interprets the images himself and reaches a diagnosis correlated with his physical exam. Other than Patient Bob spending a few grand to update his Last Will And Testament and throw away his light blue polyester leisure suit, complete with bellbottoms, lest his children clean his closet after his certain upcoming cardio shutdown and realize just what a quirky old nutcase he was, the end result is fine.
Is all now right in the world? Hardly!
Why? Because those incorrect records are still out there, lurking somewhere within files that could be sent to an adjuster or underwriter: one who will then use the incorrect information to reach a conclusion. The insurer might refuse a perfectly good, hey, profitable, term life insurance policy or discredit a valid claim.
I can’t say it loud enough. YOU are what your file reflects, not what YOU reflect.
Let’s stress this again by talking more about Dr. Radiology. If an accident victim or a workers’ comp claimant presents with a low back problem that is exacerbated by a diffuse arthritic condition or a birth anomaly, reading the x-rays taken just after the incident may be a crapshoot. Here’s a piece of the puzzle that many in the insurance world may be unaware of: X-rays are routinely thrown away — just like so many other business records are discarded — on a seven-year cycle. In such a situation there is no way for Dr. Radiology to properly read the pictures except for him to determine that there was a preexisting condition and to get his hands on those records to establish some sort of baseline.
How often is that done? Patient Bob, aware of this quirk of the medical field, just happened to have a ten-year-old MRI for comparison – allowing the radiologist to see a baseline, make a realistic decision relative to the progression, and reach what was at least close to a correct explanation of the actual condition immediately prior to and right after the “incident” under consideration. In the insurance world, you first receive the most recent diagnostics. Then you chase down the prior medicals. This practice, although there is no real alternative, can be dangerous.
Recently, while I was in the role of Patient Bob and having some radiology studies done, I slipped in a few questions to the technician shooting the films. The answer to one of those questions, “Do you do your flexion/extension study films with the patient standing or lying down on a table?” really gave me food for thought. The tech said, “If the patient can stand up and bend forward and backward, the studies are generally done with the patient weight-bearing. If the patient cannot stand up and bend, then the study is done table top.” My follow-up question was, “how much flexion and how much extension is the norm for a study?” The tech replied that he asked the patient to flex and extend to pain tolerance. “So,” I said, “if the patient can only bend three degrees in flexion and two degrees in extension, do you mark that on the information that is transferred to the radiologist?” His answer was “no.” Nowhere was there communication on the degree of flexion and extension to Dr. Radiology.
As a practicing orthopedic surgeon, I trusted and relied upon radiological reports. I also did something that many specialists do not do — I read the films myself to confirm that the films did not conflict with the one-onone examination findings. Now (thankfully) retired, I have been made aware of a break in the system. Double checking and vigilance was paramount to a correct diagnosis and treatment plan.
Think about this for a moment.
Dr. Radiology reads the pictures, reaches a conclusion, and forwards that conclusion to YOU — all without fully knowing what the parameters of testing were. A flexion/extension study determines hypermobility. When Dr. Radiology opines that a patient does or does not have hypermobility, the adjuster makes a couple of assumptions: 1.) Dr. Radiology is trained to interpret pictures and his opinion was based on full incoming information; and 2.) Dr. Orthopedist takes that reading as gospel, using it to decide the course of follow-up care.
Let’s get more specific, using a real-time example.
On a recent medical case review that was referred to me, the patient’s orthopedist wanted to fuse L4/L5 and L5/S1. A double fusion. Dr. Orthopedist produced medical literature supporting his position. When I reviewed the literature and read his resultant report, I saw that he specified that there was hyperflexion and hyperextension, and that information formed the basis for his decision to perform a double fusion.
The patient’s x-rays did not support that; there was no visible hyperflexion or hyperextension. A proper file review does not question the knowledge of the doctor or rate his medical abilities on a one-to-ten scale; a proper review looks only at what is written and at what is cited as the basis for the continuing care. In this particular case, Dr. Orthopedist’s documentation and investigation had no basis. Had he known that the xrays actually showed that flexion was about eight degrees (to pain tolerance) and extension was about four degrees (to pain tolerance), he would have/should have known that those films were worthless for making a determinative diagnosis. They revealed nothing about hyperflexion or hyperextension. Nothing at all.
If 45 degree flexion and 20 degree extension x-ray studies were done — what we consider the norm — and if they radiologically confirmed hypermobility, that would prove that the fusion was appropriate. But that was not the case.
A normal uninjured spine can flex 90 degrees, which is touching your toes. It can extend (backwards) 35 degrees. There is no possible stressing of the L4/L5 joint until the patient has moved at least 45 degrees (The only exception would be a serious birth defect; however, that would be obvious in an x-ray.). That means that no abnormal movement can possibly be seen until the joints are stressed at those levels. So a patient’s x-ray showing an eight degree flexion provides no actual confirmation of hypermobility. In the case at hand, with no documentation of how much the patient DID bend, recommending a double fusion borders on reckless overtreatment. In other words, a flexion/extension study done on a table is of no use at all in determining hypermobility. The same films, shot standing up but only to pain tolerance (when those specific degrees are not part of the report), are also useless. Except to generate revenue.
So what’s the problem?
In the old days we had Dr. Welby, and he knew the patient via his history. Doc Welby probably attended the patient’s birth, was there to cast his elbow when he broke it, removed his appendix, etc., Because he treated him for a few decades, there existed a continuity of information.
Today, in a medical world where most doctors are “specialists,” there is separation of informational sources, and seven minute visits do not permit even the brightest doctors – – particularly in cases where the technician produces incorrect information because of lack of training or because there is no information about the parameters of the testing – – to reach a proper conclusion, they just go ahead and do what General Practitioners do: they make a referral and pass along those incorrect records.
I can’t say it loud enough. The patient IS his chart; the chart is not necessarily the patient. Now the files go to the specialist, who reads the information and either diagnoses the patient from that information or sends him to someone else — or he treats the patient based on the erroneous information that was created. And we wonder why medicine is going to hell?
Technology is more sophisticated. Information is more vast. That’s the catch. The sheer volume of information at our very fingertips necessitates the need for more specialists. The bottom line, the buckends- here place, is that the people producing the initial information are not being trained appropriately or consistently on the use of the newest technologies and of the old diagnostic procedures, so the information is not moved up correctly. It’s nearly impossible to correct a medical file once the information has become part of it. Each step of the way, the next “specialist” is using information that may well be inaccurate. At the root of the problem is the fact that the pieces never come together into a total profile of the patient. Everything is segmental in today’s medicine.
Let’s go one step further. When you pick up a file and read the patient’s history and note that he is a diabetic, you don’t know whether he is a brittle diabetic who has been on insulin for the past twenty years or whether he has just crossed the line into type 2 diabetes and has not yet experienced atrophic changes. The brittle diabetic is far more likely to experience a more traumatic effect in an accident because of tissue changes over the past twenty years. He has interstitial, joint, vascular, neurological, visual and cardiac changes – his whole body has changed over the last twenty years because of his diabetes. Imposing/applying trauma, a car accident, a work-related accident, or a slip-andfall will likely produce more extensive changes. A patient who has had type 2 diabetes for one year, who is well controlled and has good systemic integrity (still), will not experience the same degree of injury – but if the medical records do not define what “diabetes” means with regard to that individual patient, how can the adjuster or SIU staff make a proper determination?
What’s the answer other than endless informational forms? There is none. In my opinion, you have an impossible job. It starts at the tech level and carries all the way through the system of specialists and produces unusable information which you must then interpret to reach a fair and reasonable determination. Good luck.
Let’s talk about some car crash studies which I found fascinating. I had the luxury of being exposed to the Crash Data people when I spent a day at the Las Vegas racetrack watching them stage accidents, put sensors on dummy dummies, put sensors on LIVE dummies, do head-on collisions, collisions against immoveable structures, and collisions between car and bus (two vastly different machines). Then I was able to talk to the driver who participates in slow-speed accidents and to the biomechanical engineer.
I’ve treated posttraumatic patients for years; I’ve been the victim of an accident; but there is no way to really appreciate what we are talking about other than to experience an accident as an observer. The focus is not on how your own body is being torn in two; it’s on what specifically is happening when two objects collide. (There’s a three-page cover on this event in this issue of the JCFR. With photographs.)
I stood 12 feet from a concrete pile as it was struck by a car going 55 mph. Every time I think about that impact today, I experience a wave of fear. I could feel that impact almost like a bomb going off. Pictures were being taken, video cameras were recording, accident reconstructionist types were in heaven. If you’ve never attended this annual event, I heartily recommend it. Even this now-retired orthopedic MD learned a thing or two.
The insurance industry places emphasis on the size of the accident. Low impact vs. high impact. Adjusters understand that they must consider the cumulative force of two objects colliding. If both are moving vs. if only one is moving. So two vehicles hitting each other in the 20 mph range equate to a more significant impact that one vehicle hitting a stationary object. It’s the force of the impact that gets distributed into the vehicles and its occupants. In almost all cases, the initial reports provide just the bare basics of information. An accurate determination needs more; how tall were the occupants, what did they weigh, were they reaching for the radio, how was the injury affected by the headrest, the seatbelts, etc. There are an infinite number of variables, including age of the victim, genetics, the muscularity of the victim, and whether the victim was aware that the impact was about to occur. (Why do drunks total cars against a tree and have minor injuries? Because the drunk was a limp doll and had no ability to respond to the accident; he did not complicate his injuries by going into a guarding stance.).
From a conceptual basis, this accident happens within a tenth of a second. When the person becomes conscious that a collision is going to happen, the body instinctively tries to protect itself. All systems are instantly on Red Alert. Everything starts to respond, to tighten up and do what it is supposed to do. The reaction time of the muscle is slower than the impact that is delivered, so the muscle is in the process of contracting but has not gone into full contracture – and this means that it is vulnerable to tearing. When I was able to talk to and examine the live dummy (Rusty), the driver of the vehicle that did a 15 mile per hour impact against concrete blocks, he told me that he consciously tried to override his protective mechanism of putting his feet out in front of him by crossing them in front the seat. And he still could not override that reflex action to hit the brake. It’s a subconscious reaction. The human body has built in entities to protect itself, and those jump into participation whether you like it or not.
What must be understood by competent adjusters is that rotation is the cause of disc tearing. It’s the rotation and tearing that allows the exit of the nuclear material. Ninety-three percent of cars currently produced have automatic transmissions: the right foot is going to hit the brake … or if the car is stopped in an intersection it will be their right foot on the brake. This position fixes the pelvis on the right side and would be more apt to produce a left posterior bulge or rupture at L5/S1.
Remember that in a study of 100 people who were given MRIs, 67% of the subjects were found to have ruptured discs already. Keep that in mind when a report mentions a ruptured disc and then correlate it with the amount of trauma and the resultant symptoms. The same number, 67%, do not produce pain. This study was done with random people, random ages, random everything.
So how does this translate to what a doctor sees? When the information generated by the reports contains inconsistencies with the neurological, muscular and skeletal response that the doctor would expect, it raises a question of validity. When I get an MRI that says there is a L4/L5 blown disc, but dermatone testing (that prickly little needle we run over you) tells me that there are changes in the S- 1, something is wrong. They just don’t fit. Again, it’s an impossible job.
With this in mind, it’s important to update your post accident interview questions along with the times and with the changes in technology. The devil is in the details. Car manufacturers are making vehicles safer. The structures/frames are safer, the airbag systems are safer, etc. The basic constant is the vehicle. What is not constant is the occupant( s). They are the variables; so what needs to be found out (other than the basics that were being covered 20-30 years ago) are things like where the occupants were located in the car and what were they doing at the time of impact. It’s also important to find out the sizes of the people in regard to height and weight and to then apply that information to the structure of the seats and the placements of the headrests. A driver reaching out to change the radio station or extending his arm in any way, who is then involved in an impact might well be expected to suffer a rotator cuff tear because his arm would be extended without support. A 5’2” person might get protection from a headrest, whereas a 5’10” person is driven up in the seat and the headrest becomes a fulcrum. If the car has a clutch and manual transmission, I expect the left foot to inadvertently fix the pelvis on the left side, allowing the upper extremity to rotate to the right side. In this scenario, a posterior ruptured disc at L5/S1 would not be unreasonable – even in a very low impact collision.
Summary: Puzzle Pieces.
If the information was generated correctly and passed through specialists and if it was all interpreted correctly, you’ll get a valid diagnosis and appropriate treatment recommendations. But the system is so flawed that when the pieces come in, if even one does not “fit” because it is incorrect, it throws everything else off kilter and the resultant diagnosis is incorrect. And then the treatment is incorrect. It only takes one crooked domino.
The body is an amazing mechanism, an intricate machine based on survival. Good or bad, it will heal itself. A ruptured disc that does not specifically rub on a lumbar nerve will dehydrate and stabilize in a six-month period. If exterior forces are placed on it, it will start to bring in scar tissue to fixate it and make it stronger. If that does not work, because the scar tissue is being torn all of the time, it will bring in bone and fuse itself. If you break your arm and it is not immobilized, it will develop a rudimentary joint to allow the motion to take place. The body will do its best to repair itself given the insults that it has to absorb during the repair. Some of these insults are synonymous with the word “treatment.”
(By the way, in next month’s column I’ll be addressing Physical Therapy, Pros and Cons, in response to the various questions that have been sent in on that topic.)
[color-box color=”gray”] Dr. Bob is an Orthopedic M.D./ Surgeon (retired) educated at ASU and USC. [/color-box]