Department of Industrial Relations
Industrial Medical Council Public Meeting
Holiday Inn, LAX
Thursday, October 19, 2000
1. A meeting was attempted but a quorum was not present.
Ira Monosson, M.D.
Richard Pitts, D.O.
Michael Roback, M.D.
Patricia Sinnott, PT, MPH
Lawrence Tain, D.C.
Robert Larsen, M.D. Richard Sommer, Esq. D. Allan MacKenzie, M.D. CM
Marvin Lipton, M.D. Glenn Repko, Ph.D.
Maria Mayoral, M.D. Paul E. Wakim, D.O.
Steven Nagelberg, M.D. Gayle Walsh, D.C.
Jonathan Ng, M.D. Benjamin Yang, C.A. OMD
2. Consent Agenda
b. Executive Medical Director's Report:
c. DIR/IMC Update:
d. Legislative Update:
e. DWC Report:
3. Education Committee Meeting:
A quick meeting was held. It was stated that the regs have been set up to allow for a very quick approval process.
Jim Fisher stated that because of AB 776 not going into effect until January, after that, IMC is going to approve providers quickly. He expressed that he would like everyone to get their forms in sometime after the first of the year. Ms. Przepiorski asked whether they should be running a course in competition with the IMC because they see IMC's courses as a test balloon to see if it covers the area.
Mr. Fisher stated it was a learning process. He mentioned forms will be put up on the website to be downloaded. The most significant change in the regs is that one does not have to wait 60-days prior to advertising a course. Ms. Przepiorski reported that they receive a number of calls. Dr. Susan McKenzie stated she has been receiving comments all along and will incorporate them.
David Kizer stated IMC just put out a newsletter.
Dr. Anne Searcy reported on the scores for the last exam, which were held on September 23. IMC is recommending 70% passing rate. The reliability for both Acupuncture and QMEs was very good. For the Acupuncturist, that would pass 56%, which is in the middle of what IMC has done before. For the other QMEs, it would pass 73% of them. This is consistent with the previous exam and passing rates. The number of people who have passed has gone from 66% to 93% on the first test. An analysis is done to make sure that the questions are not harder or easier than what they were before. The test was reviewed and some questions were thrown out. Paper was provided for people to write their comments during the test and their comments are then reviewed by a panel.
4. Neuromusculoskeletal Committee Report
Dr. Roback opened the meeting and stated that regarding the guidelines, they were very good at getting basic, general, foundational ideas out but not do well in dealing with exceptions, treatment exceptions. He stated that this would be more focussed on by the chiropractic and osteopathic community. These are the standards of an orthopedic exam. They do not deal with factors such as single-joint problems and the stress test. The Council has never identified how to handle certain techniques which may not be universally accepted by all groups but have a strong basis in one group or another group. They are looking at basic requirements for an examination – minimal requirements. He did not feel the guidelines should be viewed as the maximum. He commented that if one had a particular test or particular technique that one believes is valuable, should it be mandatory? Or should it be accepted as a test to give information but not required to be accepted as the minimal standard? He asked if there should be a standard to review records. He asked if there was anything that was not acceptable and should be eliminated.
Someone asked for clarification on the last sentence under "Measurements" regarding the distance from the elbow in Section II. Dr. Roback explained the measurements and the distance.
Dr. Tain suggested that the bulk of all procedures should be standardized. Dr. Roback did not agree. He was not sure that standardization of (i.e. occiput to cervical motion) is necessarily examiner agreed on by all the parties. Dr. Tain commented that range of motion is the standard.
Ms. Rea Crane commented on a previous meeting regarding this and that there were more physicians present.
Dr. Roback asked if everyone should be mandated for height and weight. Also if all areas - knees, back, hand and wrist should be evaluated? He commented that if one looked in a large number of reports, height and weight would not be found. He stated it was not considered mandatory. Discussion ensued.
Dr. Roback mentioned that resistance should be measured and described in a standard way. Dr. Tain wanted to discuss the issue.
Dr. Roback stated that the best way to do it would be to put degrees and percentage of normal for that age group.
Dr. Tain commented that the cervical spine will be an issue. He also commented that the examiner needs to adjust what the norms should be in a particular individual (i.e. someone that is 90-years old vs. 21-years old). He agreed that it should be measured in degrees and then rounded off.
Dr. Roback commented that some of the issues have to do with the points and authorities behind which you actually develop what you say. In a chiropractic exam, there is a restricted glide of C4 and C5 with left lateral rotation at 450. Dr. Roback stated that the minimum needs to be mandated. There are some individuals who are specialists in neck who can go further than someone who is just a standard examiner. He then asked if degrees should be required. The audience answered in the affirmative. Discussion ensued on measuring the back.
Dr. Tain asked if the standard will still be Pakard-Thurber. He also asked if Pakard-Therber can be supplemented by saying a goniometer should be used.
Dr. Roback asked for a show of hands if there should be degrees in range of motion for the neck. Then asked if it was not necessary percentages to also show hands. It was agreed to have degrees.
Dr. Roback asked if "estimated normal" should be put in. Discussion ensued. Dr. Roback stated to list degrees, estimated normal, the IMC should find a normal and then put it out for public consumption. He asked if a goniometer or estimate should be used for range of motion. He confirmed that it does not have to be a goniometer, that estimation is enough. Dr. Roback asked a question to the raters since they rate on active motion. If passive motion should be used for rating or is it just an addition? It may be too soon to say, we may want to say "in the future". But did not feel they can not go for passive. Discussion ensued.
He then stated that upper extremities should be examined. He asked if distance from the elbow should be put in. He then asked if it should be measured at maximum circumference? Or standard distance from the elbow on everyone? Discussion ensued.
Jaymar was brought out for one of the standards. Will other equipment be accepted? Discussion ensued. A comment was made that loss of strength is being looked at. Dr. Roback stated that there were at least three different types made by a manufacture that made some sort of a test to determine normal. He commented that the difference is he did not feel it was publicly disseminated in the same way. With grip strength you can use any standard equipment that has been used in the open medical labor market. Dr. Tain commented that the Jaymar has been used as the standard for many years then all of a sudden something else that has come up in the market that is valid. And now were going to compare the Jaymar and the goniometer. Discussion ensued. Dr. Roback asked how many people feel it should be any piece of equipment one wants as long as it's standardized. Then asked how many people feel it should be the Jaymar only. If an alternate piece of equipment, one has to state the equipment, have in possession some knowledge of the standard in case someone asked to produce a reference by which one is making their decision, one will be able to do it. Someone commented that the documentation should be in the report. Dr. Roback asked if the norm should be in for the Jaymar. It was affirmative. Discussion ensued.
Comments were made to the second sentence in Section E. Dr. Roback stated that the specified test are not the limit of tests which make it significant information to determine disability. It was agreed to delete the last sentence in Section E. It was agreed to change the sentence reading "resting muscle tone shall be described as increased". Limited to the c spine, it was also agreed to put as a mandatory statement in every report that there is or is not muscle spasm in the cervical spine.
Dr. Roback suggested that "muscle tone shall be described and other changes of muscle activity (i.e. muscle spasm, fibrillation, etc.) should be described when present and may be considered as a finding of disability."
He also suggested to change under "motor testing" in cases of questionable muscle weakness. Muscle testing may be corroborated by findings of neurological damage or presence or absence of neurological damage on an EMG.
Dr. Tain suggested on that on "cases of questionable effort, confirming examination, testing or evaluation, should be reported." Discussion ensued.
Dr. Roback felt he was interpreting it differently. Where it says "reduced efforts", he felt that documentation as to the reasons of ones conclusions must be presented and other testing may be indicated. It was agreed.
Under 'sensory testing", the third sentence, second line, was agreed to be deleted.
Dr. Pitts suggested "any abnormalities should be described fully correlated with expected for ________"(too many people talking at the same time). Dr. Roback agreed.
On reflexes, it was suggested that it should read "shall be evaluated." Also to include triceps, biceps, pec___ radialis. It was agreed.
Under "coordination", it was agreed to delete sentence two.
Under "central nervous system", it should read, "central nervous system function may be affected by cervical injuries such as, visual, auditory, and balance these may require evaluation". Discussion ensued.
It was decided and not use the word "should" and be generic.
The remainder of the meeting was not recorded.
5. Fee Schedule Committee Report
6. Discipline Committee Report
Thursday, October 19, 2000
IMC Staff present:
James Fisher Sylvia Martinez
Gerry Evans Teidi Padua
Elizabeth Ignacio Anne Searcy, M.D
David Kizer, Esq. Larry Williams
Susan McKenzie, M.D.
DWC Staff present:
Members of the public present:
Linda Coltrin, CA Chiropractic Assoc. Jennifer Orosz, HNC Insurance Solution
Rea Crane, CWCI Michael Pulley, Workers' Comp Adv
Robert Flint, CCN Diane Przepiorski, COA
Moses Gomez, Fraud, DOF Patty Siglock, Sigmed
Lisa Guthman, Barbara Stanfield, CCA
Bill Hutchins, e-Rehab Ken Young, OPSC
Dr. Parag Mehta
Sheri Nolen, HCN Insur. Sol.
Jan Nguyen, Care Solutions