To CME or Not to CME
To CME or Not to CME
With apologies to The Bard –
“To CME, or not to CME: that is the question; Whether ‘this nobler in the mind to suffer The slings and arrows of outrageous medical opinions, Or to take arms against a CME, And by opposing end them?”
Authority for the ever-ubiquitous Commission’s Medical Exam (hereafter CMEs) can be found in C.G.S. §31-294(f) which provides in relevant part: “An injured employee shall submit himself to examination by a reputable practicing physician or surgeon, at any time, while claiming or receiving compensation, upon the reasonable request of the employer or at the direction of the Administrative Law Judge. The examination shall be performed to determine the nature of the injury and the incapacity resulting from the injury…” The Guidelines of Cooperation provide that the CME is “selected on the premise that this physician is free of any bias or interest, thus enabling the physician to exercise independent medical judgment.” (June 10, 2023 Revision, p.20) The Workers’ Compensation Act mandates a process of informal dispute resolution to achieve the goal of fair and expeditious determination of claims. The thesis of this article is, to paraphrase a famous quote, that CMEs are like wasabi: they are very powerful and should be used sparingly. This author would argue that when they are used judiciously, they are an indispensable tool that can often move a case toward resolution quickly and fairly, but when they become the rule, rather than the exception, their pervasive use may become antithetical to the purpose of the Act.
While authority for CMEs has always been contained within the statute, their prominence became supercharged with additional thrust about 30 years ago beginning with Iannotti v. Amphenol/Spectra-Strip, 1829 CRB-3-93-9 (1995) aff’d, 40 Conn. App. 918 (1996) when the CRB announced: “Although we do not find error in the Commissioner’s failure to explain his credibility determination in this particular case, we want to stress the importance of a commissioner-ordered medical examination and the need for a commissioner to explain his or her reasoning in not crediting the examiner’s report.” The upshot of freighting CMEs with so much import is reflected in the advice that I typically gave to my own clients until about five years ago when another line of cases began to develop. Until that time, I said that a CME was not merely a tie-breaker between a treating physician’s opinion and a contrary RME; it was game over. The score was not merely two to one, it was ten to one.
The sea change or CME change began to emerge in the last five years when some intrepid Administrative Law Judges (hereinafter ALJs) began to show a willingness to diverge from the CME’s conclusions and to accept the CME simply as one more opinion. See Madden v. Danbury Hospital, 5745 CRB-7-12-4 (2013); Mauriello v. Craftsmen Litho, 6256 CRB-5-18-3 (March 22, 2019); Smith v. Regalcare at Waterbury, LLC, 6316 CRB-5-19-3 (March 10, 2020); Secula v. SBC/SNET, 6314 CRB-5-19-3.
(March 10, 2020); Goulbourne v. State of Connecticut/Department of Correction, 6329 CRB-1-19-5 (June 10, 2020); Reveron v. Compass Group, 6358 CRB-5-19-11 (Sept. 16, 2020); Rousseau v. Acranom Masonry, Inc., 6366 CRB-5-19-12 (Feb. 3, 2021) and Baldino v. Rondo of America, Inc., 6365 CRB-5-19-12 (April 7, 2021). In two of these cases, as noted in R. Carter, D. Civitello, J. Dodge, J. Pomeranz and L. Strunk, Connecticut Workers’ Compensation Law (Thomson West, Connecticut Practice Series Vol. 19, 2008) §17:13 specifically the Mauriello and Secula decisions, the CRB stated it was unnecessary for the trial commissioner to articulate the reasons why the CME’s opinion was not adopted, clearly retreating from the earlier line of cases and perhaps, thereby diluting the potency of the CME opinion. However, the authors of the treatise conclude that “…the commissioner’s examiner’s opinion is given great weight by the commissioners, and all else being equal, the commissioners will generally find in accordance with their examiners’ opinions.” Id.
With the exception of one of the above-cited cases, either the CME and/or the treating physician was deposed, and sometimes the RME. Clearly if one is going to assail the CME report, there is still a considerable financial and time-consuming burden to be successful. In two recent cases in which I needed to overcome the CME’s report, I brought in the treating physician to testify live at the formal. In both cases the ALJ was able to ask any relevant questions she needed answered on the medical issues in the case. Obviously, the cost of bringing in a physician to testify live at a formal is prohibitive and you can only do it in cases which would financially justify it. But I think in the right case a judge will be more impressed by a treating physician testifying live who can answer the judge’s questions than by a deposition transcript of an RME/CME.
Typically, a CME is ordered when the RME has an opinion which is diametrically opposed to that of the treating physician. CMEs are a necessary tool to provide the trial judge with an expert opinion on a specific medical issue in difficult, contested cases where the judge may require additional information. When the CME is used prudently, and saved in the tool bag for special occasions, it is very helpful. For example, in a case involving whether chemical exposure caused cancer in an employee, the ALJ may well need additional help from a physician of her choosing to help clarify issues of causation. Similarly, where there is a question of whether a claimant suffers from PTSD, an ALJ may want a trusted psychiatrist to weigh in, or in a case of an electrocution injury, the opinion of a CME by a neurologist may be helpful to the ALJ.
These are examples where expert testimony may help inform the ALJ’s ultimate determination as the factfinder in an area of medicine about which she has little or no knowledge. But there is a strong temptation to use the CME as a shortcut to expedite a case, to force parties into a quick resolution of the claim. Is a CME’s opinion necessary when there is a question of causality in a garden variety disc herniation injury, or to determine whether a requested medical procedure is curative or palliative? The Chairman’s office does not track the percentage of cases that settle in the wake of a CME, but my guess, based on anecdotal evidence, would be that most cases settle after a CME.
The CME is a legal fiction in which a physician chosen by the trial judge may be temporarily cloaked with special powers whereby his or her opinion is accorded extraordinary weight. The parties and the trial judge are all asked to suspend their critical powers of analytical reasoning and accept that the CME will provide an objective opinion that is difficult to challenge. Within the framework of this legal fiction, the CME’s opinion may be fairly viewed as a rebuttable presumption on the issue in question, a presumption that can only be rebutted by clear and convincing evidence to the contrary. In reality, CME physicians are mere mortals who have their own busy practices and who are allotting perhaps one hour to reviewing the indexed records and five to ten minutes examining the claimant. After all, the same doctor, who enjoys the confidence and authority conveyed by the judge appointing him or her as an expert in a hearing at 10:30 a.m. may very well be disrobed and stripped of his superpowers when that physician is relegated to the pedestrian status of a treating physician at the 10:45 a.m. hearing. It’s not as if these anointed physicians are retired or selected from some sacrosanct stable of doctors who only engage in these exams. They are deputized, artificially and temporarily vested with special authority, and endowed with a gravitas that is necessary to create this fiction. It is clearly harder to subscribe to this fiction when the ALJ unilaterally decides whom to appoint without consultation of the litigants as will be discussed below in greater detail.
There are at least several common situations in which CMEs are ordered by the ALJ. Often, it is at the request of one of the parties. There are instances in which claimants counsel has a reputable, skilled physician, (perhaps even one who has performed many CMEs) who has provided a strong opinion counter to that of an RME whose credibility, having been too long in circulation, has come to resemble a coin that has been worn a little too smooth. Or the reverse is equally possible where claimant’s counsel has a weak report from an overly enthusiastic surgeon who wishes to proceed with surgery, but a thoughtful, cautious, well-regarded RME opposes the surgery. In each of those scenarios the party hoping for the CME is mobilizing the CME as part of a favorable litigation strategy, namely, that the CME will bolster a weak case that may not survive the formal. But arguably, there has not been a sufficient joinder of the material medical issue in such a case. Why give the opposing party a free shot at suddenly improving a bad case?
Another scenario in which an ALJ will sometimes request a CME is when each of the parties has a solid report from a reputable physician. In such cases there is clearly a joinder of issues in a case that is ready to litigate. Each of the parties may be loath to introduce a new opinion into the equation, yet the ALJ orders a CME to try to move the case toward a resolution, and perhaps save administrative resources. I would argue in a case where neither of the parties wishes to have a CME, the parties should be allowed to try their cases the way they stand. It is akin to a game of Blackjack in which both players want to stand pat with the cards they have but the dealer introduces a wildcard opinion that is likely going to cause one of the litigants to fold. While it is ultimately the trial judge’s prerogative to seek an expert opinion in addition to those of the treating.
Black’s Law Dictionary defines legal fiction as “An assumption or supposition of law that something which is or may be false is true, or that a state of facts exists-which has never really taken place.”
physician and the RME, in the above scenario the ALJ might reconsider the urge to order a CME in favor of allowing the parties to prosecute their cases with the existing opinions.
The ALJ will sometimes ask for the input of counsel in selecting this physician which may make the selection process more palatable if counsel can agree upon an acceptable physician, but more often, the trial judge keeps her own counsel on this matter. Effectively, this gives counsel an opportunity to bolster an unfavorable opinion. One might ask why opposing counsel would rebuff an opportunity for another physician to weigh in on the matter. After all, isn’t this the ultimate purpose of having a CME, by helping the trier of fact understand the medical issue in the case?
The problem with that rationale is that it invites too many unintended consequences. The standard check-in-the-box forms utilized by most ALJs do not provide essential definitions for terms, such as “substantial contributing factor” or “reasonable medical probability”, terms necessary to provide a meaningful opinion. While many of the physicians who participate in the workers’ compensation system in Connecticut are facile with such nuanced definitions, many are not. (This author attended a seminar in which an orthopedist frequently used as a CME lectured about what criteria he needed to provide an opinion “beyond a reasonable doubt” in a workers’ compensation case). Further, there are some doctors whose opinions on certain medical issues are a foregone conclusion. For example, in a case involving a dispute about a concussion, there are certain doctors who still adhere to the outdated and disproven notion that if a patient does not lose consciousness, she did not have a concussion. There are orthopedists who disregard the concept of adjacent level disc disease. There are some physicians who do not believe in chronic regional pain syndrome, and other doctors who will automatically wean any patient from narcotic medication, without exception. When these doctors are utilized as CMEs, a more jaundiced practitioner might wonder whether the humanitarian spirit of the Act is being eroded in the name of a more expeditious resolution of the case.
The language of the statute states that the scope of a CME is “to determine the nature of the injury and the incapacity resulting from the injury.” It does not authorize the use of a CME when the issue to be resolved is whether medical treatment is reasonable or medically necessary. Yet there are countless CMEs routinely ordered to determine whether opioid medication should be continued, or whether a certain surgery is reasonable, or whether a claimant has a body mass index that makes a proposed surgery unreasonable. Arguably these issues are outside the authority conveyed by the statute, and would theoretically be subject to challenge, although this author is unaware of any cases on point.
In the rare instances in which, in this author’s opinion, a CME should be utilized, this author would strongly recommend Judge Barton’s approach of allowing the litigants to prepare the letter to the CME for the judge’s signature, to make sure that the CME addresses each of the relevant issues in the case, and that the doctor understands the legal threshold and definitions of specific terms such as “a substantial contributing factor.” To go even a step further, counsel should be allowed to agree upon the CME chosen as the examiner. If counsel are allowed to participate in the selection of the CME physician and the drafting of the letter to the CME, then it is much less likely that one party will come back to the judge to ask the CME for a clarification of the report, which will make the doctors’ and the judges’ lives easier. And if counsel agree on the CME to be selected, then the criteria for the disappointed lawyer to return to the ALJ to ask for a clarification of the CME’s opinion by way of a follow-up letter or deposition should be very high indeed.
In response to the protestations of CME physicians who are frequently asked to clarify a muddy report, some judges, who ultimately have to send the request for clarification to the CME, have been reluctant to send follow-up requests to the CME, but instead, direct the litigants to take the CME’s deposition. Due to the doctors’ busy schedules, this can often take several months to organize, sometimes more. In addition, this expense is borne by the attorney requesting the deposition, which in the claimant’s case, seems particularly onerous, especially when the attorney may have objected to the CME before it was ordered. Several years ago, this author was required to drive to Glastonbury on three separate occasions to take the CME’s deposition in three installments because the physician would only allow one hour of time—at 7am. This took approximately six months to play out. In the meantime, the case was put on ice and valuable time was wasted. (It was worth the trouble, ultimately, as the ALJ ignored the CME’s negative opinion at trial). Even worse, other judges are increasingly reluctant to entertain a request to take the CME’s deposition because of their legitimate concern that doctors who are too frequently deposed may not continue to participate in our system. Clearly this line of reasoning raises some due process implications, although this author in unaware of any cases on point. Yet.
There are inevitable attendant delays occasioned by the appointment of a CME such as when the physician has an emergency surgery that preempts the CME appointment, resulting in a rescheduling delay measured in weeks, if not months. Or the CME may be habitually late in getting out his CME report, sometimes only responding after counsel has had to request a hearing or two to have the judge prod his CME to respond. Occasionally the CME is asked to comment upon one question, say whether a procedure is reasonable or necessary, and then gratuitously opines that the previously compensable injury was not causally related to work. Or, as in a case I recently tried, the CME to whom I vigorously objected, mistakenly believed he was being asked to provide his opinion about whether the claimant sustained an acute injury on a date certain rather than over a 34-year period of repetitive insult. The CME opined that there was no evidence of an accident on the last date of injurious exposure, and therefore, the “injury” was not compensable. Here again, the ALJ ignored her CME at trial, but this unnecessary detour caused a significant delay and ultimately did not assist the ALJ in deciding the issue of compensability.
Clearly every case cannot and should not be tried. Business needs to be moved, cases need to be resolved quickly and efficiently, but not at the expense of a fair and equitable resolution. There are instances in which CMEs must carry more weight than either the treating physician or the RME, especially if the litigants agree upon the CME beforehand, otherwise the legal fiction does not work its magic. At the same time, we must recognize that CMEs are neither inviolate nor invincible; they can and should be challenged when there is a legitimate basis for doing so, and when the financial ends justify the means. This is especially true when the CME is one of the “usual suspects” whose conclusion is foregone, and where the opinion is forced upon unwilling counsel. There has been a “market” correction in just how much value a CME should have, and while its value may have dropped, it still carries significant weight. If ALJs only use CMEs in the appropriately rare cases, counsel will avoid the expense and time of having to challenge them. As the old saw goes: too much of anything is good for nothing.