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Independent Medical Examinations 

By Sanjay Adhia, M.D.

What you need to know about forensic psychiatry IMEs, or “psych evals”

What Is an IME?

IME stands for independent medical examination or independent medical evaluation. An IME is a medico-legal exam conducted by a third-party, unbiased examiner, such as a forensic psychiatrist.

IMEs are also conducted by other healthcare professionals who are nonmedical examiners, such as psychologists.

An IME is generally a face-to-face examination. However, a video IME may be necessary in some cases. Both types are discussed here.

Medico-Legal IME vs Clinical Exam

A clinical exam is performed to treat a patient and establishes doctor-patient confidentiality. A medico-legal IME is conducted to contribute information to a forensic psychiatrist’s assessment and ultimate findings.

In a lawsuit, the IME is used to evaluate an examinee, usually a plaintiff or defendant.

Law and Motion

People are generally cooperative when undergoing examination, but not always. In some cases, a forensic psychiatrist may feel an IME is indicated, but it may not take place. For example, an examinee may be reluctant or even refuse to undergo the psych IME. In such cases, a Motion to Compel an IME is sometimes necessary. The court could restrict the IME by limiting how much time the doctor is permitted to take, or the scope of discussion.

Processes like motions or judicial decisions are specific to a legal matter and are unrelated to the clinical exam, where treatment is the focus.

Confidentiality in an IME

There is no doctor-patient relationship in an exam for a legal matter. Confidentiality is limited. In fact, anything said in the examination may be relevant when the doctor testifies as an expert witness.

The Function of a Medicolegal IME

IMEs are objective, and are not for purposes of medical treatment. An IME is conducted to determine medical information and render a medical opinion by an examiner. Elements include diagnosis, prognosis, and treatment questions. Damages are usually considered. Psychiatrists and psychologists are also trained to assess malingering (i.e., lying for secondary gain.)

The IME may be requested by an employer who needs to know if an employee is fit for duty–able medically and mentally to perform the essential functions of their job.

An attorney may request an IME where litigation involves a medical condition. Did a medical condition contribute to a disputed issue? Is it the result? What are damages if a mental, emotional, or physical injury is found to be caused by the event in question? Medicolegal IMEs are not limited to these scenarios, of course.

An IME may be requested by an insurance company, though the expert witness is retained by counsel for the insured or insurer.

Government agencies or other entities may request an IME for a range of reasons. For example, the Defense Department assessing combat-related injuries or VA claims for treatment may require an IME.

Can an Attorney Choose the Examiner?

In many cases, each party will retain its own examiner. In some cases, both sides will agree to use one examiner. Such an examination is known as neutral medical exam (NME) or an agreed medical exam (AME).

Can a Treating Physician Perform the IME?

A treating physician abides by the Hippocratic oath. The oath states “primum non nocere,” which is Latin for “first, do no harm.” Thus, the treating physician is inherently biased, regardless of whether the person being examined is plaintiff or defense.

IME Psych Evaluation medicolegal forensic Independent Medical Examination

What Is the Difference Between an IME and a Clinical Exam?

The purpose of a clinical exam is to evaluate and treat a patient. Thus, there is a doctor-patient relationship. Confidentiality is required.

The purpose of an IME is to evaluate an examinee and provide a medicolegal opinion. There is no doctor-patient relationship and confidentiality is limited.

Generally, an IME entails a far more detailed evaluation and report than a clinical exam.

A good IME requires objective data. In a clinical setting, a patient’s description of their symptoms (sometimes called a self-report) may be sufficient to initiate a course of treatment. In a medico-legal setting, however, additional data is often required to render an opinion with reasonable medical certainty.

What Is the Procedure for an IME?

I will consult with the retaining party and determine what is being asked. It could vary between one question, such as a diagnosis, or dozens of detailed questions.

I will carefully review the records and identify any records that were omitted. I will also review other IMEs and expert reports, if available.

A detailed psychiatric interview with the examinee or examinees will be conducted. Topics would include psychosocial history, family history, medical history, psychiatric history, and psychiatric review of systems (comprehensive exam of mood, psychotic, anxiety, trauma-related and other symptoms utilizing the DSM-5) and a mental status exam.

If necessary, I will identify and interview collateral informants.

After thoroughly reviewing the data, I will formulate a provisional opinion. Often, I will discuss the findings with the retaining party. If requested, I will proceed with the report.

The report will include all the elements of the interview, usually with a summary of the records and collateral interviews. I will discuss the DSM-5 basis for the diagnoses. I will also discuss why the examinee did not meet criteria for other relevant diagnoses.

I will then explain my opinion and answer any specific questions. Usually, the nexus between the opinion and the psychiatric aspects will be detailed.

As much as I enjoy testifying or being deposed, generally many attorneys would like to quickly resolve a case for their clients. I have found a well-written report will often eliminate the need for a lengthy trial.

Why Retain a Board-Certified Forensic Psychiatrist to Conduct an IME

A forensic psychiatrist has specific training and experience in conducting medicolegal evaluations.* Board certification in Forensic Psychiatry requires the completion of a year of fellowship and passing a rigorous examination about medicolegal questions.

A board-certified forensic psychiatrist is likely a board-certified general psychiatrist with clinical experience and practice. It would be advisable to retain an independent medical examiner who is actively involved in clinical practice. For example, the psychiatrist may have a private patient practice, work in a hospital or other clinical setting, and/or volunteer as a treating provider.

A clinical practice will ensure the examiner has a better understanding of matters like medical standard of care, maximal medical improvement, and other nuances.

On occasion, a Board-Certified Forensic Psychiatrist will have other board certifications, such as Brain Injury Medicine ** or Sleep Medicine.

Board certification and an active clinical practice form the basis to overcome any challenges during a voire-dire that the disclosed expert is not adequately qualified to render expert testimony.

What Is a QME and PQME?

These terms are used primarily in Workers’ Compensation cases. QME stands for “qualified medical examiner.” Many states have panels of QMEs from which Workers’ Compensation claimants can choose. PQME means a “panel-qualified medical examiner.” Certain state Workers’ Compensation programs utilize such examiners with state-by-state requirements, which may include a special examination and credentialing process. Psychiatrists and psychologists may be QMEs, but they are not equally appropriate for every case.

What Is a DME?

A DME is a defense medical exam. It is a court-ordered exam of the plaintiff by the defense expert.

Health Care by Video
vs.
Medico-Legal IME by Video

Healthcare Treatment

During the COVID-19 pandemic, many physicians provided telehealth services by video or phone. This delivery of treatment is well-suited for psychiatry and was used long before the pandemic. I have even provided telehealth care to death row offenders at the Supermax Polunsky Unit. Although medical providers have generally returned to in-person visits, many providers continue to offer video healthcare appointments.

Medico-Legal Examination

Medico-legal psychiatric IMEs can also be performed using video conferencing platforms such as Zoom and Skype. I was asked to perform an IME by video when an examinee was isolated geographically (the examinee was an Arizona resident in Panama at the time of the IME), and in another case, the examinee was isolated by a health condition. (Read more.)

While an attorney may consider a virtual IME for convenience or cost, I do not make the decision, as my role is as an impartial expert only.

Legality of a Video IME

There is no definitive legal precedent or professional standard about video IMEs in a forensic evaluation to my knowledge. Guidelines are suggested about Workers’ Compensation IMEs by video by the American Academy of Psychiatry and the Law; they do not establish a protocol regarding a video IME in civil litigation, criminal, or other venue.

If a video IME is conducted, the Court might decide whether or not to allow a forensic psychiatrist’s testimony based on opinions rendered after a video IME.

Endnotes:

* “The 1999 examination was the last one which did not require that the applicant had completed a fellowship in forensic psychiatry. Beginning in 2001, completion of an accredited fellowship was required. The first recertification examination was given in 2004.” American Academy of Psychiatry and the Law, “ABPN Certification in the Subspecialty of Forensic Psychiatry” “History.”