Sample — IME Report Critique
| Claimant: | Ms. Jane Doe |
| Referral Source: | Mr. C. J., XYZ Insurance Company |
| IME Examiner: | J. Q. S., Ph.D., LP |
| Date of IME: | 1/2/2006 |
| Type of report critiqued: | Neuropsychological evaluation |
| Current IME report reviewer: | N. A. Ph.D., LP |
Introduction and reason for referral:
This report concerns the neuropsychological independent medical evaluation (IME) performed on January 2, 2006 by Dr. J Q. S., Ph.D., a neuropsychologist in private practice. XYZ Insurance Company requested Dr. S. perform an IME to help determine Ms. Jane Doe’s functional capability. Ms D. suffered a traumatic brain injury secondary to a motor vehicle accident on February 2, 1999. XYZ Insurance requested this review to assist in more clearly understanding Dr. S.’s conclusions. Dr. S. has been unable to sufficiently respond to the insurer’s questions in this regard.
Documents submitted for this review consisted of Dr. S.’s report and test data. At the request of the insurer, there was telephonic communication with Dr. S. to better understand his insight and perspective during the evaluation and writing the IME report. A summary of this communication was sent to Dr. S. subsequent to the conversation.
Brief summary of Dr. S.’s report:
Dr. S. evaluated Ms. Doe for psychological and neuropsychological problems that her physician believes are secondary to the head injury sustained on the above mentioned date. Please refer to Dr. S.’s report for further details regarding Ms. Doe’s medical history.
Dr. S. interviewed Ms. Doe for approximately 1 hour, and conducted a battery of neuropsychological tests for an additional 4 hours. Dr. S. personally administered all tests. Dr. S. also administered the MMPI-2 (an objective measure of personality and mood, with built-in validity measures).
Dr. S. concluded that Ms. Doe put forth full effort on all tests, and that the resulting test scores were valid. He indicated that Ms. Doe’s overall intellectual abilities were in the Average range, as were a variety of other abilities related to her ability to pay attention, understand spoken language, speak fluently, move her body in a coordinated manner, and understand abstract concepts. He concluded that her memory skills fell within the lower 10%, compared to the general population.
Responses to referral questions:
1. Were psychological test(s) (with appropriate norms) chosen and administered correctly? Was the selection of psychological tests thorough?
Overall, test selection was appropriate. With one exception, noted in my response to question #2 below, the tests Dr. S. administered have accepted reliability and validity data recently published in professional journals. Significantly, however, apparently to accommodate the short period of time that Ms. Doe had available to participate in this evaluation, Dr. S. administered abbreviated versions of several of these tests. These tests were the third editions of the Wechsler Adult Intelligence Scale and the Wechsler Memory Test, as well as the Booklet Categories Test. According to the test manuals, tests administered in this manner yield scores that can vary considerably by chance alone.
Further, because of the brevity of the overall evaluation, additional tests that could have assisted the doctor in evaluating Ms. Doe’s ability to think both abstractly and quickly, were not administered.
Therefore, Dr. S.’s conclusions regarding: a) Ms. Doe’s overall intellectual abilities, b) her ability to think quickly, and c) her ability to understand abstract concepts are not as reliable as they would have been if the tests had been given in their entirety and if a wider variety of tests had been administered.
2. Did the doctor thoroughly explore the validity of this individual’s complaints?
The validity of this claimant’s responses was evaluated in regard to the severity of her psychiatric symptoms, such as depression, and of her reported cognitive difficulties.
First, Dr. S. assessed the legitimacy of Ms. Doe’s complaints of psychological problems, specifically her level of depression, by giving her the MMPI-2. The MMPI-2 contains the world’s best-researched and most respected scales for assessing truthfulness in reporting psychological symptoms such as depression. Dr. S. correctly indicated that the MMPI-2 results suggested Ms. Doe responded truthfully about her level of depression and about other psychological problems not related to cognitive functioning.
The other general area in which Dr. S. assessed validity was the claimant’s reports of cognitive impairment. To assess the legitimacy of her reports of cognitive dysfunction, Dr. S. administered the Rey 15-Item procedure. This is a relatively brief assessment tool developed in the 1960’s to evaluate the legitimacy of reports of memory dysfunction. Dr. S. correctly indicated that Ms. Doe’s score of 10 yielded equivocal results. In other words, persons with scores such as Ms. Doeís are not clearly exaggerating nor telling the truth about the severity of their memory difficulties. According to some research, approximately 40% of individuals with similar test scores are simulating or exaggerating memory difficulties. However particularly in the past 10 years, the usefulness of the Rey 15-Item procedure has been severely questioned, and it is now considered by the majority of neuropsychologists to be obsolete for most purposes.
In summary, The Rey 15-Item Procedure is an outmoded measure of the validity of memory complaints, and Ms. Doe’s score on this test did not clearly establish a pattern of valid or invalid responses.
More recent, well-established tests to assess the validity of cognitive dysfunction include The Test of Memory Malingering (TOMM), the Word Memory Test (WMT), and the Validity Indicator Profile (VIP).
3. Were the doctor’s opinions confined to his/her area of expertise?
On page 9 of his report in the second paragraph, Dr. S. stated, “The combination of Ms. Doe’s current physical problems with vision and mobility, and her cognitive deficits, likely make it impossible for her to understand moderately complex directions at the workplace and keep up with her current caseload.” Commenting on the potential impact of Ms. Doe’s physical problems was beyond the scope of the assessment Dr. S. was asked to complete, and likely falls outside of his capabilities as a psychologist.
4. Please explain the doctor’s response to my question #4, which read “Dr. S., please indicate whether this individual’s impairment, if present, is caused by physical or by psychological factors.”
In his response to you, Dr. S. stated: “This claimant’s cognitive difficulties are secondary to either a hippocampal or mesio-hipppocampal primary auditory verbal memory deficit, or an associated organically-based difficulty with processing efficiency.”
Dr. S. is stating that there is a physical cause for this claimant’s cognitive problems. He likely bases this conclusion largely on the fact that the portions of the brain in and near the hippocampus are sometimes responsible for similar cognitive problems in other patients with brain injuries.
5. Were the objective test data the doctor obtained consistent with his/her conclusions?
Dr. S.’s conclusions are consistent with objective neuropsychological test data. However, there is reason to question Dr. S.’s confident determination that this individual has memory deficits. As explained above, this uncertainty results from both Ms. Doe’s equivocal score on the outmoded Rey 15-Item Procedure, the fact that Dr. S. administered some abbreviated psychological tests, and the abbreviated test battery that he chose.
6. Based on the data submitted for your review, please speak to the impact of Ms. Doe’s reported memory problems on her ability to perform daily tasks.
There is some question as to whether the current low scores on tests of memory are valid. However, validity issues aside, persons with similar memory scores, interview data, and medical histories usually can consistently understand and recall simple (but not complex) concepts and directions. They can take multiple telephone messages, understand their content, and deliver those messages to the appropriate person. They can learn and recall the instructions for new computer programs of moderate complexity such as MS Word, although this may require them to take notes. Such people typically have no difficulties remembering and following relatively simple 1 and 2-step tasks, but can have more difficulties with lengthy multi-step instructions. They usually can perform two projects at once, remembering where to start again on the tasks that were interrupted.
Their ability to remember information is usually not reduced by a moderate number of distractions, such as those that commonly occur when many people share the same office space. Further, there is no indication that fatigue or psychological problems, that tend to fluctuate over time, have a significant impact on this claimantís ability to remember daily tasks.
7. Is your interpretation of the information collected by the IME consistent with Dr. S.’s conclusions? Please elaborate.
The written IME report, including interviews with the claimant and her husband, review of the tests administered, their interpretation by Dr. S., and the telephonic interview conducted with Dr. S. on (date) generally support Dr. S.’s conclusions. However again, the questionable validity of some of the testing diminishes the confidence that can be placed in some of Dr. S.’s findings.
Please feel free to contact me if you have further questions.
N. A. Ph.D., LP
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