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The medical clinician and disability evaluation
SYMPOSIUM
The
ON
DISARILITY
Medical
Clinician and Disability Evaluation
EARL D. MCBRIDE,
M.D., Oklahoma
City, Oklahoma
specific awards for amputations at various IeveIs, which is a compromise for the sake of expedience. From the medical point of view the scientific significance of physical disability cannot be measured by- monetary values established on the basis of amputation. What then is the medical examiner to do other than to compromise on scientihc fundamentals in evaluating disability under the rules of the court? If the statutory award for amputation of an arm at the shoulder is specified at $0 per cent of permanent total disability, can the doctor’s opinion that this is a greater or lesser disability be of any value? How should back or head injuries be measured? Can a back injury be 75 per cent of total permanent disability when it would not be considered nearIy as cIisabIing as the loss of an arm at the shoulder, which has a statutory value of only $0 per cent? Can a fracture deformity- of the forearm be rated as a $0 per cent Ioss of use of the hand when it is not as severely disabIing as the statutory value of amputation of the thumb which is considered onIy 30 per cent loss of the hand? Should two injuries of a SimiIar nature resuIt in any greater disability compensation in the state of Oklahoma than in the state of New York? Judging by the aforementioned, is it not time that the medica profession establish scientific fundamentaIs upon which disability could be evaIuated? The subject is too extensive in scope and far too compIex for the average clinician to comprehend. A vast medica knowledge of such subjects as anatomy, physiology- and clinical diagnosis is necessarily precluded. It often involves, as well, fundamentals of biomechanics, biochemistry, physics, geometry and mathematics. Where the true static, kinetic ant I dynamic aIterations of the structures of the human body are concerned, how can the clini-
first compensation acts were established in this country about forty-five ,years ago and two principal objectives were initiated to benefit the injured Iaborer: (I) freedom from the uncertainties of common Iaw litigation, thereby reIieving a burden on pubIic charity and (2) subsistence payments to tide the victim over the period of wage losses during recovery from injury. The latter objective has been accompIished ver_v well, but litigation stiII demands major judrcia1 responsibihty in the settlement of claims for tota and partiaI permanent disabiIity. No improvement seems to have been found for the provisions in the compensation Iaws which designate specific awards based on amputation values. Since the residuals of injury often resuIt in partial permanent disabiIity other than that of amputation, litigation is necessary to evaluate the disabiIity. The services of the medical profession are of essential importance in the administration of justice under the compensation Iaws. The responsibility of the medical profession is essentiaIIy twofold. (I) The treatment and rehabilitation of the injured worker must be determined and (2) the extent of injury to the body and the residual disability limiting the worker in pursuing his livelihood must be determined and evaIuated. In this panel discussion we are concerned with this second phase of the medica responsibiIity which invoIves the doctor’s opinion on the extent of permanent partial disability. Unfortunately this fieIcI of medica practice is Iacking in scientific fundamentaIs. In the first pIace, the scheduIes for disabiIity found in the statutes are not based on scientific deductions. The present compensation Iaws are but a prototype of the earIy enactments which estabIished
T
EVAL~XTION
HE
703
American
Journal
oj Surgery,
Volume
yr.
April,
1056
McBride cian be an expert scientific witness if he has no greater ability for medica anaIysis than that of Iooking at an x-ray of a bone or joint deformity, observing the history and cIinica1 findings and rendering onIy an arbitrary opinion as to the extent of disabiIity? Is he not IikeIy to be subject to false impressions and influences beyond customary medical reasoning? Inasmuch as the disability awards provided by IegaI enactments are more or Iess arbitrary, it has been suggested that a comprehensive scheduIe of ratings for a11 grades of disabiIities be estabIished by a medica committee. The American MedicaI Association is considering such action. This, no doubt, would be of utmost vaIue to the busy cIinician who has no time to go into the finer detaiIs of the medica anaIysis of disabiIity. The necessity stil1 remains for a practica1 method of making a comprehensive medica anaIysis of a11 the eIementary factors of disabiIity upon which to arrive at a dependabIe percentage of permanent disabiIity. Since the IegaI enactments for tota and partiaI disabiIity are arbitrary vaIues and since the medica evaluation of disability is for the benefit of the court in estabIishing a Ioss of earning capacity, the medical opinion can be IittIe more than a thorough analysis of a11 the factors bearing on the abiIity of the disabIed person to continue working for his IiveIihood. Why not, then, appIy the cIinica1 observations to a system of medica anaIysis which wiI1 give a thorough over-a11 average percentage of Ioss as compared to norma ? By such a method each and every factor must be evaIuated for the percentage Iess than normaI. What is the percentage of functiona loss to the body or parts of the body? The anatomy has been aItered to what percentage? The clinica symptoms indicate body deficiency to what percentage? To what extent of norma percentage are the readjustment and reactions to job restoration handicapped? Is it not true that a careful analysis of a11 these factors and an average of the percentage vaIues wouId give a satisfactory answer to the disabiIity probIem? The author has advocated a system of this kind for many years.* About the onIy objec-
tions that have been raised are those reIating to the difficulty in understanding the method and the amount of time it requires. The fundamenta1 principles of medica responsibiIity cannot be compromised. The answer is either right, wrong, or not appIicabIe. A brief statement of this method of anaIyzing disability foIIows. DisabiIity is divided into two principal components, nameIy, (I) Ioss of function and (2) loss due to physical disorders in relation to work capacity. Loss of Function. The Ioss of body function must be analyzed and evaIuated independentIy on movement and action of the injured parts of the body. The disabled body, or parts of the body, shouId be determined for Ioss of function by the foIIowing: (I) quickness of action, (2) security and confidence, (3) coordination and skiI1, (4) strength, (3) endurance, (6) safety and (7) influence on re-empIoyment. Physical Capacity.
Disorders
in
Relation
to
Work
The extent of actua1 mass damage to the anatomy is determined by cIinica1 examination, x-ray and other laboratory procedures. An evaIuation of the actua1 anatomic damage as compared to the norma is decided upon. The cIinica1 manifestations are thoroughIy investigated and weighed with the history and subjective cIaims of the patient. A percentage is then estabIished as an evaIuation for the abnormal versus the normal. The restrictions of disabiIity in relation to physica requirements at work are anaIyzed. The extent to which activity is to be restricted in Iifting, puIIing, standing, crawIing and kneeIing shouId be determined as shouId a11 other activities which must be appIied to normal work. The percentage of Ioss is then decided upon. The restrictions of working conditions and a Iowered tolerance for environmenta inff uences are considered. Can the patient work in outdoor exposure? Is he IikeIy to be affected by dampness? WilI he be endangered by certain machinery hazards, sIippery floors, and the Iike which are found in average working conditions? The percentage of depreciation is decided upon. The reactionary interferences influencing return to work, or the intangibIe factors aItering future endeavor to work, are appIied to the disability evaIuation. The age of the person, the adverse reaction of the empIoyer to re-hire, seniority rights, Iimited opportunities for re-
* MCBRIDE, E. D. Disability EvaIuation, 5th ed. PhiIadeIphia, 1953. J. B. Lippincott; American Academy of Orthopaedic Surgeons Instructiona Course Lectures, WI. 12, January 1955; J. Znternat. Coil. .%rgeO?lS, 24: 1955. 706
Medical
Clinician
and
habilitation, the likelihood of repeated esacerbations of disabling pain, and many other similar intangible factors shoukl be weighed as to their influence on the disabled person as compared with his norma state. A percentage of loss is then established. The final percentage of disabiIity may be obtained b\- taking an average of al1 the percentages of loss decided upon under the various divisions of analysis. An average of the percentages of each of the physica disability factors and of the functional factors will give an average overall percentage of disability. It is the author’s opinion that the functional factors of loss are actually more important than the applied physical disorders, so that the average percentage of the functional factors may be
Disabilit;v
Evaluation
weighted by .-s and the average percentage of the pIty+l disorders factors weighted by the remammg .25. The formula then can be stated : Per cent Average Function Loss X .T$ + Per cent Average Physica Disorders X .25 = Per cent Disability It is safe to say that if an existing disability is anal?-zed in the manner described there will be a conscientious feeIing of thorough investigation and the percentage of evaluation \vill not be far from right. A chart has been devised for the convenience of keeping a case record of the disabilit? evaluation. Any reader interested in this chart may contact the author.
The
ON
DISARILITY
Medical
Clinician and Disability Evaluation
EARL D. MCBRIDE,
M.D., Oklahoma
City, Oklahoma
specific awards for amputations at various IeveIs, which is a compromise for the sake of expedience. From the medical point of view the scientific significance of physical disability cannot be measured by- monetary values established on the basis of amputation. What then is the medical examiner to do other than to compromise on scientihc fundamentals in evaluating disability under the rules of the court? If the statutory award for amputation of an arm at the shoulder is specified at $0 per cent of permanent total disability, can the doctor’s opinion that this is a greater or lesser disability be of any value? How should back or head injuries be measured? Can a back injury be 75 per cent of total permanent disability when it would not be considered nearIy as cIisabIing as the loss of an arm at the shoulder, which has a statutory value of only $0 per cent? Can a fracture deformity- of the forearm be rated as a $0 per cent Ioss of use of the hand when it is not as severely disabIing as the statutory value of amputation of the thumb which is considered onIy 30 per cent loss of the hand? Should two injuries of a SimiIar nature resuIt in any greater disability compensation in the state of Oklahoma than in the state of New York? Judging by the aforementioned, is it not time that the medica profession establish scientific fundamentaIs upon which disability could be evaIuated? The subject is too extensive in scope and far too compIex for the average clinician to comprehend. A vast medica knowledge of such subjects as anatomy, physiology- and clinical diagnosis is necessarily precluded. It often involves, as well, fundamentals of biomechanics, biochemistry, physics, geometry and mathematics. Where the true static, kinetic ant I dynamic aIterations of the structures of the human body are concerned, how can the clini-
first compensation acts were established in this country about forty-five ,years ago and two principal objectives were initiated to benefit the injured Iaborer: (I) freedom from the uncertainties of common Iaw litigation, thereby reIieving a burden on pubIic charity and (2) subsistence payments to tide the victim over the period of wage losses during recovery from injury. The latter objective has been accompIished ver_v well, but litigation stiII demands major judrcia1 responsibihty in the settlement of claims for tota and partiaI permanent disabiIity. No improvement seems to have been found for the provisions in the compensation Iaws which designate specific awards based on amputation values. Since the residuals of injury often resuIt in partial permanent disabiIity other than that of amputation, litigation is necessary to evaluate the disabiIity. The services of the medical profession are of essential importance in the administration of justice under the compensation Iaws. The responsibility of the medical profession is essentiaIIy twofold. (I) The treatment and rehabilitation of the injured worker must be determined and (2) the extent of injury to the body and the residual disability limiting the worker in pursuing his livelihood must be determined and evaIuated. In this panel discussion we are concerned with this second phase of the medica responsibiIity which invoIves the doctor’s opinion on the extent of permanent partial disability. Unfortunately this fieIcI of medica practice is Iacking in scientific fundamentaIs. In the first pIace, the scheduIes for disabiIity found in the statutes are not based on scientific deductions. The present compensation Iaws are but a prototype of the earIy enactments which estabIished
T
EVAL~XTION
HE
703
American
Journal
oj Surgery,
Volume
yr.
April,
1056
McBride cian be an expert scientific witness if he has no greater ability for medica anaIysis than that of Iooking at an x-ray of a bone or joint deformity, observing the history and cIinica1 findings and rendering onIy an arbitrary opinion as to the extent of disabiIity? Is he not IikeIy to be subject to false impressions and influences beyond customary medical reasoning? Inasmuch as the disability awards provided by IegaI enactments are more or Iess arbitrary, it has been suggested that a comprehensive scheduIe of ratings for a11 grades of disabiIities be estabIished by a medica committee. The American MedicaI Association is considering such action. This, no doubt, would be of utmost vaIue to the busy cIinician who has no time to go into the finer detaiIs of the medica anaIysis of disabiIity. The necessity stil1 remains for a practica1 method of making a comprehensive medica anaIysis of a11 the eIementary factors of disabiIity upon which to arrive at a dependabIe percentage of permanent disabiIity. Since the IegaI enactments for tota and partiaI disabiIity are arbitrary vaIues and since the medica evaluation of disability is for the benefit of the court in estabIishing a Ioss of earning capacity, the medical opinion can be IittIe more than a thorough analysis of a11 the factors bearing on the abiIity of the disabIed person to continue working for his IiveIihood. Why not, then, appIy the cIinica1 observations to a system of medica anaIysis which wiI1 give a thorough over-a11 average percentage of Ioss as compared to norma ? By such a method each and every factor must be evaIuated for the percentage Iess than normaI. What is the percentage of functiona loss to the body or parts of the body? The anatomy has been aItered to what percentage? The clinica symptoms indicate body deficiency to what percentage? To what extent of norma percentage are the readjustment and reactions to job restoration handicapped? Is it not true that a careful analysis of a11 these factors and an average of the percentage vaIues wouId give a satisfactory answer to the disabiIity probIem? The author has advocated a system of this kind for many years.* About the onIy objec-
tions that have been raised are those reIating to the difficulty in understanding the method and the amount of time it requires. The fundamenta1 principles of medica responsibiIity cannot be compromised. The answer is either right, wrong, or not appIicabIe. A brief statement of this method of anaIyzing disability foIIows. DisabiIity is divided into two principal components, nameIy, (I) Ioss of function and (2) loss due to physical disorders in relation to work capacity. Loss of Function. The Ioss of body function must be analyzed and evaIuated independentIy on movement and action of the injured parts of the body. The disabled body, or parts of the body, shouId be determined for Ioss of function by the foIIowing: (I) quickness of action, (2) security and confidence, (3) coordination and skiI1, (4) strength, (3) endurance, (6) safety and (7) influence on re-empIoyment. Physical Capacity.
Disorders
in
Relation
to
Work
The extent of actua1 mass damage to the anatomy is determined by cIinica1 examination, x-ray and other laboratory procedures. An evaIuation of the actua1 anatomic damage as compared to the norma is decided upon. The cIinica1 manifestations are thoroughIy investigated and weighed with the history and subjective cIaims of the patient. A percentage is then estabIished as an evaIuation for the abnormal versus the normal. The restrictions of disabiIity in relation to physica requirements at work are anaIyzed. The extent to which activity is to be restricted in Iifting, puIIing, standing, crawIing and kneeIing shouId be determined as shouId a11 other activities which must be appIied to normal work. The percentage of Ioss is then decided upon. The restrictions of working conditions and a Iowered tolerance for environmenta inff uences are considered. Can the patient work in outdoor exposure? Is he IikeIy to be affected by dampness? WilI he be endangered by certain machinery hazards, sIippery floors, and the Iike which are found in average working conditions? The percentage of depreciation is decided upon. The reactionary interferences influencing return to work, or the intangibIe factors aItering future endeavor to work, are appIied to the disability evaIuation. The age of the person, the adverse reaction of the empIoyer to re-hire, seniority rights, Iimited opportunities for re-
* MCBRIDE, E. D. Disability EvaIuation, 5th ed. PhiIadeIphia, 1953. J. B. Lippincott; American Academy of Orthopaedic Surgeons Instructiona Course Lectures, WI. 12, January 1955; J. Znternat. Coil. .%rgeO?lS, 24: 1955. 706
Medical
Clinician
and
habilitation, the likelihood of repeated esacerbations of disabling pain, and many other similar intangible factors shoukl be weighed as to their influence on the disabled person as compared with his norma state. A percentage of loss is then established. The final percentage of disabiIity may be obtained b\- taking an average of al1 the percentages of loss decided upon under the various divisions of analysis. An average of the percentages of each of the physica disability factors and of the functional factors will give an average overall percentage of disability. It is the author’s opinion that the functional factors of loss are actually more important than the applied physical disorders, so that the average percentage of the functional factors may be
Disabilit;v
Evaluation
weighted by .-s and the average percentage of the pIty+l disorders factors weighted by the remammg .25. The formula then can be stated : Per cent Average Function Loss X .T$ + Per cent Average Physica Disorders X .25 = Per cent Disability It is safe to say that if an existing disability is anal?-zed in the manner described there will be a conscientious feeIing of thorough investigation and the percentage of evaluation \vill not be far from right. A chart has been devised for the convenience of keeping a case record of the disabilit? evaluation. Any reader interested in this chart may contact the author.