Opinion ID: 2066743
Heading Depth: 2
Heading Rank: 2

Heading: The AMA Guides (4th ed.)

Text: [¶ 12] In the discussion that follows, we conclude that because the AMA Guides's definition of permanent impairment closely parallels one that includes any loss or abnormality of psychological ... function[,] see AMA Guides at 1 (quotation marks omitted), the psychological sequela of a work-related physical injury may be included when determining permanent impairment. In addition, we conclude that the reason the AMA Guides did not adopt fixed percentages for psychological injuries is not because the AMA Guides views such injuries as not subject to assessment. Rather, fixed percentages were not adopted out of concern that precise measures would likely ... be used inflexibly by adjudicators, who then are less likely to take into account the many factors that influence mental and behavioral impairment. AMA Guides at 301. The AMA Guides recognizes that there are circumstances in which it is essential for an examiner to estimate the degree of impairment associated with a psychological injury and, in such circumstances, using the ordinal or numeric scale might be of some general use. Id. [¶ 13] With the enactment of title 39-A, the Legislature mandated that the Board establish by rule a schedule for determining the existence and degree of permanent impairment based upon medically or scientifically demonstrable findings. 39-A M.R.S. § 153(8)(A) (2007). The schedule was to be based on generally accepted medical standards for determining impairment and could incorporate all or part of any one or more generally accepted schedules used for that purpose. Id. The purpose of the schedule is to reduce litigation and establish more certainty and uniformity in the rating of permanent impairment. Id. [¶ 14] Pursuant to section 153, the Board adopted the fourth edition of the AMA Guides for use in determining the level of permanent impairment. [3] Me. W.C.B. Rule, ch. 7, § 6. The rule provides: Permanent impairment shall be determined after the effective date of this rule by use of the American Medical Association's Guides to the Evaluation of Permanent Impairment, 4th edition, copyright 1993. (Emphasis added.) [¶ 15] The fourth edition of the AMA Guides defines impairment and permanent impairment as follows: Impairment is defined in the Guides as an alteration of an individual's health status. Impairment, according to the Guides, is assessed by medical means and is a medical issue. An impairment is a deviation from normal in a body part or organ system and its functioning. The Guides defines permanent impairment as one that has become static or stabilized during a period of time sufficient to allow optimal tissue repair, and one that is unlikely to change in spite of further medical or surgical therapy. The Guides definition of an impairment closely parallels that of the World Health Organization (WHO), which has defined an impairment as any loss or abnormality of psychological, physiological or anatomical structure or function. AMA Guides at 1. [¶ 16] The major objective of the [AMA] Guides is to define the assessment and reporting of medical impairments so that physicians can collect, describe, and analyze information about impairments in accordance with a single set of standards. Id. at 7. Although rating impairments cannot be totally objective, use of the Guides increases objectivity and enables physicians to evaluate and report medical impairment in a standardized manner, so that reports from different observers are more likely to be comparable in content and completeness. Id. at 5. [¶ 17] The AMA Guides attempts to achieve objectivity and standardization by assigning percentages of impairment to different conditions based on specific measurements or assessments performed in a standardized manner. See id. at 5, 7. However, the AMA Guides explicitly cautions that it does not and cannot provide answers about every type and degree of impairment. Id. at 3. It is a guideline to be used in conjunction with the expertise of the medical profession. See id. [¶ 18] There are no numerical percentages assigned by the AMA Guides to mental and behavioral disorders not caused by a neurological condition. Id. ch. 14. The editors of the fourth edition explain their decision not to establish numerical percentages for non-neurologic mental impairments as follows: [U]nlike the situations with some organ systems, there are no precise measures of impairment in mental disorders. The use of percentages implies a certainty that does not exist, and the percentages are likely to be used inflexibly by adjudicators, who then are less likely to take into account the many factors that influence mental and behavioral impairment. Also, because no data exist that show the reliability of the impairment percentages, it would be difficult for Guides users to defend their use in administrative hearings. Id. at 301. [¶ 19] The AMA Guides sets forth a method of evaluating mental impairment at section 14.7. Id. at 300-02. Four categories of functional limitations are identified: (1) activities of daily living; (2) social functioning; (3) concentration; and (4) adaptation. Id. The physician is directed to inquire into and record observations about these categories during the examination. Id. A table serves as a guideline for rating mental impairment in each of the four areas of functional limitation on a five-category scale: none, meaning no impairment; mild, meaning impairment compatible with most useful functioning; moderate, meaning impairment compatible with some but not all useful functioning; marked, meaning impairment that significantly impedes useful functioning; or extreme, meaning impairment not compatible with useful functioning. Id. at 301. [¶ 20] Chapter fourteen cautions that [t]ranslating these guidelines for rating individual impairment on ordinal scales into a method for assigning percentages of impairments, as if valid estimates could be made on precisely measured interval scales, cannot be done reliably. Id. However, it also acknowledges that when it is essential to make an estimate, doctors must attempt to do so as accurately as possible using their best clinical judgment: Physicians, of course, must often make judgments based more on clinical impressions than on accurate, objective, analytic empiric evidence. In those circumstances in which it is essential to make an estimate, the ordinal or numeric scale might be of some general use.... Eventually, research may disclose direct relationships between medical findings and percentages of mental impairment. Until that time, the medical profession must refine its concepts of mental impairment, improve its ability to measure limitations, and continue to make clinical judgments. Id. [¶ 21] Because duration of disability benefits under Maine's Act are premised on the determination of a threshold numerical level of impairment, see 39-A M.R.S. § 213, it is essential for an evaluator to make a numeric estimate of the degree of impairment if the evaluator determines that an employee who has suffered a work-related physical injury has, as a consequence, also suffered a loss or abnormality of psychological function that has reached a level of maximum medical improvement.