John Kuhnlein ,DO, MPH, CIME, FACPM, FACOEM

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• John Kuhnlein ,DO, MPH, CIME, FACPM, FACOEM
• Medix Occupational Health
• Ankeny Iowa

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Energy in the executive is a leading character
in the definition of good government. A feeble
executive implies a feeble execution of
government. A feeble execution is but another
phrase for a bad execution and a government ill
executed, whatever it may be in theory, must be,
in practice, a bad government.
Alexander Hamilton, Federalist Papers, No. 70
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Energy in editorial control is a leading
character in the definition of a good Guides. A
feeble or misguided editorial control implies a
feeble execution of the Guides. A feeble
execution is but another phrase for a bad Guides
and a Guides ill executed, whatever it may be in
theory, must be, in practice, a bad Guides.
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So what do you need to know about the 6th Edition?

• The Iowa Task Force regarding the use of the 6th
  Edition voted against its use in Iowa, and Ill
  try to explain my thoughts about this. You can
  view the report at the Iowa Workforce Development
  website.
• One can look at this position in a number of
  ways
• Wait and Watch what happens in other states prior
  to considering implementation
• Not never, just not now
• Never in its current iteration and format

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The 6th Edition uses 5 new axioms for impairment
rating (2)

• The Guides adopts the terminology and conceptual
  framework of the International Classification of
  Functioning, Disability and Health (ICF) Fig 1-1
  (3) Old model 5th Fig 1-1 (8)
• The Guides becomes more diagnosis based

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The 6th Edition uses 5 new axioms for impairment
rating (2)

• Simplicity, ease-of-application, and following
  precedent, where applicable, are given high
  priority, with the goal of optimizing interrater
  and intrarater reliability (italics added)
• Rating percentages functionally based
• Conceptual and methodological congruity within
  and between organ system ratings

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Some of the basics -

• The Guides originally came from a series of
  articles in JAMA from 1958-1970 The
  First Edition of The Guides
• Subsequent Editions have been evolutionary in
  approach the 6th is revolutionary, using a very
  different model, not only conceptually, but in
  how ratings are practically derived.

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So whats different?

• In the other Editions, we took the injury apart
  into range of motion, motor, sensory, ligamentous
  structure, sometimes DRE and then combined them
  back into the impairment-it was mostly based on
  the physical examination regardless of diagnosis,
  most of the time

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So whats different? Remember this is simple and
easy.

• Radically different methodology based on a
  Clinical Diagnostic Class (CDX), which assigns
  impairment to the median value in a grid of
  impairments, with several exceptions.
• The CDX is then modified using the Net Adjustment
  Formula (NAF) using modifiers for functional
  history, physical examination, and diagnostic
  studies (GMFH-CDX)(GMPE-CDX)(GMCS- CDX)

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So whats different? Remember ease-of-application!

• This model is used most of the time, except for
  
• mental health,
• carpal tunnel syndrome, Table 15-23, (449)
• sometimes upper extremity, (amputation, some CDX
  3 and 4 injuries) (461) and
• sometimes lower extremity (amputation, some CDX 3
  and 4 injuries) (543)

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The 5th is far from perfect

• No real scientific support for impairment rating
  values always has been a consensus process.
• If the doctor doesnt read the book, significant
  errors may ensue.
• Open the book, look at a few tables and use one
  of the numbers to assign a rating. Some docs
  dont even do this much.
• The doctors dont mention the tables and pages so
  the reader can follow where the numbers are
  coming from.

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The 5th is far from perfect

• Lack of internal consistency-visual system
  ratings arent consistent with the MSK chapter
  ratings.
• Sometimes there are significant gaps between DRE
  impairments-whats wrong with 3? It jumps from
  0 (DRE I) to 5 (DRE II) Fig 15-3, page 384
• Sometimes major nerves are missing, e.g. in the
  lower extremity, Table 17-31, Page 544

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The 5th is far from perfect

• In the case of multiple spine surgeries- you use
  the ROM method (379-380), but the numbers come
  out LOWER than if you only have one surgery.
  With one surgery only cervical fusion is minimum
  25 BAW Fig 15-5 392
• Mental health issues have no ordinal values

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The 6th has some advantages

• The spine gaps are filled in
• Nerves are addressed that werent before
• There is a methodology for rating mental health
  issues-although in error originally. Recently
  corrected in the first 52 page errata.
• Tendinitis/epicondylitis handled now
• May be a bit more straightforward if the strict
  methodology is followed, although the exceptions
  are significant and confusing.

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The 6th Edition has issues

• So many issues, so little time
• THE PARADIGM SHIFT
• What is a paradigm shift
• Who voted to say we needed a paradigm shift in
  the first place?
• By physicians for physicians but
• AMA was threatened by lawsuit by ACA if the
  wording didnt change
• No one asked the end users (e.g. the workers
  compensation users) if needed or wanted at all.
  It doesnt appear that the true impact on the end
  users was considered
• Methodology includes disability issues so mixing
  impairment with disability measures

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The 6th Edition has issues

• THE PARADIGM SHIFT
• Despite the editors assertions that this edition
  of the Guides will move the process forward
  there are still practical issues of
  implementation that, if considered, dont seem to
  have been considered important.

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The 6th Edition has issues

• THE PARADIGM SHIFT
• May produce untoward and unexpected outcomes or
  harm to either party the 2006 injury vs. the
  2008 and outcomes. 25 v. 6, MH issues
• There doesnt seem to be a mechanism in place to
  assess /- impact for adaptation. Rondinelli
  comment 2/1/08 re AMA actuarials

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The 6th Edition has issues

• THE PARADIGM SHIFT
• Do No Harm principle - issues of harm to
  employee, multistate employer, physicians
• Physicians who write Guides forget common sense.
  They get bound up in methodology, testify as to
  science, and studies, but forget to step back and
  look at this as a social process. We hear about
  studies and evidence based medicine, but no
  comment upon real implementation problems and
  issues

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The 6th Edition has issues

• THE PARADIGM SHIFT
• My view intriguing concept, but
• Iowa should wait and watch. Let sister states
  who mandate use find out if this paradigm is
  usable and then reevaluate.
• Not never, just not now.

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The 6th Edition has issues

• Changes in Ordinal Values- Untoward and
  Unexpected Outcomes
• Cervical Fusion ratings may be dramatically
  different. 5th 25-28 DRE. 6th may be 6 or 0
  BAW. Table 17-2 page 564.
• Mental health now present so ratings here may go
  up. You have numbers where you didnt before.
• Tendinitis
• Uncertain whether certain conditions change
  dramatically, if overall ratings go up/down

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The 6th Edition has issues

• Cultural and Racial Issues
• Reported to Task Force that QuickDASH, AAOS, PDQ
  not culturally sensitive.
• People of culture are often also people of
  different race.
• Because of the way the questionnaires are used,
  there may be either an advantage or disadvantage
  to people of culture and color. See pp. 446-447
  6th Edition re QuickDASH scoring.

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The 6th Edition has issues

• Physician Issues
• Carpal Tunnel syndrome can be diagnosed using one
  set of EMG/NCV criteria but is rated using
  another set of EMG/NCV criteria. This creates a
  double standard. (446)
• Physicians may see complaints to state Boards of
  Medicine for unnecessary surgery. Maybe not.
• Task Force was told that the EMG/NCV standards
  outlined in Appendix 15-B were determined by
  consensus. They are not the criteria from AMA
  component societies. But AMA says it wants Guides
  to be more objective. Seems this is not.

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The 6th Edition has issues

• Physician Issues
• The learning curve
• 8 hour course work at several hundred dollars
  expense if not more because of travel expenses.
• Dr. Melhorn indicated about 25-30 hours necessary
  to learn on your own.
• If physicians simply pick up the book and look at
  tables and figures, the errors will increase,
  with increased case cost.
• Will fewer physicians do ratings?

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The 6th Edition has issues

• Physician Issues
• 52 page errata took 3.5 hours for one Task Force
  member to correct with the 6th Edition, i.e., the
  11 cm PDQ line, the MH BPRS
• More errata may be coming, uncertain now.
• If physicians who rarely use the book dont
  review and correct with the errata, error rates
  will go up
• If the reader doesnt know if the physician was
  aware of the latest errata, confusion will ensue
  as to whether the rating is incorrect. Was the
  reader aware of the most recent errata?

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The 6th Edition has issues

• Consensus
• Editorial Issues
• Dr. Rondinelli 85/15 issues
• Dr. Mueller listing issues
• Dr. Colledge issues
• Dr. Douglas Martin issues brought to Task Force
• hidden agendas and biased allegiances which many
  physicians (involved in the development of the
  Sixth Edition) cannot say
• Dr. Brigham issues

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The 6th Edition has issues

• Bias? Unattributed statements in the text,
  unrelated to impairment issues per se
• Mental health impairment limited to one
  diagnosis(349) Malingering T. 14-3, (350)
• UE three nerve issue (448)
• MMI at two stable OVs one month apart after CTR
  (447)

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The 6th Edition has issues

• Bias? Unattributed statements in the text,
  unrelated to impairment issues per se
• Unreferenced LE CRPS comments re incorrect
  (539) Table 16-15 (541), also see bibliography
  preliminary, proposed
• Issues related to excluding GMFH (LE 516), GMPE
  (LE 517), and GMCS values (UE 448 re postop
  EMG/NCV)

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The 6th Edition has issues

• Consensus and bias
• Who wrote the chapters? We couldnt find out.
• Who were the authors who
• Might have hidden agendas and biased
  allegiances who
• Made up the consensus that
• Created the paradigm shift with the
• Potential cultural/racial issues that
• Might create problems for physicians?
• And why did this book get hurried in the rush to
  publish, and who made the corrections
• Published in the 52 page errata that had to be
• Rushed to publish because of the original
• Rush to publish a version weve been told is
• A beta version?

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The 6th Edition has issues

• Interrater Reliability
• Editors mentioned this several times in
  discussions with the Task Force
• So what? The deck is stacked anyway.
• There will be greater interrater reliability
  because there are essentially only five choices
  anyway based on the CDX

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The 6th Edition has issues

• Interrater Reliability
• Problem is accuracy in ratings not interrater
  reliability which comes back to the consensus.
• If the consensus is biased, the data in the grids
  is bad.
• If the data in the grids is bad then the ratings
  are bad. Physicians can all come up with the
  same number but if the data is bad, then the
  rating is bad, it will still be an incorrect
  number

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The 6th Edition has issues

• Simplicity and ease of use
• Remember that there are occasions when the GMFH,
  the GMPE, and the GMCS can be disregarded, based
  on the particular scenario.
• Remember that you can have objective physical
  findings that can DECREASE the rating.

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Summary

• Wait and Watch the 6th implementation in other
  states. Basically let other states find out if
  these are all valid concerns.
• There is no harm in waiting.
• Not never, just not now.

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