This article is a transcription of an episode of the RateFast podcast, which you can listen to by searching “RateFast” in iTunes or the iOS podcast store.
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Doctors like Dr. Teodoro Nissen find joy in helping out those in need. From pediatrics and pathology to orthopedics and sports trauma, he has followed a path of healing the less fortunate and ultimately settled on being a QME in workers’ compensation.
Follow Dr. Nissen’s talk with RateFast correspondent Claire Williams to discuss why he chose the path that he did, and what is so rewarding about working in the field of workers’ comp.
QME (noun) – qualified medical evaluator. Physicians who are certified by the Division of Workers’ Compensation – Medical Unit to examine injured workers to evaluate disability and write medical-legal reports.
Orthopedics (noun) – the branch of medicine dealing with the correction of deformities of bones or muscles.
Pathology (noun) – the science of the causes and effects of diseases, especially the branch of medicine that deals with the laboratory examination of samples of body tissue for diagnostic or forensic purposes.
Pediatrics (noun) – the branch of medicine that involves the medical care of infants, children, and adolescents.
Claire Williams: Today I am joined by Dr. Nissen to discuss what it’s like being a qualified medical examiner in California. Good morning, Dr. Nissen.
Dr. Teodoro Nissen: Good morning.
Claire Williams: So, let’s start off: What is your medical background?
Dr. Teodoro Nissen: I went to the University of California, San Francisco for medical school, and during medical school I got some crazy idea to do a pathology fellowship, so I did that. And then afterwards I stayed on at UCSF, did my residency in orthopedic surgery, and then I had the difficult task of going to Lake Tahoe and doing a fellowship in sports and sports trauma. After that, I came out into private practice at St. Luke’s Hospital in San Francisco, which is in the Mission. I did that for a couple years, and then I opened my own practice, Bay Area Orthopedic Surgery & Sports Medicine in 2008, which seems like a long time ago right now.
Claire Williams: [laughs] It sure does.
Dr. Teodoro Nissen: Thanks, [laughs] you’re not supposed to say that.
Claire Williams: And what got you interested in orthopedics? Was it just doing the fellowship?
Dr. Teodoro Nissen: No, actually I was interested in pediatrics. You decide when you’re a medical student. And I was interested in working with children, and then I somehow got hooked up with Norman Otsuka, who was at UCSF, who’s a pediatric orthopedist. And it seemed like the perfect meshing of worlds. You could work with your hands, you could help people who really needed to be helped, and the results were concrete and immediate. Most of the decisions are in the treatment, and there’s where most of the creativity and autonomy and most of the fun is. And so it just seemed like it — you know, I’m from a working-class family, and it seemed like these are the type of people that you were gonna help, people who use their bodies and their hands to make a living. So, I did it.
Claire Williams: Sure, great. And how did that eventually translate into doing workers’ compensation?
Dr. Teodoro Nissen: I think workers’ compensation is very blue-collar, and so most of the people who are injured are working-class folks. I know I do see some managers and administrators, some CEO’s and upper administrators, but most of the time it’s people who are driving forklifts and working for UPS and picking grapes. Those are the people who I really wanna help and I feel that really benefit from the help that you can offer.
Claire Williams: Definitely. And on that benefit, why in particular did you decide to become a qualified medical examiner?
Dr. Teodoro Nissen: When I got out of the fellowship, one of my partners in the group I joined just encouraged me to do it, and I really didn’t know what it was. So I just studied and took the test, and I really didn’t use it for a while. And then as I started to do workers’ comp, I realized I didn’t understand it. And so I actually started doing QME’s so I could understand the process better to help my patients that I was treating. And the more I got into doing the QME’s, the more I get into it, the more I really enjoy working through the QME process and that whole arena, and so it kind of just took on legs of its own.
Claire Williams: Definitely, it seems like something where you have to enjoy the process if you’re going to do it well.
Dr. Teodoro Nissen: [laughs] Right, because there’s a lot not to enjoy.
Claire Williams: Yes.
Dr. Teodoro Nissen: It’s a frustrating system, it’s a government system. And so there’s a lot of things that don’t really make sense, I think, to most people. But it’s a system we have, and I think the more you understand it and the more you can navigate through it, the more you can help yourself, and especially your patients.
Claire Williams: Mhm. So on that, what were or what are some of the biggest challenges you face in doing QME evaluations correctly?
Dr. Teodoro Nissen: Well, I think there’s a lot of different factors. On the patient level, there’s a lot of different forces at play when a patient is injured at work or has a disability or impairment. There’s the patient’s perspective, there’s the insurance perspective, sometimes you have lawyers that are mixed in. And then you have, what the state of California allows, there’s like these different forces that are pulling at the same issue from different angles. And so that can be a little bit difficult to tease out, and like what the facts are, and how to apply which policies or laws to which situations. And that actually is some of the fun, but it’s also some of the frustration.
Claire Williams: Definitely.
Dr. Teodoro Nissen: It can be a little bit uncertain. You can use any of the four corners of the AMA guidelines, for example, to rate somebody for apportionment. It’s not cut and dry, and so you have to give your best medical opinion.
Claire Williams: Right.
Dr. Teodoro Nissen: Which, as you know, being a physician, isn’t always so certain. You’re not always so “This is the way it has to be.” You can, like any person, see it from different perspectives, and you have to navigate that, and obviously use your medical judgment. It’s like anything in medicine. There’s a little bit of uncertainty that is inherent in the process that can feel a little bit overwhelming or I guess can feel uneasy. It’s a legal system, so there’s the depositions and attorneys and there’s some secondary gain there, and that can get a little bit frustrating at times. And it’s quite, it’s a very tedious process, you know. The exams are an hour or more, there’s a lot of charts to review and a lot of minutia and repetition, and there’s a lot of information to kind of sift through to try to parcel out what’s useful and what is applicable, and so it can take quite a bit of time.
Claire Williams: Definitely. It seems like the State requires this objective data to be drawn from a lot of subjective reports from the patient and the attorneys and medical history and that in itself seems like quite a challenge.
Dr. Teodoro Nissen: Yeah, absolutely. And that’s a lot of the challenge of medicine, you know.
Claire Williams: Right.
Dr. Teodoro Nissen: A lot of why we treat patients, patients don’t come to us and say “I have a tibial fracture.” They come in and say “I’m in pain, I can’t walk.”
Claire Williams: Mhm.
Dr. Teodoro Nissen: And even that right there is very subjective, you know. And so, that’s a lot of the — I don’t think we’re ever gonna get around that, and so for as long as we can incorporate it and know that’s what we’re dealing with, I think it makes it more palatable and workable, so to speak.
Claire Williams: Yes. And with that workability, do you find that there’s a specific degree of that in doing QME evaluations?
Dr. Teodoro Nissen: Absolutely. You know, the Guides are kind of a blessing and a curse, you know.
Claire Williams: [laughs] Yes.
Dr. Teodoro Nissen: They’re there to support you, and you can point to them and ask “Will the Guides allow for this?” And that’s actually true, but the Guides aren’t very comprehensive, they’re not that thorough, and they’re not necessarily all that applicable all the time.
Claire Williams: Right.
Dr. Teodoro Nissen: So they may help you, but they also may hinder you or they just might not work. They might not be applicable. Or they just don’t make sense. I think the art of being a QME is to work within the four corners of the AMA Guidelines and what’s allowed, and be as creative as you can, but you want to be as accurate and precise as you can, right?
Claire Williams: Mhm.
Dr. Teodoro Nissen: You want it to be an accurate rating, you want it to work out for the patient, for the insurer, you want it to make sense. It doesn’t do any good to go off on a philosophical tangent or get on a soapbox when you’re doing these types of things.
Claire Williams: Yes, I like that, the art of being a QME, because it seems like it so much does require both creativity and critical thinking.
Dr. Teodoro Nissen: Yeah, absolutely.
Claire Williams: So, is there anything you’d like to see changed or improved in the QME process, either for doctors or injured workers themselves?
Dr. Teodoro Nissen: Yeah, I think transparency around the privilege of medical care.
Claire Williams: Yeah.
Dr. Teodoro Nissen: It seems like there’s a very wide spectrum of cases we see. You know, I see cases that come, where the patients had surgery a month ago and then someone’s already asking for a QME, which is too soon for example, and then it gets pushed through. And then you have patients whose case has been going on for 15 years. And you have the utilization review baked in there, and you have these peer-to-peers, you have all these kinds of checks and balances, but it doesn’t feel like there’s a real cohesive approach to allocating medical care or resources that anyone can point to and say like “This is what we’re doing, this is the stage we’re at, this is the process.” And it’s very transparent, and we can all look at it and say “Okay, this is where the case is and this is what can be expected, these are the next steps.” It seems like it’s really kind of all up in the air. Even what insurers are paying for or not paying for.
Claire Williams: Mhm.
Dr. Teodoro Nissen: For example, joint replacements are just on the cusps. Recently, in the last, I’d say 5 or 10 years, they would never get approved. Now, insurers are paying for knee replacements or total joint replacements. But some of them are, and some of them aren’t, so it depends on the carrier. Some of them are using some guidelines, and others are using different guidelines, and so it seems a little scattered, right, there’s no cohesion. And so if the system had some cohesion — that’s what they try to do with the AMA Guides. But if you’re gonna try to do the system where you are going to have objective findings, and you are going to have guidelines, then it feels like you might want to make them comprehensive and applicable, accurate and meaningful. Because right now, it seems like they’ve made a step, but they haven’t made a really thorough step. And so it adds to a lot of the confusion and uncertainty, I think it adds to a lot of the issues we’re having with patients kind of toiling in the system for a long period of time with no direction, so to speak.
Claire Williams: And do you see that change coming from above, like from the State, and the State requirements? Or being pushed for by the medical community?
Dr. Teodoro Nissen: Well, I think it would have to be, it would have to come from the State. I think it’s pushed forward, you know, organizations like the California Orthopedic Association (COA), they’ll push for these changes. But like anything in the State that’s a state policy or legislation, it just takes a really long time and I’m certain that what they spit out at the end isn’t necessarily what was intended at the beginning by the time it’s hacked up. Maybe that’s just the way of the world. Again, you can’t rally against it or get up on a soapbox, you have to say “This is the way it is,” like “What can we do within the system to make it better?”, to help injured workers back to work or get them accurately rated, and something that works for employers, and for the injured workers. I mean, that’s the system that you really want in the end.
Claire Williams: Yep. And so, for our listeners who are maybe thinking about getting into the QME business, what advice do you have for them?
Dr. Teodoro Nissen: I think, to do it. [laughs]
Claire Williams: Yeah. [laughs]
Dr. Teodoro Nissen: I always say I came in as a roundabout way, because I really didn’t know what a QME did. You know, I just took the test, to be honest with you. I was just out, and we didn’t do much workers’ comp where I did my residency, it was mainly academic. Just do it, and get in with a group. You can have some mentors, you know, for example, like John Alchemy, he’s just a whiz.
Claire Williams: Yeah.
Dr. Teodoro Nissen: And so it’s been really great for me to — I’ve been a QME since 2006, but even now — to hear him and run cases by him and chew on the different aspects of it — you’re not gonna know it all. You’re not gonna go in and have this thing all memorized and you’re just gonna go out and do it; that’s not the way it works. This is a refinement process, and you kind of take on cases that are a little bit lighter and easier, with one body part, and you kind of just roll with it a little bit and it’s like any iterative process. You’re gonna make mistakes, as long as you can go back and say “Wow, I thought that was the right rating, but it’s not.”
Claire Williams: Mhm.
Dr. Teodoro Nissen: You know, sometimes depositions are a blessing, and you can learn so much from someone saying “Hey, I’m not seeing it the way you’re seeing it.” And as long as you can kind of get off the defensive posture and ask “Well, what are you seeing?”, you can learn a lot. And so I would say do it, and be open to change, and to know that you’re going to get better at it, but you’re also going to be wrong sometimes and right sometimes. And that’s just the way it goes.
Claire Williams: Yeah, to keep that learner’s mind.
Dr. Teodoro Nissen: Yeah, absolutely. It’s like a learning mindset, versus you have to have all the answers ahead of time, and it just doesn’t work like that. Because also the process is changing, the laws are changing, so everything’s going to be in flux. So you kind of have to get comfortable with uncertainty.
Claire Williams: Yes. Okay, well, I’m curious if you have any last closing thoughts for our listeners? And if not, how they can reach you, perhaps if they have any questions?
Dr. Teodoro Nissen: You can reach me at my email, which is firstname.lastname@example.org. And yeah, I’m happy to answer any questions or provide any support that I can.
Claire Williams: Great, well thank you so much for joining us today in this great discussion on being a QME.
Dr. Teodoro Nissen: Alright, thank you.
Narrator: Thank you for joining us for this episode of the California Workers’ Comp Report. You can follow RateFast on Twitter at @ratefast, or visit www.rate-fast.com to learn more.