This information is designed to aid practitioners in making decisions about appropriate care. This document does not define a standard of care nor should it be interpreted as legal advice. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.
IME (Independent Medical Examination) is familiar terminology in widespread use. However, the term NTME (Non-Treating Medical Examination) has been used in this Guideline as it more accurately conveys the physician's relationship with the person being examined.
A NTME is a clinical examination performed at the request of a third party (the "requesting party") by a physician for employment, legal, financial, or insurance reasons relating to the person being examined (the "examined person"). The examination commonly includes a review of clinical data (history, physical examination, and test results). The examining physician often is required to answer questions concerning diagnosis, impairment, and causal linkage.
One must distinguish a NTME from a medical report to a third party by a patient's treating physician (e.g. driver's medical report). In the case of a NTME, the examining physician has not been involved in the patient's care previously and will not be involved actively in the care afterward. Sometimes the physician is mutually acceptable to the requesting party and to the examined person, being paid equally by those parties, and reporting to both sides. In other cases, the examined person may feel that he or she is under some compulsion, legal, financial or otherwise, to submit to the NTME. What is expected of the examining physician will vary according to the purpose and context of the examination, the contractual arrangements involved, and the desires of the examined person, the primary care physician, and others who may wish to utilize the examination results.
A physician conducting a NTME ought to be impartial, ideally through having no involvement at any time in the examined person's medical care; in other words, separation from the examined person being examined. If there has been a therapeutic relationship in the past, this should be disclosed by the physician to the requesting party when contacted to do the NTME. That disclosure might be seen as disqualifying the physician. There also should be no relationship between the physician and the requesting party except on a fee-for-service basis for the NTME; where another relationship does or may be perceived to exist, it must be declared openly by the physician to the examined person and in the report.
The examining physician should be wholly objective and impartial. This does not mean that the physician is to be professionally "unsympathetic", brusque, or indifferent to the examined person's concerns or complaints. A truly professional physician can be helpful and supportive to the examined person as well as objective and impartial in commenting on such issues as diagnosis, causation, and prognosis.
Concerns regarding NTMEs
Questions and complaints arise about third party services, of which NTMEs are a large component, at a greater rate than most other types of service provided by physicians. Provision of NTMEs tends to attract complaints; available statistics from other Canadian jurisdictions show that this practice type is over-represented among physicians with multiple complaints. This observation is not specialty specific other than to the extent that certain specialty groups tend to be asked to do NTMEs more commonly than members of other specialities.
The CMPA also has observed that physicians who do NTMEs are at a higher risk for complaints to licensing authorities such as the College of Physicians and Surgeons of Newfoundlandand Labrador. These complaints touch on a number of specific issues including:
- Timeliness of reporting
- Content of report; inaccuracies of findings and interpretations
- Perceived conflict of interest
- "Hired gun" perception; perceived bias
- Ownership of report
- Responsibility to pay for report
- Adequacy of consent process
- Discomfort with the perceived "power" of the examining physician
- Opinion outside the limits of the physician's perceived expertise.
Purpose and Limits of this Guideline
This Guideline is intended to serve as an aid to physicians who do NTMEs by setting out principles which may reduce the possibility of dissatisfaction with the examination and of confusion regarding the purpose of the NTME.
Some types of non-treating medical assessments may differ from the above "Definition" of the NTME in ways that make it inappropriate to apply all of the principles in this Guideline to them. Examples of similar professional activities would include:
1) Occupational health examinations and fitness for work assessments; even though frequently undertaken by non-treating physicians these differ from NTMEs in that:
- disclosure of clinical findings and opinions (regarding prevention, diagnosis, or treatment) to the job candidate or employee is usual and proper, as is appropriate communication with the treating physician;
- disclosure to the employer (as the requesting party) is usually limited to fitness for job demands, and does not usually include clinical details or options;
- occupational health examinations provide a health benefit to the job applicant or employee; for example, education about job hazards, identification of individual risk factors, and assessment of work-related health effects.
Notwithstanding these differences, the principles regarding disclosure, consent, and conduct of the examination outlined in this Guideline are still applicable.
2) File reviews; these are done without explicit consent from, or direct contact with, the examined person. Such reviews call for extra caution, especially when commenting about the appropriateness of past medical care.
Potential for Conflict and Dissatisfaction
Even prior to the NTME, there may exist an adversarial or potential adversarial relationship between the examined person and the requesting party. The relationship between the requesting party and the examined person may be one of employer and employee, insurer and insured, or defendant and plaintiff.
In cases of such an adversarial relationship, the examined person may be predisposed to disagree with the examining physician's report when it impacts unfavorably on a claim for damages, benefits, or pension. This disagreement may concern the presentation of facts, diagnosis, causation, prognosis, recommendations concerning treatment, rehabilitation efforts, complementary therapies, and/or return to work, disability, impairment and/or accuracy of medical history. It may simply be based on a misunderstanding of the role and/or impact of the examining physician's opinion.
Arranging the NTME
The examining physician should:
- Provide the requesting party with clear directions as to the location and appointed time for the NTME. This will be useful to assist the examined person in finding the correct location at the correct time.
- Understand the purpose of the NTME and discuss that understanding with the examined person.
- Confirm with the requesting party the time lines requested, and the fees and expenses payable and by whom. A fee may be included for cancellation with short notice or no show where there is not an adequate reason.
- Confirm that the requesting party will pay for any new or repeat testing (lab, x-ray, etc.), if necessary.
- Adhere faithfully to the contractual terms and instructions. Never accept a fee where there is an expectation, direct or indirect, that the physician will write a report favourable to the requesting party in this matter or generally.
- Consider providing a sample consent form so that the examined person can consider it and, perhaps, review it with a lawyer. This will avoid delay at the physician's office.
- Understand that when a NTME is being conducted under the Newfoundland Rules of the Supreme Court (Rule 34) the examined person may appoint a physician of his/her choice to be in attendance at the NTME. That physician has no right to participate actively or interject in the NTME. His/her role is that of observer. You should be aware that the observing physician may be required to comment upon the NTME report, recording his/her observations as to the physician's manner, technique, tests conducted, etc.