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Thread Title: Rating Fibromyalgia by analogy in AMA
Created On Wednesday January 14, 2009 3:24 PM

smtilley
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Wednesday January 14, 2009 3:24 PM

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I have a case with an AME report. The AME has rated fibromyalgia using the AMA Guides by analogizing to congestive heart failure and assigned WPI of 35% based on Class 3 congestive heart failure. I know there is a debate on the proper place of analogies in rating under the AMA Guides. Has anyone seen this type of analogy and anyone have any ideas of how to overcome such a finding?

7dayweekend@mindspring.com
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Thursday January 15, 2009 8:46 AM

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I would think a half decent DA could destroy that AME in a depo.

smtilley
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Thursday January 15, 2009 9:23 AM

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Well, I'm not sure what you are implying but it is my intention to depose the AME and do my best to have him see it differently. However, this is not a D.C., this is a MD with years of practice. It may be that the doctor can analogize in this manner, as some on these boards have suggested in other threads. However, I have not had much experience with fibro and the AMA Guides so I am looking for any constructive guidance. Thank you for your reply though, I'll certainly keep it in mind.

7dayweekend@mindspring.com
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Thursday January 15, 2009 7:25 PM

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Didn't know you were a DA from your post. Sorry.

AMA considers it a controversial pain syndrome not ratable.

I don't know how he pulls this off .

Or how he expects the defense to ever use him again.

That's pretty brazen IMHO.

BTW, fibromyalgia has nothing to do with fibers and muscles.

Edited: Thursday January 15, 2009 at 7:42 PM by 7dayweekend@mindspring.com

stewshe@comcast.net
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Friday January 16, 2009 5:47 AM

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7 day,

The AME has simply proved he/she is not a baby splitter! I suspect in another fact situation the AME would not be afraid to give "-0-"! That is probably the reason the defense agreed to this particular AME. I know of a few AMEs who have given 100%s as well as "-0-" PD in the past. I respect them for the courage of their convictions...and carefully send cases to them!

The fact the AMA has not given its blessing to "fibro" is interesting, but not conclusive, and probably not admissible.

Yes, fibro is controversial, but in years past so was a surgeon washing his hands before delivering a baby, bringing infection to the mother. Actually, many surgeons did not wash their hands before surgery.

Carpal tunnel condition used to be considered simply "lazy workers," and in fact many ERs see it that way today!

From the fact something is controversial and perhaps rejected by many, it simply does not follow someone is "wrong" for holding an opinion on either side of the issue.

I know of a psyche doctor who in 20 years NEVER once found industrial injury.

Another doc, specializing in hearing loss, does not believe cumulative exposure to noise causes hearing loss!

These are their "opinions," however, many non-superdefense orientated persons dealing with w/c in Calif. would simply consider them whores!

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7dayweekend@mindspring.com
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Friday January 16, 2009 8:11 AM

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You could "prove" you're not a baby splitter by giving a 100 pct WPI for a cold. Or zero for a spinal cord injury. Obviously both of these are erroneous but that's not my point. The issue is evidence based medical reasoning, which is lacking in this analogy regardless of the numerical rating. He could have made the case using comorbidity arguments but the CHF argument is weak.

There are docs who have an opinion that AIDS is not caused by HIV. They make fools of themselves trying to defend that position though they have a following. Everyone is entitled to an opinion, and everyone else is entitled not to respect it. This can quickly descend into relativism and pseudoscience. At a certain tipping point, it no longer makes sense to go to medical school but to major in marketing.

IMHO, I think this doc was begging to be deposed.

Besides, functional restoration (sometimes with extreme exercise) is the newest trend in treating fibromyalgia, and the creator of the term has said it's not a disease but a functional syndrome.

Even if you accepted the idea of rating by analogy, you would do it in the central nervous system or psych chapter not the cardio chapter. Fibro is NOT a rheum disease nor a muscle disease (there is no lab test, and there have never been abnormal biopsies), not a disease of the left ventricle, but considered now to be neuropsychiatric, and is treated with SNRI antidepressants and Lyrica.

Evidence-based standards are supposed to be in effect. Fibro and CHF are completely different illnesses. There's so much psych comorbidity in Fibro anyway, why not just rate in using the GAF, which is more accepted and difficult to rebut? If the patient is having moderate difficulty functioning due to the psych comorbidity, then that would warrant a 50-60 GAF which would earn a 15-29 percent WPI not including FEC adjustment.

I never put anything in a report that I know I can't defend in a depo. Why make a weak argument when you can make a strong one?

Ask him if he treats his fibro patients with digoxin and diuretics and ask him if he treats his CHF patients with Cymbalta and Lyrica. I bet he doesn't.

Edited: Friday January 16, 2009 at 8:45 AM by 7dayweekend@mindspring.com

7dayweekend@mindspring.com
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Friday January 16, 2009 3:09 PM

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Also Google Frederick Wolfe + fibromyalgia.

Doc Newton
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Wednesday February 04, 2009 11:08 AM

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"Even if you accepted the idea of rating by analogy, you would do it in the central nervous system or psych chapter not the cardio chapter." ..................."Ask him if he treats his fibro patients with digoxin and diuretics and ask him if he treats his CHF patients with Cymbalta and Lyrica. I bet he doesn't.""

These comments while well intended miss the point of "rating by analogy", and also fail to recognize the basic concept of what constitutes an analogy. This is from an online dictionary defining the concept of analogy: "reasoning or explaining from parallel cases." Put another way, an analogy is a comparison between two different things in order to highlight some point of similarity. There need not be multiple points of similarity and trying to find them undermines the very concept of the analogy type reasoning. The "analogy" therefore need not be in the same category as the disease in question.

Here I suspect that the AME was looking at loss of functioning and impairment of ADLs, and fastened on Congestive Heart Failure as an "analogous" condition which would have similar repercussions. Thus to me, the questioning of the DA should not be " What does CHF have to do with Fibromyaligia?", but rather "How is it that the effects of FM are similar to those of CHF?", "Why did you select Class III instead of Class II or Class IV?". Those of us QMEs/AMEs who are struggling with the AMA Guides to find ways of accurately rating a case need to expand our thinking. I give kudos to the AME in this case for a creative way of framing the case.

For further reference on the limitation of the Guides, we need look no further than yesterday's landmark WCAB "en banc" cases which will no doubt upset the entire apple cart. Should be interesting.........

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7dayweekend@mindspring.com
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Wednesday February 04, 2009 10:11 PM

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Well Doc, as of yesterday you are correct at least legally. The AMA Guides don't matter anymore. This Guzman decision just said you can use whatever you want to come up with a rating. However, the AMA Guides do say fibro is not ratable.

BTW if any medical student or resident I was supervising confused the symptoms fibromyalgia and CHF, I'd try to have him thrown out of the program. That AME may get away writing that to an attorney not trained in medicine, but if he ever tried to pull that at a medical conference, he'd be a laughing stock.

It's actually a horrible analogy. A better one would be hypothyroidism but that's not right either. The closest I can really think of is opioid induced hyperalgesia.

But hey why not just go for it anyway? The WCAB says keep throwing until something sticks.

Edited: Wednesday February 04, 2009 at 10:23 PM by 7dayweekend@mindspring.com

Doc Newton
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Thursday February 05, 2009 8:59 AM

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Hey 7 Day, you write "BTW if any medical student or resident I was supervising confused the symptoms of fibromyalgia and CHF, I'd try to have him thrown out of the program. That AME may get away writing that to an attorney not trained in medicine, but if he ever tried to pull that at a medical conference, he'd be a laughing stock. .

And you would be correct in tossing him! But here, it is not the "symptoms" that are at issue, but rather the impairment that arises from them. A low back injury is not to be confused with a heart attack, but under the 1997 PDRS each could cause a Disability precluding Heavy Work. Two different conditions with similar Disabilities. Oh, I like your idea of using Hypothyroidism as an analogous condition, and will have to keep that in mind for future reporting. Thanks!

-------------------------
Fredric H. Newton, MD
Founder/CEO, Newton Medical Group
www.newtonmedicalgroup.com
Neurologist
510-208-4700
rick.newton1@comcast.net

7dayweekend@mindspring.com
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Thursday February 05, 2009 11:17 AM

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What they have in common is fatigue but little else. Most diseases have some level of fatigue. A better analogy than CHF would be influenza. Fibro patients aren't at risk of sudden cardiac death.

Google Frederick Wolfe and fibro. He came up with the designation. Read his recent mea culpas.

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