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IN THIS EDITION:  
AMA 4 Guides Impairment Assessment Training E-Newsletter
Issue date: Wednesday 10 August 2007
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Welcome From The Chair

AMA 4 NEWS

Expression of Interest - Medical Panels

Website Consent Form

Module completion

Public Forum

Stream 2 Given The Thumbs Up

IN THE COURTS

Spotlight On: The Wrongs Act

TAC v Elworthy

Mountain Pine Furniture P/L v Taylor - Watch This Space

Determining Non-Secondary Psychiatric Impairment

MODULES IN DETAIL

Method Of Grading Motor And Sensory Loss In Peripheral Nerve Lesions

Quick Tips For Impairment Assessment

Checklist: Third Party Examinations

Calendar Of Upcoming Modules

   

Welcome From The Chair
Welcome to the first newsletter from the Australian Medical Association, Victoria (AMA Victoria). In our inaugural issue we include the latest AMA 4 news, a section on court proceedings and legal terminology, an article from Professor Richard Stark on the use of the Gradation Table and a useful checklist from Dr Robert Adler regarding third party examinations.

We welcome all articles relevant to AMA 4 for publication, and will commission articles of specific interest to the training course. Finally, I invite all course participants to be involved in this newsletter as a public forum. Please write in with your comments, suggestions or concerns about any aspect of your learning, to provide us with a comprehensive overview of the AMA 4 training course.

Dr Tony Buzzard
Chair
Impairment Assessment Training Management Committee

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  AMA 4 NEWS

EXPRESSION OF INTEREST – Medical Panels
The Medical Panels Office is currently recruiting impairment assessors. Expressions of interest are sought from medical practitioners in active clinical practice in Victoria.  Current members of Medical Panels who wish to be re-appointed should also submit their interest and re-apply to Medical Panels.

Fees payable to panel members reflect the responsibility and professional standing of the appointment.  For further information contact the Medical Panels office on 03 8256 1555 or see http://www.medicalpanels.vic.gov.au for further details.

TWO REMINDERS:

Website Consent Form
All previous participants are reminded to send in their consent form regarding inclusion in our new AMA 4 Guides website. Should you require another copy of your form or further clarification, please contact Dorothy Aban on 03 9280 8764, e-mail iat@amavic.com.au or fax to 03 9349 5248.

Module Completion – Send us your Case Study
A number of clinicians undertaking some modules have not yet completed the case study assessments.  We are unable to supply certificates of completion until these assessments have been carried out, and the committee would like to urge you to complete the assessments to receive your final certificates.

Public Forum
The AMA 4 newsletter is not just a vital tool of information – it’s also a forum. Participants are invited to share their thoughts, issues and ideas on their AMA 4 training with our readership. Please email us iat@amavic.com.au if you would like to share your experiences, and we will address these topics in upcoming issues.

Stream 2 Given The Thumbs Up
According to recent evaluation by Stream 2 participants, the AMA 4 training modules are relevant, informed and highly detailed. Feedback showed that the importance of accurate assessments was emphasised in the course, as well as observing legal guidelines and impressing a greater awareness of legislation. Participants voted an overwhelming 100% satisfaction rate regarding the relevance of the course to their understanding of legal requirements.


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  In The Courts
From tricky legislation to impact assessment in action, we take a look at AMA 4 and the law.

Spotlight On: The Wrongs Act
Qualified Impairment Assessors (an ‘approved medical practitioner’) may be asked to carry out an assessment in relation to a personal injury which comes under the purview of the Wrongs Act 1958.  Section VB and VBA of the Act are the relevant sections.  An Assessment under the Act is not connected with assessments made for the purposes of accident compensation or workers compensation.

Under the Act, claimants are only able to access damages for ‘non-economic’ loss if they have suffered significant injury.  Significant injury is defined in the case of psychiatric injury, as impairment of more than 10%, and in the case of injury other than psychiatric, whole person impairment of more than 5%.  (The three other categories of significant injury are the loss of a foetus, psychological or psychiatric injury arising from the loss of a child as a result of an injury to the mother or the foetus before, during or immediately after the birth, or the loss of a breast.)

Non-economic loss is defined as pain and suffering, loss of amenities of life or loss of enjoyment of life.

The assessment is carried out using the AMA4 Guides in the same way as for transport accident compensation and workers compensation, including in relation to psychiatric impairment, asthma and infectious diseases. The threshold in the Wrongs Act in relation to hearing loss assessments is different from those used for transport accidents and workers compensation.

A respondent who disagrees with an assessment may refer a question in relation to the assessment to a medical panel.

For further information Click Here or download a full copy of the Wrongs Act.

Transport Accident Commission v Elworthy
The Supreme Court of Victoria dismissed the appeal in Transport Accident Commission v Elworthy regarding the combining of values to calculate impairment percentages of the lower extremity. The court affirmed the following:

  • Whole person values are to be used when combining multiple lower extremity impairments.
  • The maximum value of 40% whole person impairment cannot be exceeded for one lower extremity
The plain words of the Guides text must be followed and the use of the guides is to promote precision, certainty and consistency.

Further details about the decision can be accessed here. An expanded reference chart is available to attendees of the stream 1 and 2 training sessions to assist practitioners.

Mountain Pine Furniture P/L v Taylor – Watch This Space
We are currently in the process of incorporating new changes to the Spinal module curriculum now the appeal decision regarding the Mountain Pine Furniture P/L v Taylor case has been handed down. We will provide all participants with further updates as soon as this material is completed. Please click here for a copy of the appeal decision.

Determining Non-Secondary Psychiatric Impairment
The Transport Accident Act 1996, the Accident Compensation Act 1985 and the Wrongs Act 1958 all impact upon the determination of psychiatric impairment. With confusion among examiners, plaintiffs, insurers and the courts, these guidelines are timely, and provide a framework to improve agreement between medical examiners.

For further information regarding these advisory annotations, click here to download the 12-page document.

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  Modules In Detail
Our module practitioners discuss the finer points of AMA 4, in theory and practice.

Method Of Grading Motor And Sensory Loss In Peripheral Nerve Lesions
By Professor Richard Stark, Chair Neurology Spinal Reference Group

There is some confusion as to the correct method for choosing the percentage figure for grading motor and sensory loss in peripheral nerve lesions.

The correct procedure is to determine which grade or category of loss is appropriate for each relevant nerve using Tables 20 and 21 of Chapter 4 of the text. After determining which Grade is correct, the most appropriate percentage figure within the range offered for that Grade is then applied.

Thus a patient with Grade 4 power in the distribution of the median nerve above mid-forearm would, from Table 12 of Chapter 3, have between 1% and 25% graded loss. The allocation for complete motor loss of this nerve is, from Table 15, 44% upper limb. The calculated impairment could therefore be anything between 0.44% (rounded to zero) and 11% of upper limb. While this may seem a wide range, Grade 4 power may range clinically from a barely detectable reduction of power to power just sufficient to overcome minimal resistance as well as gravity.

The example at the foot of the first column of page 49 appears to be the source of some confusion. In that example, the examiner chooses the maximum figure in the range (25% for Grade 4 power). Some have interpreted this to mean that the maximum figure should always be chosen. This interpretation is clearly incorrect for 3 reasons:

  1. As indicated above, there can be a great difference in clinical effect between loss of power (or sensation) at the bottom end versus the top end of a defined grade.
  1. If the Guides did not intend the ranges to be used, why were they provided (rather than a single percentage figure for each Grade)?
  1. There are examples provided in which less than the maximum figure for a grade is used. For example on page 51 a sensory grade of 20% (not the maximum 25%) is used and on page 53 a motor grade of 40% (not the maximum 50%) is used.

The Neurology Reference Group has always taught that the full range of percentages for each grade is available for use and confirms this opinion.

Quick Tips For Impairment Assessment
When examining and measuring for shoulder movements: asking the patient to move both shoulders provides stability to the shoulder girdle, and assists in accurate measurement of shoulder movement.

Provocation testing such as a straight leg raising test is of no value for a back impairment assessment and should be avoided.

When measuring and recording range of movements for the upper extremity using the provided charts in the guides is useful, and will help the examiner avoid missing impairments.

When grading Peripheral Nerve Disorder using Tables 11 and 12  (Chapter 3 pages 48-49), be aware that the grading for sensory deficit is from 1 to 5 for increasing severity, and from 5 to 0 for increasing severity, with the grading for motor deficit reversed.

Grip strength: although grip strength impairment is not frequently used there are some injuries (such as significant forearm muscle trauma) where using the Jamar dynamometer may be relevant. After testing with the standard grip technique, checking the results with the rapid alternate hand technique i.e. quickly gripping with alternate hands, will demonstrate a more accurate reading.

provided by Dr John Malios, AMA 4 Guides Committee of Management

CHECKLIST: THIRD PARTY EXAMINATIONS
Unfortunately, complaints about third party examinations are relatively common. They can mention that the independent impairment assessor was rude or dismissive, demonstrated a lack of respect for privacy, and at worst, an exacerbation of injuries.

With prior expectations built up during clinical consultations, it is sometimes a surprise to the patient to be treated differently during an M-L assessment. The following practical safeguards are recommended to establish an environment during such examinations that minimises the risk of complaints to the third party or the MPBV.

1. Explain, explain, explain: A minute of explanation can save hours of correspondence with the insurer or the Board. Be sure to discuss beforehand the extent of the examination, including questioning and physical examination.

2. Practical safeguards: Extend the same courtesy and respect you would normally show your clinical patients. Provide facilities for privacy, and do not record conversations without the patient’s consent.

3. Get organised: Restrict your report to your area of expertise. Allocate enough time for the assessment, and record the time you spent. Avoid causing unnecessary pain, and explain in advance what you plan to do.

-Summarised from the Core Module presentation given by Dr Robert Adler, Deputy President Medical Practitioners Board of Victoria.

Calendar Of Upcoming Modules
Places are filling up fast for the winter/spring AMA 4 modules.  Register your interest here.

 

MODULE

DATE/TIME

Lower Extremities (Stream 2) Fully Booked

6th September at 6:30pm

Visual System (Stream 2)

11th September at 6:30pm

Hand & Upper Extremities (Stream 2) Fully Booked

11th September at 6:30pm

Spine (stream 2) Fully Booked

19th September at 6:30pm

Core (Stream 1) Fully Booked

20th October at 8:30pm

Core (stream 2) Fully Booked

20th October at 11:30am

Psychiatry (stream 1) Fully Booked

22nd October at 6:30pm

Ear Nose & Throat (stream 1)

1st November at 6:30pm

Respiratory (Stream 2)

1st November at 6:30pm

Psychiatry (Stream 2) Fully Booked

26th November at 6:30pm

Digestive (Stream 2)

27th November at 6:30pm

 

The 2008 program will be available soon. Register your interest here to receive the 2008 program.

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