In 1847, the American Medical Association adopted the world's first national code of professional ethics in medicine. For the more than 160 years, the AMA's "Code of Medical Ethics" has been the authoritative ethics guide for practicing physicians. Currently, the AMA has 200 ethical opinions. The chiropractic profession needs to learn from the AMA and, in the end, further protect our patients and doctors from fraud and abuse. In this case, I make the argument in order to protect against IME and peer review abuse.
The AMA's Code of Medical Ethics, Opinion 10.03, is titled "Patient-Physician Relationship in the Context of Work-Related and Independent Medical Examinations" and outlines a cogent relationship that should exist between both IMEs (independent medical examiners) and IEPs (industry employed physicians). The AMA writes:
Despite their ties to a third party, the responsibilities of IEPs and IMEs are in some basic respects very similar to those of other physicians. IEPs and IMEs have the same obligations as physicians in other contexts to:
(1) Evaluate objectively the patient’s health or disability. In order to maintain objectivity, IEPs and IMEs should not be influenced by the preferences of the patient-employee, employer, or insurance company when making a diagnosis during a work-related or independent medical examination.
(2) Maintain patient confidentiality as outlined by Opinion 5.09, "Industry Employed Physicians and Independent Medical Examiners."
(3) Disclose fully potential or perceived conflicts of interest. The physician should inform the patient about the terms of the agreement between himself or herself and the third party as well as the fact that he or she is acting as an agent of that entity. This should be done at the outset of the examination, before health information is gathered from the patient-employee. Before the physician proceeds with the exam, he or she should ensure to the extent possible that the patient understands the physician’s unaltered ethical obligations, as well as the differences that exist between the physician’s role in this context and the physician’s traditional fiduciary role. (http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion1003.page)
Although the AMA worked hard to protect patients and doctors from improper IME and IEP examinations, they are a labor organization and neither a regulatory body, nor a court of law.
However, upon joining, members have to agree to abide by the Code of Ethics, which is a contractual obligation and has legal precedent in tort (trial) proceedings. In addition, many regulatory bodies seek counsel from state organizations to determine if a doctor is practicing within the current standard of care and ethics for his/her particular state.
It is here where every national and state chiropractic organization has the ability to level the playing field in protecting both patients and doctors by having a code of ethics outlined and agreed upon by all of their members. This creates a standard of practice in the state and should an improper IME, IEP or peer review be performed, then there are guidelines to justify recourse. Although some states have ruled that IME, IEP and peer review doctors are not subject to state licensure disciplinary boards as a result of their interpretation of "duty of care" or the legal obligation of the doctor to the patient because they believe no doctor-patient relationship exists, many states do hold the IME or IEP doctor to the same standard as the treating doctor. This dichotomy creates a problem in those states where a doctor can tell half-truths, report only snippets of research or do only a partial examination for a desired conclusion and not be subject to losing his/her license. Courts in New York, Maryland, The District of Columbia, Arizona, Michigan, West Virginia, Montana, and The United States Court of Appeals, Fifth Circuit, among others, have ruled that these doctors are responsible in a doctor-patient relationship.
Should an independent examining doctor do an improper or fraudulent examination in any of those states, the code of ethics will weigh heavily against them. In states like Alaska, Missouri and Colorado where there is no "duty of care" and it has been determined there is no doctor-patient relationship for independent examining doctors, the Code of Ethics then helps litigators, to some degree, in creating justice for the injured. Furthermore, it can help give direction to creating legislation to overturn the court rulings that currently protect the licenses of IME, IEP and peer review abusers. We must never lose sight of the fact that independent examining doctors have a tremendous personal financial gain to render a desired diagnosis and conclusion and there have to be checks and balances in place to ensure an honest opinion is rendered.
I strongly suggest that every state and national organization adopt a version of the following language as a code of ethics standard for all of their members:
Chiropractic Code of Ethics:
A. Conduct of Independent Examiners
(1) Evaluate objectively the patient’s health or disability. In order to maintain objectivity, independent chiropractic/medical evaluations should not be influenced by the preferences of the patient-employee, employer, or insurance company when making a diagnosis during any type of independent chiropractic/medical examination, including, but not limited to, sequellae from auto accidents, on-the-job injuries and pre-employment physicals.
(2) Maintain patient confidentiality as outlined by the State of [add your state].
(3) Disclose fully potential or perceived conflicts of interest. The doctor of chiropractic should inform the patient about the relationship between himself or herself and the third party as well as the fact that he or she is acting as an agent of that entity. This should be done at the outset of the examination, before health information is gathered from the examinee. Before the doctor of chiropractic proceeds with the exam, he or she should ensure to the extent possible that the patient understands the doctor of chiropractic’s unaltered ethical obligations, as well as the differences that exist between the treating doctor's role and that of the independent examiner.
(4)The examining doctor shall:
- Include all pertinent and related diagnostic findings and test results in his/her report(s).
- Consider all pertinent and related diagnostic findings and test results when rendering a diagnostic conclusion.
- Include complete pertinent and related research, when applicable, in rendering a conclusion.
- Perform examinations to the same standard as he/she does for all other patients with similar diagnoses.
- Note in his/her report(s) the absence of any diagnostic or test findings when he/she is aware he/she does not have possession of said reports or results.
Adopting these standards is taking the first step towards leveling the playing field to help ensure that our patients get the care they need and that doctors receive the payments they are entitled to for rendering necessary services.
- American Medical Association. (n.d.). History of AMA ethics. AMA Code of Medical Ethics, Retrieved from http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/history-ama-ethics.page?
- American Medical Association. (1999). Opinion 10.03 - Patient-physician relationship in the context of work-related and independent medical examinations. AMA Code of Medical Ethics, Retrieved from http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion1003.page
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