QME Implicit Bias in Medical Evaluations and Reporting [Anti-Bias Training]by William W. Deardorff, Ph.D, ABPP.
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Implicit biases in healthcare have been found to contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This course will explore definitions of implicit and explicit bias, the nature of implicit biases, and how they can affect health outcomes. Because implicit biases are unconscious, strategies will be reviewed to assist in raising professionals' awareness of and interventions to reduce them.
OVERVIEW
As a brief overview of implicit bias, review the following video (Concepts Unwrapped) from the McCombs School of Business. This video is a part of Ethics Unwrapped, a free online educational video series about ethics produced by the Center for Leadership and Ethics at The University of Texas at Austin. Ethics Unwrapped offers an innovative approach to introducing complex ethics topics and behavioral ethics ideas in a way that is accessible to both students and instructors. You can find the video here:
https://www.youtube.com/watch?v=OoBvzI-YZf4
INTRODUCTION
In the 1990s, social psychologists Dr. Mahzarin Banaji and Dr. Tony Greenwald introduced the concept of implicit bias and developed the Implicit Association Test (IAT) as a measure. In 2003, the Institute of Medicine published the report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care highlighting the role of health professionals' implicit biases in the development of health disparities. The phenomenon of implicit bias is based on the assumption that while well-meaning individuals may deny prejudicial beliefs, these implicit biases negatively impact their clinical communications, interactions, and diagnostic and treatment decision-making.
One explanation is that implicit biases are a cognitive, heuristic, or mental shortcut. These “shortcuts” offer individuals general rules to apply to situations in which there is limited, conflicting, or unclear information. Use of a heuristic results in a quick judgment based on fragments of memory and knowledge, and therefore, the decisions made may be erroneous. If the thinking patterns are flawed, negative attitudes can reinforce stereotypes.
In health contexts, this is can be a problem because clinical judgments can be biased and adversely affect health outcomes. The Joint Commission provides the following example: A group of physicians congregate to examine a child's x-rays but has not been able to reach a diagnostic consensus. Another physician with no knowledge of the case is passing by, sees the x-rays, and says "Cystic fibrosis." The group of physicians was aware that the child is African American and had dismissed cystic fibrosis because it is less common among Black children than White children.
Review the following video on implicit bias in medicine (Implicit Bias in Medicine “The Elephant in the Waiting Room; The Empathy Project).
https://www.youtube.com/watch?v=d8feuAvxDlI
The purpose of this course is to provide health professionals with an overview of implicit bias. This includes an exploration of definitions of implicit and explicit bias. The nature and dynamics of implicit biases and how they can affect health outcomes will be discussed. Finally, because implicit biases are unconscious, strategies will be reviewed to assist in raising professionals' awareness of and interventions to reduce them.
The Kirwan Institute for the Study of Race and Ethnicity
The Kirwan Institute has developed a short video course that will introduce you to insights about how our minds operate and help you understand the origins of implicit associations.
The Institutes offers a total of four modules with brief lessons in each. For this course, we only require reviewing Module 1 and Module 3; however, if you so desire, there is excellent information in the other Modules. You can read the transcipts of the Modules here (from OSU) or here
IMPLICIT VS. EXPLICIT BIAS
In a sociocultural context, biases are generally defined as negative evaluations of a particular social group relative to another group. Explicit biases are conscious, whereby an individual is fully aware of his/her attitudes and there may be intentional behaviors related to these attitudes. For example, an individual may openly endorse a belief that women are weak and men are strong. This bias is fully conscious and made explicitly known to others. The individual's ideas may then be reflected in his/her work as a manager.
The term "implicit bias" refers to the unconscious attitudes and evaluations held by individuals. These individuals do not necessarily endorse the bias, but the embedded beliefs/attitudes can negatively affect their behaviors. Implicit biases can start as early as three years of age. As children age, they may begin to become more egalitarian in what they explicitly endorse, but their implicit biases may not necessarily change in accordance with these outward expressions. Because implicit biases occur on the subconscious or unconscious level, particular social attributes (e.g., skin color) can quietly and insidiously affect perceptions and behaviors. According to Georgetown University's National Center on Cultural Competency, social characteristics that can trigger implicit biases include:
An alternative way of conceptualizing implicit bias is that an unconscious evaluation is only negative if it has further adverse consequences on a group that is already disadvantaged or produces inequities. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.
When the concept of implicit bias was introduced in the 1990s, it was thought that implicit biases could be directly linked to behavior. Despite the decades of empirical research, many questions, controversies, and debates remain about the dynamics and pathways of implicit biases.
OTHER COMMON DEFINITIONS
In addition to understanding implicit and explicit bias, there is additional terminology related to these concepts that requires specific definition.
Cultural Competence Cultural competence is broadly defined as practitioners' knowledge of and ability to apply cultural information and appreciation of a different group's cultural and belief systems to their work. It is a dynamic process, meaning that there is no endpoint to the journey to becoming culturally aware, sensitive, and competent. Some have argued that cultural curiosity is a vital aspect of this approach.
Cultural Humility Cultural humility refers to an attitude of humbleness, acknowledging one's limitations in the cultural knowledge of groups. Practitioners who apply cultural humility readily concede that they are not experts in others' cultures and that there are aspects of culture and social experiences that they do not know. From this perspective, patients are considered teachers of the cultural norms, beliefs, and value systems of their group, while practitioners are the learners. Cultural humility is a lifelong process involving reflexivity, self-evaluation, and self-critique.
Discrimination Discrimination has traditionally been viewed as the outcome of prejudice. It encompasses overt or hidden actions, behaviors, or practices of members in a dominant group against members of a subordinate group. Discrimination has also been further categorized as lifetime discrimination, which consists of major discreet discriminatory events, or everyday discrimination, which is subtle, continual, and part of day-to-day life and can have a cumulate effect on individuals.
Diversity Diversity "encompasses differences in and among societal groups based on race, ethnicity, gender, age, physical/mental abilities, religion, sexual orientation, and other distinguishing characteristics". Diversity is often conceptualized into singular dimensions as opposed to multiple and intersecting diversity factors.
Intersectionality Intersectionality is a term to describe the multiple facets of identity, including race, gender, sexual orientation, religion, sex, and age. These facets are not mutually exclusive, and the meanings that are ascribed to these identities are inter-related and interact to create a whole.
Prejudice Prejudice is a generally negative feeling, attitude, or stereotype against members of a group. It is important not to equate prejudice and racism, although the two concepts are related. All humans have prejudices, but not all individuals are racist. The popular definition is that "prejudice plus power equals racism". Prejudice stems from the process of ascribing every member of a group with the same attribute.
Race Race is linked to biology. Race is partially defined by physical markers (e.g., skin or hair color) and is generally used as a mechanism for classification. It does not refer to cultural institutions or patterns. In modern history, skin color has been used to classify people and to imply that there are distinct biologic differences within human populations. Historically, the U.S. Census has defined race according to ancestry and blood quantum; today, it is based on self-classification. There are scholars who assert that race is socially constructed without any biological component. For example, racial characteristics are also assigned based on differential power and privilege, lending to different statuses among groups.
Racism Racism is the "systematic subordination of members of targeted racial groups who have relatively little social power…by members of the agent racial group who have relatively more social power". Racism is perpetuated and reinforced by social values, norms, and institutions.
There is some controversy regarding whether unconscious (implicit) racism exists. Experts assert that images embedded in our unconscious are the result of socialization and personal observations, and negative attributes may be unconsciously applied to racial minority groups. These implicit attributes affect individuals' thoughts and behaviors without conscious awareness. Structural racism refers to the laws, policies, and institutional norms and ideologies that systematically reinforce inequities resulting in differential access to services such as health care, education, employment, and housing for racial and ethnic minorities.
MEASUREMENT OF IMPLICIT BIAS: THE IAT
Project Implicit is a research project sponsored by Harvard University and devoted to the study and monitoring of implicit biases. It houses the Implicit Association Test (IAT), which is one of the most widely utilized standardized instruments to measure implicit biases. The IAT is based on the premise that implicit bias is an objective and discreet phenomenon that can be measured in a quantitative manner. Developed and first introduced in 1998, it is an online test that assesses implicit bias by measuring how quickly people make associations between targeted categories with a list of adjectives. For example, research participants might be assessed for their implicit biases by seeing how rapidly they make evaluations among the two groups/categories career/family and male/female. Participants tend to more easily affiliate terms for which they hold implicit or explicit biases. So, unconscious biases are measured by how quickly research participants respond to stereotypical pairings (e.g., career/male and family/female). The larger the difference between the individual's performance between the two groups, the stronger the degree of bias. Since 2006, more than 4.6 million individuals have taken the IAT, and results indicate that the general population holds implicit biases.
If you would like to take the Implicit Association Test (IAT), you can do so at the following link (Outsmarting Implicit Bias, Harvard University). This is not required as part of this CE course but is highly recommended.
https://outsmartingimplicitbias.org/module/iat/
Measuring implicit bias is complex, because it requires an instrument that is able to access underlying unconscious processes. While many of the studies on implicit biases have employed the IAT, there are other measures available. They fall into three general categories: the IAT and its variants, priming methods, and miscellaneous measures, such as self-report, role-playing, and computer mouse movements. This course will focus on the IAT, as it is the most commonly employed instrument.
The IAT is not without controversy. One of the debates involves whether IAT scores focus on a cognitive state or if they reflect a personality trait. If it is the latter, the IAT's value as a diagnostic screening tool is diminished. There is also concern with its validity in specific areas, including jury selection and hiring. Some also maintain that the IAT is sensitive to social context and may not accurately predict behavior. Essentially, a high IAT score reflecting implicit biases does not necessarily link to discriminating behaviors, and correlation should not imply causation. A meta-analysis involving 87,418 research participants found no evidence that changes in implicit biases affected explicit behaviors.
HEALTH DISPARITIES
Implicit bias has been linked to a variety of health disparities. Health disparities are differences in health status or disease that systematically and adversely affect less advantaged groups. These inequities are often linked to historical and current unequal distribution of resources due to poverty, structural inequities, insufficient access to health care, and/or environmental barriers and threats. According to research, in general, once a face appears to be about 67% human (going from doll to face), it looks alive, like it has a mind, and like it can feel pain. In the same doll to face research, the faces of outgroups (dissimilar to you) must be significantly more human looking before willing to say they can think or feel. This is an implicit bias.
Health disparity has been defined as: “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage”. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.
As noted, in 2003, the Institute of Medicine implicated implicit bias in the development and continued health disparities in the United States. Despite progress made to lessen the gaps among different groups, health disparities continue to exist. One example is racial disparities in life expectancy among Black and White individuals in the United States. Life expectancy for Black men is 4.4 years lower than White men; for Black women, it is 2.9 years lower compared with White women. Hypertension, diabetes, and obesity are more prevalent in non-Hispanic Black populations compared with non-Hispanic White groups (25%, 49%, and 59% higher, respectively). In one study, African American and Latina women were more likely to experience cesarean deliveries than their White counterparts, even after controlling for medically necessary procedures. This places African American and Latina women at greater risk of infection and maternal mortality.
Gender health disparities have also been demonstrated. Generally, self-rated physical health (considered one of the best proxies to health) is poorer among women than men. Depression is also more common among women than men. Lesbian and bisexual women report higher rates of depression and are more likely than non-gay women to engage risk behaviors such as smoking and binge drinking, perhaps as a result of LGBTQ -related stressors. They are also less likely to access healthcare services.
Socioeconomic status also affects health care engagement and quality. In a study of patients seeking treatment for thoracic trauma, those without insurance were 1.9 times more likely to die compared with those with private insurance.
For this course, please review the article “Implicit bias in healthcare professionals: a systematic review” (Fitzgerald and Hurst, 2017) or here
For this course, also review the article Eliminating explicit and implicit biases in health care: evidence and research needs (Vela et al., 2022) or here
For this course, also review the video Implicit bias in healthcare. Tulane Medicine Grand Rounds. Quinn Capers, M.D., Vice Dean for Faculty Affairs, The Ohio State University College of Medicine.
QME Evaluation and implicit bias
You may wonder why the DWC is now requiring a QME CE course on implicit bias. It appears that this stems from a class action lawsuit in 2016 that alleged the California Workers' Compensation system engaged in systematic discrimination against woman. Filed by a group of individual female workers and the Service Employees International Union (SEIU) California State Council, the suit describes several cases in which women’s disability benefits were slashed because state-trained Qualified Medical Evaluators (QMEs) attributed their work-related health conditions in part to the “risk factors” of their gender or reproductive capacity.
One plaintiff, Leticia Gonzalez, worked 40 hours a week for 17 years as a technician at a telecommunications company, mostly spent typing at a desk. She developed pain and numbness in her neck, arms, wrists, and hands, which persisted even after surgery. A QME diagnosed her with work-related carpal tunnel syndrome and nerve damage in 2014, granting her permanent disability benefits. But the QME attributed 20 percent of Gonzalez’s injuries to the “non-industrial factors” of her age and gender. “Carpal tunnel compression neuropathy is almost ubiquitous in the female population in her age demographic,” the QME wrote. Because she was a woman, Gonzalez got less compensation than she would have if she were a man.
Veronica Kelley, an events manager, also developed carpal tunnel after several years of daily office typing. The suit states that she started experiencing symptoms in early 2013, but it took her until August 2014 to get an appointment with a specialist in the workers’ compensation system. By that time, she was pregnant. Kelley brought her four-month-old baby to her appointment with a California QME in February 2015. According to the lawsuit, the QME “expressed annoyance” that the baby was there and asked Kelley repeated questions about breastfeeding and how it affected her carpal tunnel symptoms.
Kelley allegedly noted several times that her condition had begun before she’d even gotten pregnant. Still, the QME reported that Kelley’s carpal tunnel was “either the result of or aggravated by her pregnancy and breast feeding” and “should be expected to improve with the simple passage of time including when she stops breast feeding her infant.” Since that report, Kelley has stopped breastfeeding and has reported no improvement in her symptoms, indicating that the QME’s evaluation was based on gender-related bias and not an accurate assessment of her workers’ compensation claim.
These two cases (Leticia Gonzalez and Veronica Kelley) provide excellent examples of potential gender bias in a QME evaluation in which an apportionment rating is made based on an assumption about a risk factor related solely to the injured worker’s gender.
“California’s system of workers’ compensation perpetuates the type of overt sex discrimination that is a relic of a past era,” the complaint reads. “It deprives women workers of fair compensation on the basis of stereotypes about gender and women’s reproductive biology. … By permitting and condoning the distribution of workers’ compensation benefits on the basis of sex, the State of California sends a clear message that women’s work is worth less.”
The complaint alleges that being a male or having male reproductive characteristics are never cited as pre-existing conditions, risk factors, or reasons for reducing disability benefits or workers’ compensation. It also claims that California’s system of benefit allocation for permanent disability underestimates harm specific to women—namely, the effects of breast cancer—by using the American Medical Association Guides to the Evaluation of Permanent Impairment. These impairment ratings are medical assessments that affect benefits, with a higher impairment rating translating to higher benefits. If a man has his prostate removed due to work-related prostate cancer, the AMA guides usually grant him an impairment rating of 16 to 20 percent. A woman who’s had a mastectomy during or after developing work-induced breast cancer will get up to a 5 percent impairment rating if she’s of reproductive age and no impairment rating at all if she’s older than that.
That’s what happened to another plaintiff, law enforcement sergeant Janice Page, who got breast cancer and underwent five surgeries as a result, including a mastectomy of her right breast. When she filed for workers’ compensation, the examiner determined that her breast cancer was an effect of years of exposure to carcinogens in her workplace. The suit details a slew of lasting physical, psychological, and emotional consequences Page has suffered since her mastectomy. But since she was past childbearing age, Page was granted a zero percent impairment rating for her work-induced mastectomy, as if she’d have no use for her breasts beyond their functioning as milk producers.
The Page case is an excellent example of an evaluation and rating of permanent disability resulting from industrial breast cancer in which gender bias impacted the assessment of the impairment that resulted from breast cancer and its treatment.
The suit also cites cases wherein women’s awards for work-related “psychiatric injuries” like depression were reduced by as much as 80 percent because of “perimenopausal factors” and “gynecological issues,” rulings that seems to rely on the old sexist myth that women endure hysterical bouts of mental disturbance due to the workings of their reproductive organs, making their suffering less acute than men’s. In workers’ compensation cases, those stereotypes can cause real financial damage to someone who’s earned a fair award but finds herself hampered by the fact that she was born female.
Guidance for Considerations in Rating Impairment from Industrial Cancer
The Department of Industrial Relations has set out guidelines related to rating impairment from industrial cancer. The link can be found here and the article is reproduced in the following:
https://www.dir.ca.gov/dwc/FAQ/Rating-impairments-Guidance.html
General Reminder
Doctors performing a medical-legal evaluation for purposes of a workers’ compensation case must examine for and report all rateable impairments resulting from an illness or injury, including cancer, and/or from the effects of treatment for such cancer. The purpose of this form is to provide physicians with additional guidance concerning the types of impacts and impairments that injured workers who have been diagnosed with and treated for cancer may experience. Practitioners are reminded that an appropriate rating under the Guides for any form of cancer should take into account all impairments, including those caused by cancer treatment, found through a full and thorough medical evaluation. (If a practitioner is unable to evaluate or to rate an impairment because it is outside their scope of practice and area of clinical competence, they should advise the parties accordingly so they may obtain any necessary additional evaluations.)
The DWC’s goal is to ensure that all impairment related to industrial cancer is rated adequately and appropriately. In assessing impairment related to any industrial cancer, the evaluating physician should consider the following, among any other factors that apply based on the medical evaluation:
For example, for an injured worker diagnosed with and treated for breast cancer, a proper impairment rating would take into consideration the following factors where applicable, along with any others that may apply:
Surgical treatment may involve removal of the breast(s) (mastectomy). This may be given 0-5% whole person impairment per the AMA Guides, page 239.
Surgical treatment may result in skin disfigurement. Physicians may assess this type of impairment under the AMA Guides, sections 8.2 and 8.3, pages 175-76, and as illustrated in the AMA Guides, Table 8-2, on page 178.
Surgical treatment of breast cancer may also result in loss of upper extremity function. Assessment of loss of upper extremity function may include:
Decreased range of motion in upper extremity, including shoulder joint, which may be evaluated under range of motion charts in AMA Guides chapter 16, and/or reduction in upper extremity strength, which may be evaluated per Table 16-35. This may result from surgical incisions, scarring, skin and tissue removal, tightening of remaining skin and muscle, and related issues.
Neurologic impairment of the upper extremity nerves, which may be evaluated utilizing the AMA Guides. Tables 16-13, 16-14 or 16-15 are used to identify maximum values of affected nerves. Tables 16-10 or 16-11 are used to assess the percentage of motor or nerve deficit of affected nerves. Neurologic impairment is calculated per the AMA Guides instructions, section 16.5 on pages 480-95.
The removal of lymph nodes in the treatment of breast cancer may cause lymphedema (swelling) in the arms for some patients. If so, the physician should use AMA Guides chapter 16 to assess function impairment such as decreased range of motion and strength loss in the upper extremity. Pain related to swelling may be rated (see #8 below). Upper extremity strength impairment may be evaluated per AMA Guides Table 16-35.
Breast cancer treatment may involve the prescription and long-term use of hormone therapy (e.g., Tamoxifen) and/or aromatase inhibitors (e.g., Anastrozole (Arimidex), Exemestane (Aromasin), Letrozole (Femara).) These medications may have side effects causing impairment, including joint pain (see the range of motion tables in AMA Guides chapters 16 and 17 if range of motion is affected), menopausal symptoms (see AMA Guides Tables 7-9, 7-10, 7-11), and loss of bone density. Impairment resulting from these medications may be evaluated under appropriate AMA Guides tables, including those indicated above, or the physician may consider 1-3% WP impairment for effects of medication per AMA Guides, pages 20 and 600.
Breast cancer treated with chemotherapy may result in chemotherapy-induced amenorrhea, loss of ovarian function and premature menopause. Impairment of this nature may be assessed utilizing the AMA Guides, section 7.8, on pages 163-169 (depending on impairment class, 0-35 percent WPI). Chemotherapy may also cause a number of other side-effects, some of which may be permanent, such as anemia (AMA guides Table 9-2), kidney damage (AMA Guides section 7.3), increased bleeding (AMA Guides Table 9-4), loss of taste (AMA Guides page 262 1-5 WPI), or reproductive impairments (AMA Guides Tables 7-9., 7-10, 7-11). As part of the evaluation, the physician should discuss any long-term impact of chemotherapy with the injured worker, and review literature as necessary concerning the known impacts of particular chemotherapies.
Radiation treatment for breast cancer may cause scarring or other skin impairment. Physicians may assess this type of impairment under the AMA Guides, sections 8.2 and 8.3, pages 175-76, and as illustrated in the AMA Guides, Table 8-2, on page 178.
For chronic pain related to breast cancer, its treatment or resulting lymphedema, a pain add-on of up to 3% WPI per PDRS page 1-12 may be considered. Also, the physician may consider any AMA Guides table, chapter or method to assess chronic pain in accordance with the Almaraz/Guzman decision. The Almaraz/Guzman decision allows the physician to use any chapter or table in the AMA Guides that they believe most accurately reflects the impairment. The opinion must set forth the physician’s facts and reasoning which justify their use of a particular chapter or table in order to be considered substantial evidence.
Any other impairments identified by the physician related to the breast cancer or its treatment may be assessed using the appropriate AMA Guides impairment table, and the doctor may consider any table within the Guides to provide an accurate assessment of total impairment per the Almaraz/Guzman decision.
When rating medical reports involving breast cancer, the DEU rater should assess whether the reporting physician has considered all areas of potential impairment related to the breast cancer and its treatment. If it appears that the physician has failed to address any areas of potential impairment, the DEU rater should annotate the case, noting each of the areas of potential impairment as listed above that have not been addressed by the physician. The following are examples of ratings that take into account the various considerations outlined above.
Case Examples:
Case Example 1: A 48 year-old female police officer suffers from breast cancer which requires chemotherapy and bilateral mastectomy. The surgical removal of the breasts rates at 5% WPI. This is only one of the many factors that apply. She experiences chemotherapy-induced menopause (28% WPI) and bladder impairment (12% WPI). The combination of these particular impairments will result in a combined WPI of 40%. The resulting permanent disability rating for this impairment is set forth below.
Rater annotation: The physician may consider cosmetic impairment as a result of mastectomy under AMA guides chapter 8 Table 8-2. The physician may also consider pain add-on of up to 3% WP for excess pain that effects activities of daily living.
Case Example 2: A 38 year-old female firefighter suffers from breast cancer that results in a single mastectomy. The loss of breast may constitute a WPI rating of 3% under the Guides. She suffers from loss of shoulder motion, which may rate at 4% WPI, and skin disfigurement as a result of the loss of the breast which results in 9% WPI. She experiences significant residual pain as a result of the mastectomy, resulting in an additional 3% WPI. The combination of these particular impairments will result in a combined WPI of 19%. The resulting permanent disability rating for this impairment is set forth below.
Checklist for Physicians Evaluating Breast Cancer Impairment –
Does the injury involve removal of a breast? If so per AMA Guides section 10.9a, page 239, physician should consider up to 5% whole person impairment. [For other cancers, consider the immediate impact on other body parts of any surgeries.]
Disability Evaluator should rate impairment under disability number 10.00.00.99 and adjust for FEC (1.4 modifier), occupation and age
Was there surgical treatment that resulted in skin disfigurement? If so, this impairment may be under AMA Guides sections 8.2 and 8.3 and impairment assigned per Table 8-2.
Disability Evaluator should rate impairment under disability number 08.01.00.00 and adjust for FEC (1.4 modifier), occupation and age
Did the surgical treatment result in range of motion impacts? (For breast cancer, consider reduction of shoulder or other upper extremity motion.) If so, physician may evaluate per AMA Guides section 16.4i and impairment assigned per Figures 16-40, 16-43 and 16-46.
Disability Evaluator should rate impairment under disability number 16.02.01.00 and adjust for FEC (1.4 modifier), occupation and age
Did the surgical treatment result in loss of muscle strength? (For breast cancer, consider whether surgery resulted in loss of upper extremity strength. If so, physician may evaluate upper extremity strength loss per AMA Guides section 16.8.) Strength impairment is assessed per AMA Guides Table 16-35. Strength impairment would not be rated if the loss of strength is caused by decreased motion or pain.
Disability Evaluator should rate impairment under disability number 16.02.02.00 and adjust for FEC (1.4 modifier), occupation and age
Did the surgical treatment, if any, result in neurologic impairment? (For breast cancer, consider impairment to the upper extremity nerves.) Neurological impairment may be evaluated utilizing the AMA Guides section 16.5 and Tables 16-13, 16-14 or 16-15, to identify maximum values of affected nerves, and Tables 16-10 or 16-11, to assess percentage of motor or nerve deficit of affected nerves. Decreased motion or strength as a result of neurological impairment would be encompassed and therefore not rated separately.
Disability Evaluator should rate impairment under disability number 16.01.02.03 or 16.01.02.01 and adjust for FEC (1.4 modifier), occupation and age
Was there any chemotherapy treatment, and if so, were there any permanent impacts? (For breast cancer, consider whether chemotherapy resulted in amenorrhea, loss of ovarian function and premature menopause.) Impairment of this nature may be evaluated utilizing the AMA Guides, section 7.8, on pages 163-169 and impairment assigned per tables 7-9 or 7-11.
Disability Evaluator should rate impairment under disability number 07.05.00.00 and adjust for FEC (1.4 modifier), occupation and age
Was there any radiation treatment, and if so, were there any permanent impacts from the radiation? (For breast cancer, consider whether there was any scarring or other skin disfigurement.)
Is the injured worker taking any long-term medications to prevent recurrence or advancement of cancer, and if so, are there any ratable impacts from those medications? (For breast cancer, consider whether the use of Tamoxifen or aromatase inhibitors has any impacts, including joint pain.) Impairment due to side effects of medication may be evaluated per appropriate AMA Guides section and table related to side effect. If there is no applicable AMA Guides table that reflects impairment due to the side effect of medication, per AMA Guides 600, a side effect due to medication may receive a rating of 1-3% WP impairment.
Disability Evaluator should rate impairment under disability number related to the side effect and adjust for FEC (1.4 modifier), occupation and age
Does the injured worker have any chronic pain related to the cancer and/or its treatment? A physician may consider a pain add-on of up to 3% WP per PDRS page 1-12 for pain.
Disability Evaluator should add pain impairment to disability related to the pain and adjust overall whole person impairment for that body part for FEC (1.4 modifier), occupation and age
Final note to Disability Evaluator: In reviewing the medical report, if it appears that the physician has failed to consider one or more of the areas of potential impairment as listed above, the rating should be annotated accordingly so that parties may follow up with the physician on that issue. The Disability Evaluator may then issue an amended rating based on any additional information received.
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