Great. Thank you. Well, hello everyone. I'm Sunil Savarwal, and it is my pleasure to introduce you guys to Dr. Rondinelli. So my role in this is purely as an interested participant. The reason I came about to be moderator was that we were brainstorming topics that would be of interest for Medical Grand Rounds as part of the AAPMNR Medical Education Committee. The reason I suggested this topic was because I know that, you know, a lot of folks I've heard from and have continued to hear from is people who want to diversify their practice or supplement it. And those who might be thinking of transitioning and a lot of people have to COVID especially have been rethinking practice or, you know, thinking of retirement, but still want to continue to do something. It seems like, you know, this is a relatively low stress, predictable kind of area of practice focus. So, you know, there's obviously interest amongst that and I see there are already 40 participants on this call. So, and more are joining in every few minutes. So, so it's great. I am not going to spend too much time. Dr. Rondinelli has an extensive CV. Let me say that when we talked about this topic then there was question is who's going to present it. And the first and only name that came to my mind was Dr. Rondinelli. I've known him since early days in AAPMNR when I heard him present at the AAPMNR. I think he gave a Zeiter lecture and also was involved in the pre-conference and post-conference courses that used to be held on disability evaluation in the 2000s. And I know, you know, so he's also the, so there are many, many things that Dr. Rondinelli has done, but I think when you look at the reference list in the last slide. For those who don't know, he was the chief medical editor for the sixth edition of the Guides for the Evaluation of Permanent Impairment published by the AMA, which is the current edition. And it's updated periodically. This was, I think, in 2008. They do have an editorial process to update it regularly, so they updated it, but it's still called the sixth edition. He's also written, and that's also part of your reference list, he was one of the editors for the PMNR clinics of North America in 2019 on disability evaluation where he's written a couple of really good chapters on it, which he will refer to, I think, and provide you in the reference list. But just briefly about Dr. Rondinelli, so he started his career in physical anthropology, which I believe really put him in great sort of stride in terms of interest in actually measuring and quantifying physical impairments. And he has been in extensive work as a clinician, really well regarded in our field for many, many years, served as the professor and chair at the University of Kansas Medical Center for many years. He was a board member of the academy. He's been a president of the AAP. He has done extensive publishing, I think more than 70, 75 peer-reviewed publications, books and books chapters, including the ones that I spoke about and spoken extensively on this topic. He is a certified independent medical examiner, a member of the American Board of Independent Medical Examiners, and has many, many awards and recognitions. The one that impressed me most in his CV, he's the fourth-degree black belt taekwondo recipient, but he has many awards. So we could go to the next slide. And I think, Dr. Rondinelli, maybe you are able, because looking through your CV and your introductions, I felt that that itself was a learning point in terms of, you know, how to best position yourself to market your services to folks who might be looking for your services. So I'm sure you might talk about that. But Sami, can we advance to the next slide? So... We can. I am running into another issue of not being able to... You could go back to that other mode. Okay. I think that's what we'll do. Sorry about that. That typically doesn't happen. I think I just wanted that the next slide is really about how the flow is going to be for this particular talk. And that's number five, I think. And so, Dr. Rondinelli is going to be presenting. Earlier, for those of you who haven't checked your email, I believe for all people who registered, you got an email from AAP Menard with two attachments, case studies. And I do want to tell you about a funny thing that happened in the last two hours or so, which you may have the same things that I did. I kind of looked at those attachments and panicked. I thought, there is nothing redacted. There's a name there. And then, of course, I realized that the name of the person was Hurtman, which made me think maybe, hopefully, this is a fictitious name. The orthopedic surgeon's name was Carver. So, of course, that was Dr. Rondinelli's sense of humor. So, rest assured, I made some panicked phone calls and emails, but rest assured, there is no personal health information being shared. So, those case presentations have been sent to you. I think there are some restrictions in Zoom in terms of uploading them, although Sami is going to try that. But we'll share the screen and go over those. I think they have a lot of good learning points. Dr. Rondinelli will leave time for questions in between. He's going to first talk about how and why physiatrists can best position themselves to be the disability evaluation specialist, take some questions, then present the case in two parts, and really cover key concepts and take home points with final takeaways. So, I think that is all that I have to say, and I'll turn it over to Dr. Rondinelli. Thank you. So, thank you all for joining us. I am Bob Rondinelli. I'm semi-retired as a physician, and I've been around quite a long time. I'm 74 years old. And so, some of those accomplishments and things that happen, if you stick around long enough, a lot of neat things can happen. Fortuitously, for me, when I took an interest in this was that right around the late 1990s and into the early 2000s, there were a number of medical entities that sprung up that were trying to capitalize on the demand for people to do disability evaluations. Largely within workers' comp, not entirely. And so, the American College of Occupational and Environmental Medicine sprang up, and they started physician education programs to get doctors from all fields to come and take their courses, and so on. And then the American Board of Independent Medical Examiners, the ABIME, about the same time was formed to provide a certified training and education program, which they still do. You can go online and look at them if you want to get some additional information on how you can become certified as an independent medical examiner. We, the Academy, came to myself and one of my partners in crime, Dr. Richard Katz, and we both had a strong interest in this area. And the Academy at the time said, let's create a course where the participants can get a certificate, and it's taught by physiatrists. And so we took that on. We didn't have a textbook, so as a result, we co-authored a text, which appeared in 2000, called Impairment Rating and Disability Determination. And what was nice about this was it incorporated a number of PM&R docs to help us write it, and it got out there, and the American Medical Association got wind of it. At the time, they were using this Volume 5 of their Guides to the Evaluation of Permanent Impairment. And Linda Cacciarella, who was the lead editor on that particular project, came to our course and was blown away. And some of the things that we were doing was we were critiquing the AMA approach because we felt that this type of measurement was either bereft of functional assessment or it was severely overlooking what's really going on, so that you could have somebody who's a transradial amputee here in Des Moines, Iowa, a farmer gets his hand in a corn picker or something like that, he can come to Methodist Medical Center where I'm at, it's a Level 1 trauma center, and get his acute injury repaired very quickly. A hand surgeon can help with that process, and pretty soon he's got a very nicely healed limb. In the meantime, he's getting very rapid treatment with the therapies that he needs, OT and PT, and the prosthetist comes over, and eventually he's fitted with an upper limb, body-powered prosthesis with an industrial hook and can go back to doing about 95% of what he did before. But if somebody else might come in with a less effective outcome and possibly some type of severe neuropathic pain could arise and things like that where they can't accept the prosthesis and so they don't gain that level of function. So what we tried to do was convince the AMA, and they did, and we ended up creating a sixth edition of the guide that came sensitive to functional assessment, that's the guide, sixth edition here. The other thing it did is it incorporated a number of PM&R physicians, myself and Dr. Katz were two of six editors on that project, and then we had a lot of contributors from the PM&R field. And so just before all that happened, we did a stint with the PM&R clinics, and I was pushing that a PM&R box, this is a field that's wide open, and so we should proceed. And so if you could have the next slide, please. I think that as a preferred IME specialist, we have a lot of expertise and claim to fame that I think has served us well. So for example, we're inherently familiar with neuromuscular and musculoskeletal injuries, that's a large part of what people experience in the work arena, our perspective on functional outcome measures and assessments. We develop tools such as a FIM, so we understand that when you're trying to get somebody from a temporary situation where they're being treated, and they're being out of work, and they're being paid by Worx Comp, into a situation where they can go back to work quickly and expeditiously. Alliant's share of the cost associated with this is administrative and time downtime, and so anything we can do to move a claimant through expeditiously is important. The cost containment strategies, I have a little anecdote, when I was, I traveled around a lot. First job I had was at New England Medical Center in Boston, that was before Asuna's time, but I spent a while there under Bruce Gans, and then I moved on to Colorado, and while I was there, I was exposed to the AMA guides. And basically, I was working in a hospital Rose Medical Center where we had a very prominent outpatient and inpatient physical therapy program that included work injury, and one of the things there was the chief, the president of our medical staff was a very erudite neurosurgeon. He was also a JD, so, and there was a popular joke called Night Court, and he was one of these guys that I don't know when he ever slept because when he wasn't operating or doing things, he'd go down and he'd be participating as a judge at Night Court, of all things, and he did that as pro bono work. So he was a really good guy, but what he did is, he knew, you know, when he could operate safely on somebody with back pain and there's not a whole lot of those, and most of his cases with back pain were an albatross to him because he didn't know what else to do, so he put him in therapy. And he was running up the cost of our therapy, et cetera, et cetera, so they got me involved, and I went and sat him down and said, look, you're a brilliant guy, you got all these talents, you do surgery, post-op recovery, we don't want to say anything about that, but you've got somebody that you're not going to operate on, why don't you hand them over to me, and I'll take care of them, and I'll take care of their therapy. And he was glad to do that, and as a result, we cut our lengths of stay in therapy precipitously, et cetera. So we're inherently good at doing the right thing with these kinds of patients. I have the next slide. Maybe you could just put that X where it says always use subtitles, then the slides might get a little, you know, at the very right side where it says always use subtitles, and lower down next to the slide. Yeah, thanks. So, along with that, we have, when you're treating somebody, you also have to know when enough is enough, and we do functionally designed goals, and when they're achieved, they're no longer tenable, we can move on and get them out of treatment. And that's closely linked to a concept of maximum medical improvement, which I'm going to talk about, and I look at it as maximum functional improvement. When I decide somebody shouldn't be treated, we can close their claim. It's usually when we've done everything we can, and we can still do maintenance things with home exercise and things like that, but they're basically not expected to get any better. Some of the tools we use to determine strength, range of motion, things like that are inherent to what I learned when I was a physical anthropologist. And they're not, you know, if you're hanging around therapists who are doing musculoskeletal rehab, they do a lot of neat things with boryometers and stuff like that to document the improvement of their patients. And again, finally, one of the things that this involves, the physician has to be prepared at maximum functional improvement to say if this individual is going back to work and restrictions are indicated, we have to know why. And so having a good background in the functional consequences of what they're asked to do and the risk that poses is very important. Okay, next slide. So basically what I'm going to talk about a little bit is a real life experience I'm having doing independent medical evaluations. What they are, or independent medical examinations, that's an interchangeable term, but basically what this is, is the medical examiner is independent. He is not, or she is not directly involved in the treatment of the claimant or the patient. And the reason is, we're supposed to be impartial. We therefore cannot, if we are treating the claimant, then we assume a role as a physician patient relationship and we're by definition their advocate. We're not the advocate, we're not the adversary. We're supposed to be totally impartial. There are other things in work comp claims that this comprises. Personal injury claims are a little different. I'm going to be going after a menu of things I'm going to walk through that work with compensation requires, it's their convention. Some of them are germane to personal injury claims, some others are not. Personal injury is more about finding fault and then attaching monetary value to the severity of the fault. Whereas what I'm doing is, and what I'm talking about, it's more about identifying a problem, labeling it medically, and then talking about the consequences of it, and the fact that it was created in the process of some type of an injury And if all that lines up, then figuring out how bad it is using something called an impairment rating guide and then affixing an award and making restrictions to pursue it to that award. So that's the kind of difference. Chart reviews, I hardly ever do them, because then I don't have the access to the claimant or the patient to talk to them and examine them. And I can't tell you how many times I'll go in, I'm inherently conservative, and I started out in this whole business, representing the defense, that's the companies that are getting, having to deal with claims against them that have financial ramifications, etc, etc. And I found the defense side of things very easy to do. All I had to do was be willing to think it through and you can argue two sides of anything and come down on the side of saying, there's nothing seriously wrong here. And what I found out is, along the way, being a PM&R doc and having to work with patients that might have the same physical impairment and very different outcomes, we're not all equal, we're not all the same. And so there's extenuating circumstances, context, the whole thing that the ICF goes after with personal environment, social environment, everything else that contributes to how severely impaired and disabled somebody ends up. And so my caveat is chart reviews are probably, in more instances than not, invalid presumptions about what's really going on. Next slide. Okay, so the IME is basically then an evaluation by an examiner who's not treating the patient in some way. And we have to do a chart review and summary documentation for our report that shows that we're a mirror of things. Some of this can be, you know, I've got a case sitting in front of me right now. 1600 pages of stuff. It has nothing to do with the actual problem that this guy had, which is he fell down a flight of steps, five steps and hurt his head and they're debating whether he had a mild TBI or not. But everything else is there if I want to look at it. And then I've got about 150 pages of medical review that really pertain to the fact that this guy had no loss of consciousness documented and had how he was when he walked into the ED, etc, etc. And normal CT scan, yada, yada. So we have to be flexible enough and review the pertinent things and then reflect that in our documentation. History and physical examination, I'm going to walk through very quickly some of the key points that I've acquired in doing this because this is going to be something that is read by attorneys, not doctors, and they're basically duping it out. Most of my referrals now come from the plaintiff side of things, and then the opposing counsel and their representatives that may be also offering an independent evaluation to rebut what I'm saying. But anyway, at the end of this, I give the attorney something straightforward down to earth that they can understand and then the rationale, how it fits into the ward, why. And again, I base a lot of this on the functional impact I see it having on somebody. This goes a long way. And then I have to answer some standard questions and address certain concepts in the courts of answering those questions, if those attorneys, the information they need, and justify the type of discourse that goes on when they're mediating a claim with another attorney or when they go to a deposition or into an actual trial. Next slide. Okay. Let's see. We got a little break here, I guess, for questions, if there are any. And I would say, as you think of any questions along the way, just put them in the chat and we'll bring them to Dr. Rondinelli's attention either at the end or if they're pertaining to a particular slide, then in between. Now I think we've got the first part of our case presentation. Is that correct? Yeah, that's correct. So I'll go ahead and share the case A. So if you're able to see this, I'm not seeing anything, but I don't need to, because I've got it right in front of me. I'm going to pull it up just right now. And I'll also say that you all have it in your email, so even if you don't have it, here, it's got a lot of good points highlighted. Okay, there we go. Yes. So what I did is I split this into two parts. The first part is pretty much the chart review, interviewing the claimant and the questions I'm asking, and then getting ready and the examination. The second part is, what do I do with all that information to answer those particular questions? So I set this up in a way that you could look at. I started with a real case, changed the names, changed the dates, changed a lot of stuff, made it a lot shorter, but the structure includes some elements and things that I think are worth mentioning. So first of all, see the forest through the trees. When you start working with attorneys, you know what they're looking for. I'm not saying give them what they want. Give them what they're looking for so they understand where you're coming from. And that goes a long way in terms of business if you're trying to get these people to come back and use you time and again. And you have to frame your arguments accordingly. So in this case, I got an interested attorney. I'm addressing this to, I've got a claimant. His name is Ernest Hartman and his date of injury is specified. And then I start out indicating that thank you for referring this claimant. And I've reviewed substantial records on this claim. And I talk a little bit about this. In this particular case, I say I spent 90 minutes personally interviewing and examining claimant exclusion of composition of this letter. The reason this is important is a lot of these things, they may go to trial. They probably don't. You've got two attorneys opposing to try to get together and mediate and split the difference or something like that. And then they don't waste a lot of time and money in the courts and so on. But in order for, if there's an IME and I'm providing and they want to pay me for my time, which is what they pay me for, I'm covering things that include a chart review, a hands-on interview and exam, and then a subsequent dictation of report and et cetera, et cetera. And I tell them pretty much a portion of my time in each of these things and how much total time. And then I build by the hour in order to ensure that they get as much as they can this. If this goes to court, a judge may award the cost of the IME or he may not, but they've all agreed as a matter of policy that any hands-on face-to-face type of encounter that I had should be reimbursable. And so it just helps them sort out how much this is costing my charges and where it's going and then how they disperse. Because at the end of the day, if it doesn't get resolved, it comes out of the award that the claimant received. So, okay. Then I let them know I'm board certified. I've got all kinds of credentials having done what I've done. And I think that it helps in a way to blow your own horn a little bit in this sort of thing, because when they're putting your CV and your work and you're calling your report up against somebody else, a lot of this has to do with credibility. I've been in Iowa for about 20 years now and seriously doing IMEs as opposed to hospital-based work for about seven years. And I've got, I think in the last seven years, I've been deposed three times. I haven't gone to court once, believe it or not. I think a large reason for that is I am very straightforward. I write good reports. I'm literate enough to do that, substantiate them, and people don't want to tangle with me. And I know what I know, and I stay on the footing. If anybody wants to come and challenge me about my interpretation of function or what I'm doing, I try to be conservative to a point. A plaintiff's attorney cannot pay me for my opinion just for my time. But at the end of the day, I go forward with some conviction that I'm doing the right thing for the entire system by being fair and perceptive and correct. And so I delight in doing this work. And it's really, there's very little drag on me for doing it the right way. The other thing, so then I go on. I'm not now, nor do I intend to enter in a physician training relationship. I explained to them that I can interpret tests. If we need some additional tests, I can recommend them. I can't order them. And then I can interpret them, but I can't treat because of what we talked about. Then the other, so in the history of present illness, I want to basically get a sense of, and in this case, this is somebody that was hired in September, 2018 and worked for two and a half years before reporting a work-related injury. That goes a lot towards his credibility. He survived, he's been in some kind of a productive capacity working for somebody, good job satisfaction, not shopping around, doesn't have an erratic work history bouncing from here to there. Did he have any prior history of injuries, work-related, any claims that were granted and what were those? We're looking for red flags, particularly in relation to the credibility of this plaintiff or the person who's claiming the injury. The other thing is it's nice to know what they're doing. In this particular example, this is somebody who's got a medium heavy work. So he's maximum lifting would be 50 to 75 pounds unassisted, but he can carry 80 pounds, 40 in each arm, spools of wire or whatever it was that he was handling as an electrician. So I know what his baseline was and where he needs to get back to. Then did a discrete injury occur? If it did, it makes it a lot easier to work within a model. This guy, he had no prior back problem, let's say, and he lifted a 95 or 100 pound something, felt a twinge of pain or a pop in his back and some ridiculous complaints that were never there and he goes on from there. You've at least got an event and whether it's credible or not, it's something to focus on. A lot of these are things where somebody might have come in with a mild back strain, that's very common. Maybe after the second or third visit, they get x-rays and they've got spondylosis. Well, everybody's got that. So what do you do with something like that? Basically, you don't always get a discrete injury or you may have somebody that had prior injury, a prior injury got better and then all of a sudden now something's happened and he's not getting better. By teasing out on the front end what's going on, when you come back to the issue of causation, you can deal with that ambiguity if it exists. Also, you want to know how this claimant is perceiving their pain, the level of severity, the quality. In this particular case, this was somebody who fell, landed on his right shoulder and then sought immediate medical attention, which not everybody does. Credibility goes away to some degree when you've waited a month before you show up and are claiming an injury that happened a month ago, but it does happen and sometimes it's very explainable and understandable. Somebody who takes a fall, want to make sure they didn't do something else, hit their head, etc. That's very important to make sure that you're not dealing with somebody who's got a mild traumatic brain injury on top of everything else that's getting out of hand. Then the imaging studies go to the severity of the impairment and obviously if somebody has a spinal fracture or dislocation or something of that nature, that's a quantum difference in terms of what you can objectively verify relative to somebody who's got a complaint of radicular pain. In this particular case, the first blush, this guy, a 35-year-old, and this was a non-dominant shoulder injury and pain strain. They treated him with Catorlac and medicated him with cyclobenzaprine and NSAIDs, etc. Then he goes on, doesn't get better, so he gets referred to an orthopedic shoulder specialist, Dr. Carver, who finds some unilateral positive impingement signs and is convinced that there's something there. Based on the fact that they didn't see anything with the work up to date, he orders an arthrobrand, he's perceptive enough. At the end of that, I said May 24th, it should have been April 24th because otherwise he's going to be reviewing an x-ray that was taken two weeks later. Anyway, he ends up with a full thickness rotator cuff tear involving the key tendons, the supraspinatus, no atrophy, so it looks pretty acute, no labral tear to compound the problem. He gets sent over to Dr. Carver, who does an arthroscopic surgery on May 5th. That includes a mini open repair, subacromial decompression, two very common things, and in this case, I highlighted a distal clavicular excision. All that means is there was some impingement going on in the, that's a partial arthroplasty, if you will, of the acromioclavicular joint. That thing, for whatever reason, when you go to using the Amy Kites Fifth Edition, which is what we use in Iowa, if you have a shoulder injury and you had surgery and you have a distal clavicular excision, it automatically gives you 10 points of lower extremity impairment, automatically, in addition to any range of motion loss, anything else. You wouldn't want to miss that. I'm just calling attention to it that there are those diagnoses out there that are worth something, whether there's any functional ramification or not, it's just the way it is, and it doesn't mean if you pick that, you can't use other things as well. In this case, it's a diagnosis that can be combined with other conditions, and I just want to make you aware, when you're dealing with musculoskeletal injuries, very often you do have these images, and it's funny because sometimes the surgeon forgets to say he did it in his op note, and then later he refers to it, and I've seen that, and then I had to go back and verify, but then once I've got that distal clavicular excision, I want to hang on to it and make sure that it's not contested down the road, so I have to verify that. Okay, so the post-op course was uneventful, and then at some point here in October, about five and a half months later, this doctor opines that Mr. Hurtman, it should be, reached maximum medical improvement on October 15, 2021. Well, so what I have to do as I'm reading all this and take note is when I talk to the client, is there data to support or refute that he's done everything he can at that point, and then we can move on, and then I can reference that date per MMI if that's appropriate, or if I don't agree with it, I should be collecting data to refute that opinion, because a lot of times these guys get rushed through, and they don't necessarily get, or they, you know, it's, I hate to admit it, but doctors will kind of, whatever paintbrush they're using paints a picture of a hunky-dory situation with their excellent surgical care, and they claim it is feeling just the opposite, and that's not all fabricated. There are situations that I see that are kind of surprisingly bothersome that this sort of thing goes on, but again, it's important to satisfy yourself that what needs to be done was done, etc., and then he's also postulating an impairment rating, kind of one to two percent range. Well, right there, he didn't even acknowledge the 10 percent that's there for the distal clavicular excision, so in this particular case, Dr. Carver isn't being fair to his claimant. Okay, chief complaint. What's so important about this is how is the person now, if you're getting them to the end of the rope and the case closure, you're not being asked to treat, you're asked to close their claim, how bad are they relative to what they were like before? So, one of the things I do, and you should by all means learn to do, is provide a reliable, valid, functional review of systems, and what's nice about some of the tools out there, and I'm not here pushing anyone, I use some of these really simple things like, in this case, there's an upper extremity functional scale, which is a sub-report, albeit subject and inventory, of 20 items, 18 of which are specific tasks relating to upper body ADLs and work functioning, and the other two are they're grading themselves overall on their work ability and their recreational pursuit that they still do them, and so it's a five-point scale, and what you end up with is an index, in this case, 20 times 4, 4 is the highest score, means there's nothing wrong with you, you're as good as baseline, and his raw score was 46, so he divided by 80, and he gets an index of 58. What that means in this particular case is he's perceiving he can do 58% of what he was doing before got hurt, which means he's perceiving he's 42% disabled, so now if I go and he gets a 2% impairment rating, I can argue that, you know, hey, wait a minute, now, you know, he's got a discipline decision worth 10%, and there's some other things going on. I'm not going to get him to 58%, that's a hopelessly large number, but I can sway the opinion of a person who reviews all this when they go to mediation, who's the deputy, and he's probably somewhere in the middle, not an attorney, not a doctor, but somewhere in the middle trying to figure out how he can resolve this thing fairly, so the more information I can give him that's credible, reliable, and clarifies what's going on, the better, so functional review of systems, that should be any PM and R docs' forte, and we do it better than just about anybody else. Okay, I'm going to speed up here a little bit, past medical history, barriers to recovery, potential red flags, prior musculoskeletal trauma, repeated injuries, multiple network contemplates, things like that would be concerned, social history, what kind of support system and safety net does this individual really have to turn to when we're this child, and then finally, goals, and in this case, if you read it, they're pretty legitimate, he wants to continue performing his present job with GE, acknowledges he has some residual difficulty, particularly working at above shoulder level, and I'm going to come back to that, because this guy did a beautiful job of telling me what's really bothering him, he can't sustain work at or above shoulder level, and if he could, he'd be doing his work, and if he can't, he needs some help, and the system is a little bit off kilter at this point, because nobody's figured that out. Okay, physical exam, I'm downplaying this specifics, don't really matter here, I can include things like Waddell's test, you can argue many of these tools that I have and work with as to whether they're worth anything or not theoretically, and in terms of a research environment, they may not be, but in terms of me understanding what the claimant I'm examining is telling me, either through body language, through their, what they're telling me verbally, or what they're displaying, I can size that up and weigh it and get a feel for, is this a person for real? I would tell you this, almost all of the time, I come away at the end of one of these things feeling like this individual is for real, and whether they've got me fooled or not, I'm sympathetic to that, and I'm responding to that, and I feel good about myself as a doctor, because I'm able to do that. So that's the first half of the H&P, any issues or questions about that? So Bob, just to heads up, we have 13 minutes to the end, so I think one question that has come up is how was the raw score translated into the index? So it was divided by 80, which is the max, and it's a percentage of eight. Great, and then Alan has written that disability insurance industry is another potential good source of business other than workers comp, so. Yes, there are more, I'm picking the one that I'm most familiar with and doing most of my work with as an illustration here, but yes, it does not. Okay, so let's see, we're gonna, I wanted to talk about some concepts and just walk through them. So the next slide has scientific versus legal problem. Sorry, I'm working on that. If you want to just go through it, Dr. Rondinelli, I'm working on sharing it. Thank you. One of the things that we have to do is deal with causation and causation means why did this, why are these, why is this condition present? Is it an injury? Is it an illness? Is it something else? And in talking about this, we have to use a probability and medical probability is scientific probability and it gets to be no hypothesis. The probability that this is not true after a significant finding is less than 5.05, but in the legal arena, but only has to be more likely than not, which means it's more than 50%. That's not very scientific, but if you can say after reviewing this, I believe it's more likely than not that such and such happened that this individual basically strained their back and got a herniated disc and resulting radiculopathy that wasn't there before, then that's what we need to be able to do and put it in those terms. Okay, next slide. So causation means that event A gives rise to an outcome B and in medical legal terms, it means within medical probability, which is more likely than not. And so again, one of the first things they ask is what are the diagnoses and I have to list them and then of those diagnoses pursuant to this claim, what causal relationship do they have to the injury that's being claimed? And that's where I have to go through each one and then point out if there's a probable cause or not. Now, causation could be proximate or ultimate or both. So approximate causation would mean, yes, so-and-so fell, slipped onto mice, fell and fractured their wrist. And so that's a direct proximate cause and they were doing it on the way into their place of work on an icy day. So it happened on the way to work. And so it is proximately causally associated with work and therefore this claim is being managed under workers' compensation. Ultimate causation is a little bit more complicated, but basically if I can show ultimate causation as well, what that means is, is the work that the individual is doing at the time the injury occurred a culpable situation? If they weren't working, would this have happened? So an example would be, I saw somebody that was a new employee of a mattress company and first week back at work, it was flu season, they went and have a flu influenza. And he basically had eight or nine years earlier, a small reaction, didn't wanna get it. And then they kind of didn't coerce him, but they strongly suggested that if he gets the flu and this is work, he's not gonna be compensated for it. And so he decided to go ahead and get the flu shot. Well, he got the flu shot, unfortunately, five weeks later or something like that, he ended up with a Guillain-Barré paralysis that was quite significant. And in terms of the, it's all worked out, what criteria you have to meet for them to attribute proximate causation to the flu shot, which they did, but ultimately was he at work? He got the shot at his workplace. And so, yes, I think it all fell in together, but it wasn't because he was working on the mattress or whatever, but he got his Guillain-Barré. So those are two concepts. I'm just throwing them out there. And in this case, just to give you a little idea of what we're talking about. Okay, next. Exacerbation is temporary worsening of a condition, which is aggravation, which is permanent worsening in terms of something when you have a preexisting underlying condition. So let's take a lumbar spondylosis. You get, you're a 42-year-old individual for last eight years, you get cyclical back pain, comes and goes, when it comes, maybe it's the weather change, maybe it's not, maybe you work out sometimes and then you don't and you go back and you got your back pain, you treat it with an NSAIDs, stretch, exercise, it goes away and then you keep on going. So that's not uncommon. Then somebody like that gets an injury and they're not getting better and they're claiming something's different and they image them and basically all they end up with is maybe a disc bulge here or some foraminal stenosis there and things like that. And so what do you do with that? So I've got a little diagram, it doesn't, I can hold it up here, sorry. But the basic idea is- Bob, just to let you know, you have about seven minutes to nine to the end. I'm gonna hold this up and I'm gonna try, can you all, if you can see that, there's a curve from here to here because you're starting out here functionally and over time you decline. If you've got a back problem, it's not really stopping you and you're, for the most part, you get good till you get really old like me. Down here, this would be a cyclical event, maybe you've got a strain of your back and it's a dotted line and you lose your function for a while and then you climb back and as time goes by, you're back to where you were and you continue your eventual decline. That's a temporary exacerbation, that's the technical term point. That's not worth anything to work with, because you've been healed and there's no residual. But here, if there's a sentinel event and you drop down and you stay down and you never get back to that other curve that's what we would consider a permanent aggravation. So you may have a condition, spondylosis, dysbiosis, et cetera, and then if you can make a case that somehow this is quantitatively, functionally changed over time, that's a defensible point and might allow for some compensation. Okay, let's see. Permanency. In order to determine whether somebody is eligible for a reward, they have to basically have a permanent injury, which is either a new injury, acute injury, or a permanent aggravation of an underlying condition. There's a healing period that's arbitrarily set as 12 months. Doesn't have to be, but a lot of people, what they'll do is they'll do an operation like a low pedicup repair, and then on the first year date of anniversary of it, they'll say you're an MMI if everything went well, and then they can move on and settle their claim. A lot of them get settled much sooner than that, six months. I think basically a lot of it has to do with are there any residuals, and if so, are there things that can be improved by? So that all has to be addressed when you're walking through what the conditions are at MMI. Now, MMI means maximum medical improvement, which also, let me see, I'm getting a little ahead of myself here. Let's go to, yeah. So this is a point in the recovery process where a necessary and appropriate diagnosis has been provided, an adequate healing period has transpired, and there's no further expectation of physical or functional recovery to occur with additional or ongoing treatment in the future. So that's the point which we should be moving on, closing the claim, and as long as you've got those requirements met, you can do that. Next slide. There's a question about MMI in the chat, which is how do you determine that the patient has exhausted all treatment probabilities? For example, do you think of things like PRP stem cells or spinal cord stimulation? Right. I think that's a matter of opinion, and that's a good question. It's a complicated answer. A lot of this may have to do with what things are available, realistically available for that individual in their environment where they're being treated. I see a lot of people that have psychological issues, PTSD, possible mild TBI, and they can't always get the necessary and appropriate psychological care they need, and sometimes you get into a situation where you say, unless this can be done, they're not at MMI, but then I also know that this thing may go on forever if I don't close it, but I can give a provisional rating, assuming based on what I know what's happening, and people have to use judgment. We are at 8.57. There's a question about what happens if the event runs over time, Sammy, and we want to be as cognizant of time as possible, but I think it's okay to go over about five minutes or so. We will try not to do more than that. So there are a couple more questions and we can take those at the end. Yeah. I think it would be nice to, if you want to finish up, Dr. Rondinelli, your final thoughts, and then we can open the last few minutes up for any questions, and this might just be a good opportunity for a part two. Well, I'll try to kind of cut to the chase here. So let's see. Next slide. I only have about four or five slides, and I can maybe make points whether we do the actual chat review or... So a permanency, we've already talked about that. Impairment rating, basically, so an impairment is basically defined as any loss, loss of use or derangement of a body part or an organ system or organ function. So it can be a functional loss or physical loss, and the AMA guides is divided up into sections on different body systems, as cardiopulmonary, respiratory, vascular, GI, vision, et cetera. These are all organ systems. For our interest, most of what we do is with the musculoskeletal, which has three organ systems, spine, and then the upper limbs and the lower limbs. So those are treated separately, and there's separate chapters on them, and they all have slightly different ways of approaching them. But anyway, in order to know what we're dealing with, we're dealing with that loss of use or loss of function in that particular organ system. Can you go to the next slide? So ratings can be scheduled. That means they're specific to upper or lower limbs or right to left side. So if you have a right upper limb rotator cuff tear and impairment, you're gonna be rating that to the upper limb on the right side. I don't have time to go into this, but if you've got a right and left, you can't just combine them because it has to do with, you can't get more than 100%. If you start adding things, you can exceed 100%, but each time you add, it's a residual of what isn't already spoken for. So if you have a 20% impairment of the foot, and then you've got a 5% impairment of the shoulder on top of that, well, then it's 5% of the residual, 80%, not 5% of 100. Okay, second thing is what difference does all this make? Can you go ahead to the next slide? Well, okay, hold on, you skipped something. So what I wanna point out here is how we can be a little bit creative in what we do. My last slide, I'll speak to it, and then I'll go to that creative piece of this. A physician may be expected to recommend permanent restrictions. That's what the attorney wants you to do because if you can bolster and justify the restrictions, and that claimant can't go back to their usual job, and it's incumbent upon the employers to find another job to compensate them for a wage loss differential if they take a lesser job. And that adds up to a lot more money than the impairment itself does. The impairment is a different schedule than the restrictions are. Now, how do I deal with this? In this particular case, this individual had a shoulder rotator cuff repair. He got 10% for his distal clavicular excision. He lost some range of motion of his shoulder, which was worth about another 4% to the upper extremity. He had about a 14% upper extremity impairment. What else he had was he was talking, if you remember, he couldn't lift his arm, forward flex above or abduct in above shoulder level. And so his job required him as an electrician to work above his head and things, and he couldn't sustain that. So I, independent of all this, including the guys, I can look at somebody, I can put ink on their shoulders where the scapular spines are, and I can compare the angle of inclination and show a difference in cases where you might not think that's there. And also the excursion of the scapulothoracic joint, we call scapulothoracic rhythm. That's linked to an important force couple that's very powerful and allows us to put our shoulder, the actual glenohumeral joint in a position of function and sustain it. This guy had weakness and insufficiency there that was getting in his way. And so what I argued was the convention in Iowa is the glenohumeral joint is shoulder, period. Shoulder is upper extremity impairment, but if you've got something you can show that affects him proximal to the shoulder, and in this case, the scapulothoracic joint, that's taken place over his thorax and it's part of his torso. That's not a shoulder, that's considered whole person. And I can't rate that because there was no, there's nothing in the guides telling me how much scapulothoracic rotation is worth or not worth, but I can say because he is showing this decrement in his torso and I can't rate it, I can take the rating of his shoulder and convert it to a whole person. I'm multiplying by 0.6. So 15, 0.6 times 15 is I think 9% whole person. Now I restrict him, he goes back to work and he should avoid activity at or above shoulder level. If he can't be accommodated, he then gets compensated. And that's, I can tell you since I've been doing this, there's a lot of shoulder attorneys in town and they know who I am and they're seeking me out because I'm circumventing a major impediment that the system has put up to recognizing a very important part of their function and rewarding them when we don't have it, rewarding them primarily by giving them the restrictions they need. So that's the basic kind of approach I have in philosophy. And hopefully that gives you a little idea what you're getting into if you decide to do this kind of work. Dr. Brandenella, do you want to just show the reference slide at the end? Just there were a couple of questions about that. Do you have anything else in the other slides that you want to highlight? No, I think we're good. Okay. So there was a question about the name of your textbook and Alan has responded, it's impairment rating and disability evaluation. Yes, I think we're going to be sending the slides out after this. Let me see if there are other questions. There was a question on remote IMEs in California allowing that if both sides agree, what are your thoughts on remote IMEs in the future? Well, I actually copyrighted a remote. At one time, 12 years ago, there was somebody doing something for the Defense Act. He was an entrepreneur in Europe who was trying to get injured workers. There were soldiers fighting in conflicts involving the U.S. and in support of the U.S., but they weren't U.S. citizens and they were getting work injuries. And I developed a remote template where the doctors out there could actually, if they do it correctly, give me the data that I could try and do an impairment rating remotely. So I'm guilty of contemplating and trying something like that. What happened was it didn't pan out and we didn't do it for reasons other than what I told you. But I think anything is possible. The real question is how, when you start compartmentalizing things and cookie cutter approach to it and you get away from the individual and the personal contact that means so much, you're diluting things and probably gonna get misled. So that's a double-edged sword. I wouldn't condemn any system that's trying to, in a cost-effective way, get some type of a job done. Fortunately for me in Iowa, we have a rather broad bandwidth of fair market value for what we do. We're not regulated on how much we charge. I know what the standard going rate is. I have very satisfied customers coming to me and lots of them. And I think if I were practicing in some other states, I wouldn't be able to do nearly what I'm doing here. But on the other hand, I don't have the need for something like that. But in a state like California, if they figured out a way to do that, it gets claims resolved quickly and efficiently and fairly, it deserves some kind of a trial, I suppose. Well, thank you, Dr. Ronnelli. There's their comments. I think Richard has written an excellent presentation and I think we can all agree that it was very, very informative. Sorry, we ran out of time. Do you have any last minute sort of take-home points, things you want to stress? I know your case presentations are already sent out. The slides will send out after this. So do look at the, people should definitely look at the things Dr. Ronnelli has highlighted in his case presentation. But Bob, do you have any last minute take-home messages? Yeah, for me, I look at it, I come full circle. At one point, I thought people doing what I'm doing, are just out to make money and they're not to be believed. And I've come full circle to where I'm looking at people that are denying the reality that people who get injured at work and trying to downplay it for the system's sake are shortchanging a lot of people in various ways. And again, I had an attorney tell me right to my face, you know, if you want to help this guy, you want to put a brace on him and he doesn't want that and I can help him a heck of a lot more than you can by getting a financial reward. That's a sad reality, it's probably true. But I just approach this on my terms. I know how to fix certain things. If I see an opportunity, I can't treat them, but I can make a case for doing that before we close the claim. And sometimes that is done. And when it does, it can still enhance the award somebody might get. If they end up with a justifiable AFO that they didn't need and they've got a gait impairment, that's worth a lot. If they don't have the brakes and they can't get out and walk around and they're double losers because they're not getting compensated for what they've lost and they really are functionally impaired. So there's a way to make this a win-win for the system and for yourself if you play it straight like a doctor should and use the strength of what you've got in functional assessment to guide you. I think that's the main point I made. Thank you so much. Thanks. Thanks, everybody.

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