Establishing a Strong Medical Foundation for Life Care Planning: Life Care Planning Physiatrist, or Treating Physician?

When a life care plan is produced to identify an injured individual’s residual medical conditions, medical needs, and associated costs, the following question is often raised:

Who is best suited to establish the medical foundation of a life care plan?

According to the essential text the Life Care Planning and Case Management Handbook, “For a life care plan to appropriately provide for all the needs of an individual, the plan must have a strong medical foundation. Physicians specializing in physical medicine and rehabilitation (physiatrists) are uniquely qualified to provide a strong medical foundation for life care planning based on their training and experience in providing medical and rehabilitative services to individuals with disabilities.

Physiatrists are, by their training [in orthopedics, neurology and rehabilitation medicine], experienced in dealing with individuals who have catastrophic functional problems. Additionally, physiatrists are trained to anticipate the long-term needs of their patients.”

It is not by accident that Section 1, Chapter 2 of the Life Care Planning and Case Management Handbook is entitled “The Role of the Physiatrist in Life Care Planning”. It states: “Physiatrists are experts in the medical and physical treatment of disabling illness and injury, and they “have long been recognized as uniquely qualified among medical specialists to provide the scientific and medical foundations essential to the development of life care plans.”

“The foundation of many life care plans is limited by the plan developer’s experience and the frequently marginal input from treating physicians. Especially in developing a plan for an individual with complex health care needs due to a catastrophic injury or illness, the life care planner and the treating physicians may have very little experience in dealing with a person with similar medical issues.”

Both Physiatric life care planner and treating physicians have meaningful roles, each with their own strengths and weaknesses.

Treating Physician: Pros

• Treating physicians may have areas of relevant specialization, e.g. family medicine, internal medicine, orthopedics, neurology, neuro surgery.
• Treating physicians may be more accessible to the subject (as in the case of a smaller community).
• Treating physicians may have the benefit of multiple evaluations.
• Treating physicians may have long term relationship with subject.
• Treating physicians may have knowledge of specific, relevant medical conditions.
• Treating physicians’ relevant specialization may shed light on specific medical conditions, and this is helpful because it provides objective evidence of the condition’s existence.
• Treating physicians’ may identify very specific and specialized needs, e.g. medication, procedures, or surgeries, which helps to reinforce a life care planners opinion regarding future medical requirements.
• The reality is, some people live in rural areas and don’t have access to specialists, therefore, the treating physician (specialist or non-specialist) serves as a medical resource that would not otherwise be available.
• Obviously, serial assessments are beneficial in their respect a treater’s ability to identify, manage, and refer subjects to medical specialists. Opinions formulated on a serial basis may be especially useful in both formulating opinions regarding a subject’s conditions and future medical requirements.
• A treater’s contact with a subject on a repeated basis may be assigned greater weight or validity in the mind of judge or jury.
• The propensity for a subject to fully disclose all aspects of very personal health conditions, limitations and challenges, may be greater with a treating physician, with whom a subject has a long term relationship. This would assist a treating physician in his/her acquisition of objective findings.
• A treating physician who has a long term relationship with a subject may have a greater understanding of their “pre-relevant injury/illness”, premorbid conditions, which would assist the treating physician to more accurately delineate care needs that are specifically and exclusively attributable to the relevant cause of injury or illness.For example, the treating physician may have been the first to address the relevant injury/conditions, and often during deposition or trial, a cross examination may focus on the treating physician’s initial documentation of subject’s, symptoms, and clinical findings, as well as any established diagnoses. Given that the documentation most proximal to the event is often afforded considerable weight, the fact that a treating physicians “was actually there”, and has empirical experience with the specific subject matter, places him/her in a particularly strong position to address that area of cross examination.

Treating Physician: Cons

• Treating physicians may have a limited scope of knowledge of relevant medical conditions and their consequences.
• Treating physicians are often unable to properly assess a subject’s overall medical status and need at the time of a life care plan’s formulation.
• Treating physicians are often unable to establish a sound medical foundation for all, or the most relevant medical conditions, i.e. the treating physician may have a very narrow scope of knowledge.
• Conversely, some treating physicians, family practitioners for example, may possess broad, yet relatively shallow body of medical knowledge relevant to subject’s specific diagnostic conditions and/or long term needs.
• Treating physicians, when providing and documenting care within medical records are often exclusively focused on the past and the present, i.e., on a visit-to-visit perspective, and not on the future, especially the long-term, and/or lifetime needs of a subject.
• Often, due to the nature of a primary care practice, a treating physician may afford very limited time to the evaluation of a very complex problem.
• Even treating physicians that specialize in a particular area of care, may lack full understanding of the impact of the injury or condition, on a subject’s disabilities, which include his/her capacity to perform personal, social and/or occupational demands over the course of his/her lifetime.
• It is common for care to be delegated to mid-level practitioners with a shallower and/or narrower body of medical knowledge, which may result in incomplete discovery of the full impact of the relevant injury or illness. These same individuals may have limited capacity to perceive pathological changes over time, and thereby lack capacity to formulate appropriate care for those changes.
• A treating physician may have had early contact with a subject, but there may be a lapse in his/her involvement, which would hinder his/her ability to understand the state of a subject’s relevant, residual medical conditions at the time of a life care plan’s formulation.
• Without access to a comprehensive review of all relevant records, which may have been created subsequent to a treating physicians last contact with a subject, and access to a more recent interview and examination, the treating physician would be placed at a disadvantage in respect to establishing an accurate and comprehensive medical foundation—something which is fundamental to the production of a strong medical foundation within a life care plan.
• While specialized care is good, its narrow focus may not identify all relevant medical conditions, consequences, and/or needs.
• Treating physicians are often narrowly focused upon the issues at hand at the time of a subject’s actual visit, and rarely, if ever do they give consideration to the full impact of a subject’s condition, the condition’s progression, and a subject’s future needs (especially beyond the time of the subject’s next visit).
• The objectives of treating physicians are not the objectives of a life care planner, e.g, the objectives of a treating physician are frequently focused on a clinically-related, specific condition or symptom, rather than on a comprehensive analysis that considers the overall impact of the relevant injury/illness. For example:
  • The Progression of a relevant injury/illness
  • An impairment’s impact on a subject’s function, i.e. disability (alteration in capacity to perform personal, social, or occupational demands as a result of impairment)
  • Consideration of a relevant comorbidities’ impact on injury/illness, e.g., aggravation
  • The scope necessary to address the formulation of a subject’s probable duration of care
• The objectives of treating physicians are often focused on short term objectives rather than on long term, and/or lifelong objectives.
• Treating Physicians are commonly unfamiliar with proper life care planning methodology.
• Treating physicians are almost always unaware of the Clinical Objectives of Life Care Planning.
• Treating physicians are often unavailable, unwilling, or unable to assist life care planners in the development of their plans’ medical foundations.
• Treating physicians often do not have time, or make time to respond to requests for information, and if and when treating physicians do respond, they often afford limited time to meaningful consideration.
• Treating physicians often formulate conclusions and recommendations for treatment based upon treatment and/or reimbursement guidelines, instead of upon the needs of the subject, and/or the provision of optimal medical care. This can affect significant disadvantages in respect to identifying important future medical requirements, especially those related to phase changes, that is, progressive symptoms and/or disabilities affected by post traumatic degradation and aging, Examples of how this may result in shortcomings in a life care plan may include: lack of consideration of necessary medications, assistive devices, attendant care, and even surgical needs. These considerations are extremely important, as they may disqualify their a treating physician’s testimony.
• A treating physician unfamiliar with relevant, reliable, peer-reviewed life care planning methodology, is likely not familiar with the proper mindset in respect to the Clinical Objectives of Life Care Planning.
• An unawareness of the Clinical Objectives of Life Care Planning presumes an unawareness of the type of care necessary to attain those objectives, i.e. optimal care based upon “need”, rather than reimbursement”, etc.
• Most treating physicians are simply not committed to the outcomes or to the quality of life care plans, many of which involve subjects they have not seen for years, or hardly remember. To say the least, more often than not the treating physician assumes no ownership over the diagnostic conditions specified in a life care plan, nor do they assume any ownership over the proper formulation of care that may last throughout a subject’s lifetime.

Life Care Planning Physiatrist: Pros

• Physiatric training is a blend of orthopedics (musculo-skeletal), neurology, and rehabilitation medicine, which is particularly relevant to the long term care necessitated by the subjects of life care plans.
• Physiatrists are experts in the medical treatment and rehabilitation of disabling illness and injury.
• Physiatrists typically follow subjects on a long term basis and have the ability/opportunity to evaluate and treat individuals at different phases of their condition(s).
• Most life care planning physiatrists are committed to the pursuit of continuing education in life care planning.
• The very nature of physiatric practice requires physiatrists to be able to understand treating physicians documented medical records, and physiatrists are accustomed to contacting treating physicians and/or other medical specialists when necessary.
• Physiatrists are widely recognized for their diagnostic acumen, which includes their clinical evaluations, and their capacity to interpret and clinically correlate diagnostic studies (e.g. x-rays, CTs, MRIs, etc.), as well as other clinical findings.
• Physiatrists receive mandatory training in Electrodiagnostic Medicine, which is particularly relevant to the evaluation and management of non-catastrophic spinal and peripheral nerve injuries (which comprise a vast number of the cases for which life care plans are commissioned).
• Physiatrists know and understand the therapeutic treatments and objectives set forth by other rehabilitation professionals.

Life Care Planning Physiatrist: Cons

• Like all training programs, Physiatrists’ training programs may vary, and their training may not have been as comprehensive as the typical PM&R program.
• Some physiatrists pursue narrower practices, e.g. pain management, electro-diagnostics, sports medicine, etc.), or they devote themselves completely to an outpatient practice (it should be noted that an out-patient practice may see many more non-catastrophic spine injuries, therefore making the circumstance an asset in non-catastrophic spine cases.
• Many Physiatrists are reluctant to engage themselves in medical-legal issues.