Hello, hello. Welcome back from lunch. Thank you so much for coming back and working with us this afternoon. A couple of announcements. Please don't forget to evaluate all of these sessions on your AOFAS app on your phone. Also, as a reminder, the welcome reception starts today at 4 30 in the exhibit hall, and it's just upstairs across from where you picked up your registration badge. Finally, you can claim CME in the mobile app. CME claimed is for the entire annual meeting, including this pre-meeting day and the regular program. And so you go to the program icon and then select claim CME credit. So we have a very exciting and fun afternoon planned for you, which is going to start with the esteemed Dr. Walter Hembree. He's going to be talking to you about pain perspectives, treating CRPS and pain syndromes in workers' comp. All right. Well, good afternoon, everyone. I will be speaking on pain perspectives, treating CRPS and pain syndromes in workers' compensation. And Greg was nice enough to give me this topic and also give me the 1 30 postprandial hour, but try and keep it as interesting as it possibly can be. So these are my disclosures, nothing pertinent to this topic. So why is this important? Why do we care about pain syndromes and nerve pain in the setting of work comp? Well, as Greg mentioned earlier this morning, we may be asked on occasion as doctors who perform IMEs or treat work comp patients, we may be asked on occasion to opine on treatment for nerve pain. And so it's important that we're able to distinguish CRPS versus a mononeuropathy versus malingering and be able to speak that language of the pain management doctors. So this will be kind of a deep dive into complex regional pain syndrome. That'll be the bulk of this talk. And we'll start there. So from a historical standpoint, CRPS was first described in 1864 by a prominent Civil War era doctor named Silas Weir Mitchell. He coined the term causalgia. And of note, he also coined the term phantom limb pain. Other terms that have been used for CRPS over the years include reflex, sympathetic dystrophy, post-traumatic dystrophy, pseudocatrophy, algodystrophy, and sympathetically maintained pain. So what is it? Well, it's a dysfunction of the central and the peripheral nervous system that involves hyperalgesia and allodynia in an extremity. And so hyperalgesia is pain out of proportion. So an exaggerated response to a nociceptive stimulus. Allodynia is foreign pain or a non-painful stimulus such as cold or light touch become painful. And it's important to remember, as has been mentioned earlier this morning, the diagnosis is based on clinical findings. There are no definitive diagnostic tests for CRPS. Traditionally, there are two main types. There's CRPS 1 where there is no confirmed nerve damage and CRPS 2 where there is associated nerve damage. And keep in mind for CRPS 2, by definition, the symptoms must extend beyond the territory of the injured nerve. Otherwise, it becomes a mononeuropathy. And then recently in 2019, a focus group of the IASP met in Valencia and came up with a third subgroup called CRPS with remission of some features. And that's essentially patients that previously met criteria for CRPS but no longer have all of the symptoms. As far as epidemiology, this was a large database study, about 33 million patients. The prevalence of CRPS in this group was 0.07%, with the peak incidents being in the fifth and sixth decades of life. There are multiple factors associated with CRPS, the most prominent being female gender. Another smaller database study, about 6 million patients, where the prevalence was 1.2%. This was a retrospective analysis of over 1,000 patients with CRPS, the majority of whom were female. Most of the patients were CRPS type 1. And there were a variety of causative factors. The big three were fractures, blunt trauma and sprains, and surgery, all of which we treat and or perform as orthopedic foot and ankle surgeons. CRPS is strongly associated with fibromyalgia. At least in one study of the upper extremity, fibromyalgia increased the risk of developing, or the risk of fibromyalgia was 2.5 times out of controls in that patient group. So we'll move into pathophysiology. So traditionally, CRPS is thought of as an autonomic dysfunction, but there's actually multiple factors at play, including generic inflammation, what's called neuropathic inflammation, autoimmunity, genetics, epigenetics, and even psychology. We'll touch on each of these. So in CRPS, there's inflammation, there's activation of the immune system that is persistent and amplified. In essence, the immune system is in hyperdrive. And so in this acute warm phase, there are pro-inflammatory mediators, and then it eventually evolves into a chronic or cold phase where there's activation of the keratinocytes, the osteoblasts, and fibroblasts. So again, the immune system is in overdrive. This results in a cytokine cascade. The release of these cytokines, such as IL-6, IL-1 beta, and TNF alpha causes histamine vasodilation, which leads to warmth, redness, swelling, often seen in the acute CRPS phase. And then these pro-inflammatory cytokines ultimately activate osteoblasts and osteoclasts. This contributes to the rapid bone turnover and the osteoporosis that's seen in chronic CRPS. There may be some antigen-mediated response as well. It's been shown that there's increased number of helper T-cells and cytotoxic T-cell lymphocytes in CRPS patients. And then in terms of the so-called neuropathic inflammation, it's been shown that there is an activation of the C-fiber peripheral nociceptors in CRPS patients. This changes the apparent pain signals toward the dorsal ganglia, which in turn increases the pro-inflammatory neuropeptides, including substance P and calcitonin gene-related peptide. And these neuropeptides bind keratinocytes, leading to proliferation of those cells, which in turn contributes to the hyperalgesia and allodynia. Another study looked at the A-alpha and A-delta nerve fibers and showed that the A-alpha nerve fibers are degenerated, but the A-delta nerve fibers are spared. And these are the myelinated fibers that transmit fast pain signals, and it's thought this might contribute to the hyperalgesia and allodynia. As far as the autonomic nervous system, in the acute phase of CRPS, the sympathetic nervous system activity decreases. Neuroepilevels decrease. The peripheral alpha-1 adrenergic receptors are upregulated, and this all causes vasodilation and warmth and erythema in acute CRPS. In chronic CRPS, there's sympathetic upregulation. Neuroepilevels increase. There's downregulation of the peripheral alpha-1 receptors, and this all results in vasoconstriction and a cold and clammy limb. This study had patients in the acute phase of CRPS, and in that phase, again, there's upregulation of the alpha-1 adrenergic receptors on the dermal nerves. And this study injected phenylephrine, which is analog of the alpha-1 receptors, and that caused hyperalgesia in this patient group. There may be an autoimmune component to CRPS. It's been shown that there's increased levels of IgG and IgM antibodies. These are thought to sensitize the nociceptors and help maintain that painful hypersensitivity. And patients with CRPS have also been shown to have increased serum levels of autoantibodies against certain receptors, including the alpha-1 adrenergic, the B2 adrenergic, and the M2 muscarinic receptors. So traditionally, there's never been shown a definitive genetic component to CRPS, but familial aggregation and similar symptoms in certain subgroups of patients indicate there may be a genetic link. There has been shown to be an increased expression of HLA DQB1 in CRPS patients, and this gene is expressed by immune cells, including macrophages, B cells, and activated T cells, and this may contribute to the downstream inflammatory response. It's also been shown that there's different exosome uptake in CRPS patients. Remember, exosomes are those vesicles that carry proteins and genetic materials between cells. How they play a role in pain syndromes is not fully understood. Epigenetics is a study of how cells control gene expression without altering the DNA sequence. DNA methylation is one epigenetic factor. This study looked at soldiers who underwent amputation for trauma. Of the nine who developed CRPS, they were shown to have different DNA methylation profiles, and many of these genetic areas corresponded to the immune system. And then psychology. Again, traditionally, it's never been borne out a true link between psychological factors and CRPS, so newer studies suggest there may be a link. This particular study looked at CRPS patients versus major depression patients versus controls, and they showed that major depression did not necessarily predispose to CRPS, but it may contribute to the chronicity of CRPS. Another study compared CRPS patients to generic chronic pain patients to controls. There's a much higher percentage of patients in the CRPS groups who met criteria for PTSD as compared to the chronic pain and control group. Again, this was not causation. This was just a higher prevalence of CRPS and PTSD and CRPS patients. Moving into diagnosis, we heard a little bit about this this morning. Again, I can't stress this enough. CRPS is a clinical syndrome. Remember, a syndrome is a condition characterized by a set of associated symptoms. There is no single diagnostic test that will confirm or rule out CRPS. So CRPS is diagnosed based off criteria developed by the International Association for the Study of Pain, or IASP. They first met in 1993 in Orlando and came up with their first set of diagnostic criteria. However, they didn't account for the motor and the trophic features, and so this first set of criteria lacked specificity, which led to over-diagnosis, too many false positives, and unneeded treatments. They met again in 2003 in Budapest, and they refined the criteria. These are now known as the Budapest criteria, and this is how we diagnose CRPS. Here they are. We saw some slides on this this morning. These are the Budapest criteria. It must be continuing pain, which is disproportionate to any inciting event. They must report at least one symptom in three of the four following categories, including sensory, vasomotor, pseudomotor edema, and motor trophic. And furthermore, they must display at least one sign in two or more of the following categories, those same categories, and there's no other diagnosis that better explains the signs and the symptoms. And so Hardin et al. compared the 1993 and 2003 criteria, and they both had very good sensitivity, and the specificity improved from 0.41 to 0.68, and so per the authors, the new criteria were valid. Just as a side note, it's important to know there are the clinical Budapest criteria, and there are the research Budapest criteria, and these are two different sets of decision rules. The clinical emphasized sensitivity, so the patients have to report three of four symptoms, and the research criteria emphasizes specificity. They must report four of four symptoms. The specificity actually is not terribly different between the two. It's 0.68 versus 0.79, and these authors advocate that we really don't need the two sets of decision rules because they're more or less similar. In 2019, a focus group of the IASP met again in Valencia, Spain, and updated the assessment instructions and taxonomy for the ICD-11. It's important they did not change the wording of the Budapest criteria. They did not want to invalidate the criteria, and they also came up with that third subtype that I mentioned earlier, CRPS and remission. So this is a nice little chart that I took out of that paper from 2019. They borrowed this from the health service in the UK, I believe. It's a nice checklist, essentially, of the Budapest criteria, and I'll draw your attention here to the signs, and again, this is really what you can hang your hat on as an independent medical examiner. Signs are things you can see or feel on examination, and so as Dr. Guyton mentioned this morning, when I do an IME report, I will always mention presence or absence of Budapest signs, so I'll say something to the effect of no evidence of sympathetically maintained pain, or there are no trophic changes, no dependent rubor, no sweat asymmetry, no allodynia present on exam, and pictured here would be dependent rubor in the right foot there. And again, CRPS is a clinical syndrome. There is no single diagnostic test is diagnostic, but there are tools that have been described over the decades. They're sometimes utilized as kind of pieces to the puzzle, so to speak. One of those is radiographic osteopenia. This can occur starting anywhere from four to eight weeks after onset of symptoms, can be seen in up to 40% of cases, and may be related to the disuse osteopenia. The dysregulation of the osteoclasts and osteoblasts may play a role as well, and again, it does not define CRPS. Three-phase bone scan. Again, we heard about this earlier. This is an off-sited study, a meta-analysis that basically showed there was a positive bone scan was not concordant with the presence or absence of CRPS, and so again, positive bone scan does not define CRPS. There's sweat testing. This investigation performed neurologic sweat testing in 102 patients with CRPS. The indices that correlated with the clinical diagnosis, meaning the Budapest criteria, included resting sweat output, the quantitative pseudomotor axon reflex test, and skin temperature reductions. And then there's thermography. Infrared thermography has been shown to have a 93% sensitivity and 89% specificity per vasomotor issues, not necessarily CRPS, and a temperature difference of one degree Celsius is considered significant. It should be noted that the focus group in 2019 in their paper indicated that an examiner can document a temperature difference just by feeling with the back of their hands. You don't necessarily have to use fancy equipment to look at and see the temperature difference or feel the temperature difference in the limbs on the exam. Electromyography, we'll touch on this a little more near the end of the talk. It can be useful for identifying nerve lesions and CRPS type 2. It can also be useful for assessing some types of mononeuropathies. And then the sympathetic block, that can be diagnostic. It can also be therapeutic. We'll discuss more on this in treatment in the treatment section below. It's generally considered successful or diagnostic if the patient reports more than 50% relief of pain after the block. So moving into treatment, goals of treatment are early recognition, alleviate pain, restore limb function, and improve quality of life. And this is kind of a laundry list of treatments. And again, you don't have to be an expert in all of these. You just need to be aware of them and know how to speak the language when writing up your IME report and or communicating with pain doctors. These are the non-interventional treatments, and we'll touch on each of these, including the pharmacotherapy, of which there are many. So physical therapy is often utilized in CRPS. There's multiple therapy modalities that are employed for these patients. The overarching goal is to decrease fear of pain and decrease kinesiophobia, which is fear of movement. This Cochran review of 34 RCTs showed very low-level overall evidence with significant bias in terms of the effect of PT for CRPS patients, and they recommended larger-scale randomized controlled trials for better evidence. And so just from a practical consideration, when is it appropriate to go ahead and refer a patient to physical therapy versus to pain management? This is sometimes doctor-dependent. I will say in my own practice, if the diagnosis is a little equivocal, if it's an earlier acute presentation and a reliable patient, I may go ahead and send them to therapy to start some movement desensitization and see if things will settle down. If it's a difficult patient or obvious full-blown CRPS, I refer to pain management. Graded motor imagery. These are essentially brain exercises that are designed to affect the cortical changes that are seen in movement and pain disorders, of which mirror therapy is a part. Pictured there is mirror therapy, and that's watching the non-painful limb move in a mirror, in essence tricking the brain into thinking that the painful limb can move without pain. This was a review of six RCTs looking at graded motor imagery and mirror therapy and showed that the overall evidence was rather poor and heterogeneous, and there was no evidence that these were better than other treatments. Transcranial magnetic stimulation is applying pulsed magnetic field to the brain, again trying to induce cortical excitability and change the sensitization that occurs in these pain syndromes. This was a systematic review of 106 studies. TMS appears effective for some pain types, but data is kind of limited for other pain types, including CRPS. This particular study included 23 patients with CRPS type 1 in the upper extremity. They underwent 10 daily sessions of TMS for sham, and the TMS group showed a significant reduction in pain relative to the control group. Scrambler therapy was developed in Italy. It was FDA approved here in the States about 2009, and this entails placing electrodes applying electrical stimulation above and below the pain location. So, the goal is to replace the pain signals with signals of the adjacent non-painful areas and, in essence, scramble those pain signals and reset that central sensitization using a proprietary algorithm of sequences and waveforms. So, this was a good review article on scrambler therapy that was in the New England Journal recently. It's been shown to be effective for post-herpetic neuralgia, post-surgical pain, spinal stenosis, neuromyelitis optica, and cancer pain, but data is extremely limited for CRPS, so there is a smattering of case series out there already using it for CRPS. This was a four-patient case series out of Italy in a pediatric hospital showing near full pain relief in these patients and improved quality of life. Another small study with two patients showing significant pain relief and improved function and quality of life when used for CRPS. Traditionally, we'll move into pharmacotherapy now. Traditionally, NSAIDs and steroids have been utilized for CRPS patients in an effort to control the pain and improve their ability to engage with physical therapy and rehab, but the data is somewhat limited, especially in terms of NSAIDs. This was an RCT double-blind study using aspirin as a prophylactic measure after distal radius fracture, and they found no difference in CRPS incidents between the two groups. Steroids, on the other hand, may offer some benefit, especially in the acute phase of CRPS. This study looked at patients after stroke who developed CRPS and compared oral prednisolone daily versus paroxysam daily for four weeks, and the prednisolone was better at reducing the symptoms. Steroids may be less effective in the chronic CRPS setting. This study looked at 31 patients who had had CRPS for at least three months and compared different dosages of oral prednisolone taper and showed no improvement in either group in terms of their average pain intensity. Bisphosphonates, on the other hand, they have been shown to be moderately effective for CRPS, and it's in addition to affecting how osteoclasts absorb bone or don't absorb bone, it's thought that bisphosphonates may modulate the inflammatory environment as well in CRPS. This was a randomized controlled trial, 21 patients after stroke who developed CRPS. They had three infusions of pomidronate versus oral prednisolone, and the pomidronate was equivalent in terms of the pain control to the steroid. This meta-analysis of four RCTs included 181 patients with CRPS type 1 and showed significant pain reduction in the bisphosphonate group compared to placebo, and they concluded it was safe and effective. Gabapentin. Gabapentin is a commonly prescribed drug for all types of pain syndromes, including CRPS. It's important to note that it's only FDA-approved for partial seizures, post-therapeutic neuralgia, and restless leg syndrome, and data for Gabapentin in other neuropathic pain is limited, and up to 50% of patients report side effects, arguably the most common of which would be drowsiness, somnolence. This study estimated less than 1% of outpatient use of Gabapentin is for FDA-approved indications in the United States. So, again, it's off-label for CRPS. Generics have been available as of 2004, and probably the most off-sided side effects that I hear from patients is drowsiness or somnolence. This was an RCT that compared Gabapentin amitriptyline in kids with CRPS or other types of neuropathic pain. Both these medications equally and significantly reduce pain in this study. And then pregabalin. I would argue the data is even more limited for pregabalin in CRPS. Again, it's off-label. Generics have been available as of 2019, and generally has a similar side effect profile to Gabapentin, including the drowsiness, somnolence issue. Ketamine. Ketamine antagonizes the NMDA, nociceptive pathways. These get upregulated in the inflammatory environment of CRPS patients. It's been shown to be fairly safe without major reported complications. Sometimes benzodiazepines are prescribed to counter the occasional psychomimetic effects that occur. This was a meta-analysis of IV ketamine used for CRPS, and it was shown to be effective in the short term, meaning less than three months in these patients. This investigation compared daily IV ketamine to placebo infusion for 10 days, and then followed the patients for three months. The ketamine group had a significant reduction in pain relative to placebo, with no pain reductions noted in the placebo group. Ketamine can also be administered topically. This was a study that looked at topical 10% ketamine cream versus placebo, and showed better allodenia relief in the ketamine group. And the authors noted there were no systemic ketamine levels detected in this patient population to avoid those occasional side effects you see with IV administration. There are a smattering of case reports out there using oral ketamine as well to treat CRPS patients. Antioxidants, of which vitamin C is probably the most commonly investigated medication in the literature, and is typically used in a prophylactic measure, and most commonly in the upper extremity after distal radius fracture. This was a meta-analysis of three RCTs with 875 patients who took vitamin C for 50 days after surgery, and showed a significant decrease in the one-year risk of CRPS. Another meta-analysis in vitamin C noted moderate heterogeneity among the studies, but the vitamin C group appeared to have significantly reduced prevalence of CRPS after radius fracture. There's at least one study out there using vitamin C prophylactically for foot and ankle patients. This was a study of 329 foot and ankle surgery patients who took a gram of vitamin C for 40 days post-op, and the authors reported a decreased risk of CRPS. Other antioxidants, this study looked at DMSO compared to N-acetylcysteine. The DMSO is more effective for warm CRPS, and the N-acetylcysteine more effective for cold CRPS in this investigation. There are some quote-unquote newer medications that are starting to be used for CRPS patients, one of which is naltrexone. It's been used off-label for other autoimmune diseases, including IBD and MS, and this is a reversible competitive antagonist of the opioid Mu and Kappa receptors, and so it's a non-opioid therapy showing promise for CRPS patients. This was a case report of two patients who had failed other therapies and had a positive response to low-dose naltrexone. Botox. Botox has been used off-label for neuropathic pain syndromes. Its mechanism of action as pertains to neuropathic pain is not fully understood. There are some studies out there looking at Botox in CRPS. This was a meta-analysis of 25 randomized controlled trials showing that Botox was effective for treating both muscular pain and non-muscular pain, of which CRPS was one part. This study was a prospective series of patients, small group, with refractory CRPS that underwent monthly Botox injections for nine months and had significant reduction in pain scores. Cannabis. Cannabis appears to be beneficial for neuropathic pain syndromes. There's high heterogeneity across studies, and the exact dosage and duration of therapy remain poorly defined. This investigation was 27 patients with CRPS, and they attempted to control the dosage using these metered inhalers, and the experimental arm of patients in this study showed a significant reduction in pain intensity. So, we'll move now into the interventional treatments. These include plasma exchange, sympathetic blocks, spinal cord stimulation, peripheral nerve stimulation, dorsal root ganglion stimulation, and even amputation. So, plasma exchange is used in other autoimmune conditions. This was a study that looked at plasma exchange in the setting of CRPS in 33 patients. Ninety-one percent reported significant reduction in pain after the initial series, and about half of those had sustained relief with weekly maintenance. And so, we touched on sympathetic block in the diagnostic section. It can also be used as treatment, and so this entails injecting local anesthetic, sometimes mixed with steroid, at the L3 body waste and watching that dilution migrate caudally and cranially along the L2 to L4 pre-vertebral sympathetic chain. This study looked at the use of sympathetic block for a variety of pain syndromes. Two hundred and fifty-five of the patients in the study had CRPS. Of those, 61% reported more than 50% pain reduction with the sympathetic block, and about 70% of those had relief for one to four weeks. They did note that the sympathetic block did not predict success of a subsequent spinal cord stimulator. This was a systematic review of 12 studies looking at sympathetic blocks for CRPS. Overall, the quality of evidence was very low or low, and they were unable to support or refute sympathetic blockade for CRPS. This was an interesting survey of about 250 pain physicians on how they perform their sympathetic blocks. 73% perform one to three consecutive blocks, so they'll repeat the block if the patient reports at least 50% improvement after the first one, and 53% injected the L3 level, 39% injected the L2 level, and about half add steroids to the block, and this is just to show that there are no specific guidelines in terms of how these synthetic blocks are administered, and so it's all over the board in terms of what pain docs do. And so that brings me to this point, and that is pain improvement after a sympathetic block is subjective on the part of the patient, and failure to respond to a synthetic block does not mean that they don't have CRPS. All right, again, it's a syndrome diagnosed with a Budapest criteria. Moving into spinal cord stimulation, this is a study that was done in the United States, and it was a study that was done in the United States, and it was a study that was done in the United States, and it was a study that was done in the United States, Moving into spinal cord stimulation, traditionally spinal cord stimulation entailed a tonic electrical stimulation of the dorsal columns of the spinal cord, and this is based on what's called the gate control theory, whereby stimulating the large fiber neurons blocks the transmission of pain from those small fiber afferents, so those A delta and C nociceptors. Nowadays, pain management doctors are using what's called high frequency spinal cord stimulation, so that's 10 kilohertz, and this was a study that looked at 12 CRPS patients that had a permanent implant of a high frequency spinal cord stimulator. Average fallout was about a year, and 67% had at least 5% relief of pain. There's also peripheral nerve stimulators. This was a retrospective review of 165 patients who had a peripheral nerve stimulator implanted for CRPS. It should be noted the data is confounded by the fact that many of the patients in this study also had indwelling spinal cord stimulators, but at 12 months, there was a significant, albeit not clinically meaningful, decrease in pain. Their opioid therapy decreased from 62% to 41%. 51% reported functional improvement. However, there was a relatively high rate of surgical revision, over 30%. This is in the upper extremity, but this study looked at placing a peripheral nerve stimulator on the brachial plexus in CRPS patients. At 12 months, they reported significant reduction in VAS pain scores, neuropathic pain scale, and SF-12 physical and mental scores. We're moving to dorsal root ganglion stimulation. Remember, the dorsal root ganglion is where the sensory neurons sit, and they give off their axons that then combine with the motor axons from the ventral root to form a mixed spinal nerve. It's thought that stimulating the dorsal root ganglion directly, so direct stimulation of the dorsal root ganglion, will have benefit in that it addresses specific dermatomal distributions of the pain. There may be some advantages to DRG stimulation over spinal cord stimulation in that regard. These are nice x-rays from this paper by Deer et al. showing where these leads go when they're placed. On the left there, you can see where the DRG leads are placed into the foramina, and they rest against the dorsal root ganglion, whereas in spinal cord stimulation, the leads are placed in the medial or perimedial epidural space along the main cord. This study looked at patients with lower extremity CRPS, DRG stimulation, and they compared DRG stimulation versus spinal cord stimulation. The DRG group had a higher percentage of patients who reported at least 50% pain relief at 3 months. Moving into amputation, this is a described treatment for CRPS in severe recalcitrant cases. This was a systematic review of 11 studies, 8 of which supported amputation. 66% of these patients had improved quality of life. Two-thirds were satisfied, but only about 37% could use a prosthesis. There was, however, a high rate of complications. There was phantom limb pain in 65% of patients, recurrent CRPS in almost half of them, and stump pain in 30% of patients. This was a systematic review of level 4 studies. This included 26 studies, 107 patients. Again, a high complication rate, about a 50% recurrence rate of CRPS, 23% reported phantom limb pain, and only about 40% could use a prosthesis, whereas 75% were initially fitted. This was a single center study on amputation out of the Netherlands. They reported 77% of patients in this study reported an importance improvement in their mobility. 73% had an important reduction in pain. About 70% were still using a prosthesis at final follow-up, and they only had a 9% recurrence rate of CRPS, a little lower than those other studies. This one compared 19 amputees versus 19 non-amputees, all of whom had CRPS. In this study, all outcomes favored amputation in terms of the pain scores. This group concluded that amputation should be considered for intractable CRPS that hasn't responded to other treatments. I think nowadays, especially in terms of pain syndromes, no talk would be replete on amputation without mentioning targeted muscle re-innervation. I think we're all familiar with this at this juncture. Targeted muscle re-innervation involves transferring a mixed or sensory donor nerve to a motor nerve supplying a single muscle unit, and the whole goal is to prevent that disorganized axonal growth, which leads to stump neuromas and recurrent nerve pain after amputation. An alternative is what's called a regenerative peripheral nerve interface, or RPNI, and that's where you implant the free nerve end into denervated muscle graft, either from the amputated portion of the leg or from the residual stump. The data on using these techniques in CRPS patients may be limited to this one paper. This is the only one I could find. This was four patients with CRPS that underwent amputation. This was three BKAs and one AKA. Two of these patients had both residual limb pain and residual phantom limb pain. One had residual limb pain only, and one had phantom limb pain only, and they reported no other complications. From a practical standpoint, if you're going to operate on somebody who has CRPS or has a history of CRPS in that same limb, is it appropriate to do prophylactic measures? This could be vitamin C. There's at least one study out there showing good effect of using prophylactic calcitonin in this patient population. I think it's doctor-dependent, but at our own institution, we will often admit these patients for regional pain catheters and or ketamine infusions. You have to communicate closely with your pain management team and your anesthesiologist when you're going to do that. The end of this talk will focus just a little bit on mononeuropathies, because I think it's important to be able to have some basic understanding of mononeuropathy versus CRPS. Mononeuropathies are neuropathies or neuritis of an individual sensory or motor nerve. It's important that this be distinguished from CRPS type 2. Again, these patients do not meet Budapest criteria, meaning the symptoms are localized just to the territory of that one nerve. Don't forget the utility of just a simple diagnostic block, especially for the cutaneous mononeuropathies of the sural nerve and the SPN. Some common mononeuropathies that we treat in the lower extremity or that we see, I would say, include superficial perineal neuritis, sural neuritis, common perineal nerve palsy, and tarsal tunnel syndrome. The AMA guides to the evaluation permanent impairment fourth edition, which is what we use in my state of Maryland. This divides peripheral nerve injuries in the lower extremity into three categories, the motor, the sensory, and the dysesthesia. You can actually give a claimant an impairment rating based on an injury to an individual nerve based on this table 68 in the fourth edition. SPN neuritis can occur often after trauma like ankle sprains or ankle fractures. This was a clever little study that showed increased excursion and strain of the superficial perineal nerve with simulated invergent ankle sprains and cadavers. It can be injured and lead to nerve symptoms. We all know that the sural nerve can be injured or damaged from a variety of etiologies. This retrospective review of ankle fractures showed a 9.8% of sural nerve injury after ankle fracture. All of these occurred during posterior approach surgery for the ankle fracture, and the majority or most of them result spontaneously over time. Now, if they don't resolve, what can you do? Well, as was mentioned earlier, you can refer them to a plastic surgeon or sometimes neurosurgeons who specialize in peripheral nerve surgery, or if you feel comfortable doing this yourself, you can excise and bury the sural nerve. This was a recent study actually out of Iowa, a case series of 21 patients that came to me in proximal implantation that showed improvement in their foot and ankle ability measure and VAS pain scores. They did note that preoperative anxiety and depression were negative prognostic factors as you would expect. Electrical studies. These can help, number one, establish that there is a relevant nerve injury. They can help localize anatomically where that nerve injury is located. They can give information on the timing of the nerve injury and the chronicity of the nerve injury, and they can also help assess the pathophysiology of the nerve injury, meaning they can help determine if it's a focal demyelinating injury, a conduction block like tarsal tunnel syndrome, or if it's a more global axonal injury. These have three main components. There's the motor conduction study, the sensory conduction study, and the needle electromyography. Motor conduction studies include the CMAP amplitudes, the compound muscle action potential amplitudes, the distal motor latencies, and the motor conduction velocities. And the CMAP amplitudes can be reduced from a lesion at any point along the motor nerve pathway. So as an example, this would be a motor conduction study of the common perineal nerve, and you'll note here when the stimulating electrode is placed above the fibular head, the CMAP amplitude decreases, and that's indicative of a compression neuropathy conduction block at the level of the fibular head and neck. Sensory conduction studies, these include the SNAP amplitudes, the sensory nerve action potential amplitudes, the distal sensory latencies, and the sensory conduction velocities. SNAP amplitudes are generally low or absent in a lower extremity mononeuropathy. And then you have your needle electromyography, and this is where the examiner looks for patterns, which muscles are normal, which are abnormal, and they look for these positive findings, fibrillations, and what's called positive sharp waves. And they work from distal to proximal to try and locate where the lesion is in the nerve. And so the needle exam, the electromyography can provide a temporal course to the nerve injury based on the presence or absence of these fibrillations and positive sharp waves, and also based on the morphology of the motor unit action potentials. So looking specifically at tarsal tunnel syndrome, electrical studies often focus on, number one, excluding other potential diagnoses like an S1 radiculopathy, a sacral plexopathy, a sciatic nerve injury, or just generic peripheral neuropathy. It's been shown that mixed nerve studies, meaning placing electrodes just on the soft tissues medially and laterally, is more sensitive than an isolated tibial motor conduction study. And often the needle exam is unnecessary if you find there's a discrepancy between the latencies between the good limb and the bad limb. It's essentially diagnostic. That being said, are there specific electrical criteria for diagnosis of tarsal tunnel syndrome? This group out of Egypt would say that yes, there are these thresholds that if you meet any one of these in terms of the distal motor latencies or the CMAP amplitudes, then the patient has tarsal tunnel syndrome. But I would say more often the examiner will refer to the normal extremity. And so what they look for is increased latencies, so meaning increased time for that impulse to travel the nerve, decreased velocities, and decreased amplitudes of the action potential on the bad side as compared to the good side. And so this is a nice little pictogram demonstrating that. And this is in chart form, again showing that the latencies are increased and the amplitude is decreased in the medial and lateral mixed nerves as compared to the good side. So from a practical consideration, this was mentioned earlier, there are no specific latency asymmetries that are diagnostic of tarsal tunnel syndrome. Electrical study interpretation does have a subjective component to it, especially in tarsal tunnel syndrome. And some plaintiffs' attorneys will refer to specific doctors to whom they to obtain a favorable report. So you just have to be able to understand some of the verbiage and lingo in these reports and make your own interpretation of them in conjunction with the exam and the patient's subjective complaints. So if you remember nothing else from this talk, remember the Budapest criteria. You don't have to have them memorized, just know what they are in general and be able to reference them. And again, the signs are what we can really hang our hat on, especially as independent medical examiners, because that's what you can see and feel as opposed to what the patient reports, which could be all over the board. Thank you. Nobody wants to hear from their senior partner that, hey, I want you to give the comprehensive talk on CRPS. And you did it. So that's great. I know it's a slog and it's hard to get through, but it's actually really important because these things do matter, and they matter a great deal. They matter a great deal in work comp. They'll matter in your regular patients. And you don't have to make these decisions about which of the drugs is appropriate. But you will, if you do enough work comp, be occasionally asked to opine, is the treatment reasonable? Is it necessary? And you don't want to have to have them go out and get a separate IME from a pain doctor if you can avoid it. It certainly slows the process down. It's usually better if you can know the lingo, know what the language is, and at least opine as to its reasonableness if it's mentioned. Thank you. We'll have questions at the end if people have specific questions about some of those things. That was a very dense talk. Next, we're going to have Brad Brainerd come up here. Brad is unique amongst my foot and ankle colleagues in that Brad is now essentially doing really only medical legal evaluation as his primary practice mode. And he, I think, does more of this than anybody I know. Brad's going to come up and talk to us about ratings. And what we're going to do is go through the sixth edition, because that's the one he is used to. As I mentioned earlier, if you try to go through all of the various types of ratings done in various jurisdictions of various states and provinces, we'd be here all day. The sixth edition is the most modern edition. So Brad's going to go through that, and it has a little bonus. Even though it's not on your schedule, Brad is going to go through cost estimation in workers' comp, which is a little separate side topic in and of itself. So, Brad, why don't you come on up? First of all, I'd like to particularly thank Greg and Michelle for giving me the coveted right-after-lunch spot. I think I have the perfect antidote, which is a little talk about impairment ratings. But before I get to that, there were a couple questions that were posed earlier in the session this morning that I thought were worth addressing, because I didn't have a mic at the time, so I thought I'd just throw this out here while I'm getting started. One of the questions was the use of a goniometer, which I think is obviously a good thing to do to try to give you objective data. The guides actually say that you should do three measurements of active motion and select the highest value that you've obtained. One thing that I do in addition to that is use photography. I take pictures of the joint motion so that later on I can measure with a goniometer off the photo to see that that confirms what I suspected it was from my measurement with the goniometer in real time. Additionally, the photographs can be helpful when you're looking at objective parameters, such as calf atrophy. Like Greg said, you can take a measurement which is really good. You want to find a specific location measure from there on each side. I use the popliteal crease and then you have a target on one side which is your normal and then on the other side you've got your atrophy, I hope. The photograph then can actually show that as well to sort of confirm what your measurement has told you. Additionally, the photographs can show an active sense of if you have the claimant doing a heel raise bilaterally and you have them pause at the top of their heel raise, you'll see the definition is much better on the normal side than it is on the compromised side. The other question that was posed was in regard to having a lawyer involved in a person's work comp claim. My perspective on that is that I think you need to read the room. If you have a claimant who is fairly savvy with the healthcare system, has a pretty straightforward injury, they may be able to navigate things on their own. If, on the other hand, someone doesn't appear to be that familiar with healthcare, how it's delivered, how to navigate through these work comp channels, they may benefit from having legal representation. What you have to keep in mind, too, is that typically, at least in our community, work comp lawyers get about 25% of the settlement. That's in perpetuity. That's why a lot of these work comp lawyers retire much later than their fellow lawyers, than other specialties. Anyway, on to the headline. The sixth edition, and I have no disclosures to make. The big difference with the sixth edition compared to the previous iterations is that now the methodology has been changed, and the real function that is paramount here is the diagnosis. It's a diagnosis based system. It's called DBI, the diagnosis based impairment. The idea is that this improves the inter-reliability of other people doing the evaluation so that you come up with the same answer. Also, it takes into account functionality and how this particular impairment affects the individual. Now, the guide's textbook is the sixth edition, and there's a hard copy, but in 2023, there was a supplement, if you will, or an online edition, which has come out that's corrected some of the typographical errors that were in the book. Nonetheless, I'll be talking about the book mostly because it's a little bit easier to turn the pages than it is to scroll through an online document. Now, I have what's called the 14 commandments, and that's in the front part of the textbook, and these are some of the basic principles that undergird all of the sixth edition. If you have questions about methodology or what you can and can't do, a lot of times it helps just to turn to this page and see some of the basic principles, and that can help dictate your progress as you go forward. I highlighted a couple of things just to bring out that an amputation, that's going to be the most significant impairment that you'll have. So if you're doing a rating, you cannot exceed the amputation level for the extremity. And then, next one down is the importance of maximum medical improvement. I think you should always preface your report by saying that the person is at maximum medical improvement, thus it's appropriate to do an impairment rating. Because if they're not, then you really shouldn't be doing an impairment rating. If you preface it with the point that they're at MMI, then it is reasonable to go forward and calculate the impairment rating. A couple other points, the guides are really directed toward objective findings and things that you can measure that can't be influenced or altered by the claimant. And the reality is they're kind of a paucity of truly objective things. Atrophy is one, reflexes probably. We like to think range of motion is, but that's got some flexibility that the claimant can influence. So you try to find as much objective information as you can to make your determination. Now, even though the main basis for your rating should be the diagnosis, there are other methodologies that can be utilized. And the examiner is charged with using the method that provides the greatest benefit to the claimant. So if you are in a position where two methodologies could reasonably be used, you're ultimately obligated to use the one that gives the highest benefit. Now definitions are inherently kind of boring, but they can also help you a great deal. These are the definitions that come from the guide's textbook itself. There's a glossary at the back that's very helpful, and it talks about impairment, talks about disability, and it talks about IME. Now, I would recommend that if possible, before any deposition or court appearance, that you commit these three to memory. Now, that sounds a bit daunting, and I have to do it before every single one. I can't keep it in my head permanently. But once you get the hang of it, there's a certain similarity between the first two, and the third one is really important, because you will be asked, what is an IME? Well, this morning you heard Greg talk about, what's an IME? And it was an hour of non-stop information, and background, and all sorts of elements. So, you don't want to go into a deposition and try to answer that question on the fly. We're going to just get into the weeds. So, the best thing you can do is, they ask you, what's an IME? And you say, a one-time evaluation performed by an independent medical examiner, who is not treating the patient or claimant to answer questions posed by the party requesting the IME. Drop the mic. That's it. That answers the question. You've got a plausible source for that answer, and you can leave it at that, and you don't have to go into the weeds. So, just to give an example of impairment and disability, let's say we have two workers here. One is a telemarketer. The other one is a primo-ballerina. And somehow, through their occupations at work, they both end up with crush injuries. They lose the end of their big toe. They have traumatic amputations at the IP joint of their great toe. Well, when you look through the guides, essentially that's going to give you a 5% impairment of the lower extremity. Now, that telemarketer there, after it's all done, he's medically stationary. His impairment's 5%. And look at that. He's looking good. He's ready to call you every day and follow up and see if there's anything that you need. The ballerina, on the other hand, her career's over. She can't function without the end of her hallux. So, even though they have the same impairment, the disability, or the participation limitations, or the lack of functionality is far greater in the ballerina. Now, the guides divides the lower extremity into three regions. The hip, knee, and foot and ankle. And you are charged with trying to identify the one diagnosis that best explains the impairment for each particular region. So, if we're talking about the foot and ankle, ideally you're going to have one diagnosis that refers to the worst problem in that area, and then you base your subsequent evaluation on that. Now, you'll find that there's a lot of levels of five in these impairment books. And, that five-fold number turns up in a lot of different situations. So, in here, it usually goes from no problem, mild, moderate, severe, very severe. So, you have that five range degree of severity. And that comes up in a number of different situations as we move on. Now, when we're talking about impairment rating, I equate it somewhat to how do you calculate your income tax liability. And I pulled up Greg Guyton's return here, and there were so many zeros, I couldn't get them all on there. But, the basis of your income tax, what are you going to pay, it all comes down to what's your income. So, that's tantamount to the DBI in your impairment rating. Then, after that, you're going to adjust for other considerations just as you do with an impairment rating. So, with the impairment rating, you start with your DBI, then you work through your functional history, your physical exam, and then your clinical studies. So, when you're doing your taxes, say the functional history is some kind of a deduction or a child credit, the physical exam might be a tax credit, charitable contributions, clinical studies are what's been withheld. Once you win all those things down, boom, then you're at the end. That's what you owe in taxes, and that's sort of what your impairment is at the end. So, everything starts with the DBI, the diagnosis based impairment. They call that the key factor, and that's what you'll look for in the guide's book to identify where you're going to start. Now, that's going to determine what's called the class, and the class is going to be in the vertical axis, and once you're in the class, you can't change out of there. You can move within the class based on the grades, and again, we've got that five levels of determination. We go through A, B, C, D, and E. I'll show you a grid in just a minute, which will make it a little bit more clear, and the non-key factors, once you've got your DBI, it's going to be your functional history, your physical exam, and the clinical studies, and again, once you've got that class selected, you stay in the class, you can't move out of that. You can only move within it based on these non-key factors. Now, there's some other ways that you can do impairment ratings. Although the DBI is the preferred one, there may be situations in which it's more appropriate to use other methodologies. One of those is range of motion, and I'll give an example of each of these as we move along. Amputation can be another way, or peripheral nerve deficit. CRPS, as we just talked about, is another one. So let's just try a simple kind of an example. If we have a delivery driver, and he falls out of his van, injures himself, gets sort of a Liz Frank injury, and don't be too harsh on my clinical scenarios, because I'm really trying to show how you work the impairment rating system, rather than getting too much into the actual delivery of care and the clinical workup. Let's just say that he's got this pain at the Liz Frank level. Plane radiographs, they look fine. He still has symptoms months and months down the line, so somebody gets a bone scan, it lights up at the Liz Frank level. He says, you know, I can live with it. I just have an orthotic. That's enough for me. I think I've gone as far as I can go. So at that point, we believe he's at maximum medical improvement, and so it's appropriate to go ahead and try to rate him. So this is an excerpt from The Grids, and you'll notice that in the book, there are all kinds of these things, and these are where you pull up your diagnoses. Now, the authors of the text have appreciated the complexity of the foot and ankle world, because they've devoted eight pages to diagnoses, whereas the hip and knee just get about three, three and a half pages. Still, it's not always enough. Sometimes you can't find the diagnosis that you'd like, and we'll talk about that in just a second. So we go to the foot and ankle grid and we look for a Liz Frank type injury, and you can see on the left-hand side, Liz Frank is located there. And then as you go across, again, you have that level of five entities going class zero through four. And as you go to the right, those are increasing severity from zero to four. And of course, as you get more severity, you'll have a higher rating. So we look at this case and we say, well, in this one, he's got a non-displaced radiograph and findings are kind of minimal. And so below it, you can see it says mild motion deficits, mild malalignment, angulation. That's more than he has. So that's really not appropriate. So I think it's fair to say that we could use that class one and you drop down to the grade C and that's your default setting. That's where you start is with the C designation once you've ascribed a DBI. So this is a class one. In the vertical column, you go down to the C grade. That gives you 3% lower extremity impairment to begin with. That's where we start. Then we go to the next part, which is to do our modifiers, those non-key factors, which were functional history, physical exam, clinical studies. Here's the grid for functional history adjustment. This is all in the textbook. And again, you can see there's that five-fold pattern again, from a grade modifier zero to four. As you go left to right, you go through that same progression of severity from no problem, mild, moderate, severe, very severe. The gait derangement is sort of the driver of this process. And you can see how the descriptions vary in terms of severity as you go from left to right. Minor things are such as a little bit of a limp, maybe an insert in the shoe, that type of thing, going on to orthotics, braces, cane, crutch use, and so forth. The very bottom, there's a designation about the lower limb questionnaire. That's sort of fallen out of favor. There's no numbers attached to that. And the examples that are used in the textbook don't refer to that parameter. So generally, you're going to use that gait derangement to make your functional history assessment. So in this case, if you look to the top of the yellowed area, that grade modifier is a one. So we have a grade one modifier. The next thing we do is we take a look at the physical exam. And there's a very busy slide. Same deal, you have those five elements with no problem, mild, moderate, severe, very severe. And you can look through there and you can see that a number of different factors are considered, range of motion, muscle atrophy, limb length discrepancy, and so forth. So you look through that and you see what findings did you have on your exam and where do they fit on this grid. So in this case, we'll say that he had a centimeter of calf atrophy on the involved side. That again gives you a grade modifier of one. The final is clinical studies. And that can refer to imaging studies, plane radiographs, MRI, CT, nerve conduction tests, what have you. And again, you've got those five different levels, zero, mild, moderate, severe, very severe. And you look through again and here's different parameters that are identified. In this case, we're looking at alignment and the alignment looks fine. There's just a confirmatory bone scan that has highlighted the condition. So we'll call it a grade modifier one as well. Now comes the math part. And this is called the net adjustment formula. And looks like a bunch of arithmetic problems, but it's not quite as daunting as if you just remember that it's grade minus the class. And so the grades are what you just determined in those three previous settings. And the class is always one in this case. So it's one minus one, one minus one, one minus one. So nothing really changes very much from our modifiers. So in a sense, we stay at the same place on the grid, which is 3% lower extremity impairment. Now the way the guides are set up, the upper extremity is considered more important than the lower, go figure. And so in those cases, the upper extremity is considered to be 60% of the whole person. Whereas the lower extremity is 40%. So when you have your final lower extremity impairment, you can either refer to table 16-10 and see how that converts to a whole person impairment. Or if you're precocious and good at math, you could say, well, a 3% lower extremity impairment, 40% of that is 1.2. And you round down. So that gives you one as a whole person. So you can either do the math or you can just go to the table and read it off. Now the guides might seem kind of rigid or a framework of very little ambiguity or nuance. But really there's an opportunity for you as the examiner to use your medical knowledge and judgment to come to some of these ratings by virtue of other means. And that is the guides charges you with the opportunity, if you don't have a diagnosis that fits in the formal grids, you can rate by analogy. In other words, you have to figure out what's the closest thing that would approximate the issue in question. So let's take this same driver and let's say that he is unhappy with his midfoot. And after a while he decides he's just going to go ahead and have it fused. So he undergoes a midfoot fusion, the alignments right on, functionally he's doing pretty well. He's reached maximum medical improvement and now it's time for a rating. Well the guides grids have ankle fusion, subtalar fusion, talon-avicular fusion, great toe fusion, but they don't have midfoot fusion. So there's this gap. There's no midfoot fusion in the guides. So now you're charged with rating by analogy. How can you do that? And however you choose to do that, you need to be able to support it in your report. So you need to explain how you arrived at this particular answer. And so in this case, I went back and I looked at what are these other fusions, the ankle, subtalar, talon-avicular, those are all rated at 10% of the lower extremity. Now whether or not you agree with that or not is sort of a moot point. That's what the rating is. So in my estimation, a midfoot fusion is not as debilitating as a talon-avicular or an ankle fusion. And so I think it should be less than 10%. Now admittedly, you could say, I'm going to use the analogy, these other fusions are in the foot. I'm going to just plug it in at 10% just like those other ones. But I think that's a little disingenuous. And so the way I looked at it is to look at the, and here's the different fusions at the 10% level, the ankle, subtalar, talon-avicular, and so forth. But if we go back to the Liz Frank, which was the original diagnosis, and we go back to that grid that we used before, above the area that's yellow highlighted for this example is where we were before when we had just sort of an uneventful Liz Frank's midfoot sprain. That's where we got that 3% value. But now with a fusion, that's more debilitating in my estimation. If you look at the class one designation, which I've highlighted, the default value there, that's C grade, that's a 7% lower extremity impairment. It's not exactly what this person has, but in my estimation, it's probably a fair way to evaluate what that impairment is. If you go further to the right in the class two areas, those are higher values at that C level, the default level. You've got 16 and 16. So that gets you up way too high in my opinion. So I would rate this by analogy. I would explain just what I've spoken with you all of why I'm starting at this 7% rather than 10% for the other types of fusions. So if we go through this second example, now he has a midfoot fusion that's well-heeled, well-aligned, everything's good. It's a little disingenuous to say he has no problems. So we'll say he has a mild problem in his functional history, he wears an orthotic perhaps. So we'll call that a grade one modifier. Then when we get to the physical exam, let's say he's got a little more atrophy now. Before he had a centimeter, but now he's got two centimeters of residual calf atrophy. So as we look at the grid for the physical examination, you see that two centimeters of atrophy puts you into the grade modifier two. So before he was a grade modifier one, but now that's been increased to a two. The clinical studies don't really add a whole lot here. We just know that he has good alignment and that the imaging studies confirm what we've done with the fusion. So that's a grade modifier one. So we come to that adjustment formula again, which we said was grade minus class. So in this case, he had a grade two on the second entity there. You can see one minus one on the functional history, but two minus one on the physical exam, clinical studies, one minus one. And so I kind of think about when you're a little kid, if you're in history class in middle school, you can't change your class. You're just stuck in history. You can't take econ or soc. You're in history. You can affect your grade. You can move your grade depending on your performance on essays and tests, pop quizzes, whatever. So the grade can move around. You can go from left to right. But once you've established the class, which you've done by your DBI, then you can't move to another class. So here we've got our class one. We dropped down, but we did move over one level from the C to the D, and that gives you an 8% lower extremity impairment. So in this case, I would say an 8% lower extremity impairment is the answer to the question. If you go to the values table, that'll tell you the conversion. That's equal to 3% of the whole person. If you want to confirm that, yeah, that sounds like it's the right answer, if you take 8%, what's 40%? Since we're talking lower extremity, 40% of 8 is going to be 3.2. Round down, that gives us 3% of the whole person. There's a big old template that you can complete that's in the guide's textbook that's very busy and very intense with all kinds of boxes and things to check and fill in. And I'm not sure that adjusters or civilians appreciate that much detail. I think they like to get something that cuts to the chase, and that's what I hope this grid does. This is what I've come up with on my own, and I would preface the answer to the final impairment by saying something like, there is a 8% permanent impairment of the right lower extremity, methodology and calculations are attached as a separate addendum. So then I have this format that I use where I put the DBI, the diagnosis-based impairment, spell that out. Then all those tables and grids are identified by table and page, so that if the adjuster wants to look it up, they can find it. Talk about functional history, exam, clinical studies, that net adjustment formula, and then you're going to come full circle from that first area where you have your diagnosis-based impairment table. You're going to go back, circle around to that at the end to get your final result, which is the 3% lower extremity impairment. We talked about that other methodologies can be used for calculating impairment ratings, and sometimes range of motion is a more accurate way to do so. You may not like this example, but I think it points out a way to show the methodology. Let's say somebody had a minor ankle sprain, they put a cast on them in urgent care, then they got arrested and they were incarcerated for a while, so they ended up having the cast on for three months. Well then they get out of the cast and their ankle doesn't move very well, they go through rehab, all this happens, and they're no better. So let's say their final range of motion arc is basically from neutral, and then they have 10 degrees of plantar flexion. If you try to decide what kind of a diagnosis-based impairment you would use, that really doesn't lend itself to the categories that are in the guides tables. So then you think about, what's the main issue here? And that is, this person has really compromised motion. And so that's the impairment, is the motion loss. And when you do range of motion, that's a standalone calculation. You just do that. You don't mess with functional history, exam, clinical studies, or any of those other things that we talked about. So there's a special table for each of the major joints in the foot and ankle. If we go to the one about ankle motion, you'll see that a 10% dorsiflexion gives you a mild severity impairment of 7%. The plantar flexion is even more pronounced. That's in the next column over, which is highlighted in yellow. That's the moderate loss. And that's where the 10 degrees falls in. And so you have 15% lower extremity impairment due to the plantar flexion loss. Now when you're looking at the single joint, you can add those two values together to get your final answer of lower extremity impairment. So this is pretty straightforward math. I can do that in my head. 7 plus 15 is 22% lower extremity impairment. Amputation is another category that is appropriate. And as you can see from the grid, there are all different levels expressed in these columns based on where the amputations occurred. And you just identify what's appropriate for their particular case. You start at the default level of C as your grade. The class is what you're going to determine based on the amputation itself. And then you go through the same process with functional history, physical exam, and clinical studies. The caveat is that you can't have over 100% lower extremity impairment. You have to be amputation level. Traumatic peripheral nerves can also be used as a rating. It's not to be used for entrapment conditions, but rather traumatic injury. And the differentiation that you need to make is the nerve purely sensory or does it have motor function or is it mixed? And the charts that you have available or the grids will break that down. So this one that I have here is just the basic sensory nerve. So if you had the sural nerve, you can see that's down on the left-hand side. And there's not a lot of wiggle room. You just go through that class one and that's your starting point. The way that you're designed to make your evaluations for sensory nerves, it's going to be light touch, either your fingertip or a cotton swab, and then sharp and dull discrimination, which you can do with a pin. Motor function, you assess by muscle strength, just like Greg was showing on the pirate. You use your zero to five grading scale for muscle strength and use that as you go and increase in severity. If you have a mixed type of nerve, which has both motor and sensory function, you again look at the grid and you'll see they're broken down into just sensory nerves, motor nerves, and mixed. And you can find what applies to your case and use that as your default starting point. Verbiage is really important when you're using the guides. And one of the things that you want to distinguish is what it means to add versus what it is to combine. And adding is what you would assume is just simple mathematics, as you would assume two plus two is four, four plus four is eight. So when you're told in the guides that you add, it is what you would think it is. When you're told that you combine, that's a whole different story. And it's a different methodology. And as the guides explain, combining as opposed to adding ensures that the total value will not exceed 100% of the whole person. And it takes into account the impairment of one body part on another body part. So the combining comes into play when you are instructed to combine the values rather than add them. So there's a whole appendix in the back of the textbook. And this is just a small excerpt that shows how this whole combining business goes on. You'll find that if you pick a number on the vertical axis, and then you are going to combine it with one on the horizontal axis, for small numbers, it turns out to be equal to adding. But as you get to higher and higher values, then it kind of skews things a little bit. And I have an example at the end I'll use to show how that works. Let's say we have a polytrauma patient and they've reached maximum medical improvement and you're asked to do an impairment rating. They've got a recurrent dislocation of their hip. You've done the calculations and it's 30% lower extremity impairment. They've had a patella fracture in the knee. That's given them a 10% impairment. And lastly, they've got a Liz Frank injury in the foot, comes out to 16% lower extremity. So now when we're looking at combining these three regions, we don't add them up to say there's a 56% impairment. Rather you are told or instructed that you combine these values. And when you're told to combine, that's when you use that big old table. And the methodology for combining three or more numbers is that you take the first two highest numbers and combine them. So in this case, 30 plus 16 gives you 41. So that's where that funny math comes in. That's from the combined values table where you go down each axis, match it up, and you'll find what the combined value is. So once you've done the first two highest values, you've got 41%. Then you add that third or you combine that third value of 10% and if you do the cross match with 41 and 10, that gives you 47%. So the end result is that when you're explaining that you have a 47% lower extremity impairment, it's not 56. That's the adding. You combine. So you have 47% of the lower extremity. Then if they ask, well, what's the whole person impairment? You know now it's going to be 40% of that. So you multiply that out and you get 18.8. So you'll round up 19% of the whole person and that's the final answer for what this particular impairment would be. The second part of my talk is pivoting a little bit into charges and medical charges are sort of this mysterious thing which we know is out there but nobody quite seems to know what are they or how much are they and what should be a reasonable expectation. And so I wanted to talk a little bit about that. It doesn't play much of a part in work comp but it certainly is a big part of personal injury. So if you're doing personal injury cases, this can be very helpful. You'll be asked about charges with regard to physicians, hospitals, therapy, radiography, physical therapy and so forth. So let me give you an example. Say you come up to me and say, hey Brad, what's the average cost of an avocado in Tucson? Well I'd have to look into that. It turns out that if you look at a major grocery chain that's in Arizona, they own three different subsidiary stores, grocery stores, and nonetheless they have one common supplier for their avocados. So all these avocados come up from Mexico, they go to the central warehouse and then they're disseminated to the various stores. Well the first store, as you can see, has concrete floor and fluorescent lights and you can get an avocado for 99 cents. If you go to the next level of their stores, there's some faux wood flooring, they still have the fluorescence, but now it's going to be $1.99 for an avocado. And lastly, if you go to the top end of their stores, you've got custom Mexican tile, halogen lights, Amazon mist indicating the, or irrigating the produce every half hour. But those avocados, if you look at the top right, are $3.99 a piece. So essentially it's the same avocado, but it's 99 cents at one place, $1.99 somewhere else, and $3.99 at another store. That's kind of the way medical charges go. And when I've been asked to comment on charges, I think you are wise to talk about a range. It's not an absolute, it's going to be a range, and it's probably a bigger range than you would think or you would hope is reasonable. I know in Arizona, in my community, you can have a total ankle replacement for just under $50,000 at one hospital, whereas another facility, I know it's $100,000. That's still probably all within the range of the community, but you have to appreciate there's going to be some individual variants. Initially, when asked to comment about medical charges, I would opine that based on my training experience and so forth, looking at all these EOBs or explanation of benefits of what things were charged, that I had a good sense of what's reality and what isn't. That sort of came down a little bit when I was testifying in a trial, and I've included some of the transcript. Basically the defense attorney was asking me about, did I know how much the equipment at the facility cost? Did I know how they set their fees? Did I know what their profit margins were? Was I privy to the board deciding what was necessary to make an adequate profit? On and on. There were probably eight stock questions along those lines, and each time I have to So if you're a jury member and you get to hear this for every single provider, physician, therapist, radiology facility, hospital, all I did was say, I don't know, I don't know. I didn't feel real good about the experience, but it sort of backfired because the jury didn't like that line of questioning, and there was a plaintiff's verdict. But it made me think a little bit about how we got to that place, or how I got to that place, and I thought, you know, there's got to be some information out there that I can use to give myself even more credibility. And so I think you have a chance to have this informational goldmine coming in as you review personal injury records, because invariably, along with the medical records that you're diving into to make your report, you will also get the medical charges. And these things are all itemized, I'm sure you've seen them, and it's a nuisance to go through them, but it's a treasure trove of information that you can use, and it can help immensely, because now you have tangible evidence of what really gets charged. And at least in Arizona, the charges are what matter. The reimbursement is not a factor. The settlements are based on the charges. And so there's a vested interest in having charges being higher if you're a plaintiff, plaintiff's lawyer. So these are EOBs that come in and so I've started to save this information and record it. Right now honestly it's more of a spiral notebook than it is a bunch of supercomputers, but I'm hoping someday I can get to that point. And then just to give you an idea of what's out there, I thought this was just kind of interesting because if you have, at least these are Arizona charges, if you have a life flight, helicopters coming to transport you, it's going to be a little over $38,000 for the flag fall. Once they take off, boom, that's the charge. Then they charge $265 a mile, so it depends on how far you want to go. Ambulances, it's kind of the same story. It's a little over $1,100. These are different providers within the county and then it's about $20 a mile after that point. Emergency rooms, it's kind of a whole gamut here. There's going to be a base charge that ranges from $3,000 to $10,000. Level one trauma centers invariably will have some kind of a trauma surcharge because they've got extra resources and availability and all that sort of thing. These are three different trauma centers. It's interesting how close they are to each other in terms of what their surcharge is. X-rays kind of fall into the same deal. Private radiology charges for foot and ankle films, hospital, private orthopedic practice, level one trauma center, boom, a lot more. CT scans, private facility, not very much. Level one trauma center, quite a bit more. Again, these are the normal charges that we are seeing in the community. Room charges, these are three different hospitals and $2,200 to $2,700 somewhere in there per day. Operating room charges in a level one trauma center, this is typical for most ORs, but it's going to be higher for a level one center. $9,700 for the first 30 minutes and then each additional 15-minute increment adds more charge. Same deal with anesthesia. You're going to have a basic charge usually for the first 30 minutes or so and then each 15-minute increment after that gets billed as an additional. Recovery room, same kind of principle, 30-minute time for a block. Some places will add it per 15-minute block, others do it by the minute, so they're really keeping tabs on that very closely. Dwight Eisenhower was the one who coined the term military-industrial complex, which was sort of this joining of the military and big business to wield control and power. I think today when you're looking at medical charges, I can live with a range that's a multiplier of one or two, maybe three times. That's probably a reasonable position to take within a community. So if I'm going to be critical of charges by some provider, I think it has to be quite the outlier. Needs to be really out beyond those small multiples. And so what I've coined the medical-legal-industrial complex is where you're quite likely going to find some of these aberrations. And you may be asked, are these charges reasonable and normal within the community? And typically the place where you're going to find that these variations exceed those normal parameters would be in these injury clinics, which are often, as Greg has talked about, lawyers, doctors sort of working together in an unholy alliance. And so there's potential for excessive charges getting generated. This is a note that I copied from a chiropractor, and he said, patient needs to be seen ASAP. It's likely surgical. There are good limits. That means the insurance company has a big limit on this case, so there's a lot of money to be had. It's an odd thing to put in your progress note, but there it is. Then I came across the case where a podiatrist was treating an acute perineal retinacular tear, and he did a repair of the retinaculum, deepened the fibular groove, said that he repaired a perineal tendon, but he didn't describe which one it was. And for all of that, there was a charge of $23,832. That's probably tenfold what you would expect to be paid. So I thought that was excessive, or beyond the range of the community that I would expect. Similarly, this is another injury clinic. This is for an ankle injection under a fluoroscopy, and numbers are a little small, but it's over $8,000 for a steroid injection into the ankle. Again, I would say that exceeds the range that one would expect within the community. So thanks for listening. I appreciate your staying awake in this postprandial period. Welcome to the world of IMEs, and come join me. It's a very deep dive into some very complex subjects, and really appreciate it. Again, I want you to think of these talks more as references, because obviously you're not gonna be able to take away sixth edition guides just from that talk, but it was a really beautiful exposition. Thank you very much, Brad. We're gonna move on and get through the last two talks, and then have a little open session for question at the end. What we're gonna do right now is give an example of a little brief taste of what it's like to be deposed. So we're gonna bring up Gary, who examined me as the pirate a little bit earlier, but Gary's gonna be deposed, and he's gonna be deposed by Brad, who is licking his chops to be a lawyer for one day. So I've invited Brad to serve as a lawyer, and then we're gonna have an actual real lawyer who is going to oppose Brad, and we'll see how that goes. And so Michelle is gonna serve as the court reporter, and we'll see how this goes. So if we can bring up Bill. Bill McVisk is our guest. We need to bring him up on Zoom. Bill is coming in from Chicago. There he is. And is he... I don't see him moving. There he is. Okay, Bill is with us. Bill, can you hear us? I can hear you. Fantastic. All right, I'm gonna move over to the other podium. We can hear you just fine. All right. And Gary is going to be our deponent. So Bill, everyone is here as planned, and what we thought we would do here is, this is essentially a reference for people who've never been deposed, who've never been in that setting. So what I want to do, Bill is our... He is our counsel for the American Board of Orthopedic Surgery. So he's... I am on the American Board of Orthopedic Surgery. Bill is doing us a great favor by showing up today. Really appreciate your willingness to do this, Bill. So the first thing I want is, Bill, if you can just tell us just what the goal of a deposition is. What are the types of depositions? What's the difference between a depo and court testimony? And then, lastly, who asks for and who pays for a depo? Just some basic information. Okay, and basically the goal of a deposition, when I'm the attorney taking a deposition, I need to find out what the witness has to say. You know, and in a lot of situations, I'm not able to find that. For instance, if I am a defense attorney defending a personal injury case, I can't find... I can't call up the doctor for the plaintiff and say, what did you find? What were your findings? Tell me about what you did. The only way I can find that out is by taking the deposition of the plaintiff. So part of me is to find out what that is, what they're going to tell me at trial, so I know what's their testifying at trial I need to know. The other thing I'm trying to do is to try and see if I can get them to say something that will help me, so that if they say something I don't like at trial, I can use their deposition testimony to impeach them. So I'm hoping they'll say something stupid if they're on the other side. And so that's another... like you said, there are two types of depositions, and part of this depends on which state you're in, because every state has a little different procedure. In Illinois, where I practice, you have a discovery deposition and a trial deposition. A discovery deposition is what I just said, talking about I'm trying to find out what you have to say. Those depositions, if the witness isn't around or something, I usually can't be presented to a jury. On the other hand, if that witness is testifying at trial, I can use what they said during the deposition to impeach them. The other type of deposition is what's called a trial deposition, which they pretend basically is not just the way you would do it at trial. The party presenting the witness does the direct examination, the other party does a cross-examination, and those depositions can usually be read directly to the jury, or if they're televised, and these days that's much more common than it used to be, they can be presented on screen before the jury. So those are the types of depositions. Right. So one of the things that may commonly happen as you are the deponent, if you are being deposed, is you'll have a prep session with the attorney. It's worth knowing that that can be paid time, so that is your time, and you can bill for the prep session. And then Bill, if you could just tell us, what do you tell your deponents at the time of a prep session right before that depo happens? Well, I will say first of all, those usually last an hour or two, because I want to go over what they're going to say and kind of do some mock stuff. But the main thing I'm really trying to get them to do, first of all, obviously I want them to tell the truth. The worst thing a witness can do is not tell the truth, because that really is going to come back and haunt them. The other thing I want them to do is answer the question, but generally if it's a discovery deposition particularly, I don't want them to answer more than the question. So the example I tend to give is, if I ask you if you are wearing a watch, the typical conversational response is to say, oh yeah, and it's 430. In a deposition, your answer is yes. You know, you don't need to elaborate other than to say yes, your answer is yes, I'm wearing a watch. Let them ask you what time is it, and is your watch set to Eastern Time or Central Time or etc. So those are the things I kind of try and get through the procession. Great. So we're going to move ahead and do an example of a depo, and we're going to stop at little points along the way just to make a couple of little key points that you would probably want to remember if you are in fact the person being deposed. So they usually start with a court reporter who lets us go on the record. So Michelle, go ahead. Hello everybody, we are going on the record at 314 p.m. Do you swear to tell the truth, the whole truth, and nothing but the truth? I do. All right, and then Brad will start introducing himself. I'm Brad Brainerd, speaking for the insurance carrier. And I am Bill McViz, on behalf of the plaintiff, Mr. Edward Teach. So the first, typically what will happen is they will start by sort of establishing your credentials in some form or fashion. So Brad will go ahead with direct. Would you state your name please? Gary Stewart. And are you currently an orthopedic surgeon? I am. Could you give us a background of your educational training? I did my medical school at Drexel University in Philadelphia, my residency at Drexel University in Philadelphia, and my orthopedic foot and ankle fellowship with Steve Conti in Pittsburgh. And have you ever been sued for malpractice? No. Have you ever had any board complaints against you? No. Have you ever had your hospital privileges suspended or revoked? No. Please describe your practice profile for me. I'm an orthopedic surgeon. I specialize in orthopedic foot and ankle surgery. What percentage of your independent medical examination work is plaintiff related versus defense? 50-50. Be prepared for that question. The question is going to come your way almost every time. And another thing you can do with that is you really should keep a log of your IME work, whether it's plaintiff or defense, because the best thing you can do is when they ask that question, if you have the last five years and you can say I've done 75 IMEs for plaintiff, I've done 75 for defense, so I'm 50-50 both ways, that'll shut it down right there. You've got numbers to back it up and you just move right along. And if it's a med-mal deposition, guaranteed you're gonna get it. So Dr. Bonnet, what records did you review for this case? Dr. who? You're Dr. Bonnet. Well, you were Dr. Bonnet earlier. Okay, all right. I had to make sure. I didn't know if this was a trick. I've trained in Philadelphia. I've got to watch out for you, lawyer. Say that again? What records did you review before you saw Mr. Teach? The records that were forwarded to me. And how long was the interview and examination of Mr. Teach? One hour. And did you have any awareness that Mr. Teach had a prior right ankle history? Objection. I did not. I'm sorry. No, go ahead. So what just happened is Bill objected. And if this were a trial testimony, the judge would then come in and say overruled or sustained. But he's just getting it on the record. So the point here is that you be prepared for that. When you're doing a depo, one or the other attorney may object. Be prepared. What you should do is just pause briefly and then go ahead. You are allowed to go ahead. Just because Bill objected doesn't mean Gary can't answer the question. So in 2003, Mr. Teach had an ankle arthroscopy and findings were identified at that time were you aware of that? Yes. And how does that impact your current evaluation of this case? Well, you know, when I am evaluating an ankle, I evaluate it in multiple different ways. You know, I'll evaluate the motion, I'll evaluate the sensation, I'll evaluate if it's loose, if it's loosey-goosey, if they're walking with a loosey-goosey type walk, if they walk with a kind of a limpy, loosey-goosey walk, I will do a loosey-goosey examination on that patient and just make sure that they're not as loosey-goosey as they used to be. Did Mr. Teach give you a history of his injury? He did. He talked about how, you know, he was an orthopedic surgeon and that his loosey-goosey ankle was from a gangplank that he was walking on and then after that he kind of tripped and he felt kind of loosey-goosey with his loosey-goosey ankle. Now, what are the basic elements of managing that injury which he sustained on the gangplank? Well, quite commonly when you have a loosey-goosey ankle, you will first treat it maybe short-term in a cast and then sometimes with a loosey-goosey ankle, you'll go ahead and you will maybe brace it after and with a loosey-goosey ankle, you'll put it in physical therapy and sometimes loosey-goosey ankle will get better that way. So, wouldn't you agree, doctor, that if this patient would have been benefited from physical therapy but didn't participate, that could compromise his outcome? Can you repeat that question? Could you read that back, please? She wasn't ready to read it back, but what he just did was appropriate. If you don't understand the question, you stop and you ask the question to be repeated. That's an important point. Don't just go plowing ahead. Now, we're going very fast because we're trying to give you an example of this in, you know, 20 minutes or so, but what he just did was very important. So, wouldn't you agree, doctor, that if physical therapy is an important part of treatment, that if a patient didn't participate, that could compromise their outcome? I agree that physical therapy is helpful with a loosey-goosey ankle. And were you aware that Mr. Teach did not attend all of his physical therapy? I was not aware of that. Okay. It's in your report. Now, what Brad could do at this point is he could ask Gary to refer to his report. And if he were to do that, Gary can just stop and take as much time as he needs to pull out the chart, pull out the report, and look at it. And during that time, he doesn't have to say a word. It is just fine to have an awkward silence during a deposition. In fact, it is better to have an awkward silence than for him to go on some rambling answer that may or may not make sense. Silence is okay. You say that's in the report. Let me check my report. Well, it looks like that I did. Yes, I did see that in the report. I have noted that. And did you notice that Mr. Teach did not use a cane while walking in your parking lot? I did notice that. And how did that compare with your observations of him when he was in your office? In the office, he did use a cane. And how did you reconcile the difference in ambulation? It was something that I made note of in my report. Thank you. Can you explain for me, doctor, what is symptom magnification? The term symptomatic magnification, as I'm aware of it, is when someone may have a symptom and make it seem more than what they're really feeling. Now, as I understand it, if sensory nerves supply a certain area, is that true, doctor? That would appear to be true. So if Mr. Teach was complaining of multiple areas of sensitivity, would that imply that he had multiple nerve injuries? Possibly. And how would you go about determining that? I would do a very focused exam on the area. Can you tell me what you found as far as significant physical exam findings? Well, I found that he had a loosey-goosey ankle and then he had sensation in multiple nerves. He had a sensation that seemed to be a little bit more than it should have been in his serral, saphenous, tibial nerves. Not necessarily in all of that anatomic origin and distribution. So explain to us as a layperson why Mr. Teach would have those complaints in an anatomical sense. It doesn't always make sense. Did you review Mr. Teach's MRI images or did you rely on the report? I reviewed those images myself. You saw them personally? I did. As you looked at that MRI that was done shortly after the episode, did you notice that there were any changes of acuity? I did. I noticed that there were some areas on the recent MRI that had edema and some areas that did kind of seem to result in edema. That did kind of seem to resolve on a later MRI. Now what's happening here is also very important. This is one of the reasons you read the images yourself because you will be asked that question or you may be asked that question. Now in those images, the anterior talofibular ligament appeared to be in continuity. So why would he have a quote loosey-goosey ankle? Well, when you have a loosey-goosey ankle, you can sometimes still have the ligament be intact, but it may be kind of stretched and therefore not as competent as it should be. Now, how do we know that that loosey-gooseyness wasn't a result of the injury he sustained in 2003? Well, that loosey-gooseyness was on my exam and he did have some edema on his MRI. And so that tends to show some acuity of his injury. But couldn't the looseness of the ankle pre-exist before the episode on the gangplank? It could. See, one of the things you have to understand about a loosey-goosey ankle is that, you know, it is one of these problems that can happen over and over again. It can happen shorter times. It can happen in longer times. Now, what Gary just did is roll on and provide unnecessary information. And he shouldn't have done that. So, Gary, what would you like to do on the second go here? I would, I would just, baby, shut up. I will shut my mouth. And that's exactly, that was just an example there. You don't need to extemporize. Once you've answered the question, answer the question and stop. Now, have you referred to Dr. Mann's textbook in using those resources for your opinions today? Yes. And tell me about this Roger Mann. Well, Roger Mann is a giant in the field. Pretty much that book is an authority, authoritative text that all foot and ankle surgeons have referenced. So you would agree that that textbook is authoritative? Dr. Mann is authoritative as is his textbook. So what is happening here is that Gary is falling into a little bit of a trap of the authoritative text. And the danger of stating that any one text or any one major source is authoritative is a bit of a problem. Because then anything that else is that is in that textbook or in that source can be used. Because you have accepted that as authoritative. And so be careful, be wary of the trap in which somebody will lead you down a garden path to stating that something is authoritative. Even somebody as authoritative as my fellowship director sitting right over there, Roger. So sorry, Roger. So Gary, what would you say instead? I would say I do not rely on any single paper or textbook in formulating my opinions. Doctor, wouldn't you agree that a cane doesn't seem to be indicated in Mr. Teach's case since he was ambulating independently in the parking lot? It would seem that way. Now, is there any reason that he should not be able to perform sedentary duty as an independent ambulator? I believe he can perform sedentary duties. Could he perform activity or work at a higher level than sedentary? Possibly. And could you elucidate what those levels might be? Let me check my report. I believe that that patient, based on my report, could possibly do more of a medium level at least. And describe for me what the operative procedure is that you've proposed. I propose to perform a repeat arthroscopy, as well as a lateral ligament reconstruction, most likely a modified Brostrom reconstruction. And possibly injection of PRP. And would you have any concerns about the nerve injuries that he is claiming? I would. And how would you manage that perioperatively? I might, most likely, before we do surgery, we'll have an evaluation by a specific nerve specialist, such as a neurologist, who will be able to assess the patient's condition. Specific nerve specialists, such as a neurologist, possibly have nerve studies to get a baseline of where, and another opinion on what his nerve status is before performing another surgical procedure. Please share what the postoperative recovery and rehabilitation would be like for this. Depending on what I see in the surgery, in the OR, I most likely will immobilize the patient for a short time, especially if I use some form of augmentation in the ligament. And then I will, most likely at about three weeks, based on my augmentation and surgical procedures, start with the patient in a brace and start physical therapy over a course of six to 12 weeks. No further questions. So what you just saw, there was a very fast set of questions, but we're trying to do this as an example. So now Bill will go on. Thank you, doctor. You were paid to be here today, is that right? Yes. In fact, you've been paid for everything you've done in this case, right? Yes. And what's your rate for, what rate are you charging for this? $1,000 an hour. $1,000 an hour. And how does that compare to your typical rate when you're treating a patient? Do you charge your patients $1,000 an hour to do an examination? Possibly. No kidding. Wow. Let me ask you this. How much time have you spent on this case so far? 10 hours. 10 hours. So you've already earned $10,000 for doing this work, right? Yes. Okay. Let me ask you this. You said you've testified in other cases, right? Yes. Okay. What percentage of your income comes from testifying as an expert witness? Probably 5%. 5%. And about how much is that every year? Possibly, I would make a guess, I could give more facts on it, but about $50,000 a year. So $50,000 every year. Now you don't get hired by people and you don't get to do all this work if you don't tell them what they want to hear, correct? That's not true. I am sure to remain straight down. I call them as I see them. All those questions are coming your way. They seem like they are rough. They're going to be rough. You need to just answer them straight up. Don't go into exposition. Remember, the other side is going to have another doctor, probably, and this guy is going to ask him the same questions. Any jury that sees this stuff is going to see both doctors. We're all going to look bad, but it's going to be equally bad on both sides. That's the fact of the matter is. What you do want to make sure is that your fees are not ridiculously above those that are in the community. It's going to seem to a jury that doesn't understand what's involved in your time what's involved in the hiring of your all the people that are still working for you while you're out of your practice doing legal work these are some that seem like incredibly high numbers right so you prepared a report when you after doing this right yes i you know you mentioned a loosey-goosey ankle is that a medical term no so what does loosey-goosey mean um i was trying to uh kind of be non-scientific about it but that means an unstable ankle okay so you as you said your own findings were that he has an unstable ankle as a result of this right yes okay now you did your exam you did not intend to treat miss uh mr teach when he was seeing you right i did not and in fact he was seen by people who weren't intending to treat him right yes and that was the people at bay foot and ankle yes and do you can do you know the people at bay foot the physicians at bay foot no i don't do you know if they're competent i do not you so you have no opinion in one way or the other as to whether these are competent physicians who were treated correct correct did you see anything in their uh examination and treatment that was inappropriate yes and what was that um i saw multiple diagnostic ultrasounds um they did not appear to have any therapeutic benefit or cause to be ordered multiple times i think i saw four or five of them in the report okay but you were not doing the treatment right so you don't know if they were needed or not i was not there okay and um among other things you also found in that there is um a centimeter of gastro and i'm going to totally butcher this world gastrocnemius atrophy compared to the contralateral side right what does that mean the gastrocnemius is one of the muscles of the posterior compartment that provides strength and plantar flexion to the foot and so that means that there's been some atrophy is showing there's a decrease in size and so usually that means some form of loss of motion or use or lack of use because the muscle is not as strong as the other or size the same size as the other so he's lost motion and has atrophy as a result of this accident right we would assume so okay and even your own exam you know which which you were uh being hired by the defense to do this you found objective pathology correct i did in fact clear objective pathology i did what you said yes and you also found that the injury to the lateral ankle ligament complex was work related and his treatment to date has been work related correct yes now you know you talk about sick symptom magnification and your evidence of that was the fact that when you looked out the window you saw him walking without a cane right right now have you ever had patients that you've treated that walked sometimes they felt that they needed a cane and sometimes they didn't yes so it doesn't necessarily mean they're magnifying their symptoms it may simply mean that they're just sometimes they don't need it as much as other times correct that's possible but you decided that this was symptom magnification based on my exam and and what was it about your exam that showed symptom magnification that in addition to when i would touch his leg lightly he in numerous anatomic distributions that didn't seem to make sense he would jump as though he was in very severe pain that combined with him walking without a cane without really a limp and then my office using the cane points towards possible symptom magnification okay and how do you know yeah i i know that you found that these uh you know you touched him and it was more than you anticipated are you sure that wasn't simply because he actually felt pain i'm confident that that was not that that was not the area that corresponds to his injury or his subjective findings on mri but you did find he needs surgical intervention i did yes yes what are the risks of that surgical intervention the number one risk factor would be infection it's possible that the patient would have some lingering nerve symptoms there's stiffness and if he's undergoing anesthesia there's always a possibility of death so that's a lot of risk to take for this isn't it yes it is okay so we're not getting too wrapped up in the case but the underlying context here is that mr teach doesn't want surgery mr teach wants money he wants out he doesn't want surgery and that's that's essentially where we are and you're going to encounter that that's going to happen so right we get the and then basically greg that was pretty much what i had for now yep and i think that's i think so what we would do at this point is you know look this would go on a lot longer but you get the idea and we got gary a little uncomfortable up here you're gonna be uncomfortable in a deposition the one thing that was a little odd is that brad gave the the the authoritative textbook trap which would usually come from the opposing attorney it would not come from the one that's hired you because he's not going to try to trap you in some form or fashion but the other guy might and so just be prepared but you can be surprisingly trapped by your own attorney on occasion now what would what would typically happen now is bill would reach a point where he says no further questions brad would if he wanted would redirect you have any further questions uh the mri was done nine days after the episode do you think that was appropriate yes i feel it's appropriate no it's a little too soon to do uh on further on further recollection it is a little too soon nine days after injury to do an mri thank you so and i'm just gonna leave it there because at that point that uh that first part of the answer was great for me you know even though this is a model bill's bill's playing this playing the game neither can brad and that's what you see it gets a little competitive but it's it's generally the comp the comp depots now they can get heated but most of the comp depots i've been involved with are much less emotional than if it's a if it's a med mal or if it's a tort case in general it's it's usually a bit more straightforward so at this point the court reporter would say everyone we are off the record at 338 dr stuart would you like to read or wave all right so what he just asked is read or wave bill can you tell us what that means and whether he should do it or not and what what should happen okay and in the um what that means is that in most states you're allowed to read your deposition and sign it but also make corrections to the deposition so i always recommend to my witnesses that they do read and sign and sign their deposition because that gives them the opportunity to make corrections usually most of the courts these days are only allowing you to make corrections say that there's a typographical error or she misheard something that you said but it may give you the chance to go through and if there's an answer that you just hate you know you might create a you might try to correct it and see if that gets by there we go so most of the time you're gonna if it's a unless it's a unless you're just giving a very sort of insubstantial deposition which you might they might sometimes people will depose you on something that takes 10 minutes some depots take 10-15 minutes some depots will you'll be there for three hours but if it's a three-hour version you're probably going to read and sign rather than wave when you say wave i wave my right to we read inside so waving is not what you want to do most of the time um since we have bill here and the bill has graciously given us our time we were going to do questions at the end but are there questions from the audience relevant to the deposition process while we've got bill here to to answer because otherwise it's just the stupid doctors up here so does anybody from the audience have a question regarding the depo process i get one okay we're gonna have one here and dr chodos what's your what's your question for bill yes so when someone objects does the um person testifying need to answer it or can they just stay silent afterwards they still need to answer the question not the objection um unless in very rare circumstances there the attorney who is retained them might instruct them not to answer which will almost always get the judge involved in a greater problem but unless the the attorney um that is making it unless you're instructed by the attorney who retained you not to answer you have to answer the question thanks okay any other objection i will say this the objection sometimes gives you a hint when i object i sometimes i'm trying to tell my give my witness a hint about a trap in the question so you should listen to the objection okay okay and brad has a question so bill i've been surprised at the number of lawyers who have never personally been deposed uh have you been deposed twice because it's very stressful and a lot of lawyers don't know what it's like to be on the other side i will i will the first time i was deposed i did all the things you're not supposed to i talked too much i you know just i went way beyond the question being asked fortunately wasn't a particular consequence i learned from that and the second time was much easier so i think you learn from doing depositions uh but yes it is definitely true it's a skill and you get more comfortable doing it and you have to get used to being made to look right being somebody kind of coming right at you because it will happen even in a comp deficit any other questions yes yeah hi um when i've done a number of depositions just maybe half dozen in my career so far but one of my senior partners told me to make sure i have all my documents on paper because if i have it on a computer that the computer is discoverable anything on there i mean is that something you would counsel people not to use like a computer or if you're using a computer it's just for depositions that they might try to take that computer as evidence i would be surprised if that actually worked that way i obviously the the um there's always that potential but and i wouldn't bring the computer into the deposition so anything you've got to use at the deposition i would definitely have on paper and do not be surprised if the first thing the opposing lawyer wants to do is to take all of your notes before they start asking questions they'll take all of your notes and thumb through any paper file you bring so if you bring a paper file and it may have your scribbles from your physical exam they can look through that if it has the sometimes they will want to see the letters that were used to retain you do you have communications with you know attorney brainerd and uh you know when when when did that happen they will want to see that cancelled checks that were used to pay you if you keep those in that file and you put them down on the table they can look at it well and frank most of that stuff you should be producing before the deposition and they should have the chance to go through it and look at it before the deposition so that you know when you're making notes about a file keep that in mind because anything you write down about the case while you're reviewing it that's discoverable the other side can find it out yep all right another question line of questioning about compensation what if you're asked about are you being paid for your opinion i would say i'm being paid to review the case and provide testimony i'm not being paid based on the content of my opinion thank you or you can say you're being compensated for your time yes i've heard that before thank you all right dr walker um so do you think it's not a few comments on the difference between a worker's comp deposition and medical malpractice depositions where often if you're either hired by the defense or the plaintiff they're relying on you to explain the medicine and explain you know the treatment just in terms of how you advise people to answer questions okay and i i will tell you i've done a lot more med mal depositions than i have done workers comp depositions so that that one of the things in a med mal deposition when you're doing expert work um well i'm sorry the question was the just the general differences i think that's that's what you were after key general differences in how you should answer the questions and should you be more expository about the medicine in a in a med mal deposition is that fair to air crossing i think so yeah a lot of that's going to depend on is this a discovery deposition or a trial deposition in a trial deposition where they're actually doing it like it would be a trial yeah you're going to want to make sure you do get things out the one thing about about the other only other thing is even in the discovery deposition if you don't provide an opinion during the discovery process either in your report or in your testimony you will not be allowed to present that opinion at trial so if there's an opinion that's an if there's a something that's important to your opinion you do want to make sure it comes out now the the thing is the way to do that is probably to talk to the attorney that retained you and it may be that there you know you can take a break during the deposition you might want to talk to him and just say you know this didn't come up we need to get that he can then ask you that question if he thinks it's necessary to make sure it comes up but in general i eat wet in general regardless the type of case it is you're supposed to answer the question okay we should take one more question yes hi great great talks all day thank you um the question is about you mentioned about impeach you know doctor could be impeached you know sometimes we uh i don't do a lot of deposition work but you get the second deposition by other lawyer and the first deposition you might have said a percentage and on opinion and then second time you come come and say a different percentage uh out of memory because you might not have noted it down what you said the first time so what are the you know risks of the doctor getting impeached well the risks are significant i mean in in terms of if you've testified inconsistently with something you've said during this deposition that will be used against you and one of the things that happens is attorneys share these depositions so if you say it in one case about this case um there are social messaging boards now among attorneys where you know they say have you ever taken a deposition of dr s if you do give me this transcripts so they can get those transcripts and now if you're saying something inconsistent with what you said at a deposition in the prior phase that's going to be used against a lot scarier than you think i have one question uh when when doing these depositions is it better to err towards very uh formal jargon you know medical jargon like calling something a fracture or is it okay to use more common terminology like broken bone so it's still technically accurate but maybe a little less formal i don't think i think either way is going to work and in some ways the jury is going to understand broken bone better than they are i mean fracture they're probably not going to be surprised by but a lot of this stuff a lot of the medical terminology if you can simplify it so that a jury will understand that that's a great idea how do you feel about lucy goosey a little wishy-washy we didn't know that one was coming all right bill i really thank you it's been a tremendous let's give bill a round of applause he's taken his time this is this is outside of his job duties i really appreciate it bill thank you so much absolutely you're a great help all right great we'll let you sign off all right take care all right great well let's move on we're going to uh we're going to move past this uh our next uh next talk is going to be the last one and uh so celyn brack is going to teach us basically how to incorporate this work comp into your flow into your office and how you can incorporate into your sort of financial plan with the caveats about the fact that we are not financial planners but he's going to give us a little bit of a sense of how this can be a nice augmentation to your practice if you so choose so uh there we go i was told to wait for the music all right thanks everybody the few that are still here i appreciate your time um i was told to wait to the music before i could come out so um but thanks for uh for for sticking around um you know you've heard all day uh great insight into the the nuts and bolts on creating uh a practice with ima um and workers comp and and uh how you go through the process of interacting with patients who who require those services so we're going to kind of flip it and now talk about some of the financial finances and the financial part of it um there you go all right um so here are my disclosures um now when we talk about the finance it's important that you're integrating workers comp care into your practice from my perspective um because it is another source of revenue for your practice so if you're trying to maximize uh your time in the office taking care of individual taking care of patients then workers comp my person from my perspective is one of those opportunities certainly there are financial benefits and considerations to think about and we're going to touch upon some of these the way to think about workers comp you know when one of many of us finish residency finish fellowship you hear workers comp you're like oh god that patients you dread the patient because they you know are they malingering are they not trying to get back to work it's so complicated you got to talk to the case manager you got to fill out all this paperwork and you go on hearing for so long in your training that this is such a cumbersome thing but i would tell you flip your your your thought process and think of workers comp as just another form of insurance for these patients another avenue by which you are uh collecting revenue on a patient who needs to be seen you're providing medical benefits uh to this patient they're using workers comp insurance to be able to to access those medical benefits and a lot of times they're getting wage replacement as part of their benefits of a workers comp policy and remember there's a there's a purpose for this so we heard earlier today it's really to protect the employers from lawsuits and the employees for the care that they need from work-related injuries now when you talk about workers comp it does differ significantly from other insurance mediums it's not always a blanket fixed reimbursement rate a lot of times uh your practice your business manager your hospital your health system may be negotiating these on a case by case basis although most large groups you will go and negotiate this on an annual basis the fee agreement can be negotiated for each individual patient encounter because it's usually doesn't have to be on an annual basis you don't have to have it a certain multiple of medicare um the practices have some leeway to be able to set the numbers where they want income diversification is something that you are able to do by taking care of workers comp patients you're again using another avenue to be able to generate income not just the the common private insurance carriers or the government insurance carriers remember this can create a steady flow of patients for your practice especially if you create the system to manage the demands of the workers comp patient then you can start developing a system that allows for a steady flow of patients and if a lot of these patients who come in if they come in for an ime and they want you to continue care and and that gets approved well then these can be patients who need continued care in your practice as well and there's a competitive reimbursement on this depending on state to state practice to practice this can be a highly potentially lucrative uh in quote unquote insurance for your practice uh if you take these patients so when you talk about workers comp you want to think about first how do you integrate this into your practice because there are many more demands that these patients require of your practice than just the regular patient so you have to assess the practice readiness you've got to make sure you have staff that's trained and ready to deal with the patient needs and you develop a workflow and that that includes having a fee schedule having a system to collect and manage records because a lot of these patients have been cared for by other individuals and may be coming to you with reams and reams of records you've got to have a way to schedule visits schedule imaging dme collection of funds and these are all things that your practice has to think about before you incorporate uh these patients into your practice um we talked about earlier today an independent medical exam you've got to understand what that is different than just taking care of a pure workers comp patient so here's an example of a workflow um patient comes in you do the encounter predating the patient coming in there's a lot of uh work that's been done by your staff you put in the codes uh you upload the patient note your billing director can cross check those for proper coding there's a list of codes that are generated maybe this goes to a third party company that that verifies these codes or perhaps this is done in-house once these codes are verified per the documentation that's been created and now goes out to uh to post the charges and then the collections occur um and again these typically are a significant multiplier of medicare rates now the thing you need to understand with workers comp care is that the reimbursement typically takes longer to occur than some of your other private insurance carriers as you think about potentially developing an ime and a workers comp practice you've got to think about how do you market these services and i put ime here but this also applies to workers comp and you want to create relationships between your practice and workers comp or ime servicing companies uh you can reach out to your local companies you can network with attorneys and insurance companies you can reach out to law firms um ime specific companies there are multiple uh companies out there and you can develop relationships with other health care providers but really what i found most effective rather than cold calling or advertising your your services it's really creating relationships with legal firms with employers um with the case management uh companies to be able to tap into this market so your practice hasn't developed that effective marketing strategy i think the way that your practice may reach out to new patients is not the same way that you would market these services so you want to work with your marketing team whether it's within your practice or within the health system to create a marketing team a marketing plan that's really targeted for workers comp and ime patients now when you think about how do you figure out the financials here if you're part of a big practice if you're part of a health system a lot of this homework's already been done for you but if you're in a small practice or you're on your own you've got to think about negotiating your overhead you've got to think about what is your overhead what percentage of of your overhead um is being applied to your collections you've got to identify cost components and then when you negotiate rates you've got to take all that into consideration to figure out um what is your profit margin on the care that you deliver you've always got to consider what kind of diagnostics you may may need from x-rays to mri ct scans is that something done within your practice is that something that that's done through the case manager and it's done outside the practice um you've got to think about the same thing for dme is it pre-approved before the patient comes in to be seen or is it approved on the spot after they've been seen or is it done through a prescription that's given to the case manager who then goes around and takes it to whoever the dme approved providers are so these are all things that you've got to think about as you start thinking about the finances of this now when you think about uh legal work workers comp uh work ime work especially ime work um you've got to think about what is your time worth and this was touched upon earlier today uh in the last session but you've got to figure out what is your hourly rate um and you've got to make sure it's reasonable it can't be ridiculous compared to uh the competition or compared to your local market but you've got to know what that is now oftentimes people will figure out well what is my uh annual uh annual compensation divided by the number of hours in the year you work and some some people develop it that way but you've got to work with your practice work with uh either your partners to figure out what is something that is relatively reasonable and that then applies to a lot of things medical record review and a lot of times people will put a flat fee for a certain amount of medical records either by pages or by inch so that um you're not inundated with an i'm just gonna make a number up a hundred a thousand dollars an hour and that's regardless of if you're uh reviewing 50 pages or a thousand pages right so you've got to be able to have a way to estimate the amount of work you're going to be doing and then create the charges accordingly um for patients who require depositions again you have to figure out an hourly rate that does not have to be the same rate as your record review rate um you you got to figure out are you going to do this in 15 minute or 30 minute increments similar to what lawyers do when law firms don't do it by the minute they'll usually do it in blocks of time and if you're five minutes well you get charged for the 15 minute rate or if you're 16 minutes well then you get hit with a 30 minute rate um you've got to think about are payments due in advance and if if they are due in advance how far in advance are they reimbursed so for example you you're booked for a deposition. You've cleared out half of your day. And two days before the deposition they've canceled the deposition. What happens to those funds. Do you have to return those funds. Do they get 50 percent of it back. Do they get none of it back. These are things you have to think about because it affects the revenue you generate. You've got to think about if any travel is required for you. How is that getting reimbursed at the full hourly rate or is it your half of your hourly rate. Are there stipulations that the companies have to agree to that after a certain amount of time these are not reimbursed. So a lot of things go into all of the finances letters and narratives have to be created for a lot of these patients. Is that something you've decided that you're going to bulk in or is that going to be hit with an hourly rate as well. Telephone conference calls with the lawyer or with the workers comp case managers. How does that get handled. Court testimony. Are you going to build by half day by full day. Again what are your rates for half and full day. What are the reimbursement policies on that. Cancellation fees. Is there going to be a surcharge for nights and weekends. So all these things have to go through your head and you have to figure it out before you start going into IME work legal work and workers comp type work. Now once you do that you've got to figure out before you even start this. What happens to the funds once they are collected by your practice. Now if you're in a academic practice or an employment practice who retains those funds. Is that retained by your employer. What percentage comes to you. Does it get paid into your W-2. Does it get paid out in your K-1. Does it get paid as a 1099. Or do they say here Dr. Parekh here's your check for the work you've done. You do whatever you want. You put in your personal account if you want. Or better yet if they just give you a check what you may want to do is form an LLC. All right. Now LLC is a corporate entity. It's a tax entity but provides a lot of benefits. It gives you liability protection. It can help you avoid double taxation depending on how you structure it. It allows you to allocate of profits and losses and expenses and you can choose how you want to be taxed. I'm going to talk to you about that in a minute. Now before I launch into this part of the talk disclaimer Greg already did it but I'm going to do it again. I'm not a finance planner nor an accountant nor a tax planner nor a lawyer. So everything I tell you now is not advice. It's just things for you to listen to. And you need to verify things depending on your own situation. So the corporate structures is a busy slide but there are three different corporate structures that you're going to hear about an LLC an S-corp and a C-corp. For purposes of what we're talking about let's get rid of the C-corp. I put it on here because you may have heard of C-corp at some point in your life. But really it's the LLC and S-corp. Now if you're an individual who's an individual owner probably an S-corp makes sense. It could be a single corporation owned by one individual or you could have multiple individuals. But the benefits of both the LLC and the S-corp is the profits can be taxed on personal returns which means your company doesn't get taxed for any profits that passes through on to your personal income tax. And that's where you will then pay your taxes. Now the benefit of that is under your corporation you can have a whole bunch of expenses that need to be written off of whatever collections you've created. And those can vary. I mean I know of people who put part of their office rent on there. They put a leased car on there. They put a lot of different things on there that are part of their work and related to that income and it helps to drive down their tax bracket. So that's something that you can do with an LLC or an S-corporation. There's different things that you can think about depending again how many individuals are going to be part of the corporation whether you do an LLC or an S-corp. But the bottom line is there are tax benefits for either of these two structures. Talking to a lawyer and an accountant for your individual situation is important. But the biggest thing is the tax benefit. Now there's other things that can happen right now if you have an S-corporation and it's just yourself and you're the single vote voter for that entity and decision maker for the entity. Well now you can think about opportunities to employ family members. Right. So employment of a spouse employment of kids. And what that does again is decreasing tax burdens passing that off into minors or into other individuals who fall under lower tax brackets. There are legal considerations that you need to think about for this and you do need to run this by an accountant. But again these are ways that you can retain the value of the income that you've earned and distributed amongst your family members. One of the things of great benefit is retirement savings. So if you have an LLC or an S-corp you can then do additional retirement savings for your future that you cannot do if you're a W-2 or you're getting paid out through your practice. All right. So remember with a LLC or an S-corp you can pass the profit or the loss to your personal income tax. So if you have a loss it lowers your your your income taxes. If your profit you can you can take off expenses off of your your entity. But you can do also retirement planning. So whatever profits you generated within your S-corp or LLC you can use those profits for retirement planning for yourself. Now there's two different ways you can do this. And as a big bucket I'm going to tell you that you can either secure a defined benefit that you're going to get at the end of your working years into your retirement years or you can say I'm going to have a defined contribution that I'm going to put in. So defined contribution is also known as a simplified employee pension. It's an IRA. There are contribution limits but you can contribute up to 25 percent of your compensation or a maximum of sixty six thousand dollars per year. So if you're generating for example one hundred thousand dollars of income in your LLC from the IME work and workers comp work you're doing you can put up to sixty six thousand dollars of that away into your retirement above and beyond what your other entities are doing. Your practice is doing for you. So you can imagine the numbers can build up very very quickly. The benefit also is though those contributions are tax deductible. Right. So you're not paying taxes a hundred thousand. You're now paying taxes on thirty four thousand minus whatever other expenses. So that's the SEP IRA plan. The defined benefit plan is just the opposite. You say OK there. When I retire every year I'm going to take a certain benefit amount out of my retirement plan. So the actuarials will do this complex calculation and they'll figure out OK every year. Dr. Parikh you need to contribute X amount of dollars out of your LLC out of your S Corp into your defined benefit plan. Same benefits in terms of reducing your tax burden today and giving you tax benefits for the future and being allowing you to then secure an additional retirement plan for yourself. So these are huge financial planning opportunities for you to think about on a daily basis or on an annual basis in your careers at this point in time. So here's if you're looking to take pictures. This is the picture you want to take which compares the two one next to each other in terms of contribution limits complexity and employer responsibilities. So I actually today Greg a number of individuals came up to talk to me and said you know what I'm actually thinking about slowing down in this session. This pre-meeting is a great thing because this is exactly what I'm thinking about doing more and more of. And so post clinical practice this is kind of a way that many individuals many of our peers look to slow down from clinical practice and kind of go into this kind of work or comp work. I mean work before they decide to fully retire. Now if you do that it was talked about earlier today you do need to make sure that you are following state regulations for your state that you're keeping licenses active that you're thinking about. Well if you're if you're not if you're doing radiographs in your in your office and then you're actually doing reads on that interpretations. What does that mean. What licenses you have to keep active. And so you've got to think about all the stuff and work this out before you decide that this is the path that you're going to follow. So there are licensure and board requirements that have to be reasonably followed in order to make sure that you can follow this as you start slowing down. There are challenges and solutions to doing this kind of work. There's admin complexity. Typically depending on the volume of this kind of work you're going to do you may get to a point where you need one individual managing this entire operation for you. Thinking about the paperwork and the documentation and the billing and the coding and the collections. You've got to think about communication challenges because in this situation when you're dealing with this type of work you're not only talking to patients but you're talking to the case managers. You're talking to the employer. You're talking to lawyers if they're involved. You may get deposed. So there's a lot more demand from these patients than there are from a normal patient. Think of it as a professional athlete. I mean when you take care of pro athletes or collegiate athletes there are so many different people that have to get involved in the care of that patient. It's the same kind of thing for four workers comp patients. There's regulatory and legal compliance that you have to keep up with. And if you have a an individual in your office who's making sure things are compliant that's one less thing that you have to worry about. And then again remember these patients can be complex patients. There can be a lot of other factors that you have to consider that you don't have to consider for the normal workers comp patient. And there is constantly a return to work pressure whether it's generated from you internally or from the employer or from the patient. There are pressures to get these patients back to work. So you've got to think about financial considerations. You've got to think about patient compliance and outcomes when you look at some of the data that's out there specifically from the hand literature but even from the trauma literature. It shows that these patients in general take longer to return to their activity. They don't necessarily do as well. There's a lot more complicated things that you have to think about. And all of that has to be taken into consideration when you're taking care of these patients. This is really about managing relationships with the patient with the case managers with the employer with the legal firm if they're involved. And it takes time to coordinate this care and time for you to and patients to be able to give this patient what they need for their care. And then there's always a challenge with litigation. Right. So these patients can oftentimes go to litigation and then you may get pulled into that litigation and that's further demands on your time. So there is a legal aspect to these county patients that you always need to think about. But you've got to ensure that you're compliant with regulations. You've got to continue to educate yourself and your team on best practices. You've got to stay updated on where the workers come care demands for your state. I practice in two different states. And so I've got to think about that constantly. And then I do telemedicine for a number of different states. So depending on where my patient is I've got a variety of different state requirements that I've got to follow. And so it is very important for your practice to be able to keep up with this. You've got to keep up with billing and coding. It changes every single year. You've got to know what you can bill for what you can code for both in the clinic and in the operating room. You've got to do it accurately so that you can collect on the work you've been doing and not accidentally over bill for things that that shouldn't be billed for. You've got to become very familiar with some of the terms you've heard earlier today like work hardening like functional capacity exams like disability rating. You've got to get yourself comfortable with these kind of concepts before you jump to this type of work. And then you've got to figure out how do you measure your success. Is it by the number of patients are able to get back to work. Is it by the number of patients who didn't fool you and try to game the system. Is it by the amount of revenue you generated. You've got to figure out how it is that you're measuring your success. Staying motivated is important because for if you get one of these patients who either dupes you and I've had one who did that it can really be discouraging to take care of these types of patients. And I could have swore this guy was being so honest to me. And then a private investigator came into my office hired by an employer and showed me how I was getting fooled. It happens. Staying motivated is important. So you've got to prepare your office for these types of patients. You've got to have systems in place. Make sure you negotiate competitive rates. Do good work like you would always do and plan financially for your future by meeting with an accountant and a lawyer. Thanks. So that was that was terrific. Absolutely great. The comment on generating using IMEs or using medical legal practice to generate separate schedule C income that can be incredibly useful. And you know the one thing I would say is the other the other corollary is you can do a single entity defined benefit plan where you are the employer and the benefit beneficiary that in theory can be converted to back to an IRA at the end of its time. You don't necessarily have to take the pension that you created for yourself. You can make it into an IRA. And basically the idea is to arrive at 72 with this whole separate massive IRA that you didn't have to deal with otherwise. So it's the that's the concept it's using it to double your your qualified retirement plans or triple your qualified retirement plans can be really helpful. Questions. For that great talk. Two questions. The first one. So I do some expert witness work. I don't do IMEs as of yet. I'm thinking about incorporating that into my practice for expert witness work. There hasn't really been an effect on medical malpractice insurance when you start seeing patients as IME. Is there any effect on that that you can check on or what that is. So you're saying is there is there an increment for your med mal malpractice when you start to do IMEs. Right. But you're already you're already participating as a treating doctor normally. Right. I have not seen that in general. If you retire from clinical practice your insurance goes way down. Brad you can comment on this. Yes I go up here. We have free microphone to their. OK. You know I left clinical practice so I'm exclusively doing medical legal work now. I still need to have malpractice insurance but it's substantially less. It's difficult to find insurance that specifically targets an IME practice. Rather what I've got is kind of under the auspices of an Ahmed type of thing. That's the closest they could get. I think my premium is about four thousand dollars a year. So pretty good. But in terms of if you're already insured for doing general clinical orthopedics I am not aware of a bump for adding IMEs into your practice. Anybody aware of it. I'm not aware of that as well. I think it just falls into under your your your policy that you already have for your medical practice. Generally they're happy to see you do IMEs. It's a lot less risky to them than you doing surgery. Yeah. The second question is you know like there's companies out there that will say hey we'll put you in a panel and we'll get you know cases reviewed for IMEs or whatnot. And it seems like they mostly say we'll give you a set amount per IME which includes the examination report etc. I don't know. I haven't gone too far into it so I don't know what that includes if you were to go to a deposition or trial or anything like that. But would you recommend like on one of your slides this isn't a flat fee or do you recommend billing hourly or what's your guidance there. So I would tell you that you want to come up with a whole like I have a sheet. It's a legal fee schedule. All right. And it has everything broken down for law firms to see right up front before they engage me. It's the first time they call my office. Boom. They get this and they say you want to get Dr. Correct. This is it. And it's a laundry list that they have to. They're aware of. So what you need to decide is if you're going to work with any of those organizations and they're getting a flat offer you a flat fee. What's included in that legal list and what's not included. Because if it if they're thinking include depositions. Well that's a huge hit to your time and that's not going to get compensated well enough in an IME or an expert witness case that they want you to review. So you've got to figure that out. And personally my recommendation to you is if they're giving you some lump sum low rate and that includes everything all legal work I would take it. So I have a I have one partner who did choose to do that when he was first getting started. He was doing IMEs for four hundred dollars an IME. It's quite low. Really low. And it's a lot of work. And you never know how many records they're going to send because he didn't have a restriction on how many records. So you have to be careful when you get into some of those contracts. Some people will do it just to establish their name amongst the legal community in hopes they can get drop that contract later and start doing what we mostly do which is sort of freelance work where the lawyers will contact you. But you're there meeting your fee schedule. Yeah I'll give you a perfect example. A legal firm contacted my office. They wanted me to take a look at this case. They were given the worksheet and they said oh it's not a lot of records. And they they signed up for whatever number it was. They then sent the records. I'm not kidding. This tall. And I looked at him like I'm not doing this like this ridiculous. So we went back to the lawyer and said Dr. Parks not touching this. This is the increased rate. If you're going to do it if you want him on this is when you take. And if you don't want him on this fine we'll get everything back to you and reimburse your money. And then unwillingly initially he did it and he took care of it. And I did the work for him. But you've got to be able to cover your time. It's just not worth it otherwise. So you know I have a set amount that I will include for a standard. I mean it's around 250 pages and my legal fee schedule says that. And then it's my usual legal charge. I think it's five hundred dollars an hour for further record review above that. So they'll get a certain amount with an IME. But if they send more records than that the people that are most likely to do it are outside the work comp system the work comp lawyers that you're usually working with that they're working for the carriers the carriers are looking to limit costs enough people do that maneuver where you say I'm not going to review five thousand pages of stuff without being paid. The work comp lawyers will often cut it down. Some in some cases they will even give you a synopsis of what's going on. They will sort of do some of your record review for you. So the work comp the work comp stuff is fairly smooth. It's the torts. If you become involved in a not just med mal but I'm talking about a tort that say an automobile accident or a slip and fall that's where you will commonly in my practice I will get the four or five thousand pages and boxes and boxes will arrive. You have to be clear in your legal fee schedule how you deal with boxes and boxes because they'll send it to you. And usually I say look I'll spend my time doing this but you're going to pay me for that. And it's not very efficient for them. So the other thing I'll also tell you and I've been burned twice is when is it that you give them their final product like the report. Right. So I early in doing this kind of work I gave the report naively and I then billed for the services. But what do you think happened. I never got paid. And I talked about that in the IME talk at the beginning. I don't do it. A lot of time on that case and it still pisses me off. Then that's one person. So I then decided if they want a phone call and that's there what they want from me or report that doesn't happen until all the billing has been paid up to date before what they want. Right. So that way I ensure that my risk is very little. That's the first thing. The second thing that happened to me is I did that just that recently. And the lawyer sent two checks to pay for it. And he was in a time crunch. He's like I just need to do this phone call quickly. So I did it before. I cashed the checks that morning and I did the call that afternoon. And what do you think happened to those two checks. They bounced. They friggin bounced. And and then what recourse do you have. I mean it's crazy. The bottom line is the best advice for you is to find a colleague in your community that does legal work and and use have some advice on how to structure your legal fee schedule. And it needs to be community based because the legal fees do vary community. So but you know come up with a legal fee schedule that is detailed include some of those protections for yourself including a time you know for for rescheduled IME is what your process is if they don't show. Usually you get paid. But are you going to get them have another chance to come for free. Are you going to have a no show rate. You need to find out what the standards are in your community if you're going to get started. The one of the things you know so I do expert witness work and all the things you said are 100 percent true. I have a retainer. I have a rate. All of that. But it doesn't involve actually seeing patients. You know it's just like I can do it on my own time if I have a slower day or I can do it in the evening. But seeing patients you know in person and examining them is sort of a different thing that you need to set aside more time for. And that's sort of where I was like OK. You know that can take you know you set aside an hour for the person exam or is it going to go longer. And so that's why I just wasn't sure if this is like a bundle thing where you just it's like a flat rate for an IME which includes exam report et cetera or or more like I'm still going because I'm an expert witness. I decide I just go hourly. I have a retainer. But if I go beyond that it just keeps you know the time keeps accumulating. Yeah. I think you have to decide what's custom in your in your group or your practice. But you could have a bundle for an IME that includes X number of pages to be reviewed and the exam and and the report if you want to put the report in there. But if it's anything above and beyond that then that has to get hit with the hourly rate for review or whatever it is. You've got to think about those things. The other thing I will tell you is there are some if you're trying to do this on yourself on your own and somebody wants an IME and they're like oh just come to such and such office and do it over there. Do not do that. Run it through your office because your malpractice usually is tied to the offices where you're at. And if you go off site to somewhere else and you do it you may not be covered by your malpractice. OK. So you've got to make sure it always comes back to where you're practicing. There will be very rare occasions when you have an uncooperative claimant and they will want you to go do something somewhere else. If you do that it's very expensive. I got flown to Louisiana once to see a Hallux Rigidus and I had to get a one day temporary Louisiana license and they literally spent ten thousand dollars on an evaluation of a Hallux Rigidus because it was worth it to them for the claim. But you have to go through all of these hoops. Well you had a point. Is my mic on. Just grab that mic in front of you. I think you hear me. I was going to say to your point about seeing patients. It doesn't add that much more time to your clinic day in my opinion. I think all of us in our group just work those patients in and our regular clinics. And once you get efficient at the exams it really doesn't take that long to go in and do an IME exam as long as you review the records ahead of time. There's some time involved in that. And that's what you ultimately get paid for. But for me to go in and actually talk and talk with an exam and the patient I mean it's basically like just a regular new patient visiting clinic in terms of the time involved interacting with the claimant that day. It's not that bad. At most it's twice as long if they have an interpreter or a nurse case manager. But it's it's not terribly long. So any other questions. And we can take questions on any of the other previous talks as well. I know we work on this. Yeah please. I've got one for Celine. Could you comment just briefly on the logistics of setting up an LLC. Like what do you do. You just go to LLC dot com and type in your name. How does that work. So first and foremost you probably need to talk to your accountant and your lawyer. Right. And they'll talk to you about what different structures work best for your your needs. Number one. And number two they'll also tell you what state is best to incorporate it. So even though you may be practicing in for me New Jersey you still incorporate in Delaware or Wyoming or wherever it is that they feel is tax beneficial for you. OK. And then you know they can do it for you. Your lawyer or your accountant can do it for you or you can just get on to legal zoom and do it on your own. It takes like 48 72 hours to incorporate. It's like five hundred dollars if you do it on your own. It's not a big deal. We have a question from the authoritative source. Dr. Mann. Well first of all great session. Great. Thank you. Put it together very well. When Greg was my fellow we always devoted a half day a week for industrial work and he used to work because we would have these cumulative trauma problems. And I never felt most people had cumulative trauma. I can see it in the wrist pushing on a keyboard or something like that. But everybody has to walk. And I didn't feel that represented cumulative trauma. So I had Greg and I discussed it and he went through and looked at my records. Bunions. Neuromas. What else. Tarsal tunnel. And first MTP arthritis. And I can't remember what all. We had about seven disorders. Yeah. Yeah. And looked in those charts for any evidence of work trauma or what it might involve. And he wrote a very fine paper on that which was the first one I think the literature that ever pointed out that human trauma as a cause of foot and ankle problems. It's not a real entity. I'm glad you're I'm glad we think fondly of that paper. That was. So if you are ever looking for a paper that discusses the a claim of cumulative trauma disorder from vibration or walking on uneven rocks. Roger and I have a paper from I believe 2000 and F.A.I. that uses Koch's postulates the postulates of causation of disease as a framework and is a literature review. And as you said practice review on those specific questions. And it's and it's aimed at specific arthritis posterior to Achilles issues and plantar fasciitis and tarsal tunnel. So the things that are commonly claimed. I think we'd better wrap it up. It's I learned a lot today from my fellow fellow speakers. I hope you did. I know it's a long detailed run. As I said I think this this session is going to live on mostly as a reference interview. I hope it has a long online life. I want to thank everybody. Michelle I want to thank you. These is a tremendous amount of work. Michelle did a tremendous amount of work behind the scenes here. If you don't know these pre-course meetings they start about a year and two or three months ago about 14 months ago. And it's been a long run getting to this point. And I want to thank everybody for their efforts. It's been tremendous. I really appreciate it. Thank you to all the speakers. All right. And we're certainly happy to take questions.

work comp

IME

Independent Medical Examination

clinical practice

financial aspects

depositions

legal management

Complex Regional Pain Syndrome

CRPS

AMA Guides

permanent impairment

lower extremity issues

deposition techniques

practice revenue

tax advantages