Fall 2002, Vol. 10, No. 1

Maintaining Objectivity and Consistency and Avoiding Pitfalls in IMEs

By C. Donald Williams, MD, CGP
Yakima, WA

Performing Independent Psychiatric Evaluations (IMEs) and testifying at depositions or live in court present challenges similar to those encountered in the conduct of psychotherapy. There are some potential pitfalls not usually faced in psychotherapy that are particular to the role of the independent expert. There are also technical challenges faced by the treating psychiatrist that confront the independent examiner in unexpected ways.

Unintentional or innocently arrived at pitfalls are those that arise from role confusion and unconscious countertransference reactions. The responsibility of the independent examiner is to be a seeker of truth, and not to cure. To perform that role with integrity requires informed consent on the part of the person being examined. Many examinees are unsophisticated, and may think that any doctor they see is going to try to help them. All examinees must be informed of the fact that the evaluation is not for treatment, who is paying for it, that it is not confidential, and where the report will be sent. This is also a useful intellectual discipline for the independent examiner. The psychiatrist may have been treating another patient the hour immediately before the exam, and it is necessary that they “shift gears,” both emotionally and intellectually, to conduct the examination properly.

The second "innocent" pitfall is that of unexamined countertransference, or other intense emotional responses that could contribute to distortion. The personal qualities of examinees, i.e., whether they are "likable," whether they have managed their lives in effective or ineffective ways, as well as their other personal qualities will often have an emotional impact on the examiner. Countertransference, and other emotional reactions, are inescapable. They are a threat to the integrity of the examination process only when the evaluator is not conscious of his/her reaction.

An example might be useful to illustrate this point.

A 53-year-old, 220 pound divorced woman, recovering alcoholic for 13 years, was injured transferring a resident in a nursing home from a commode to a bed. Her pain complaints appear to be in excess of the objective medical findings. She has been out of work and is on public assistance. She is poorly groomed when she arrives at your office, and makes poor eye contact. Her vocabulary and grammar are limited." Or, switch genders and change the occupation to farm worker and the injury to that of having fallen off a ladder from 5 feet. Discussion: These synopses are not meant to be complete clinical descriptions, but are intended to illustrate situations in which it might be "normal" for the examiner to discount, distance, and otherwise fail to clearly and completely assess the mental status of the examinee, and dismiss the complaints as exaggeration rather than adequately assess for depressive illness, pain disorder, and other treatable conditions.

As another example, an IME reviewed recently contained a mental status examination with no report of objective data whatever, but simply asserted that "cognitive functions were grossly normal" on the road to asserting there was no need for psychiatric treatment.

A separate psychiatric examination of this person revealed a forward digit span of 4 numbers, an inability to perform serial 3 subtractions, and a volunteered statement that before he would allow himself to lose his home because of financial hardship he would "take steps" to see that his spouse of 35 years was not left homeless. Furthermore, he volunteered that he felt guilty that he was injured (although that made no sense to him), that he felt worthless because he could not contribute financially to the household, and that he felt guilty that he was yelling at his wife for no reason. He couldn't sleep and he lacked the energy to do work around the home that he had always enjoyed. By contrast, a history of his prior workplace injuries revealed a back injury 13 years ago, followed by a 2-year process of successful recovery with physical therapy, work hardening, and a 3.8GPA at a local technical school. He then worked 10 years successfully managing a 5000-acre ranch earning $40,000 per year.

"Not so innocent" pitfalls include consciously accepting work where there is an "expected outcome." Most clinicians do not begin by deciding to offer dishonest and slanted reports and testimony. Like other ethical lapses, shading findings according to the paying audience in most cases happens gradually and incrementally. The "slippery slope" is easier to resist at the outset than it is when downhill momentum has begun to build. A conscious commitment to apply the same critical standards to all opinions and to subject each of them to review before release is a useful safeguard.

An example of how this can work in practice can be drawn from a recent experience. I had treated, and then terminated for non-compliance, a patient that had a complex history of several prior injuries. Because of the intricacies of case law regarding causality and financial responsibility in the worker's compensation arena, a situation arose in which both counsel for the employer and counsel for the former patient had the same objective; they wanted an opinion that asserted that continuing psychiatric problems were wholly due to an injury from over a decade ago, as it would affect both charges to the most recent employer and benefits to my former patient in a favorable manner. I initially agreed to testify to this effect, but after a file review and reflection on other similar cases, I realized that the case appeared more appropriate for “second injury fund” resolution. (You can use Google to look this up if you wish) I telephoned the attorney back, advised him that I had reconsidered my opinion, and did not want him to be surprised by the change. He thanked me and cancelled my testimony. I might or might not be correct in my opinion, but that is not the point. The integrity of the process was preserved and I felt comfortable that I was maintaining consistent standards of assessment and opinion.

Other threats to objectivity include overt pressures from referring sources, which may be expressed through assignment questions that are posed in a prejudicial manner and direct challenges to clinical findings, and also more subtle forms. Subtle pressures may be self-inflicted and include limited time, an internal sense of being rushed, and too little opportunity to reflect. For example, a clinician may have work presented by a scheduler in a way that seems to demand an opinion on the spot, without time to examine old records and reports. Alternatively, the clinician may take a phone call in which a regular referral source asks a question, makes a plausible comment, and then deferentially asks for a response. In this situation the "natural' response may be to make a polite, compliant, and pleasing response in order to avoid conflict and maintain the appearance of harmony. The response may or not correspond to what the clinician might opine on considered review. What is important is that the review takes place, and that an unconsidered opinion not be allowed to stand.

In summary, here are several tests one can apply to assess the quality and integrity of ones evaluations and the reports and testimony that result. These include:

• Would the opinion be the same no matter who asked for it?
  
• Is the opinion consistent with all other opinions you have offered in cases with similar fact patterns?
  
• Do you have an uncomfortable feeling in the pit of your stomach that something isn't right?
  
• Would you feel comfortable defending your opinion to an attorney in front of a jury if that attorney had access to all of your IMEs?
  

C. Donald Williams, MD, CGP is a Past President of AOOP and has a Child, Adult, and Group Psychotherapy private practice in Yakima, WA.

 
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