Flawed Promises: A Critical Evaluation of the American Medical Association's Guides to the Evaluation of Permanent Impairment Page: 967

                                
measure the knee impairment (evaluate flexion and extension with a
goniometer) (p. 59); includes a chart that translates this data into "%
Impairment of [the] Lower Extremity" (p. 6r); and in turn translates
this lower extremity impairment into "Impairment of [the] Whole
Person" (p. 65). The rules in Chapter Six ("The Cardiovascular Sys-
tem") apply to a person with heart disease. A 15-25% whole-person
impairment rating results if an individual has a history of myocardial
infarction; has no symptoms while performing ordinary daily activities;
may require medication or moderate dietary adjustment; and is able
to perform an exercise test with certain findings (pp. 126-27).
These examples illustrate several points about the Guides' system.
First, some but not all of the system-specific chapters include rules
that can generate what I will term "organ-level" impairment ratings,
such as the degree of impairment to the knee. Second, all of these
chapters set out rules for arriving at a whole-person impairment rat-
ing. Third, some of the chapters, such as the cardiovascular system
chapter, base the final whole-person rating on findings by the practi-
tioner that include an assessment of how the patient performs daily
living activities. By contrast, other chapters, such as the chapter that
covers knee injuries, require findings (such as range of motion) that
do not include ability to carry on daily activities. The Guides suggests
that the whole-person rating is the most meaningful one: it espouses~]
the philosophy that . . . all impairment ratings should be combined
to be expressed as impairment of the whole person" (p. xviii). Hence,
the book's primary rating objective is to generate a whole-person
impairment percentage that represents the impairment consequence of
injury or disease to virtually any bodily system."
II.
A. Objectivity and the Medical Nature of Impairment
Chapter One ("Concepts of Impairment Evaluation") presents the
principles and definitions that are central to the Guides. The chapter
states that the user "must understand the concepts under which the
'rules' have been developed and the intended approach for using them
to achieve objective, accurate, fair, and reproducible evaluations of
individuals with medical impairments" (p. i). Impairment, the chap-
ter emphasizes, is a "medical matter" (p. 2), a "medical condition" (p.
6), a "medical fact" (p. 4), and is "assessed by medical means" (p. 2,
emphasis in original). The book continues to stress the importance of
11 Another key objective, discussed in Part III below, is to standardize the evaluation and
reporting process.

BOOK REVIEW

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