Opening vignette

Marcus, a forklift operator with persistent back pain, attended his third IME in six months. Each examiner documented range of motion, straight leg raise findings, and MRI correlation. The focus was on physical capacity and tissue healing. None explored his fear of reinjury, his supervisor's doubts about modified duties, or his growing concern that the system questioned his credibility. The reports were clinically thorough. Yet after each assessment confirmed "capacity for light duties," Marcus remained off work, becoming increasingly worried that he wasn't improving.

Thesis

Independent medical examinations for capacity and return-to-work planning typically assess biomedical factors. Across research evidence and international scheme experience, psychosocial factors—workplace relationships, recovery beliefs, and procedural fairness—more strongly predict return to work outcomes. IMEs for RTW may be answering questions that don't identify the reasons for delayed recovery.

By the numbers (selected studies)

• 2019 • systematic review • 30+ studies: Recovery expectations and fear-avoidance beliefs show strong evidence for predicting work outcomes (1)
• No Australian jurisdiction publicly reports IME frequency by purpose—we don't know what percentage are for RTW planning vs permanent impairment vs liability vs treatment approval
• Unknown effectiveness: No data on whether RTW-focused IME findings change management decisions or correlate with actual return to work
• $800–$6,000+ per assessment, not including worker time off, travel, or downstream delays while awaiting reports and decisions
• 2024 • Comcare reforms: Requirement for treating practitioner input first, worker consultation on IME selection—recognition that current approaches need rethinking

The fundamental mismatch

For IMEs aimed at understanding why someone isn't returning to work—a common and costly scenario—we face a fundamental mismatch. These assessments typically measure physical findings: range of motion, reflexes, imaging correlation. Yet the same worker can receive vastly different reports about work capacity, partly because some examiners respond to unspoken psychosocial cues while others focus purely on biomedical findings.

Three decades of research reveals the problem: biomedical factors typically measured in RTW-focused IMEs have limited ability to predict who returns to work. Instead, psychosocial factors such as control over work decisions, colleague support, and feeling valued show much stronger associations with successful return to work (2,3). Recovery expectations, workplace support, fear-avoidance beliefs, and self-efficacy—these "yellow flags" identified since the 1990s—matter more than most physical findings for predicting return to work (1,4). Yet standard IME protocols rarely evaluate them systematically.

The assessment context compounds the problem. If workers perceive the IME as adversarial rather than supportive, they're unlikely to discuss the workplace conflicts, financial stress, or family pressures that may be the real barriers to recovery. These critical factors remain hidden when trust is absent.

The quality of the interaction also matters. Research shows patients who feel heard and respected perceive consultations as longer, while those who feel rushed or dismissed recall them as briefer than they actually were. When workers report their IME "only took ten minutes," they may be expressing how the interaction felt—hurried, impersonal, dismissive—and this will diminish the opportunity to tease out specific barriers.

The timing problem

Psychosocial barriers are most amenable to intervention early—ideally within the first few weeks after injury. Yet RTW-focused IMEs often occur later, when return to work has already stalled. By this point, fear-avoidance patterns have established themselves, workplace relationships may have deteriorated, and the window for effective intervention has narrowed considerably. We're measuring the wrong things at the wrong time.

What we don't know

No Australian jurisdiction tracks and reports why IMEs are requested or whether they achieve their purpose. We don't know what percentage are for liability determination versus RTW planning versus permanent impairment. Without this and the ability to understand the end results, we can't evaluate whether RTW-focused IMEs actually identify barriers to recovery or change management approaches. Are we systematically using the wrong tool for RTW planning? The transparency gap prevents us from assessing the scale of the mismatch.

The search for better approaches

Different jurisdictions are exploring alternatives:

Workplace integration: France, Belgium, and Germany employ physicians to conduct worksite inspections and employee examinations, addressing context rather than assessing workers in isolation (5). 

Early intervention: The NSW Injury Management Consultant model provides consultations that, if done early (e.g., 4-6 weeks), could identify issues when intervention can still make a difference. In practice, these consultations often happen years after injury when their utility is limited. Assessing the effectiveness of the NSW IMC model would provide valuable insights.

Targeted assessment: Ontario requires clinical pharmacist review at medication thresholds rather than repeated general assessments. Comcare's 2024 reforms mandate treating practitioner input first and worker consultation in examiner selection.

Volume management: Some jurisdictions cap IME frequency or require approval for multiple examinations. While acknowledging the assessment burden, this approach doesn't address whether we're using the right assessment for the right purpose.

An evidence based alternative:

Simple screening tools: Evidence-based psychosocial screening tools already exist that could bridge the gap. The Short Form Örebro Musculoskeletal Pain Screening Questionnaire, for instance, reliably predicts RTW outcomes and takes only minutes to complete. Receptionists could administer it in waiting rooms, giving examiners a framework for exploring individual barriers. Yet implementation remains rare. Orthopaedic surgeons conducting IMEs are unlikely to adopt psychosocial screening tools without systemic support. Occupational physicians, rehabilitation physicians, or IMEs specifically designed for RTW planning might be better positioned to integrate these approaches—if schemes explicitly value and fund this type of assessment.

The adversarial dimension

When IMEs become tools in adversarial proceedings, their clinical utility diminishes. Victoria's 2019 Ombudsman investigation found 50% of conciliation decisions and 70% of court decisions overturned where IMEs were disputed (6). NSW faces similar challenges, with frequent disputes requiring Personal Injury Commission resolution. The assessment context itself becomes a barrier to understanding what's preventing recovery.

Why this matters for schemes

RTW-focused assessments that don't measure what predicts return to work represent misdirected resources—not just direct costs but opportunity costs. We've inherited an assessment framework from an era when pain was understood primarily through tissue pathology. The science has evolved; our RTW assessment systems haven't. The result: repeated measurements of factors with limited predictive value while the psychosocial factors driving ongoing disability remain unaddressed.

Questions for discussion

• What percentage of claims involve IMEs and for what purposes—RTW planning, permanent impairment, liability determination?
• Who is best positioned to conduct RTW-focused assessments that capture psychosocial factors? Could occupational or rehabilitation physicians using validated tools like the Örebro questionnaire provide more useful insights than specialists focused on anatomical findings? How could schemes incentivise the use of evidence-based screening tools?
• Could earlier collaborative assessments help to identify psychosocial barriers when still amenable to intervention?
• Could we work together to design more tailored assessments that align with the evidence for various assessment purposes—biomedical for permanent impairment, psychosocial screening for RTW planning?

Bridge to next article

While IMEs illustrate how we often use assessments that don't match their intended purpose, they're embedded in broader administrative frameworks where processes meant to ensure appropriate care can inadvertently become barriers. Next: how approval pathways and administrative settings shape recovery trajectories.

References

1. Iles RA, Davidson M, Taylor NF. Psychosocial predictors of failure to return to work in non-chronic non-specific low back pain: a systematic review. Occup Environ Med. 2008;65(8):507-517.
2. Gjesdal S, Bratberg E, Mæland JG. Gender differences in disability after sickness absence with musculoskeletal disorders: five-year prospective study of 37,942 women and 26,307 men. BMC Musculoskelet Disord. 2011;12:37.
3. Cancelliere C, Donovan J, Stochkendahl MJ, et al. Factors affecting return to work after injury or illness: best evidence synthesis of systematic reviews. Chiropr Man Therap. 2016;24:32.
4. Steenstra IA, Munhall C, Irvin E, et al. Systematic review of prognostic factors for return to work in workers with sub acute and chronic low back pain. J Occup Rehabil. 2017;27(3):369-381.
5. Anema JR, Schellart AJ, Cassidy JD, Loisel P, Veerman TJ, van der Beek AJ. Can cross country differences in return-to-work after chronic occupational back pain be explained? An exploratory analysis on disability policies in a six country cohort study. J Occup Rehabil. 2009;19(4):419-426.
6. Victorian Ombudsman. WorkSafe 2: Follow-up investigation into the management of complex workers compensation claims. Melbourne: Victorian Ombudsman; 2019.