Most IMEs answer straight-forward questions on known issues. But there are those rare but important moments where we are reminded that things are not always as they seem, and that an examination can have extraordinary and unexpected value and impact on peoples’ lives. Allow me to share such a story.
Recently MCN conducted an IME on a 46-year-old woman who had back pain complaints in a workers’ compensation claim. The physicians who evaluated her found her to not be fixed and stable, and elected to order an MRI of the spine. It should be noted that the doctors felt that the findings they observed did not wholly fit with the injury claim but that they were significant. Typically an MRI would not be ordered for a low back pain complaint.
Five days after the evaluation she underwent the study. That same day MCN received a call from the radiologist who reviewed the film, calling our attention to unexpected findings of a mixed signal intensity mass involving the lower pole of the right kidney, approximately 4.5 by 4.4 centimeter. He noted that this may represent a renal cyst, but that a renal cell neoplasm could not be ruled out.
We informed the examining doctors who saw the claimant about these findings as well as the claims manager. As Medical Director, my priority at MCN changed in part from processing a report for her claim to doing right clinically by the claimant and ensuring that she was aware of these findings. I called her and told her that we had found something unexpected and explained to her the importance of prompt follow-up, and forwarded her the radiology report along with this email:
It was nice speaking to you this evening. As I mentioned, I am the Medical Director of MCN where you were seen for an IME on November 9, 2013 for your workplace injury. The report is in draft form at this point in time and when completed, will be sent to the department. I do note that the doctors who evaluated you did not regard you as fixed and stable and that you warrant either further treatment or evaluation.
As part of your evaluation, you underwent an MRI on November 14, 2013. The report is attached to this email.
As you can see, the radiologist reading this study noted an unusual mass that caused them to call our office, and it thus came to my attention. We will be letting the examining doctors know about this as well.
While I do not wish to alarm you, it is most important that you seek evaluation for this finding. It is possible that some of the symptoms you experience may be related to this rather than the injury. Regardless, it should be assessed to determine if it is of significance and warrants treatment.
I would recommend that you present these findings to your personal physician and work with them to investigate and follow up as appropriate.
I would appreciate any follow-up that you wish to offer and hope that the findings turn out to be insignificant and that you recover nicely from your injury.
Please let me know if you have any questions or if we can be of further assistance.
Thank you for your attention.
Brian L. Grant, MD
One week later I was surprised and touched by the following text:
Hi, this is (name withheld). I found out yesterday at the mass on my kidney is cancer. Will know more on Monday. Seeing oncologists and urologist. Thank you and please please please thank the two wonderful doctors that ordered the MRI and for taking my complaints seriously. Bless you all.
Several weeks later she underwent a partial nephrectomy at a large University medical center in the region. The subsequent weeks were rocky emotionally for her but in the end she was relieved to learn that she had a clear cell renal carcinoma and that the surgery was able to completely remove the tumor with all margins clear for carcinoma.
And by the way, her claim was also processed with an impairment rating relative to the back findings, and a settlement from the carrier.
My point in sharing this is that the work we do has impact, sometimes in ways we would never anticipate. In this case we identified a tumor causing back symptoms and took the necessary steps to help this patient get the right care in a timeframe that perhaps contributed to a great outcome. I am proud of all involved in this case and we all wish the claimant the best outcome.
Brian L. Grant, MD
This Sunday’s New York Times Magazine published an except of Life, Animated: A Story of Sidekicks, Heroes, and Autism, by Ron Suskind, a Pulitzer-Prize winning journalist with the Wall Street Journal. And father of Owen, who at age 3 was diagnosed with regressive autism.
The excerpt is beautifully written and moving, and provides a candid, eloquent glimpse into the twenty-year struggle of one family to communicate — through Disney characters, movies, and their themes — with their son. Well worth the read, as are the on-line comments.
Brian L. Grant, MD
My friend and colleague David Hanscom MD recently appeared on Dr. Oz discussing his experience and research on chronic pain, and the tragedy of operating on basically normal backs, on people in pain. He has published a book that anyone considering back surgery might consider reading first.
Sadly, common sense and good care as represented by Dr. Hanscom does not pay. No expensive back implants are sold, no surgical fees generated and no hospital stays take place. And for those who were not truly injured but underwent the knife for symptoms and not true pathology, they decidedly have an injury afterwards. This is tragic.
“You’ve got to play the hand you’re dealt,” says Paul Gaylord. This doesn’t sound like a loaded remark, but it is when coming from a man whose hands were, literally, dealt quite a blow; after a bout with bubonic plague he lost eight fingers (and all of his toes, and nearly his life — his recovery came after doctors had discussed with his wife when to remove him from life support after his 27th day in a coma).
MCN processes a lot of reports related to disability claims. As we address questions of causality and medical improvement, it’s important to remember that each claim is not just a report, but that it represents a person, and human suffering, and is also just a very small glimpse into a person’s life. This article is striking in its outlook, and a refreshing reminder not to confuse a misfortune in a life with an unfortunate life. Certainly Gaylord doesn’t.
“I say I’m actually a 1-year-old because I got a second chance at life,” he said. “I can do almost anything I could do before.”
Undoubtedly Gaylord has struggled immeasurably with recovery and adjusting to his new body and all that he had to learn how to do differently. But as the article notes, the Gaylords have a sense of humor about the whole thing, and Debbie Gaylord said her husband has always had a positive outlook about it.
There are numerous studies which show that an injured or sick person’s outlook and attitude are major components not just of how well they will recover but whether they will recover at all. But a study, like a report, is not a human life; and sometimes it is from that individual life that we learn. Certainly there is something to learn from Paul Gaylord and what he has chosen to share with us: that a disability or an illness does not mean that life stops. “Toes are overrated,” Gaylord said. “And I can do a whole lot with just these thumbs.”
This interesting column by Abigail Zuger MD, addresses divergent views on patient/professional boundaries. She outlines a challenge but does not answer it: when if ever is it OK to engage in the outside lives of our patients? Perhaps a good way to frame the answer is to be able to ask one’s self as a physician whose interests are being served? If it is truly the patient’s, one may perhaps breathe a sigh of relief and proceed. But how many have the capacity of introspection and self-knowledge to know whose interests are truly being served? And how many physicians’ cloudy thinking about helping their patients by gratifying immediate wishes or needs, are actually mistreating patients by for example, prescribing narcotics inappropriately, thoughtlessly filling out forms endorsing disability or other entitlements upon request, and other actions that cheapen the profession and hurt patients.
Boundary breeches are fraught with hazards. Thus they are generally engaged in by the naive, the scoundrels, or the saints. Sadly, many a scoundrel thinks their actions are that of the saint.
Occasionally my mother comments on my daughter’s weight, which strikes me as out of line since my daughter is only four years old. I don’t want to her to start having body image worries. Aside from the fact that both my daughter and her brother are on the thin side (note that my mother never comments on my son’s weight), my mother might just (inadvertently) have a point.
For many obese adults, the die was cast by the time they were 5 years old. A major new study of more than 7,000 children has found that a third of children who were overweight in kindergarten were obese by eighth grade. And almost every child who was very obese remained that way.
Some obese or overweight kindergartners lost their excess weight, and some children of normal weight got fat over the years. But every year, the chances that a child would slide into or out of being overweight or obese diminished. By age 11, there were few additional changes: Those who were obese or overweight stayed that way, and those whose weight was normal did not become fat.
“The main message is that obesity is established very early in life, and that it basically tracks through adolescence to adulthood,” said Ruth Loos, a professor of preventive medicine at the Icahn School of Medicine at Mount Sinai in New York, who was not involved in the study.
The most common orthopedic procedure in the United States appeared to be no more helpful for some patients than a completely simulated surgery, according to an unusual Finnish study.
The Finnish study does not indicate that surgery never helps; there is consensus that it should be performed in some circumstances, especially for younger patients and for tears from acute sports injuries. But about 80 percent of tears develop from wear and aging, and some researchers believe surgery in those cases should be significantly limited.
Arthroscopic surgery on the meniscus is the most common orthopedic procedure in the United States, performed, the study said, about 700,000 times a year at an estimated cost of $4 billion. Read more…