So, our next speaker is Dr. Marty Lanoff, he's a colleague of mine in Chicago. He's a clinical assistant professor in the Department of Rehab Medicine at the University of Health Science Chicago Medical School. He is a member of the medical team at Adult and Pediatric Orthopedics in Vernon Hills, Illinois. And Dr. Lanoff has had an active, very active medical legal practice for over 25 years and has given presentations and courses on the subject to attorneys, insurance representatives, and physicians. You may recognize him from previous academy full courses on this actually and other sessions at our academy meetings. So, we're very glad to have him speaking on this and welcome Dr. Lanoff. Thanks. Where did you get that anyway? So, a couple of things. First of all, my wife just texted me about Dr. Whiteson's program. She said that she listens to it whenever Howard has a rerun, by the way. Just letting you know. But she does listen to it. Pretty awesome. My wife says the same thing. Yeah. Sure. So, a couple of quick things. Just comments on this morning. Dr. Mudge Riley talked about advertising. It's going to be part of what I talk about, advertising for doing medical legal work and how it's kind of slimy and salesy. I really like that. I might use that in the future. And believe it or not, when you're giving a deposition, an attorney will ask, where do you list yourself? Where do you list your services in advertising? And in front of a jury, he certainly will say, oh, you advertise, doctor? Even though attorneys advertise. Also, Dr. Whiteson, I was also going to say that, believe it or not, I'd say two patients a week say I should go on serious exam and I should have a show. And after finding out how much you get paid for that, it has totally left the possible realm of possibility. That's less than a half hour of what lots of people make doing medical legal consultation. So... You should be a guest on Dr. Whiteson's show. Yeah. Well, we'll see. We'll talk. It's obviously a labor of love, clearly, because you love what you do, and that's pretty nice. And I don't want to sound like, you know, like I'm unethical or money-grubbing. I really think there's a big need, and we'll go into it soon. The difference between fraud and inappropriate medical care, it's a very fine line, and there's a lot of fraudulent things. And boy, you really would... I have a couple of slides. You wouldn't believe the stuff that comes across my medical legal sites when it happens. My mouth used to drop. I'm just so used to it. For instance, the big scam now is it's the same people that plaintiff attorneys will send patients to, the same guys. And they'll give these tubes, it goes to a compounding pharmacy, comes back, they give it a fancy name, and it's aspirin, acetylsalicylic acid, whatever it is, aspirin, menthol, lidocaine, and they'll throw in a little diclofenac, and they'll charge $1,500 per six-ounce tube. And believe it or not, if a jury says, okay, the person needed it, they get paid. So I'm on the other side, they say, come on, this is ridiculous. You can... $10, you can get this stuff on a... You can use salon pass for about the same, and it's not evidence-based as well. Evidence-based is large. Base is behind it. In any event. Also, giving depositions, we're gonna talk about briefly. Giving a deposition is a lot like a radio show. It's a lot like talking to patients. It's educating the person that you're talking to, but fortunately for doctor... For me, as opposed to Dr. Weitz, and I... When it's written down and it's a transcript, because they always take transcripts as you give a deposition, I can take 10 minutes if I want before I answer. He can't have 10 minutes of dead air. That would be not terrific. Dr. Khanna, who's not here. I was the awareness chair of the Board of Governors for a while, of the academy. And talk about a tough job, because as you know, my mom doesn't know what I do. It's just... And awareness has been a large part of what I've wanted to do for our field for the longest time. And I was just wondering where she was when we needed her. I actually had to... One of my favorite reporters on one of the TV shows came in to see me for an IME. That was tough. She slipped and fell and didn't have a lot going on. And I really liked her. And up until I saw her in IME, I was a big fan. And also, Dr. Daniel and I are going to have a little bit of overlap in a lot of our slides, since we kind of sort of do similar work. A couple of slides, it looks as if he stole them from me, stole a couple of my slides. You notice how... Yeah, not the greatest point. There's my name, way down at the bottom with a little bird poop under the orthopedic guys that I'm with. I'm part of an orthopedic group in Vernon Hills, which is a suburb of Chicago. I'm overhead share. I'm a unique... I have a unique practice in that I overhead share with them. I'm not an employee of the group. They send me about 10% of my patients, so they can't come to me and say, Marty, we're going to raise your overhead next week, 50%. My answer is, guys, then I'm going to leave, because you don't give me that much business that it's worth sticking around, which is a nice place to be. Dave Bagnall was the president of the academy a few years ago. I love this. I don't remember what I'm talking about next. I throw up a slide and then I go, but Viagra PowerPoint or public speaker, I love that. In any event, right, she said MSK, medical-legal. I just kind of lucked out. We'll talk about that. I've done a lot of stuff for a long time here. Why PM&R and medical-legal? We cover lots of ground, MSK, and unlike what Dr. Daniel was talking about, I stay within my field of expertise. If you're in a deposition or a trial, you have to prove that you, and there's actually something called a Dawbert standard, which I'll mention in a bit, I suppose, in passing, but you have to establish that you are an expert in this field, not just from a treatment perspective, but in terms of knowledge of the evidence. See the whole person, multi-system. A good doctor should wake up in the morning and say, what can we not do our patient today? What can we not do to them? That kind of mindset isn't even necessary in the majority of medical-legal. By the time it gets to my desk, gets on my radar, I got to tell you, the stuff that they're doing to the patients is egregious. I find that if it's even close, I don't see the patient. They're not going to spend the money and the risk of having me do an evaluation of a patient, give opinions, if it's even close, and if it's even close, I give it to them. I always give it to them. Give it to the patient. Give them the claim. We're a disability specialist, a niche, as Dr. Daniel pointed out. Mine happens to be, I fell into fibromyalgia for a long time. As it was not deemed an objective and compensable diagnosis, it's dropped off the scale in terms of lawsuits, in terms of litigation, maybe in terms of disability, and certainly in terms of treatment, it's still around, but in terms of litigation, it's just about gone. It was really hard to convince juries of people with these complaints, no objective findings, so it kind of dropped off the radar, but somehow that became a niche because they kept sending stuff to land on. Just like EMG is an interventional, since I'm an interventional doc, I'm getting sent lots of interventional cases. People doing, for instance, diagnostic medial branch block, along with trigger points and an epidural, and saying, oh, well, the patient felt better, they need to go on from medial branch blocks to rhizotomies, facet mediator, facet rhizotomies. You can't do three interventions at once and say that the medial branch block worked and then just do a medial branch rhizotomy to the facet. You see the conundrum there? It makes no sense, but they're doing this stuff. It's wholly inappropriate. If you guys aren't injectors, that might have had a lot of logic behind it. What do we do? Kara's nice enough to give me an outline of what I should talk about. Here's what we do. Here's what I do on my medical legal. I do it one day a week. On Mondays, I have a separate corporation that's out for my regular day job. This is my kind of side job. I always say in depositions, some people golf, some people do yoga. This is what I do on Mondays. Sometimes at night, some people, I have a slight, yeah. One of my friends does it when he's on vacation. That to me is not the definition of a vacation. There's IME, where you actually do a physical exam. We'll talk about the difference in Illinois between personal injury and then workers' comp. Very different systems. Then there's hybrid systems. There are hybrid systems in some states. You chart and record. It's probably the lion's share of what I do. They send imaging. They'll often give reports of the imaging. I'll ask for the imaging if it's relevant. I try not to ask for the imaging if I don't need to see it. I don't need to drum up more business. I try and think of the attorney, even though how most people feel about attorneys. The old joke, a bus going off a cliff with 100 attorneys in one empty seat, call it a missed opportunity. The old joke. I've actually told that joke in a much better way to a group of lawyers. I lecture lawyers on occasion. That's always fun. Formerly, Congress reports, Dr. Daniel said, it's so important, comprehensive and timely and be available for questions when they call. What did you mean by this? I didn't list out all the things that they want to know. They give me questions. They'll give me 15 questions with subheaders A, B, C in each. Often they're redundant questions. 90% of them I've already answered in my little summary that I give at the end. They want to make sure that their answer, I think for so many years, and this has been the last decade maybe, so many years they would send patients for evaluation, for independent medical evaluations or opinions, and the doc wouldn't give an opinion. I think they've taken the listing amount to make sure that you answer what it is that I'm looking for. It made their lives harder. It made sure the doc actually had an opinion because so often I see these IMEs, no opinions. I can't get it. They just spent a whole bunch of money to get an evaluation. The guy just said, yeah, he's saying he's sick. There's a bunch of things that need to be known at the end of an IME. You often have death by deposition, arbitration, a panel, trial. I've had a couple of Chicago police officers claiming disability, and they call me in, and the cop is sitting there. Fortunately, they leave their gun outside, and then the other cops are often retired cops and pension people there. Those are always interesting. I probably do one, maybe two trials a year. I don't want to go to trial. Trials are very lucrative. We're going to talk about it later, but I'll give it to you now. If I'm going to do a trial, I don't want to share my hourly rate. I feel that's just greedy sounding, but you can see your hourly rate can rate from different 200 to 1,500. I think 1,500 is high. I think 200 is really super low. More in the middle there is probably accurate, and it's commensurate with expertise, certainly in the amount of years you've been doing it, I suppose. You don't want to price yourself out of the market. But a trial, it's often four or five hours of preparation the night before, and if it's an entire day, if I have a day where I'm seeing patients seven to five, they pay for seven to five. If it cancels a week in advance, they pay everything. That times one of those numbers, it's a fairly lucrative thing to do. It's a lot of work. It's very tiring. It's not something I'd rather really be seeing patients. I'd rather do an evidence deposition where they come to me, they take a deposition, and then they will have an actor or sometimes a person, a junior person from the legal office, read and pretend they're me. So the jury is looking at this person talking. They'll often do a video evidence step, which I'm going to show you some pictures of later. A video evidence step is a little different. Fraud we'll talk about. It's all over the place. The definition of fraud is a willful act. Patients are willfully practicing bad medicine. And of course, by the way, they'll say, do you not approve of the... The other attorney, the opposing attorney will say, do you not approve of the treatment of this physician? My answer is no. Well, then why didn't you report them for substandard care to the medical department? Why didn't you say they're committing malpractice? Because there's a difference between... Often they don't hurt the patient. There are no damages involved. That's not my role here in this case. But also malpractice has a different standard than appropriateness of care. Frankly, they're pretty damn close in the majority of the cases that I do. And if a case is even close, as I said before, I give it to them. I go, yep, they have it. I just did it the other day. Yeah, home and office, I do most of it from home. I do. Very little travel. You often don't have to go anywhere. I have to go downtown once in a while when I'm up 30 minutes north of the city. Right, occasional... No, so personal injury. Personal injury is slip and fall, car accident, anything along those lines. Assault, although those often... Most of the assaults I see, I would go to federal court, which is a whole different animal, a whole different lecture, because people are suing the policeman or something or a jail guard or something like that. Personal injury, however, is very different. Workers' Comp in the state of Illinois, there is... They can ask a lot more stuff. They can ask you what your grade was in fourth grade math. They can do whatever they want. They really can. If you have any skeletons in your closet, don't go into this. Which, like Dr. Khanna said, the TV lady, that you're open to scrutiny, and trust me, they all talk. You say something in a deposition once, they'll bring it up 10 years later. They do. And it's funny, because I always say the same opinions because they're evidence-based. Well, then they'll say, doctor, isn't it true that you always say the same opinion? And I go, yes, thank you. Because I said, if I didn't, you'd try to impeach me, which means to say, well, you said something else in a different case. That's the goal of the opposing attorneys, to impeach you, not to talk about your opinions half the time. Probably 80% of the deposition is about how much money you make, where you went to school, are you qualified, and can I impeach you? Can I catch you? Then, about 20% of the time, they're actually talking about the case. After an attorney comes in and actually talks about the case and doesn't go through that garbage that leads them nowhere, I'll thank them. I'll say, this is a really nice deposition. I enjoyed just talking about the facts of the case. But I do talk about the facts of a person's medical illness when I see them. It's the same thing in a deposition. So discovery is where the opposing attorney comes in and wants to know your reasoning behind what you wrote down in your report. So I'll review records. I'll say, I think the patient is hurt or isn't hurt. I think they had eight weeks of disability. I think this care was appropriate. This care wasn't. And I'll say, OK, why? And they'll ask me questions. That's the discovery part. The evidence step is where the guy who retained me, for instance, in the majority of my cases, is the defense, the people being sued, not the patient side. Generally, the patient expert is usually the treater, so the person doing the treating. In any event, so the evidence deposition is where the other side, well, I'm sorry, my side that has asked me, retained me, will say, OK, we'll want to present this to either arbitrators or a jury or somebody who's going to make up their mind and saying, why do you think this doctor, and you looked at these records, why do you think that? And I give my opinions. And then the other side then asks, just like it looks like on TV, then the other side asks questions that go, well, OK, here's what you said. Why did you say that? And just goes through opinions. So that's what an evidence deposition is. And it's in lieu of being there in person at trial. Binding arbitration versus trial, they usually, a lot of them are decided by underinsured motorists, whatever, you don't need to know. It goes to a panel of three attorneys versus a trial. The vast majority settle. It's pretty rare that I even get to trial. Certainly it's rare that I even go to an evidence deposition. This is in the personal injury arena. Different from comp. It really varies from state to state. Workers comp, quite different. There's no such thing as pain and suffering. You fall down in a McDonald's, you get a scrape on your hand. If you can convince a jury that you're disabled and it hurts and that your life has changed, you can have millions of dollars. In personal injury, you can have an amputation, here's what you get. It hurts, it doesn't hurt, function, doesn't function, boom, this is what you get. No pain and suffering. It's very cut and dry. Boy, bad joke after, bad thing to say after talking about amputation. Very cut and dry, however. Arbitrators, right, evidence deposition, they either take your report or they take your evidence deposition. They skip the discovery in the state of Illinois, rarely testify live. This is the important thing. So in states like Michigan, I think it's in New York, I think it's maybe 40 states, 38 As someone goes in the personal injury treatment arena, let me back up. So how it works in Illinois is they get treated for 8 years, 10 years, and they get horrible treatment frequently until somebody runs out of money or the patient runs out of patients and then it comes to trial. And nobody contemporaneously at the same time says, yes, you can do this treatment or no, you can't. In workers' comp, they're paying, they're paying. And if they want to stop paying, they have to send the media to say, yes, the treatment is appropriate, keep paying, or no, the treatment is not appropriate, time to stop. So it's contemporaneous and they cap the bills because they stop treatment. Then they can go to court and sue, the patient can, and maybe they won't, maybe they won't. I'd like to think they won't because I'd like to think what I'm saying is honest and ethical and correct and evidence-based. It's not that, in personal injury, it's not that way, they can't stop treatment. In other states, personal injury, car accidents are, it's necessary to go for an IME, an in-bed medical eval where you go, you see the guy and you say, yes, treatment is okay or no, it's not, and it can be stopped at the time. The person's, it's called, whatever, so it's a very different system. It's called treating somebody on lien where you get paid, if the guy settles his lawsuit and he gets money paid, then you get paid as a doctor. Generally it's not something you really want to do. Okay, disability, you guys already just heard all about it. Medical mal, it's kind of messy, a lot going on. Their rates are very poor, the insurance company and lawyers' rates are often very poor, much less, usually go to trial. I did it for plaintiffs, if somebody messes up, I'm happy to say, yes, that was a mistake. I had a couple people sending me plaintiff malpractice cases, which, I mean, things like somebody took the hot rocks out of a hydrocollator and put them right on the patient's back and burnt their back. Well, that wasn't a tough one, really. So I am okay with that until they stopped paying their bills whenever I didn't agree with the fact that there was a malpractice. When I said, I don't think there's any malpractice, they stopped paying, stopped doing those. Always get money up front, I have a big slide of that to remind you. How to be a good examiner, have an opinion, we talked about that, and Dr. Daniels said it a couple of times. If you, you have to make up your mind, and if you're not sure, you need more data, or you can't tell, then say that. I'll often say, based on what you gave me, which is lacking, or I'm missing these records, or I just, I wasn't, you know, somebody has an unsustained loss of consciousness, or is this work-related? The person says yes, but nobody witnessed it, but the person, the patient says, my supervisor Joe was there, and I put in my report, I don't know if it's work-related or not, they say it is, you're wanting me to say it's not, go talk to Joe. And then when Joe gives an affidavit, then I'll say, okay, based on the affidavit, here's the answer. Do that once in a while. If you don't have enough data, let them know. Try to do both sides, testify well is really important. It is, you know, if you look at, I like to think that I'm a five out of five star guy. If you look at my ratings, I'm like a two out of five. I was just, you know, those best Chicago, best magazines. I was just in that. My mom bought 12 copies of the thing. So I like to think I'm a good doctor. On the other hand, you look at ratings, you'll see five, five, zero, zero, zero. And the fives are my patients who don't usually go on. The zeros are IMEs that I said, I'm sorry, I see nothing wrong with you, you have to go back to work tomorrow. Well, they're the ones that are motivated to try and get back at me. So online ratings, if you don't, if you care about your online ratings, don't do IME work. There's a thing called reputation defender. It's in Chicago, have you heard that? I call them to say, what do you do exactly? Just out of curiosity. For like $5,000 every six months, they will flood review sites with false positive reviews from different URLs. 5,000 every six months. Yeah. Right, don't ever change a report. Right, give me some of the doubt. And so I had a patient who, she was a claims adjuster for Southwest Airlines. And I treated her, she said, hey, do you do IMEs? I said, yes, I do. She sent me a few. And then one came in and had, I think it was a labral tear that the treating doctor was missing, didn't do an arthrogram. I said, you're stuck. Another happened to be another, it's done a labral tear of the hip that they were treating as if it was the back, missing the diagnosis. So these were both surgical cases where she had to pay a lot of money. She stopped using me. Fine, good riddance. She doesn't want to hear the truth. I don't want to work with her. It worked out just well. You know what, speaking of standing in front of this thing, I gave a talk at the academy when I first started doing this stuff, 15 years ago, 18 years ago, about, it was a Sunday morning talk. So there were six people, you know, bleary-eyed people in the end of the meeting. And it was how to give, a talk on how to give a good talk, how to give a good speech, speaking tips. And Bruce Becker, who's a longtime academy guy, he's been around forever, he's the president of Passor, I gave my whole speech, and I just sat here comfortably like this all the time. Bruce gets up and says, first thing I want to point out is, Marty just screwed up the whole time. He stood behind the podium. Good speakers should walk around. I said, Bruce, you couldn't tell me that before I got up there? In any event, I was supposed to open with that, by the way. You're supposed to open with a joke? That was the other thing we said. So anyway, here's some, you guys will hopefully have access to this. Here's some good, just IME standards. Good ethical and, oh, yeah, I wasn't supposed to show you this slide yet. I hope this is not inappropriate. I just found this really funny. We're gonna talk about marketing. This is what we call good marketing. But in any event, this stuff is online for all those references later. Oh, don't take a picture of that, Cindy. Come on. Seriously, I'm gonna get a complaint. Somebody's gonna complain, and I apologize right now. I just thought it was funny. I hope it wasn't offensive. In any event, so Marketing to Workers' Comp. This lecture's missing next year. If you'll understand why. Yeah, yeah, pretty much, pretty much. So Marketing to Workers' Comp. These are, at least in Illinois, I'm pretty sure this is fairly universal. They'll bring patients to your office frequently. They'll come to your office. The nurse case manager or rehab professional will come with a patient to your office during the visit, and their goal is to be the eyes and hands. Do we all know what they are, the rehab case managers? In any event, talk to them. They have all these CME things that they have to be part of, RING, I think it's Rehab Insurance Nurses Group, all these different groups. Get to know the nurse case managers. Do good care on the patient, and then they'll say, hey, do you do IMEs? And after a while, when they came to me and asked me do I do IMEs, I started saying to them as I walk out the door, hey, they would compliment me or say something nice about the care I gave to the patient. Often boundaries, and you make sure that you're the patient and you both restrict those or respect the boundaries of being off of work, et cetera, and patients, a lot of the more tough patients will push the boundaries, obviously, and they'll say, good job, doc, or thanks. I'll often say, hey, by the way, I do IMEs, and it's amazing how many of they go, wow, really, I didn't even think of you, and there come IMEs, so that's a really very good marketing tool. Seminar, speak to them, do a good job with them, open the dialogue, and establish a niche is really big, and Dr. Daniel said that before, a niche of whatever it is that you're good at. If you're good at it already, it's good. If you just learn how to be good at it, that's not bad either. Give them a room and a phone. Told a couple of my other friends who do IMEs, just if you give them somewhere, and frankly, one of the guys in our practice stocks it with candy and food all the time. They like to come to our office, so if it's me versus somebody else gonna do the IME, they like my office better, believe it or not. A lot of them say it really, it's a nice thing. Everybody's cell phone now, and this is an old slide, so I don't know how much the phone is important. I dictate in their presence. I always do it right away, and that way they see what I said, and you have no idea how many people will do IMEs, not for long, will do IMEs, and tell the patient and the case manager who's bringing the IME to you, tell them one thing and say something else in the report. So my report is dictated in front, and if I forgot something or something they want me to punch home a little more, emphasize, I'm happy to do it. I allow them to have input, not on the content, but on the style. Never allow an attorney, nurse case manager, insurance person to have any influence on the content, ever, ever, ever, ever. But the style or making sure I say something so that the adjuster doesn't forget, I'm fine with that. Answer, have an opinion. I cannot stress that enough. Specificity, don't say, yeah, I should, think they should do light duty. Gotta say what? Prompt, and when they call, they call all the time saying, do you do this? Do you do head injury? Will you do a brachial plexopathy? Sure. Yeah, right. So mostly out for PI. Out of residency, the guy that hired me happened to have a relationship with one particular group who is a very good, solid group of guys who are all ER docs at what is now North Shore in Chicago, North Shore Hospital Group, all ER guys. It carries a lot of work with them as well. Good guys, they send cases. They're the perfect specialty. If anybody wants to open a business, this is not a bad thought. Just somehow get insurance companies to send, to that you may know and say, send me the cases and I'll find you the right expert. These are ER guys. So when somebody comes in the ER and they diagnose, they know whom to triage the patient to. They had this particular niche and one of the guys, Danny Samuel in particular, is the guy who said, well, we'll do this. So I introduced him to them. They are the lion's share of my IMEs. A lot of the attorneys will come to me and say, I'd like to send you chart review on IMEs outside of InSpan. My answer is no. One, I wouldn't undercut the guys who introduced me. Two, they do all my billing and collections, collecting from attorneys. They do it all. They do all the scheduling, depositions. And I don't pay them anything. The attorneys actually do. So it works out great. Right, local doctor on first. For comp, right, just, I hope they like me. But I market them and when they left, I said, like I said, IMEs. And I've treated a lot of case managers, adjusters, family. One just sent me an email. Should never have given him my email. Marketing to PI, I never really have. I'm asked about how I got here and how do you market this stuff. I really never have. When they ask me the question, the attorneys, do you market, do you have an ad? My ad is no. My answer is no because they'll throw up that ad and make you look, you know, unethical theoretically. They'll paint it any way they can. There are listing and referral companies, paid ones versus free. You can do an ad, especially in the beginning, nothing wrong with it. They think that a jury's not gonna like you because you put out an ad. They'll still like you. If you do a good job, they'll still like you. LinkedIn, somebody's gonna talk about that. You wanna make sure that you put in, you're a medical legal expert. You do medical work on your LinkedIn profile. Cold call attorneys ask, talk to me after deps. Again, a guy would walk out of a dep and I go, you know, I was a treater, but you know I do medical legal work as well. It really, really drummed up a lot of business in the beginning. It did. Certification's a big question. Should you do it, shouldn't you? I didn't. It's up to you. If any, to me, the IA, I used to be ADEP back in the day. I gave a lecture. Anybody know Alf Nochumson? He's just a premier spine researcher, right? Just, I mean, an erudite, just great delivery. And I talked, I gave a talk at ADEP and he was the guy who talked ahead of me and I got up there and I said, this is like W.C. Fields said, never work with children and animals. You just can't win. I got up and talked after that guy. They have something in January. Eugene Carraghi, who's the editor of the journal Spine. I mean, he's a superstar. In my spine world, he's a superstar. Doesn't throw on my 23-year-old daughter, but he's a superstar. These are the guys they have come talk at IIME, which is what the name of it now. I think that one by far is the best. If you have any interest in doing it, they have many different programs. They're really pretty good. That would be the one I would do. It goes Illinois insured, I don't know, legal, continuing legal education. A bunch of lawyers. I've ended up giving talks to them. That's the way to end up getting more business. Insurers, subsidiary groups. I'm often asked, will you come talk to, you know, Allstate and the headquarters are pretty close to my office. And I usually limit it to, I'll say as long as there's more than 20 people. If it's a group of five, I mean, I love you, but that's not really a lot of exposure. At least 20 people have to be there if you're gonna give a talk. I actually lectured an interesting, the SIU. I don't watch these TV shows where they have all these special investigative units, but it's mostly ex-cops and private investigators working for an insurance company about fraud. And I lectured them on fraud. And they're actually, because they're the ones that look at these cases and say, should we go after these people for fraud? And I found it really hard, because again, the line between fraud and substandard care is a very tough one. So this is, and these are actual, I just had my transcriptionist pull out a couple of IME reports. And bizarre complaints throughout the, make little if any medicals to stop treating this guy. It's not even, even his doctor's not giving a diagnosis. It's never a good sign when the patient's pain diagram has pain outside of their body. Okay? This is a real one. Another IME report, none of his treaters even gave him a diagnosis. He's not candidate for any further treatment or testing. That's it. I see nothing wrong with the patient, I'm sorry. Nothing objectively wrong. Subjective complaints are pretty important, but they have to follow a pattern, for God's sakes. Anyway, testifying, discovery, I just talked about video evidence, arbitration, right, we talked about that. Well, discovery, find out the facts, evidence, again, trying to get the facts out of you in front of somebody who's gonna make up their mind, make their decision on the case to pay the person or not for their claim, and then the other side's gonna try and argue with you and impeach you. Impeach you means, you know what I mean, just say, you're lying, doctor, you're a bad person. Discredit you, your opinions, you or your opinions. If they can't discredit your opinions, I'm kind of flattered when they come and 80% of the time they're just trying to discredit me because they can't discredit my opinions. If they thought that the opinions were bad, either they're not talented enough to do so, which is not uncommon, or they realize the opinions are not arguable. I love having slam dunk cases, of which the majority, you really are, they're not even close. The DABRA standard is just a medical legal standard saying you're an expert, you have to stick to your field of expertise, always important. So when you testify, listen to the question, they'll go, and after an hour and a half of asking questions, well, when you said the guy was right-handed, did you mean blah, blah, blah? I'll stop and go, I never said he was right-handed. They'll do that, and this is just an example, they'll do that all the time, all the time. Another is, it's nice to know, I mean, it's good in life to know where the conversation's going. Well, if he's asking a question, if I answer an emphatic yes, what's he gonna ask next? What hole have I just dug for myself? It's always good to try and anticipate the next question. I mean, it's human nature. Whoops, whoops, hypotheticals. So if they go, doctor, is it possible that a fairy, well, this is very appropriate being close to Magic Kingdom, but a fairy sprinkled magic dust on the patient while he slept? And listen, from an evidence-based perspective, I know nothing about fairies, it's not my area of expertise. Maybe they're around, I can't give them a maybe because then they'll say, well, really, doctor, how long have you believed in fairies? Will be the follow-up question. So you have to be hypotheticals, that's just an egregious example of hypotheticals. They get you into trouble. You could say hypothetically, but it has nothing to do with this case, and they'll always say, doctor, I didn't ask you that, and I'll go, I know you didn't, and that's the end of that conversation. How much are they paying for your opinion today? It's always, how much are you paying me for my time away from my practice? That's the answer to that one. Good witness, confidence from boundaries. They are going to say, so I gave a dip. This was the most annoying guy, and he's in the room, and it was not a video deposition, so it's written down. So they can't see, unlike Dr. Whiteson, who can't have dead air, they can't see my three minutes of dead air while I think or look for something if I like, which I try not to do. So in this room, he kept asking me. Every time I gave an answer he didn't like, he would go, is that what you believe, doctor? Like that, like you don't talk like that in a regular conversation, and he kept doing it over and over, and I was getting tired of it. So finally, he asked me a question, and I looked at him, and I go, no, and he stared me down, and I thought he was gonna say something. I did it just as obnoxiously to him. He can't say anything on the record, because then I'll say, you've been talking obnoxiously to me, and then it's in the record. So he can't say, why did you answer? Because I said I answered just like you did. He can't put that down. That was just a fun moment. Just wanted to put that out there. Do not theorize, are they having pain? I actually, similar to what Dr. Daniel said, if a patient has pain, sure, what's the cause of the pain? Psychosocial issues, litigation, secondary gain, depression, anxiety, abandonment, sexual abuse, substance abuse, these are all risk factors for chronic pain. Is the patient having pain? How do I know? I can't jump in their head, and it is presumptive, and frankly, obnoxious, and unethical of me to say whether the patient's feeling pain or not. I can just say what the reason for the pain is, and I can't find one from a physical perspective, and I would look into the psychosocial world. How do I know that? Because there's a myriad of literature out there that suggests that, that supports that. That is evidence-based. It's good to have evidence behind everything. And then, frequently, they'll say, okay, can you give me the evidence? I'll go, sure. Then I pull, somebody asked me about psychosocial and chronic pain, I think I pulled 50 papers, and I said, is that enough? Be consistent, right? We talked about that before. I like that I'm consistent. The bullying part, the are you sure? I don't know how we're doing on time. Okay, so we, I don't publicize this. I don't like attorneys. I don't like lawsuits. I like some attorneys. My son wants to be attorney. I like him. The fourth generation, he was to be the fourth-generation Atlanta physician, and of course, he wants to be an attorney. He did it despite me. But in any event, so my wife and I sued the contract of our house. The guy was a crook. We won everything. It was ridiculous. It shouldn't have even gotten there, but he was a little crazy, a lot crazy. But my wife gave the one and only deposition of her life, and the question was something like, well, you painted that room a color, and then you had them paint a different color. There's no point to the question. And it was eight years earlier, and he goes, what color was it? She goes, I think it was a tan. He goes, you don't know the color of your bedroom? Well, it might have been, and she keeps going, it might have been, might have been, and afterwards, I said to her, you really think that he, in a regular conversation, if you said eight years ago, for 24 hours, somebody painted a bedroom you're not even living in in a house we're building, and you don't remember the color, if somebody goes, you don't remember the color, your answer would be, yeah, I don't remember the color. But in a deposition, people don't talk like that. So there's a lot of bullying, and it's not, they don't get you in a headlock and give you a noogie. It's more, they just won't accept your answer, and they try and get you to change. And you have to have firm boundaries, just like treating a drug-abusing patient or a substance-abusing patient, or just treating a manipulative patient, or talking to your bad neighbor. You've gotta have boundaries, that's super important. You have to be able, also, to justify your opinions and have boundaries with them and stick to those boundaries. Don't theorize again, don't overextend. Dr. Daniel talked about doing cardiology and other things. I cannot overextend. I've been burned by doing it before. Even though I know I'm right, I say, maybe you gotta get a, and neuropsych, that's one of the reasons we talked about neuropsych. Validity in neuropsych testing and head injury is really super important. I try and stay within the boundaries of what I do. One has to, one can be impeached as not being an expert, let alone the fact that you wanna know what you're talking about. Dental work, people hit their faces on steering wheels all the time. I go, I'm sorry, I can't help you. Right, so it's giving a trial, and I've been doing this for a while, so there's the defense side that had retained me. There's the plaintiff side who's presenting their case. They're saying the guy's hurt, blah, blah, blah, and the case was after, so I'm, it's a discovery, so the defense side presents me. I talk to the jury. The case sounded cut and dry, and this was a guy who was abusing cocaine, and we couldn't even admit that into evidence, and I said he was drug-seeking with plenty of evidence in polypharmacy, et cetera, but did you guys notice that the PMP, like in Illinois, we have the, where you can look up the prescription monitoring program. You know the VA doesn't do that, doesn't participate, so if you have a patient that is also going to the VA, he may get a ton of stuff from the VA that he's getting personally, too. I've had a couple of those, by the way. Oh, they do? Thank you, okay, I stand corrected. Thank you, good, thank you for that. That's great. You know, the VA, always a day late, just a day late in any event. So this guy was a cut and, shut and, I mean, it was over before they even started asking questions, and the attorney knew this, so he started getting very obnoxious to see if I would lose my temper at him so that I could lose credibility. So he got, I can't remember, but he's really, the stuff he was saying, at one point he screamed, are you a witch doctor? And my guy's supposed to say, objection, not misleading, what would be objection, belligerent, or whatever the word is, and after like four or five of those, I'm like, no, I'm not. So after like the fifth question, I turned to the judge and I go, can I object to the question, which is way out of bounds, and the judge said, sustained, and told the guy to back off, because my guy wouldn't do it. The reason my guy didn't do it is he knew I could fight my own battles, he didn't have to fight it for me, and that this guy's gonna look stupid attacking me, which pretty much happened, but I had had enough after a few minutes. Is that a question? Just a comment. Yeah. For the other side, do a wonderful build up. Yeah, yeah. I have no problem with putting levity into the trial, as long as it's not, you know, it doesn't detract from the seriousness of why one is there. That being said, as you can see, levity is part of who I am, and it's not a problem. Juries apparently like it. They actually poll the juries after trials. I don't do that many trials. I've run about 25 or 30 in my life. But they poll the jury afterwards, and they say, what did you like about this guy? And they say, this is how much money he makes a year doing this, and this is this and that, and they try to make you look bad. And afterwards, they go, the jury liked you. Often, it comes down to the jury liked you. I've seen some terrible outcomes in just the most straightforward of cases. The jury system is pretty good, but it's not perfect. The whole legal system. I mean, I wouldn't be here talking about this today if it wasn't for the legal system, but it is what it is. Okay. And if you can teach and testify, I cannot tell you. I think the same about radio, though Dr. Whiteson is as smooth as it can be and a verbose gentleman who's very erudite and intelligent. But for this thing, you can, I mean, so I was going to say the same thing with radio. If you can teach, you can do radio, but I don't know. I don't know if I could talk for a half hour without a guest, you know, and patch a, yeah, maybe I could. But, you know, put a patch in there. So if you could teach and testify, clearly, clearly, you can. You just, you're teaching the attorney, you're teaching the people, the arbitrators, you're teaching the jury. And that's what I do. That's why I teach medical students, because I'm teaching my patients. Might as well have somebody else in the room picking it up. So the bidness of doing bidness. Somebody doesn't show or is more than 30 minutes late for an IME, I cancel because I'm not going to put the rest of my day out for this person and it's full charge. Always has been, always will be. They'll often call afterwards. If they call and give me some story, I'll say, okay, fine, I'll split it in half, but I don't do it too often. It is just the rule. Body part. That I didn't make up. Rush University downtown has, they bill per body part. Theoretically, it's more difficult if you have an IME that's on a knee and a shoulder and a back. Three different body parts you bill. I think it's $13.95 for the IME and $600 for each additional body part. I usually stop at three, because after that it's just getting greedy. I don't think rush stops at three. But they ran the lead on what billing is. One of the rehab nurses made the mistake of telling me, so everybody in our group does it. Per injury, sure. If there are two injuries, it's that much more work, that many more records. Extra for copious records, $13.95. If I have more than a couple inches of records, or two inches, but they're really, really concentrated records, if it takes more time, I will bill over that. That's part of the agreement. You have to have an agreement letter for an IME, or for any medical legal thing that you're doing, an agreement letter first, so you can say, I told you this is what's going to happen when they call and complain, if they call and complain. Often, they don't call and complain, but once in a while, they do. Travel time, I rarely travel, but if I have to, you get to bill port-a-portal. Right, two-hour debt minimum. On the next slide, this is a little redundant. Oops. And watch that. Isn't that cool? But in any event, two-hour minimum of a deposition. I have to take that out of my day. If I'm going to give a deposition and not see patients, they're allowed three hours. I schedule two if they go over. Once in a while, I'll say, listen, I can't. But two-hour minimum, and that's what, if they cancel, and it's one week in advance if they cancel, I end up keeping the retainer, which is that two-hour minimum, and often one hour of prep time, as you'll see. Debt cancellation, right, one week. Get the deposit up front. InstaMe, fortunately, this group that I work with does all of that. But when I had done this stuff on my own, I always got money up front. Why? Because they don't pay. I got stiffed on about 70% of my bills. 70%. It's ridiculous. And they figure, well, take me to court. It'll cost me three grand to get $1,800. Cost me $3,000 to get $1,800. Once I've done that out of principle, it's not something I like to do. And it's been a long time. Right? One hour. So generally, an easy deposition is, oh, crap. I told you guys the hourly rate, didn't I? Well, sorry. I thought you said a lot of time. Crap, I have so much to go. I did, I know. All right. Rates vary. What are you doing? I was going to go an hour. 17 minutes, it says? No problem. Well, do I have 17 minutes, or how long do you want to give me? Ten? Done. Sure. Okay. Ten-ish. Got it. Done. I'm going to fly. Yes. Correct. Oops. We're pretty close. No problem. No problem. So, right, some people do different chart rates, for chart review versus meeting or testimony. I do not. I don't see the point of that, but they do. Right? In the middle there is where people usually are. I could probably raise my rate, but I find it, after you do it for so long, I find it hard to justify. It's supposed to be your time away from your practice. Can't do solely medical legal, at least in the state of Illinois. If you're just doing medical legal, they won't take you. They won't hire you. That's what I'm told by many attorneys. I've heard other people say to the contrary, but that's what all the attorneys tell me. The contrary is usually the doctors about to retire, saying they'll still hire me. Percentage of income questions all the time. What percent of your income? In the state of Illinois, the law is you either give them how much money you make, the absolute number, or the percentage of your income, but not both. They're not entitled to both. Confidentially, someone who does a lot of this work told me that they make over a million dollars a year for the last couple of years doing it. That to me is an outlier, outlier, outlier on the other end of that curve, way out of the curve. Here's some questions in a deposition, some examples. He's asking me, go ahead. Did I have an opinion? Hit it. Do I hit it? You may have to go to that little box. Yeah. Bring it up. I can't remember. This is a debt from years ago. I don't even have that shirt anymore. Can you see it? I thought the volume thing was down. We can skip. It's not a big deal. I would check the volume. Yeah, it worked before, right? That's how it goes. He asked me something about, doctor, are you sure, da, da, da, and I pretty much slammed him was the answer to that. I go, yes, and here's why. That was the example. I'm going to just put it back. I'll skip these. The next one, well, you're not a surgeon, doctor. You have an opinion on whether or not this person needed a three-level fusion surgery. My answer is I give surgical opinions every day. I don't do the surgery, but one, I give opinions whether or not the patient needs surgery. Two, they'll come to me for surgical second opinions frequently and I'll say, here's what we can do probably to help you avoid surgery or not, or you're stuck, you need to do it. Three, I know the particular surgeon to send to. I know this guy's going to do a decompressive laminectomy. I know this guy's going to do a two, three-level fusion on you. I know who to send to and what they're going to say from having done this for a long time, although I don't say that last one on the record. Am I a psychologist? In other words, this is, well, doctor, you're saying that risk factors are depression, anxiety, as well as this person's substance abuse, immediate cells, family, other abuse issues. You're talking about psychological issues and depression, anxiety are risk factors for chronic pain behaviors. Are you a psychologist? My answer is no, I'm not. On the other hand, it's part of what I do. In addition, I give them a couple of other answers. It's part of board certification and blah, blah, blah. I'm not a psychologist. I don't claim to be one, but any good doctor has to have their finger on the pulse of the secondary gain involvement. Secondary doesn't always mean they're bad people or they're crooks or they're nasty or they're malingering. Often, they really just have a lot going on in their lives and sad stories sometimes. Malingering, I rarely say someone's malingering because that is conscious intent. With the exception of a guy, again, a very Disney World salient topic, a guy who said, I can't raise my shoulder. He claims he couldn't raise his shoulder passively. I got him up, but he was resisting me. Then the next week, he was on one of the log water rides going down this, doing this. They had him on a video doing that. He claimed he couldn't raise his arm. That was an easy one. That is really tough. These are some examples of fraud. Manipulation of anesthesia nowadays is considered fraud. There's no evidence behind it, but is it fraudulent? Testing for range of motion, thermography, surface EMG we're about to see, spinal video fluoroscopy. You could tell by a patient moving their spine under fluoro that subjective movement that there's some pathology, there's some objectivity to that. They bill for this. Then non-physicians doing neurocognitive studies. This is the wife of an internist, the concierge internist that I saw last week. She brought this into me. I said, I'm going to put this in this damn talk. This is from a spinal decay report, for God's sakes. I'm here to tell patients, you're not as screwed up as you think you are. You're healthy. You just have some issues. We're going to get you functional again. The chiropractor wants this patient for life as their patient. Spinal decay report. This is a pre-printed report that he gives to everybody he sees. This is after doing a range of motion, an inclinometry, inclinometer, this little range of motion things. He charges like $1,000. I barely pay attention to range of motion because it's so subjective. I just use it as a baseline and whatever. Your body reacts to uncorrected spinal trauma, uncorrected because you need me to correct it, the chiropractor means, by changing the shape and function of affected joints. Function, fine. He changes the shape of joints. I seriously had a deposition a couple weeks ago where the chiropractor said I can cure scoliosis by pushing it back into place. On the record, I said, this person is going to win a Nobel Prize. They're going to win a Nobel Prize for a structural scoliosis. You got to be kidding me. I'd be embarrassed to say that. She said it. Arthritic effects, so it's a soft tissue injury, and our arthritic effects from the soft tissue injury will relentlessly worsen, and you can see that on an x-ray. Relentlessly. This is a soft tissue strain of a neck. I mean, is that fraud? It's certainly bad taste. Is it fraud? I don't know. Classic scenario, a friend of my attorney, huge bill for a crappy avail, all kinds of stuff they do, multiple consultations, multiple doctors, give them tubes of this $1,500 cream, multiple visits, you need me three times a week for the rest of your life, classic scenario. They'll look at a tiny little protrusion. You treat the patient, not the MRI. Guy has no, person has no radiating arm pain. They're looking at a herniated disc that's not, has no neural element compression, has non-radicular, barely any radiating pain. They developed a month after the accident, and they're doing epidurals and want to do surgery for a disc. That's unrelated to an accident, even if it were causing symptoms. You treat the right problem. Unnecessary procedures, lots of treatment over a extended period of time. FCE in-house, that's a new one. They're starting to hire people and do $1,500, $2,500 FCEs, and they're poorly done. Okay, should you do it? Is this right for you? If you cannot articulate well enough boundaries during testimony, don't do it. If you can't bake up evidence-based studies, important. You have to keep up in the literature. Don't feel comfortable talking with doctors, can't take the heat on unhappy patients like we talked about. Decisive, prompt, big time. We had a person in the practice I was with who could never get a report done. He had reports that were outstanding for months and months. That doesn't go well. Got to be around, be able to do things non-confrontational, not talking to lawyers. I'm not confrontational. I just don't shy away from it when it's brought on. This is a while ago. She's 23 now, but we were trying to find a way to tonic a tita. Yeah. Sometimes seems confusing and daunting looking at it ahead of time. That being said, once you get it, it's like shooting fish in a barrel. Talking to attorneys about things that you know better than him. Just be honest and ethical. Getting the business is, I guess, the hard part. That's it.

Dr. Marty Lanoff

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