So thank you so much. That was really excellent and very helpful, and we really appreciate you leaving your contact information if anybody has questions. Yeah. Absolutely. Don't hesitate. Great. Thank you so much. So we're going to move into our last lecture for the afternoon. And I apologize that on the program that it didn't get written out, but I think a lot of us know that IMA stands for Independent Medical Examination, and for people who aren't as familiar with them. So PM and R doctors are really highly sought after to do independent medical examinations, and so it's kind of a nice way to either augment your practice just with extra income, or just to kind of understand more like from the legal perspective. So I know that a lot of us are scared of attorneys, but when you start to do these independent medical exams and you kind of see the other side, like see how attorneys are looking at things, see how insurance companies are looking at things, I really feel like it kind of gives you an edge when you're caring for your patients to understand how the other side is looking at things to try and make sure that you can get the patient the care that they need. So I'm really fortunate to have Jackie Stokin talk to us about this. She has a lot of experience in doing independent medical examinations. So Jackie is a, I'm sorry, Dr. Stokin is a graduate of the Des Moines University College of Osteopathic Medicine, and she did a one-year internal medicine internship at Des Moines General Hospital, and then went on to complete her PM and R residency at the University of Minnesota. Holistic medicine has been her passion, and she's certified not only in PM and R, but also holistic medicine and independent medical evaluations, so you can actually get board certified and IMAs. She's an adjunct clinical professor at the rehabilitation, I'm sorry, of rehabilitation at Des Moines University, and she regularly lectures for the Des Moines Mercy Family Practice Residency Program, and she has her own private practice in West Des Moines, Iowa. So please join me in welcoming Dr. Stokin. Well, hello. Can you hear me? Yes, we can hear you. You can hear me, okay. Very good. Yes, I finished residency in 1994, and I worked with a group of orthopedic surgeons. So a few of the surgeons and a couple of the other rehab doctors would do some IMEs, so I decided to try to get involved in it. And so really, if you want to do IMEs, you need to be board certified and have at least two to three years of experience under your belt. So I started doing IMEs, and so that's what we're going to talk about today. So I'm going to switch over here to, let's see here, I'm going to share my screen, which is this. So can you see my screen? Currently, we do not see your screen. We still see you. Still see me. All right. Let me see here. Oh, I have to see share. Okay. So that's my laptop, correct? Do you see that? We see a beautiful starlight. Excuse me. Yeah. How about now? Camping. Yeah, you're good. Okay, good. So first, I want to ask everybody who's on the call, if you're on the call, if you're But just make sure yourself is muted because there was a telephone call that came through that we could so we can hear the speaker last time. Okay. So independent medical valuations, I have nothing to disclose. We're going to talk about the definition. We're going to talk about the AMA guides, RF roles and responsibilities, when they're performed, the rules for evaluation and litigation, because if you do IMEs outside of work comp, then you will probably be involved in litigation, which can be very nerve wracking. Okay. So really, why did I get involved in IMEs? Well, I just thought it would be challenging, it would be interesting. And really, I found that I was really honored to be able to get all of the medical records. And sometimes it was only a three-ring binder full of records, but sometimes it was a big box full of records. By a box, I mean a box that would carry 10 reams of computer paper. So it's pretty interesting, really, to see the cost and effect of our medical care and how we can, how things evolve over time. So what is an independent medical evaluation? Well, it's a medical evaluation, it's performed by a non-treating physician using a standard method of assessment, you know, the history, physical and report, and you want to determine permanent impairment. It can be done on children, it can be done on adults. My youngest child, I think, was about six that I did an IME on, and the oldest was probably in their 70s. So usually it's in resolution of their medical legal case, either through work comp or personal injury, catastrophic injury, or medical malpractice. Just as a note about a medical malpractice, we as PM&R aren't really involved in causation of the medical malpractice event, but really looking at the future for their medical care and everything that they're going to need for the future because of this catastrophic outcome. So as a treating physician, you can do an impairment evaluation, and I have done that, but I call it a comprehensive impairment evaluation because it's not independent. I do have a relationship. With an independent medical, well, you have no patient-physician relationship. They can be less comprehensive, but the ones I've done, they've given me, the attorneys have given me all of the old records and all of the current records. So then you conclude usually with a numerical impairment percentage or a rating that's defined by the guides. So what are the guides? The guides are a book put out by the American Medical Association. There's different editions. There's the fourth edition, the fifth edition, and the sixth edition, and they're currently working on another edition. So here in Iowa, where I am, we use the fifth edition, which is the middle one. When the sixth edition came out, and it was put together by Dr. Rondinelli, who's a PM&R doctor, but he chose people to write different chapters, different doctors, but they were all doctors who were defense doctors. So the attorneys here weren't very happy with that, and they really put up a fight that we're not going to use the sixth edition of the guides because it's too biased, because the chapters are written by defense physicians, and the ratings were lower. So that's why we're using the fifth edition. So if you go to do IMEs, then you'll have to figure out what your state is using, which edition. I think California's still using the fourth edition. So it's a huge book, and there's chapters in it for each organ system, the skin, the respiratory system, cardiac, spine, upper extremity, lower extremity, hearing. So you're able to, wherever that person has an impairment or an injury, you can figure out an impairment for them. They're about three inches thick, so it's pretty intense, and there's a lot of tables to help you out in there. And this comes up a lot of times in the depositions. Well, what did you use? I used the AMA guides. And they said, well, you didn't state exactly as the guides. I said, well, it's a guide. It's not set in stone. The AMA guides were designed to guide the physician so that we have more consistent impairment ratings. But it doesn't mean it's set in stone. So you can vary a little bit in your impairment rating. OK. So what are our roles and responsibilities as a physician? So you as a physician, if you go to do independent medical evaluations, have to figure out what your philosophy is going to be. A lot of physicians here where I am want to be defense. And my philosophy is that I'm a rehab doctor. I want to give you an independent, unbiased assessment of the medical condition. So I'm going to tell you the truth. And whatever I tell you should be the same, whether you are a defense attorney or if you are a plaintiff attorney. So the defense attorneys don't like that. They want the answers that they want. If I'm working for a plaintiff attorney and I come up with an answer that I know is not really good for their client, then I will call and say, well, this is what I think is going on. I don't really think you have much of a case here. And they always thank me for that because they don't want to have to go through that process. So I'm going to tell you the truth. And they always thank me for that because they don't want to have to try to defend something that isn't really true. So my philosophy is I'm going to be honest with you. And that's really helped out a lot because I have been hired by mostly plaintiffs, but also defense attorneys. So you have to document the injury's effect on the function and abilities and the activities of daily livings of this patient and how it's going to work throughout the rest of their life. The skills for to do an impairment reveal aren't really taught in medical school. In the book, it says that occupational medicine, PMNR, and ortho are the best evaluators for the functional or anatomic assessment. But really, I've been doing this since about 1996. And I really think the PMNR docs really do the best job, the best overview, the best outcomes. The occupational medicine physicians know their job, which is acute care. The orthopedic physician knows their surgery. But we, as PMNRs, of course, are trained to know what that patient needs for the rest of their lives. You have to understand the function and demands of their job. So you might need, and usually I ask for their job description. And then when the patient comes in, I talk to them about their job, how, you know, if it's consistent with the job description, can they, if they've had a rotator cuff tear, can they do that overhead work? Of course, they can't. So that would be one of my restrictions. So you need to understand the regulations that pertain to the medical practice in work, comp, or personal injury evaluations in your state. So it's not, you know, an IME isn't a treatment, but an assessment. So you have no physician-patient relationship. And if new diagnoses are discovered, you, as the physician, has a medical obligation to inform the attorney about the condition and recommend further assistance. So that has happened to me. I have discovered CRPS more than once, more than twice, more than five times in all of these years. And one of them, this is a very interesting case, was a woman who was actually a work comp adjuster. And she fell in the office and hit her left hip and fell on her left hip really hard. Well, they sent her to an Ocmed doc, who was very much a defense doc. Defense doc. And he said to her that her pain far outweighs her injury. He let her go on for two years like that. And she said, when she finally got to me, it was like two years after the injury. And she said, I had her take her long pants off and put shorts on. And her whole left leg was mottled purple. And I said, I looked at her, and she said, I have CRPS, don't I? I said, yes, you do. So always have the patient take off their clothing so that you can see what's going on. I don't think that, she said, I don't think that I ever took my pants off and wore shorts or anything. So I had to tell her that she had CRPS. And then she had an attorney. So we finally were able to get her some medical care for it. But at two years, we just had to try different medications for her. So when are they performed? After they've reached maximum medical improvement. And what is that? And what is that? That's when further recovery or deterioration is not anticipated. But there may be some change over time. It could involve more than one body system. And you have to use the appropriate chapters of the guides. So and it's used for work comp, like I said, personal injury, catastrophic injury, and medical malpractice. So there are various rules for the evaluation. You need to obtain consent to share the medical info with the other parties, such as the attorney. And a lot of times, the patient will ask if they can get a copy of their report. And sometimes, a defense attorney will say, I needed a copy. I said, well, you have to get it from the plaintiff attorney. So you just have to be very careful who gets that report. So you estimate the primary impairment. And then evaluate other impairments in relation to it. So if you have like an upper extremity injury that has neurological component to it, you have to deal with the neurological and the musculoskeletal impairments, according to Chapter 16 in the Fifth Edition. If you have a skin impairment, you have to deal with the neurological and the musculoskeletal impairments according to chapter 16 in the fifth edition. If you have a skin impairment with scarring that's causing a change in range of motion over a joint, you need to use a skin chapter and then combine it with the upper extremity chapter for the range of motion. If you have a loss of nerve function in the fifth edition, you can use the musculoskeletal or the neurological chapter. And sometimes there's unrelated conditions. Sometimes they'll get a patient who's been in a motor vehicle accident and they have neck, back, shoulder injuries, ankle injuries. So I have to write each one separately and then combine them at the end for their whole person impairment. So you want to be consistent. Use your clinical skill and judgment regarding the tests or measurements that are consistent with the condition. If the medical evidence is insufficient to verify that an impairment of that magnitude exists, then you can modify the impairment rating. But everything that you write down, you have to explain your reason for the modification in writing when you write your report. Can you hear me now? We can still hear you. Everything's doing well here. Thank you. You can hear? Okay. Sometimes my headpiece goes off. So you want to consider their ADLs and how the condition affects their ADLs. And when you do measurements, you want to do two or three measurements of the range of motion. And if they're within 10% of each other, then it's considered consistent. And with the whole person impairment, you round that off to the nearest and the whole number. So there is a separate chapter for pain in the fifth edition for chronic pain syndrome. I don't use chapter 18 very much. The work comp adjusters don't like it too much. The work comp administrators don't like it too much. So I like to see if there's an impairment rating in a body organ system chapter that can make an allowance for pain. For instance, you could have a lumbar injury with 5% to 8% impairment. So if that patient has had back injury and have chronic pain that's mild to moderate, I mean that's moderate to severe, I'll give them an 8% impairment rather than 5% impairment. So there's room in each impairment rating that you can allow for the pain. If they have an assistive device, you want to take it off and look at it, examine it. And also in your report, you need to decide how often they're going to need to have that replaced or fixed. So if there's a change in medical condition, sometimes the attorney will send the patient back to you to reevaluate that patient. So I had a patient who had a knee injury and I gave him a certain amount of impairment. Then he went on to have a knee replacement and he did really well after the total knee replacement. So his impairment rating actually went down and the attorney wasn't very happy about that. I said, well, but this is the way he is now. That's what a total knee replacement does. It improves, it should improve your medical condition. If there is a pre-existing medical condition, you may need to apportion the rating between the underlying or pre-existing condition and the current condition of the extremity. But you're going to have to explain in your report for your conclusions and your opinions. Like I said before, you need to use the AMA Guide to the Evaluation of Permanent Impairment Edition that's used in your state. Discuss how your findings relate to and compare with the criteria in the guides and explain how you determine the impairment rating. You have to explain the impairment value with reference to what criteria in the guides you used. Include a summary list of the impairment rating by percentage and include the calculations that you used. So this just talks about how a report is set up, which is actually what I wanted to do. I wanted to show that to you and just go through a report that I've done recently. So you want to do a history of the condition with the onset and course of the condition, the symptoms, the PE findings, treatments and response to treatment. Include work history, activities, work performed, association with the medical condition, their current clinical status, symptoms, review systems, physical exam, diagnostic studies, and the results. Then discuss the medical basis for determining MMI and then discuss how you did the impairment rating. So let's go to, I'm going to, how do I stop sharing the screen? Okay. Because what I want to do is, I wanted to bring, oh, here it is right here. Okay. So this is April 28th, 2022. I just finished this impairment rating. This is for this attorney right here, according to Mr. B. I put his date of birth, his date of injury, June 14th, 2018 to the right shoulder and arm. So dear Mr. Attorney, he came to my office April 19th. It was confirmed that he was scheduled for an IME at the request of this attorney. You have to explain the IME process to the patient. So I tell them, this is a chance for you to tell me what happened. Then I'll examine you and write a report for your attorney, but I'm not going to treat you. So that's the IME process that I explain to him so that there's no physician-patient relationship. I don't give him any recommendations. And they ask me for recommendations and I say, well, I will put it in my report and then your attorney will explain it to you. So the history was provided by the examinee who's cooperative and completed our questionnaire. He arrived on time for the appointment and reported no difficulties associated with the exam. And then I list all of the medical records that I have reviewed. And with this patient, there were quite a few. I think there was like a thousand pages or something. So this is the history of President Knowles. This is what he's told me. He's 55 years old. He was injured at work on June 14th, injuring his right shoulder. He was working as a laborer for a roofing company, climbing up a ladder and had to step laterally onto another ladder. That ladder was unstable. It began to fall and then he fell off the ladder and landed on his right shoulder. They sent him to a work comp doctor who did x-rays and then sent him to physical therapy. Of course, he didn't get any better. So then he went to see a orthopedic surgeon who did x-rays and MRI which showed a rotator cuff tear. He underwent the rotator cuff repair and then went back to physical therapy. Didn't work. He continued to have pain and they did a second MRI which showed a recurrent rotator cuff tear. And then at that point, it was such a bad tear that he recommended he have a right shoulder replacement, which he did have, and then underwent the post-op physical therapy. And so then I go through all of the records that I reviewed. And actually, I go through each time they've seen the patient. So this is Covenant Medical Center, the x-ray findings. This is the operation that he had, more x-rays. And then here, this is the initial injury or the initial time he saw a physician after the injury. Everything that happened, again, what I look for is consistency. Is he telling me the same thing he told the other doctors? Is he magnifying it or is it about the same? Or is he minimizing it? Because I want to see how consistent he is. So then I follow up with each time he saw the physician. I say, is he getting better? Is he not getting better? What medication is he on? Is he going to physical therapy? So then 218 pages of physical therapy records. I don't rule the physical therapy records. I don't go date by date. I just say extensive physical therapy records are reviewed unless they got injured or something in physical therapy, if there was an incident. Then Dr. Glasscock saw him for a well exam. I don't know why that's IME. That's wrong. So and then he also did a pre-op exam. Pre-op, yeah, history and physical. And then more radiology. And then Dr. Naylor, who's the orthopedic surgeon. Again, I look at the story that Dr. Naylor states here, see if the consistency is the same as what the, I was told by the physician, by the patient. So this is each time we saw Dr. Naylor. Keep going through it here. And then the operative reports I list here. The shoulder, right shoulder arthroscopy, subocomial decompression, distal clavicle excision, debridement of glenolabral slab lesion, debridement of biceps tendon, open rotator cuff repair, done by Naylor. The post-op diagnosis was complete rotator cuff tear, partial glenoid labral tear, impingement syndrome, partial biceps tendon tear, and they see joint arthrosis of the right shoulder. That was the first surgery. The second one was a reverse shoulder arthroplasty done by Dr. Naylor. The post-procedure diagnosis is right shoulder degenerative joint disease with rotator cuff arthropathy. And again, more of the physical therapy and appointments that he's had. Then what I found is that I wasn't doing this initially, but I found that if I go back through all of my records or all of my report up here and list all the diagnostic tests, then I can see the progression of what's happening in the body. So I list all of them, and quite often in my report at the end, answering the attorney's questions, I'll refer back to the x-rays, and it makes it really easy to do. And then I list the medical procedures. Then you have to update with the current condition. Currently complains of pain in the shoulder. He describes it as exhausting, tiring, continuous, and numb. The pain ranges from 5 to 6 over 10, and averages 6 over 10 right now to 6 over 10. Nothing helps 100%, so he's always having pain. Tylenol and ibuprofen help some, but very little, and it doesn't last long. They've tried him on gabapentin, but it doesn't help his shoulder. He does take it for his low back. So he tells me that lifting, moving, raising his arm, and sleeping make it worse. His whole right arm feels exhausting, tiring, continuous, and numb. There's no pain in the rest of his arm, and it should be in the other arm. The right shoulder replacement gave him a mild amount of relief. The pain does not interfere with walking when blocked, and this is important. This is where he's telling me how this is affecting his ADLs. Sitting there, standing for half an hour, traveling up to one hour by car, writing and typing. The pain interferes mildly with social activities, relationships, showering, and bathing. Moderately with his daily activities, his chores around the house, dressing, concentration, and his mood. And it interferes moderately to severely with his sleep. Completely interferes with lifting 10 pounds and sexual activities. Then you go through the usual past medical history, surgical history, family history, allergies, current medications, review of systems, social history, occupational history. And in the occupational history, I say he's been employed by a service nursing from 2002 until June of 2008 as a laborer. He was unable to return to work and is on disability now. So, and then I go through the physical exam, and then I have a functional assessment questionnaire that I give my patients. They, which again, is a lot of ADLs that they quantify here. Again, he tells me he can't lift up and carry up to 10 pounds, reach above his head or across his body, and do other activities as part of his job as a roofer. And then my impression, and then the discussion. So, I asked the attorneys to send me a letter with their questions, and usually it is five questions at least. Diagnosis, causation, diagnosis, causation, impairment rating, future medical care, and work restrictions. So, again, for the diagnosis, I say my diagnosis is above. Is the condition diagnosed with the work injury causally related to his work injury? And I said, yes, the condition diagnosed with the work injury is causally related to his June 4, 2018 work injury. His injury is consistent with the fall off the ladder. So, you have to quantify why or explain why. Maximum medical improvement was a year after the right shoulder replacement. So, then they want to know his impairment rating. And here you have to tell them exactly where and how you figured it out. So, using the AMA guides to the evaluation of permanent impairment, fifth edition, chapter 16, table 16-27, page 506. He is allowed 24 percent of the impairment of the left upper extremity due to the total shoulder implant arthroplasty. Now, one thing this attorney asked is, please indicate whether Darren sustained any separatably rateable impairment to his right arm. Dr. Naylor told him that he would probably lose range of motion of other joints in his arm, of his elbow specifically. So, I went and took range of motion of his elbow and there were deficits. So, that gave him another two percent impairment of the right upper extremity. So, then I combined them, 24 percent plus two percent is equal to 26 percent upper extremity impairment, and then you have to convert it to a whole person impairment. So, using the guides, chapter 16, table 16-3, page 439, this converts to 16 percent impairment of the whole person. Then he wants to know what permanent restrictions or limitations I assigned for the work-related condition, which I listed here, with 5 to 10 pounds close to the body, 1 to 5 pounds away from the body, the lifting or use at or above the shoulder height, and these are actually the work restrictions that Dr. Naylor gave him, which are pretty restrictive. Then here in Iowa, we have a little problem with shoulder injuries because they don't want to consider the shoulder part of the whole body, they want to keep it separate. So, description of additional, oh, what is the future medical that he may need? So I said he would need follow-up with an orthopedic surgeon if he experiences problems with his shoulder in the future, could require revision surgery, so I go to list that. And then there was a study that I took that from that I have listed at the end. So here in number 7, did Darren's injury involve or affect structures that are proximal to the glenohumeral joint? Well, when you have a shoulder injury, you have to rehab the periscapular muscles, which makes it a whole body then. Well, this is a big issue here in Iowa, they don't want to consider the shoulder as part of the body. So, I have to explain that the shoulders, the ball and socket joint, that's part of the humerus and the flat surface, which is part of the shoulder blade. In a reverse shoulder replacement, the ball and socket parts of the shoulder joint switches sides, which means their natural position is reversed. Therefore, it involves the shoulder blade and the periscapular muscles, which anatomically extends beyond the glenohumeral joint. So I put in a picture, because we're talking to attorneys, so they're not really physicians, they don't really know anatomy. So this helps them to understand how the reverse shoulder arthroplasty looks. Then I have to go on, he has another question. Relative to any involved structures you identify that are proximal to the glenohumeral joint, please explain whether any of these structures are not essential to the function of the shoulder. Well, they are, because it all is connected. So then I have to go through that. So it involves the shoulder blade and periscapular muscles, which anatomically extends beyond the glenohumeral joint. This requires rehab of the periscapular muscles, the rhomboids, pteroides, anterior levator scapula, and trapezius muscles, in addition to the shoulder girdle muscles. The muscles are involved in the strength, stability, and function of the shoulder. So this then leads to my assessment of the 16% impairment of the whole person, not just of the upper extremity, since it involves the periscapular muscles. And then I put in a diagram of all of the muscles here, and how it's related to the shoulder. So then at the end, you have to then say a few other things. Opinions are rendered in this case are the opinions of the examiner. It's been conducted on the basis of the representation of the claimant and medical examination. It is the assumption that the claimant representations are true and correct. So I always feel that my patients, I try to weed out if they're malingering or just telling lies. And here, the attorneys here seem to be able to weed out the weed from the shaft. So that's not too bad here. But if more information becomes available at a later date, an additional service or report or reconsideration may be requested. So here's one that just popped in my mind. I had a work comp patient sent, a Hispanic patient, who worked at a meatpacking plant. And she fell, fractured her femur. She fractured her femur and did not feel that she had good care. So she came into my office complaining of all kind of pain, limping, and just really was really kind of hard to understand why she was having so much pain. Anyway, I wrote a report. And then a few weeks later, I got a call from her attorney. And he wanted to know if I would review a tape that a private detective had taken of her where she was getting in and out of her truck, running around the street, not limping at all. And he wanted my opinion about it. So I watched it. And it was obvious that she was just putting on a big show for me. So that's what I had to tell him. So her case was pretty much determined right there that it was a fraud. So going on to the fees for my examination are reasonable based on the training experience and certification. And it's within what's reasonable here for our area. And really, in the Midwest, we charge a whole lot less than the East Coast from what I understand. The time was spent with the claimant obtaining their history, performing the eval, preparing the report, in addition to time spent by my staff in preparing the report. So then you have to say somewhere in the report that the report is based on a reasonable degree of medical certainty, independent of the requesting client. Medicine's both the art and science. And although the claimant may appear to be fit for return to duty, there's no guarantee the claimant will not be re-injured or suffer additional injury once he returns to work. So this opinion does not constitute, per se, a recommendation for specific claims or administrative functions to be made or enforced. So then I sign my name and list my certifications. So let's go out of this. And whoops. OK. So you have to be careful when you get into independent medical evals. If you want to do it, I would recommend just doing work comp first, because it's not highly litigated. They usually mediate and settle. Personal injury, you'll probably end up in litigation with either in a deposition or court trial. So the deposition's either in your office or an attorney's office. So let's see. Here we go. So you'll be sworn in, either in a deposition or the court. And this is just a picture of there'll be plaintiff and defense attorneys at court and also at the deposition. So this is the trial testimony with a plaintiff attorney. And notice the distance between the patient, or not the patient, the physician sitting in the witness chair, and the plaintiff attorney. So it'll be not as intense as the defense attorney. There's various responses of the jury to the testimony. I saw this and I said, I have to put this in, because that's a lot of times people are just like bored to death. So it's really interesting. You look over at the jury. The cross-examination, the defense attorney is the first half hour of your cross-examination. They'll be focused on you and trying to discredit you. With every little thing that you've done wrong, or if you make too much money, or if you do too many IMEs, they'll try to discredit you with all of that. And there was one deposition that I was in. The two defense attorneys were just hounding on me for making all this money doing IMEs. And I just thought, please. I mean, it was really ridiculous. At the end of the deposition, I went out to the front office, and their cars were right in front of my office. One was a Jaguar, and the other one was a BMW, and I just went, I can't believe this. I just can't believe this. You know, it's just a game. I just couldn't believe how they were just bragging on me for that. So this is just the courtroom with the jury, the attorneys, the court reporter, and the witness. So how do you get started? Well, you want to get trained, and you want to get certified, but who do you do that with? It's with the ABIME, the American Board of Independent Medical Examiners. And they have courses all year long. But then, that's only part of it. The other part is learning to be an expert witness. You have to learn the ins and outs of the law procedures and how to deal with these attorneys in the testimony. So I have had a lot of training with seek, S-E-A-K.com. So I wanted to take us there. Let's see here. Okay, well, before we leave here, you need a team to help you. You need your receptionist, your office manager, your medical assistant, and then you. You're going to need accessories, a hand evaluation kit, which is, this is an eight-piece hand evaluation kit. So you have a, this is semiswine simonofilaments. This is two-point, touchpoint, two-point discrimination. The hand grip, there's a lateral pinch grip right here. There's a ruler here to check the length of any scars. And a tape here for a circumference. A dictaphone, I dictate all my stuff and send it off to be transcribed. Your stethoscope and computer. I always take their blood pressure. I always have a digital thermometer. They get their temperature taken before they even see me. But if I have, if I suspect that they have CRPS, I need to check the temperature of that extremity and compare it to the other side. And an oximeter, which tells their heart rate and their oxygenation, the reflex hammer. So in summary, the independent medical exams is a subspecialty that can be lucrative and nice, but it can be very stressful. So you want to get trained and certified by the ABI-ME and then get further training with SEEK. And if you're competent, the attorneys will come back to you. So let's see here. I want to get out of this. How do I get out of this? I want to go to... Oh, SEEK. Okay. So this is the ABI-ME website. American Board of Independent Medical Examiners. And they do certification and recertification. I've been recertified twice now. Every five years you have to be certified. So they have in-person training in Johannesburg, South Africa, if you want to go there. Charlotte, North Carolina. And they go through the whole book. So it's actually really, really good. You learn a lot. And then in order to take the test to be certified, I think you have to have 24 hours of their courses before you can take the certification test. And then SEEK, this is the attorneys who can train you in how to be a good expert witness. This has really helped me become a really good expert witness. This one, how to start, build, and run a successful expert witness practice is really good. I mean, I've taken all of their courses. If you're just starting out, you can take that one. But this one, Law School for Experts, this was invaluable because it helped me to understand what the procedure of the deposition, what they're looking for, and how to avoid the pitfalls because those attorneys will just twist and turn you upside down. And you have to know how to deal with them. So yeah, I would just take their courses. And they have live courses. They also have online courses. This is Steve, who is really the founder of this. And I took an advanced course with him. So he puts you up on a stand and he cross-examines you. And he's from Massachusetts. I thought, thank God I live in Iowa because he just slayed me. He was terrible. Okay, so this is LiveSeek Expert Witness Training. There's virtual Zoom, Naples, Clearwater Beach throughout the year, and San Diego now. But this is on demand. The Law for Experts is on demand. That's good. And there's a lot of books and other sources. So I think that's all that I had to share with you. Are there any questions? Nothing in the chat? Anybody have any questions? How do I get out of sharing? Yeah. Jackie, thank you so much. That was a really great overview of IMEs and what you do, and how we can help our patients when they end up in these really tough situations. So thank you so much for your lecture. Okay, thank you.

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