Episode 30: Conversation with Dr. Edward Negovetich (The Physiatrist’s Role in Cases Involving Serious Injuries)

Dr. Edward Negovetich:

When somebody’s been around the block to a couple different people, nothing’s really done, nothing’s really helped, and I do my thorough interview and exam of them. Even if I haven’t cured them, if I have improved their quality of life by 20% to 30%, somebody who’s pretty miserable to begin with, that’s substantial. They’re very thankful, and so, in my practice, that’s the thing that I find the most rewarding.

David Craig – Host:

I’m attorney Dave Craig, managing partner and one of the founders of the law firm of Craig, Kelley and Faultless. I’ve represented people who have been seriously injured, who have had a family member killed in a semi or other big truck wreck for over 30 years, following the wreck, their lives are chaos. Often, they don’t even know enough about the process to ask the right questions. It is my goal to empower you by providing you with the information you need to protect yourself and your family. In each and every episode, I will interview top experts and professionals that are involved in truck wreck cases. This is After The Crash.

Today, we are interviewing Dr. Edward Negovetich Jr. Dr. Negovetich is a physiatrist, and I’m thrilled to have him on our podcast. He’s a gifted attorney or a gifted doctor. That’s a nightmare to be an attorney, right? Gifted doctor who not only works with a lot of clients, a lot of time it is people who have been involved in wrecks because they will go to a physical medicine rehabilitation doctor. So, we’re going to talk a little bit about that. He also does forensic work where he actually testifies or looks at things from a medical legal standpoint, and we’re going to talk about that as well. He also does future life care plans, and not all doctors do. We’ll talk about what that means and what that is. Dr. Negovetich, welcome to the program.

Dr. Edward Negovetich:

Hey, thanks for having me, Dave. Pleasure to be here.

David Craig – Host:

Let’s start off with just a little bit about your background. Tell us a little bit about yourself, where you went to medical school, where you went to college, and exactly what your specialty is.

Dr. Edward Negovetich:

Sure. I grew up in the northwest corner of Indiana. I went to Wabash College in Crawfordsville, Indiana as an undergrad. I graduated with my BA in chemistry and then enrolled in medical school at the Indiana University School of Medicine in Indianapolis. I graduated from there four years later, and then did my internship or transitional year at the Marshfield Clinic in Marshfield, Wisconsin, and then, I returned to Indianapolis to IU to do my physical medicine and rehabilitation residency.

David Craig – Host:

This podcast is designed for everyday ordinary folks that may not know a lot about the legal process or the medical process. Can you tell us a little bit about what physical medicine rehabilitation is?

Dr. Edward Negovetich:

Sure. It’s a small medical subspecialty. It is frequently abbreviated PM&R because it’s obviously a mouthful to say physical medicine and rehabilitation every time you reference the field. The field also is sometimes referred to as physiatry, not to be confused with psychiatry, and we are thus sometimes referred to as physiatrists, which there’s some debate how you pronounce it. Some people say physiatrist, but that doesn’t roll off the tongue as well for me, so I still say physiatrist. Anyhow, it’s a non-surgical specialty. It takes somewhat of a holistic approach to a patient in examining assorted bone, muscle joint, nerve tendon conditions, acute and chronic illnesses. During our training, we do quite a bit of following people with chronic diseases, chronic illnesses, and managing those conditions.

We also do things such as a nerve test called an EMG and nerve conduction study which is a test to diagnose nerve or muscle diseases. Also, within the scope of physical medicine and rehabilitation is the area of brain injury as well as spinal cord injury. In fact, we are frequently the doctors that staff the inpatient rehab units where someone is rehabbing after a brain injury or a spinal cord injury.

David Craig – Host:

I mean, I look at it as a blend between orthopedics and neurology. In a way, you work with both, right?

Dr. Edward Negovetich:

I completely agree. In fact, that’s oftentimes how I explain it, which actually is part of the reason I ended up in the field I ended up in, but yes, I believe it’s the old Venn diagrams where you have intersecting circles of orthopedics, neurology and sports medicine. In fact, I went to medical school thinking I wanted to do sports medicine. There’s not a sports medicine residency. Sports medicine, is if you don’t want to be a surgeon, is a fellowship after you complete say internal medicine or family practice, something of that nature. When I did my rotation in family practice, I thought there was no way that I could survive a family practice residency just because I didn’t like a lot of the other day-to-day associated with that. Then, I started thinking about other things. I really liked neurology, but by the same token, didn’t really want to deal with some of the conditions they dealt with on a daily basis and liked some of the procedural aspect, meaning injections and things of that nature.

I typically always bring my lunch or brought my lunch to school, and I stumbled upon a luncheon by the Indiana Department of Physical Medicine Rehabilitation. I went to the meeting to get a free lunch and was interested by the stuff they presented and the things they do, and I thought, “Wow, this is an interesting combination of some of the things that interest me.” I did a rotation, liked it, did an elective, and then did a second elective. I still liked it and thought, “You know what? This works for me,” and you’re right, it is an extremely diverse field, and I would say if you queried 100 different physiatrists as far as their today, day-to-day and things they saw, things they didn’t see, it would probably be very different, even though we all have similar training from a residency perspective, obviously have to pass a board exam.

There is a great deal of variety in my specialty, which I also like. I like the idea of I’m doing different stuff. It’s not every person I go in and see every single day, it’s this or that. That appealed to me.

David Craig – Host:

I see a lot of clients ask me because they don’t know the difference. They’re like, they’re having pain as a result of a wreck, a traumatic wreck, they’re struggling and there may not be anything surgical, and so they go to an or they want to know, “Do I go to orthopedic surgeon?” I mean, they don’t know where to go. A lot of orthopedic surgeons that, or they’ll go to an orthopedic surgeon or a neurologist and they’ll be referred to somebody like you in your profession, your area of expertise because they’re not really geared to get them better or to work with in or to rehab. If it’s not a surgery, then what are they going to do, at least a lot of these bigger clinics. They specialize on orthopedic surgeries on bone injuries, bone fractures, and disc surgeries. They’ll refer to people like you because you’re the ones, you’re the area that helps rehab and helps people live with the pain and discomfort that can’t be fixed.

Dr. Edward Negovetich:

Yeah, absolutely. That’s a conversation I have with many of my patients is, “Hey, look, I’m going to present you a variety of treatment options, none of which are curative, all of which are palliative. I can’t reinflate this disc, I can’t eliminate this arthritis, I can’t straighten your spine, but some combination of these things that I can offer you may help.” Then, we tackle as far as what that particular person’s personal preferences are, whether it be medicine shots, other physical medicine interventions, what have you. Then, we develop a plan as how we’re going to move forward, and you’re absolutely right as far as orthopedic surgeons or neurosurgeons. I mean, if you think about it, what drew them to those fields was they liked operating, they liked doing surgery, that’s what they want to do. They do not want to be in clinic listening to a litany of somebody’s aches and pains or cognitive issues or whatever because they barely give you two or three minutes of face time.

That’s not a criticism of the field. I love orthopedic surgeons, and if I felt I wanted to do surgery, that definitely would’ve been the field I would’ve gone in, but they want to operate, and so, they quickly look at a scan or an x-ray and say, “Yeah, you know what? I can fix you or I can’t fix you, so long if it’s non-surgical,” and really one of the things… It’s like the opening line of any orthopedic book is 90% of orthopedic issues are non-surgical. The vast majority of people with orthopedic conditions aren’t surgical, and the surgeons, by their education and training, they’re not interested in, they don’t desire to follow somebody long term who doesn’t need surgery. You’re absolutely right, they will frequently send somebody in a physiatrist’s direction.

In fact, some of the large orthopedic and large neurosurgical groups will typically employ one or two or several physiatrists under their umbrella who frequently even evaluate people first line. So, that person that walks in the door maximizes all their conservative care so that the patient is teed up for the surgeon and then the surgeon says, “Yeah, look, this is slam dunk. We should be able to do this. We should be able to get it improved.” Because a lot of times insurances will have different steps that must be done, must be taken and documented accordingly in order to approve the procedure. That is not uncommon.

The other thing that I think is a real plus to seeing a physiatrist as opposed to an orthopedic surgeon, and I see this all the time in my clinical practice as well as my forensic practice, is when somebody presents to an orthopedic surgeon and they have right shoulder, left elbow, right knee and left ankle pain, they say, “What’s the one thing you’re here for today? Let’s talk about that one thing. We’ll focus on that.” Again, because they’re not going to spend a half hour and writing an elaborate report detailing everything about every one of their injuries, that’s not exactly in their wheelhouse. Whereas in physiatry, it is. Also on the same lines, if you go see a shoulder surgeon, he’s only interested in about the shoulder, and he is going to send you the next surgeon if they think it’s coming from the neck, the next surgeon’s going to say, well, “There’s no surgery here, so go see this other guy.”

Oftentimes, especially in the bigger groups, they are very subspecialized where this guy takes care of this, this guy takes care of that. You’re really piecemealing together your care as opposed to having perhaps a central quarterback, if you will, and referring just to the appropriate surgeon as necessary once conservative care has been maximized.

Anyway, I know that was a long-winded elaboration, but I think all of that’s really relevant, particularly when you deal with people who who’ve been injured because they frequently have multiple aches and pains and several areas involved. In the acute period, if it’s somebody who, God forbid, had to be transported by ambulance to a hospital for a workup, they’re just interested in the ER in what are potentially life altering complications or injuries, and they just want to rule out the really bad stuff and then they just want you to get you home and follow up with whoever they send you to follow up with. Anyway, that’s where I think that my field is very, very beneficial.

David Craig – Host:

We see that. A client comes in after a horrific wreck, and so, initially they may have life-threatening injuries, but then the life-threatening injuries pass and now they have chronic pain. So, for example, you mentioned the shoulder, but we’ll see cases where there’s a shoulder injury, a neck injury, a back injury, and maybe even an arm, like a carpal tunnel type thing. So, it’s complicated as to what is it that is causing the pain. You go to the shoulder surgeon and the shoulder surgeon folks, like you said, focuses on the shoulder. A neurosurgeon or an orthopedic surgeon may look at the neck and say, “Okay, do we have a bad neck?” They maybe look at the carpal tunnel, but I mean it’s tricky. So, a lot of times what they’ll do is they’ll try, “Well, let’s have conservative treatment and see where we end up. Let’s try some conservative treatment. Let’s work with a physiatrist, let’s work with somebody. Let’s try to nail down and get more specifics.”

Because like you said, they don’t really want to spend every week with them coming in and talking to them. They want to know what the end product is. I assume you work with people like that trying to focus and trying to figure out what is it that’s causing the issue. Then, if you need to refer them out to a surgeon, I assume you do that.

Dr. Edward Negovetich:

Absolutely. I think you hit the nail on the head with all of that. The issue that I will encounter from time to time that I think is closely related to what you just said is, say somebody does have a neck problem that needs surgery and somebody has a shoulder problem that needs surgery, that’s two different surgeons that do those. It’s almost like they’re playing a game of chicken because no surgeon wants to operate on somebody who they know post-operatively is still going to have problems and aren’t going to be 100 percent happy. “Well, I think you should get the shoulder fixed first before we do the neck,” or, “I think you should get the neck fixed first before we do the shoulder.” So, we encounter that very frequently in regular practice as well as in the medical legal realm, personal injury type realm. So, if you could, like you said, really narrow it down, stay with some conservative treatment, the neck gets better and it’s obviously then primarily a shoulder problem that’s limiting their function or causing their pain, then that can be fixed.

An orthopedic surgeon, in my opinion, frequently they appreciate that. They like to not have confounding variables that would adversely impact their surgical outcome for what they’re going to fix.

David Craig – Host:

Our practice has a heavy emphasis on commercial motor vehicles, semi tractor trailers, large motor vehicle, large trucks, and the reality is that when 40 tons hits a car, there can be significant damage. We see a lot of mild traumatic brain injuries from that type of trauma and oftentimes also in the neck injuries. So, you’ll see somebody who has headaches, has severe headaches, and nobody knows right in the beginning, is it from the traumatic brain injury, is it from the neck injury, and I know in your practice and physiatry that you also will help people with mild traumatic brain injuries. Again, you’re not a surgeon, but a mild traumatic brain injury, you don’t need surgery. You’re not going to have surgery, but you could have long-term impacts and effects. Talk a little bit about what you offer. What services do you guys provide for people like that?

Dr. Edward Negovetich:

Well, I think the first thing is to properly evaluate the person, and you’re right, with headaches in particular, sorting out what is the cause, primarily an intracranial problem. Is it cervicogenic? Does the neck condition cause the headaches? A lot of that can be supplemented by identifying where does the headache occur? Is it the back of the head which I think’s usually going to be more likely have a significant cervicogenic component. Those certainly frontal headaches, which is a forehead area, can be referred as well. Is it unilateral? Is it one-sided, it two-sided? Does it alternate? Characteristics of their condition, and then assessing for other issues that they may notice, is their emotional liability? Are they more weepy, whiny? Are they more irritable? How’s their mood? How’s their anxiety? Do bright lights bother them? Do loud noises bother them? Are they dizzy, nauseated? Can they look at a screen and work on a screen without getting a headache?

You evaluate all of those circumstances and try to then ascertain what is their problem. and if there appears to be memory or focus or concentration or speech word finding difficulties, you investigate that. With many mild brain injuries, things should move slowly in the right direction with time. So initially, I don’t think that I am overly aggressive in either working up or more aggressively treating somebody in the acute phases. I do a lot of athletic related, sports-related concussions. I’m a sports medicine director for my local hospital, and essentially what that means is I manage all the concussions in our area. The trainers, if I’m not at the game, the trainers send me a text, say, “Hey, so-and-so’s going to be calling you tomorrow morning. Can you work him or her in?” I see a lot of these acutely as well as the ones that happened a while ago.

But in the acute phases, it’s a lot of education. It’s relative rest. It is avoid things that really make you feel awful. It’s understanding that no two brain injuries, no two concussions, are the same. Everybody’s going to heal them at different rates. There’s a variety of prognostic factors that could impact your recovery rate compared to your peers. There are things that can be done for the dizziness or what’s called vestibular dysfunction. I feel that if there is a vestibular component to the symptoms, that typically someone will get better much more quickly if that is addressed. I will very acutely send people to begin vestibular therapy for the vestibular dysfunction because I believe when there’s vestibular dysfunction, that also ramps up the headaches, that ramps up their general feeling of malaise, feeling crummy, and so, I will be aggressive with that.

In the acute phase, I don’t do much by way of prescription medicines. There are some studies, some European studies, suggesting fish oil may be beneficial and it’s not going to hurt you. I talk about that. More recently, there was a study about melatonin being beneficial in the setting, many brain injuries, even if they don’t complain of having sleep problems. Melatonin is a naturally occurring hormone that we secrete through a gland at the base of our brain called the pituitary gland. Anyway, it’s always been well known that people who have had brain injuries have issues with their sleep wake cycle, excessive drowsiness or not sleeping restfully, not being able to fall asleep or stay asleep, things like that. Anyway, I will frequently discuss supplementing with melatonin, and probably for acute management, the most recent thing that is really out there is cardiovascular activity to tolerance.

That actually, if you’re able to do something, whether it’s a brisk walk, whether it’s a stationary bike, whatever you’re able to tolerate that doesn’t promote or aggravate any symptoms associated with your condition, you should keep doing it because that increases blood flow to your brain, helps it heal and can shorten the duration of symptoms.

There’s a lot of education in the acute phase going through all those, and then as we follow them, if things become six weeks, eight weeks, then we’ll talk about, “Okay, let’s investigate with an MRI for any structural damage.” Everybody gets a CT scan if they go to the hospital, if they’ve had trauma and complains of head issues, and that’s basically to rule out, like I referred to before, a life-threatening condition. Do they have a major brain bleed? The vast majority of the time, those are negative for bleeds, but head CTs don’t show you brain bruising, doesn’t necessarily show you, especially in the acute phase, brain scarring or anything like that that we might see on an MRI. I would get structural imaging. If there’s still cognitive concerns, we would certainly do a speech and cognitive therapy evaluation and see if that is something that they can do to get better. Then, as time moves into more than four or five, maybe even six months, if there are still symptoms, I would frequently refer for a full neuropsychological test. At that time, or maybe even a little before, consider different medications that can be used to enhance cognition. If headaches are still a major problem, then we can talk about medicines to prophylaxis against headaches as well as maybe some abortive headache medicines, but I don’t try to do much of the prescription medicines, at all, for four months after the initial insult.

David Craig – Host:

I think that what’s crazy is that in my 35 years of practice and over my lifetime, the amount of information that we know about brain injuries, mild traumatic brain injuries or severe brain injuries or mild or moderate, it’s like night and day. I just recently had somebody pull up all the studies that have been done on brain injuries and following people who have had brain injuries, and so much has been done here in the last 10 years or so. A lot because of the wars. Unfortunately, we have military people coming back. The government has put a lot of money in studying because we’re having a lot of veterans come back with post-traumatic stress, but also traumatic, mild traumatic brain injuries and post-concussive symptoms, and so they’re studying that.

Then obviously we have the athletes, the professional football players, and we now know that, boy, there’s stuff that is happening in the brain that when we do an autopsy we see that we didn’t even see with, regardless of what type of scans we were using. So, we learned so much more today than what we did. When I played sports, you had a concussion and they put you right back in and they-

Dr. Edward Negovetich:

Shake it off.

David Craig – Host:

They did. I mean, there was no big deal. When my kids played sports, it was a big deal. You had to be taken out. They had to have someone like you look at them and take them out and they couldn’t play again no matter how bad. I mean, when you’re young, you want to play, but we now know that that’s not a good idea. And I think the amount of knowledge we have, it’s amazing how much more we know today than what we used to know.

Dr. Edward Negovetich:

I think you’re 100 percent correct. And even with the abundant knowledge that we have now that we didn’t have 10 years ago, I still think it’s generally just the tip of the iceberg. I come across studies from time to time, they’re looking at doing this blood test or that blood test acutely to confirm the presence or absence of brain involvement. There you mentioned the scans, and for a concussion, which would be termed a mild brain injury by definition, a concussion has a normal MRI. If you have an abnormal MRI, it’s something else. That doesn’t mean that they don’t have problems, it just means there’s no permanent structural change that that is causing their symptoms.

They do what’s called functional MRIs that mostly you only see in some of the literature and studies where they will do these functional MRIs of a collegiate football player during season, three months after the season wraps up, and follow that over time. They do studies where they have sensors inside the helmet and they video record all of the practices and they tabulate what type of forces did and didn’t result in somebody complaining of symptoms. You’re right. I mean, there’s still a ton of research ongoing and I wouldn’t be surprised 10 years from now if treatment would be much different than what it is now. It’s constantly evolving.

David Craig – Host:

Let’s talk a little bit about your clinical practice. Tell folks on a day-to-day basis, what do you do? Where do patients come from?

Dr. Edward Negovetich:

Sure. I practice in a rural area. One of the things I like about my practice is it is pretty diverse. I see a little bit of everything within my field and not just exclusively one thing which sometimes you get pigeonholed into if you’re part of a bigger group, particularly in the city, but anyhow, I see people who have weekend warrior injuries or comp injuries, people who have gotten to some type of car accident or recreational accident at home. I see people with more chronic conditions like diabetic neuropathy who have pain or numbness or weakness in their feet as a result of that. I see a great deal of degenerative conditions of the spine, of the hips, the knees, the shoulders. I see other nerve phenomenons. I mean, unfortunately, I’ve diagnosed ALS a couple times in my career, which isn’t fun. I do the nerve tests that I talked about and I do a variety of injections both in the office, joint injections, trigger injections, bursa injections, as well as some of those in the spine that require fluoroscopic, which is like x-ray guidance to deliver the medicine in the intended location.

David Craig – Host:

Where do your patients typically come from? I mean, are they referrals or are they… I mean, I go to a family doctor, but you’re not like that.

Dr. Edward Negovetich:

No, you’re right. And part of this is just the society we live in and insurance and a whole boatload of stuff. Most of my patients are referred usually by primary care or by orthopedics or by neurosurgery. Those are probably my largest referral sources. Obviously, work comp comes more from the case manager in that condition or in that situation. That’s where most of my patients come from. I do allow self-referrals, particularly if they have insurance. One of the issues sometimes in my field is a lot of docs in my field refer themselves as pain docs, and I really try to avoid that moniker. I try to avoid that label, just because of not so much now as it was maybe eight to 10 years ago, but frequently that just means, “Go here to get narcotics,” and while I do that, while I do chronic medication management for several folks, it’s not the emphasis of my practice.

So, really limiting the self-referrals is done primarily out of screening somebody so that that’s not all that person’s interested and that’s what they expect they’re going to get. If we have some notes from primary care or orthopedics, usually those will have references to whether they’ve been getting pain medicines or haven’t been getting pain medicines, if they’ve passed or failed drug tests and that sort of thing, but most of them are referred from those specialties.

David Craig – Host:

I know from my standpoint, I’ve been doing the same work for a long time, and I was just telling somebody that I was interviewing with me today that I have clients that come to me and I try to get them compensated, but I really want to make a difference in their lives. I want to improve the quality of their lives and it’s not just money. I have families who bring their kids, their adult kids to me. I have one in particular who had a severe brain injury that comes in just to meet me periodically just to talk to me and to get a hug, literally just to get a hug. His family says if they don’t do that, he really deteriorates because he looks at me as a father figure. That makes me just as happy as if I go get a certain amount of money for somebody, because I do this because I want to make a difference in their lives. I would assume that as far as your clinical practice, why are you doing what you’re doing? Why do you like it?

Dr. Edward Negovetich:

I do like it and I think that probably the most rewarding scenario that I see is when somebody who has been told by the orthopedic surgeon, “I can’t fix you, you don’t have surgery,” and the primary care doc doesn’t really know what to do with them, and we have value and say, “Hey listen, I think if we do this, this and this, I think life might be better than what it is now.” You’re absolutely right. Like I said before, even if I haven’t cured them, if I have improved their quality of life by 20% to 30%, somebody who’s pretty miserable to begin with, that’s substantial. They’re very thankful, and so, in my practice, that’s the thing that I find the most rewarding. When somebody’s been around the block to a couple different people, nothing’s really done, nothing’s really helped, and I do my thorough interview and exam of them and I review their pictures.

I say, “You know what? I think maybe this might be causing you a problem,” or, “I think this has contributing more than this has been given credit to,” and when they get somewhat better, I think that’s the most rewarding thing. That’s, I think, what I enjoy the most about my job.

David Craig – Host:

Well, I know, because I’ve certainly had clients that who happen to be patients of yours and I know that they really appreciate the fact that you work on trying to get them better, and you try to improve their quality of their life, and they speak very highly of you, and I appreciate that.

Dr. Edward Negovetich:

I appreciate that as well.

David Craig – Host:

Then, all of a sudden, you decide to do forensic work, and for the listener, forensic work means that they have looked at cases from a legal standpoint. A lot of people don’t understand, but when someone’s injured in a wreck, they can’t just go into a courtroom and say, “I tore my rotator cuff and I had to have these surgeries and I had all these bills, and it’s all related to the car crash.” That is not admissible because they’re not doctors, they are not qualified to say whether something was caused by a trauma, a car crash or not. The law requires us to prove that it’s more likely than not, more probably true than not true, that an injury was caused by the trauma, the car crash or whatever the trauma happens to be. So, we have to rely upon doctors to testify and to give us opinions and to make and help us, guide us through the process that this is related, this is not related.

We, as the plaintiff, the person who is injured’s attorney, we have the burden proof. We have to put a doctor on, and the insurance companies, the defense lawyers, they can put a doctor on if they want to, but they don’t have to. We obviously put on more doctors than the defense does because they don’t have to, and so, forensic work is evaluating this, determining whether or not an injury was caused by trauma or not in long-term effects and what are the symptoms. You have to work with lawyers to do that and I know most doctors don’t want to work with us. Why did you decide to do forensic work?

Dr. Edward Negovetich:

Part of it was because you’re right, there’s a demand for this type of thing and a lot of docs are really hesitant to it. The nature of the types of people that I see, before I was even doing any forensic work, as a treating doctor, I’d frequently get a letter from someone’s attorney that says, “Hey, so-and-so was injured on such and such date. We know you treated them from here to there. Can you draft a narrative explanation of what their injury was, any treatment that might have been related to these injuries, and if you think anything else is going to need to be done,” and this is as a treating physician.

I was doing a fair number of those and didn’t really know what an independent medical exam was at that time and came across it mentioned on some blog or something that I read. I was at a medical conference where I ran into another physician who was doing many of the IMEs that I knew and started picking his brain, talking to him about how you do it and do you like it and what are the pros and cons?

He said he had some overflow work if I wanted to dip my toes in the water and see what it was like, I was welcome to join him. I think initially I went up to his place. I think it was one Friday a month for a while, observed and talked about the cases, wasn’t drafting any of my own reports or anything, wasn’t signing off on anything, but got more of a feel for what all went into it and liked it and thought it was interesting. I’ve always enjoyed puzzles and part of actually what drew me to medicine in general was the diagnosis, figuring out what the problem is, and so, this work really appealed to me. You see it as a treating doctor, you see it on both ends where you think people are really milking it and they want you to fill out this paperwork and you don’t fill it out favorably for them because you know they’re milking it.

Then on the same time, you have treating patients who have you say applied for social security disability and got denied. And I’m thinking, “Why on earth did they deny this? If there’s anybody who is more legitimate, show me the person.” Anyway, I also enjoyed, in the forensic realm, being able to sort through the BS and, at least to the best of my ability, to the best you can and saying, “Hey, listen, this is related. This, sorry, isn’t part of it and it’s not fair for insurance staff to pay for this if it’s not related.” By the same token, if it is something that they should be paying for because they’re at fault, I think stating such is helpful.

David Craig – Host:

I think sometimes people think that, again, that just because you’re hired by a lawyer that you’re a hired gun. That means just because a lawyer hires you or picks you that you’re going to give testimony or opinions that are favorable to that side. Is that true?

Dr. Edward Negovetich:

No, and in fact, that physician that mentored me in this direction, that was one of the things he told me very, very early on. It doesn’t matter, we’re reimbursed for our time. We’re not reimbursed for our opinion. If you take a bunch of time and say I spend four hours reviewing some records and an hour interviewing somebody and then sit down and think about it, and I call you or somebody else and say, “Hey listen, I know so-and-so thinks this, this and this, but I have real problems saying because when I reviewed this record I see that this was worked on or this was done. I don’t think this is a very good case.”

From my perspective, the feedback I get is that most attorneys appreciate that because you don’t want to chase a losing case. You don’t want to chase something, spend a bunch of time in prep and depos and time and money on those things and trial if you really don’t have a very strong conviction that your client’s injuries are causally related and need to be compensated. I think that that’s helpful. I mean, I’ve done many, numerous IMEs and even recently life care plans where I was initially evaluated the records and examined and then came back and had a conversation with the attorney and said, “Listen, I don’t think that this is exactly what you thought it was going to be,” and they said, “Okay, thanks.” That’s it. Sometimes people want it in print, I think to share with their client. Sometimes, people don’t want anything in print and say, “Okay, just talk to you next time.”

David Craig – Host:

I think that’s important for people to understand is that I don’t care how good a lawyer you are, we’re not doctors. We’re not medical doctors. I don’t have a medical degree, and so we hire people like you, at least from our firm, for you to help guide us, to tell us. I mean, our client comes in, sometimes it’s purely coincidental. They have a wreck, and they had no problems before. Suddenly they have all these problems that continue to go and for six months later now they have some different problems, but they seem like in their mind they’re all related. A year from now, they’re still having issues but maybe there’s some new ones. They all think they’re all related because they didn’t have that before this car crash.

I, as a lawyer, we don’t know what it is, and the best way to lose a case is to overreach. The best way to lose a case is to claim something that’s not related. I mean, jurors are smart people. They’re average folks in each county where a wreck happens and they go in there and they’re not idiots, and they listen to the facts and they’re just like you and me. We sit there and you listen and you make a decision. If you’re lying or you’re stretching or you’re just trying to lump something in, then that’s a good way to lose a case. I don’t know any good lawyer who is honest and who actually takes these cases to trial who would ever ask somebody to say something that’s not true. That’s the best way to lose.

It’s also, in your business, if the doctor, there are doctors out there who will do that, who will give an opinion that is consistent with what the lawyer wants. The problem is that eventually they’re out of business because eventually it catches up with them. You can’t be dishonest and continue to do the same reports day in and day out, no matter what, without even seeing patients without even reviewing all the records and just cookie cuttering reports and expect that lawyers aren’t going to catch you at it. I know we’ve used you, we use other doctors, we use doctors from all over, and there’s been occasions where you’ve told us that, “Hey, look, this symptom is not caused by the trauma.” I mean, I appreciate that and I would rather know that on the front end, and I hope most lawyers are like that.

Dr. Edward Negovetich:

I think most of the work that is referred my direction, the attorneys are like-minded in that regard.

David Craig – Host:

I assume the forensic work is a small percentage of overall what you do. I mean, you’re a clinical doctor. You practice medicine day in and day out, so I would assume the forensic work is a smaller portion of what you do.

Dr. Edward Negovetich:

It is. From a time perspective, I’m in clinic or doing injections or basically in the realm of treating people clinical medicine every Monday through Thursday and every other Friday morning. I have that Friday afternoon and then the other Friday, I have a day and a half that I dedicate to doing this type of stuff every two weeks. Every now and then, I might work someone in at the end of a clinic day if there’s a time crunch that somebody needs a report by, but yes, the vast majority of the time I spend in the medical realm is in clinical medicine, treating people, diagnosing people rather than in the forensic realm.

I think that, in all honesty, even though I really enjoy the forensic stuff, I couldn’t imagine ever transitioning to not doing clinical medicine because I think doing that you stay abreast of treatment options. I think you’re more in tune with what people are doing now, even to treat other conditions. I’m far enough removed now from training, unfortunately, that I’ll see people’s medicine list when I’m treating, I’m like, “Hey, what’s this medicine for?” They’re like, “Oh, that’s a new diabetic medicine.” “Oh, okay, all right, great.” Anyway, I appreciate doing the clinical medicine. I think it keeps me on my toes doing the forensic stuff and in all honesty, vice versa, I think doing the forensic stuff has made me a better clinician as well because you’ll read other people’s IMEs, defense IMEs, you’ll read other people’s PPI ratings and things of that nature, and even their evaluation management of some people. Sometimes I’ll be like, “Oh yeah, that medicine, they’re using it off label for this. I might try. That sounds reasonable.” So, I think that even doing the forensic stuff has enhanced my clinical practice as well.

David Craig – Host:

I think one last point with forensics is that all doctors don’t want to testify. I mean, doctors go to medical school not to be hassled by lawyers, not to have to testify, and not to have to do reports. I mean, there are some who like the forensic part like yourself, but the majority of doctors, that’s not why they became doctors. So, they really dislike working with the lawyers and doing reports, and when you ask them to do a deposition, that’s even harder to get them to do. Then, if you want them to actually testify at trial, that’s nearly impossible for a lot of practicing doctors.

Dr. Edward Negovetich:

Yeah, it is tough. First of all, there’s the logistics of whenever you go to be deposed or you go to trial, particularly if the trial is at a destination somewhere you got to travel to, then you’re losing clinic time. I mean, you’re losing your billable income, you got patients that are going to have to wait, they can’t get in sooner. There’s that inconvenience. Then, you’re absolutely right. I think this isn’t something at all that you’re exposed to, certainly during medical school and I wasn’t exposed to at all during my residency. I’m not aware of anybody else, any other fields where they would’ve been exposed to it, to really have a good idea of what it is. There’s always that throughout your entire medical training, there’s always that what we call CYA, cover your hiney, where you’re documenting things just to make sure that you’ve got it in print so that somebody can’t come back to you down the road and see you for this, that or the other thing.

There is almost sort of a fostered distrust, I think, of the legal profession throughout medical training. I think the other problem is we’re trained in medicine, we’re trained to diagnose and treat patients. We’re not familiar with all of the different rules and processes involved with discovery depo, versus trial depo, versus actual trial and what’s admissible, what’s not admissible. That’s nothing that we’re given any training on. It’s you learn on the fly and some docs have no desire to, I think even there’s a control issue. I mean, as a doctor, you’re calling the shots, “Hey, this is what we got, this is what we’re doing, this is how we’re doing it,” but then you step into this realm, you’re in somebody else’s visitor, on somebody else’s home court, from being in a conference room doing a depo to being with a trial, being in the courtroom. You’re a fish out of water.

I think there’s a lot of docs that they’re comfortable enough doing the stuff that they do that they have no desire to branch out, coupled with this fostered distrust of the legal process that is I think present in formal medical training, and if you can get by some of those things. I mean, to a degree, some of it I enjoy doing it and some of it I would even characterize as being fun. I don’t know what that says about me.

David Craig – Host:

Well, and I think that’s important. Like they say, one of the greatest fears in life is speaking public speaking. Just so you become a doctor, you’re a lot more one-on-one. It’s a whole different setting in a courtroom where you’re testifying in front of six people, an audience, a judge, the lawyers. You can be a great doctor but not be somebody who has any desire to get in front of people and talk. My dad was a psychologist, so oftentimes he would get, when he was still alive, he was a great psychologist, he helped a lot of people. At the same time, he really disliked being involved in having to be deposed and show up at a courtroom where he had to talk in front of a bunch of people, where he has a son who likes to talk in front of people. Completely different skillset.

One other thing that you do is life care plans or a physician life care plans to help because again, when you walk into a courtroom, you have one shot and you don’t get to go back and say, “My client didn’t get better, or my client needs future care.” So, you have to do that all at the trial and then you have to get enough money to compensate your client so that they’re taken care of for the rest of their lives. So, one of the things that has to be determined is does somebody need future medical care? If so, what is the cost involved with that? Talk a little bit about that role you play.

Dr. Edward Negovetich:

Sure. When you do in forensic medicine, when you do say an independent medical exam, frequently you’re making a case in your report to explain causation. “These injuries are caused by this, and this is the reasons I feel blah, blah, blah, blah, blah.” With a life care plan, the main purpose is to get that dollar amount. You identify what are the conditions that resulted from said injury, what treatment will they need, what duration, what frequency, at what time in their life? You project their future medical needs and as causally related to their injuries, and then assign that a dollar value based upon current day prices.

David Craig – Host:

Because not everybody who does, if we ask a doctor to do that, not every doctor is qualified or capable of doing that. How is it do you go about determining future medical expenses for somebody’s lifetime?

Dr. Edward Negovetich:

Sure. I became certified. I’m a certified life care planner. There are certifications. I actually don’t think you have to have a certification to do life care planning. I think one of the reasons that a lot of physicians got into this realm is that historically very few physicians were life care planners. That field was dominated by social workers and sometimes therapists and vocational rehab personnel. In that scenario, those individuals have neither the legal or professional capacity to recommend treatment. Their entire life care plan is dependent upon what treating physicians tell them that person is going to need indefinitely, and exactly, to your point earlier, treating docs don’t want to talk to a life care planner and say, “Hey, yeah, I need this, this, and this and this,” and in our documentation day-to-day when I see somebody in clinic and follow up, it’s not part of my regular documentation to say, “Hey, Susie’s going to need X, Y, and Z for the rest of her life.”

It’s difficult to even extrapolate that from the medical records and then even extrapolate that from a conversation with a treatment provider because most of the time you’re not going to get phone time or face time with a treating provider to talk about the case, and I get that. Anyway, part of the shift in idea of doing life care planning and having physicians do it is if things aren’t specified specifically in the records or in a treating doc’s depo or wherever else, you have the education and training and certification to recommend treatment, you have the legal capacity because you’re a licensed physician practicing stuff. Your opinions as far as future medical recommendations are every bit as valid as, say, a treating physician’s recommendations particularly if you’ve examined the patient and done a face-to-face. Anyway, that’s a, I think, particular benefit, and most physicians probably don’t even know what the field of life care planning is to be honest with you.

I didn’t know until, I don’t know, I think it was 2016 and I was, again, I was at a conference and they had a table and I was already doing some IMEs by then. I started talking to them, “What is life care planning,” and they said, “Do you do IMEs,” and I said, “Yeah.” They said, “Well, it’s along the same lines.” They explained it, and so, I started dabbling a little bit and then pursued certification and began doing those. It’s very, very specific. You have to put, like I said, specific frequencies. They will need this medicine, 30 of them a month indefinitely for the rest of their lifetime, or stopping at age 65. Then, you cost source everything that you believe is a future medical recommendation.

Sometimes, you’ll physically call pharmacies in that individual’s geographic region to find out what the cost of this is going to be. You usually get three and average them together. There’s a database where they collect actual billing statements from insurance companies and break it all down into geographic regions and different percentiles. The commonly used numbers, the UCR 80, usual customary and reasonable rate, that 80 in, the 80 means, 80% the cost of this item, whatever it is, 80% of the people or of the facilities in this geographic region are at this dollar amount or lower. It’s a standard to use the UCR 80 eliminate some of the outliers who charge drastically more. I think that database has been around since the nineties. They have an enormous volume of data through actual billing claims to produce their data. You would look up the corresponding code for whatever medical procedure or evaluation of management services, and you can get that UCR 80 data if you subscribe to the database.

David Craig – Host:

Doctor, I appreciate you taking the time to be with us. Is there anything else you think that the average person who’s been in, them or a loved one, been in a catastrophic wreck has suffered injuries, anything they else should know about physical medicine, rehabilitation practice, the forensic work, anything else that you think that we should talk about?

Dr. Edward Negovetich:

Well, from a physiatry standpoint, I mean I joke in my local community where I’m at, because we talked before about referral sources. Frequently, somebody goes into their family doc and they said, “My hip hurts.” They knee jerk, send them to ortho. Ortho takes a hip x-ray, “You don’t need a replacement. Sorry.” Then, they come to my way and I ask, what are you here for? “My hip hurts,” and I say to them, “Can you point to me, where are you hurt,” and they point to their butt and they say, “My hip.” I say, “Okay, that’s probably not your hip. That’s probably something more spinal related, so let’s investigate that.” Then, we talk more and everything else. I feel like I should be the gatekeeper initially for all musculoskeletal care.

Unless obviously there’s a fracture, there’s some gross neurologic impairment, somebody can’t move their leg or they can’t hold their bowels or bladder together, I think we should be first line in clinical medicine. Even in the forensic realm, I think that helps because as I alluded to before, typically our documentation might be a little bit more thorough which I think is pretty important in the early stages following a wreck or another personal injury, is that the earlier you have documentation outlining the issues that are being discussed and what the treatment is, I think that only benefits that injured party because you can say, “Hey, look, two weeks after the wreck, they were still complaining of X, Y, and Z.” Whereas sometimes, and this happens unfortunately, and I get it, especially younger people, they’re relatively invincible and they’ve never had a pain that’s lasted more than a few days or maybe a week or two in their life.

It’s not uncommon for somebody to just avoid getting healthcare for six months because they think, sooner or later it’s going to go away. I don’t want to pay for it. I don’t want to take medicines. I can still do my job, whatever it is. Then, it’s really hard when the first amount of the first detailed treatment is six months after a wreck. Boy, it’s tough. I mean it’s tough then to say sort out, “Hey, this is or this isn’t.” I think more timely evaluation if there are problems is helpful. I think the nature of a physiatry evaluation is even more helpful.

David Craig – Host:

I would encourage people, if you’re injured or someone, a loved one’s injured and they’re not getting better, I think people are afraid to go get a second opinion. I think a physiatrist is a perfect person to go get a second opinion. If you’re not getting better with an orthopedic surgeon or you’re not getting the answers, or they’re not spending the time with you, which you alluded to earlier, a lot of times the way they work is they’re just not set up to spend time with people. Family practitioners are awesome, but they’re not geared at necessarily fixing your problem.

So, I think just for those people out there, if you’re having issues, ongoing pain symptoms, your life is altered. Again, if you’re not able to do the things you used to do, just ask your family doctor to get you a referral to a physiatrist, because a physiatrist can then spend the time with you and help you figure out where should you go, what should you do.  Most of the time you’re talking conservative treatment where you’re not talking about operating, and that’s what people, they don’t want to be operated on unless they have to be.

Dr. Edward Negovetich:

Right. I completely agree.

David Craig – Host:

Well, again, I appreciate you being on the podcast. This is After The Crash, and we’ve been visiting today with Dr. Edward Negovetich. Thank you.

Dr. Edward Negovetich:

Thanks a lot.

David Craig – Host:

This is David Craig, and you’ve been listening to After The Crash. If you’d like more information about me or my law firm, please go to our website, ckflaw.com, or if you’d like to talk to me, you can call 1-800-ASK-DAVID if you would like a guide on what to do after a truck wreck, then pick up my book, Semitruck Wreck, A Guide for Victims and Their Families, which is available on Amazon, or you can download it for free on our website, ckflaw.com.