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CMLE EXAM REGULATIONS
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Contents

  1. Introduction
  2. Implementation
  3. Examinations
  4. Eligibility
  5. Application Procedure
  6. Referrals and Guidance
  7. Representation and Appeals
  8. Infringements

Appendix 1: Structure of the Examination

Appendix 2: Curriculum

INTRODUCTION

This document provides information regarding training, curricula and exam regulations for the discipline of a clinical expert in Canada. These regulations govern the content and conduct of the examination leading to the award of the CSME-CAPDA Certification in Medicolegal Expertise (CMLE)and accreditation as a clinical independent expert assessor in Canada. They specify the requirements which must be satisfied before a candidate is eligible to apply to take the examination. They also specify the procedure to be followed in order to apply, limit the number of attempts and provide guidance in the event of failure. They describe the procedure for making representations and provide sanctions for infringements.

CSME is a leading national organization of professionals involved in independent medicolegal and clinicolegal evaluations. The mandate of CSME’s Board is to promote and support evidence-based medicine and best clinical practices by way of various educational and credentialing initiatives and programs. In addition, CSME provides a forum for the sharing of knowledge, experience and innovation amongst Canadian clinician evaluators. CSME currently has over 230 active clinician members. Over the past two years CSME has hosted over 700 participants at our conferences, with attendees from the clinical, legal and industry settings. Our Board consists of a broad cross-functional representation of key stakeholder groups from the fields of general and sub-specialty medicine, surgery, psychology, neuropsychology, chiropractic, physiotherapy, occupational therapy and both plaintiff and defence legal practitioners.

CAPDA is a national organization of over 100 senior psychologists who practice in the areas of psychological or neuropsychological assessment of disability and impairment. All members are bound by comprehensive standards which guide their practice and outline their obligations to the individual assessed and to the referral source. It is the mission of CAPDA to share information, develop standards of practice and conduct, educate, and advocate on matters related to third party requested assessments and other assessments and on matters of rehabilitation and disability. CAPDA holds several training workshops each year for psychologists and for other stakeholders interested in third party psychological and neuropsychological assessments CAPDA maintains ongoing liaison with other health professionals, with the insurance and legal communities, and with regulatory and government bodies. CAPDA has also been involved in the development of various guidelines for best practices in third party psychological disability assessment.

Definition of a Medicolegal Expert

The discipline of medicolegal expertise requires that a health care professional (e.g. physician, psychologist, chiropractor etc.) has strong clinical competency grounded in evidence-based research and practise with translational application skills in a particular domain of expertise. The objective is to provide evidence that is fair, objective and non-partisan, related only to matters that are within their area of expertise. The professionals must also be well informed about other disciplines and their relationship and effect on the assessment process and their findings. The professionals must acknowledge that they will be required to provide such additional assistance to a court of law (or arbitration panel) as the court may reasonably require. The clinician independent expert must remain mindful that their duty to the court is paramount and this duty prevails over any obligation which they may owe to any party or on whose behalf they are engaged.

An independent medical evaluation (IME) is the foundation that enables a medical expert to provide a considered opinion. An IME is defined as an examination performed by an independent health care professional who has no treating relationship with the examinee or requesting party, for the purpose of providing the requesting party with a non-partisan impartial clinical opinion about the examinee. The clinical opinion is communicated by means of a medicolegal report. An IME may also be identified as an Independent Medicolegal Evaluation, Independent Medical Opinion, Independent (Discipline) Examination, Impartial Medical Examination, a Non-Treating Medical Examination, an Insurer’s Examination or a Third Party Examination. This is true regardless of the discipline, be it a physician, psychologist, speech language pathologist etc.

The independent expert is required to evaluate by means of an independent medical examination (IME)any of the following: 1) the health status of a person, 2) documentation pertaining to health status, 3) assessments of a person by other health care professionals pertaining to a medical situation, injury or illness, and with this information is able to provide an opinion regarding health that will assist key stakeholders and potentially a trier of fact in reaching a decision.

Independent medicolegal reports are essential to the legal process of resolving claims for compensation after personal injury, eligibility for treatment/disability benefits or other issues of compensation related to clinical outcomes (e.g. alleged malpractice scenarios). A comprehensive, objective and informative written medicolegal report that is clear and concise will contribute significantly to the proper and just resolution of a claim for personal injuries. An evidence-based comprehensive assessment and subsequent well written report can expedite the process, reduce costs, and it may preclude the need for the expert assessor to appear in court.

The IME should be seen as a tool to assist in dispute resolution when there is an element of a clinical nature. The dispute may be narrow and specific, involving questions of diagnosis, treatment, attribution/causation, apportionment, negligence, prognosis, or damages. The dispute may also be wide-ranging, involving long-range care costs or querying fraud as required.

Purpose of Certification Assessment

The purpose of the Certification in Medicolegal Expertise (CMLE) is to harmonize and improve quality standards for competent, independent practice as a medical expert in various domains of practice in Canada. The Certification Program assesses the minimal competencies necessary to practice as a medical legal expert across a wide range of clinical scenarios pertinent to pediatric, adult and geriatric patient populations.  The Certification Program is intended to be complementary to national standards of competence within a specific health care specialty, and enhance the competent, ethical, and professional practice as a medicolegal expert. The CMLE is not intended to replace any existing College or Board regulatory functions, but rather to augment those processes. The vision for the CMLE is to be recognized as the standard of quality for medicolegal experts in Canada and beyond.

The purpose of the Certification assessment is to evaluate the competence of a wide range of health care professionals in respect of relevant knowledge and judgement in the area of medicolegal evaluation. As part of this, several aspects of competencies need to be covered, including that of evidence-based knowledge and skills pertaining to a wide range of clinical scenarios, the application of core medicolegal reasoning principles and the ability to summarize this information in a constructive and clear manner for use by clinical and non-clinical professionals alike.  In order to comprehensively evaluate this wide range of skills in an objective manner, multiple choice questions (MCQs) will be utilized as a minimum in the assessment of expertise.

The CMLE credentialing taskforce is comprised of members from CSME and CAPDA as well as consultants from other leading educational and regulatory organizations within Canada and abroad. The Exam Regulations are reviewed on an annual basis at a minimum and as required with evolving legislation changes and industry evolution.

IMPLEMENTATION

2.1.   These regulations come into effect on the 1stof January 2018, and will be valid for 3 years unless the CSME-CAPDA Board of Directors (a subcommittee of which will form the CMLE Board of Examiners) agrees a necessary change.

EXAMINATION

3.1.   The CMLE Examination will be completed in one sitting.

3.2.   Normally there will be two sittings of the examination in each calendar year. However, the Faculty may at any time decide, subject to adequate notice, to adjust the number of sittings of the examination in any year.

3.3.   Training and Examination fees: All applicable fees must be paid when the applicant submits their request to attend the training program and/or write the examination. The following fee structure will apply for all CMLE programs offered in 2018, exclusive of applicable taxes:

3.4.   Additional training modules and specific certification will be offered based on regional/industry-specific requirements and relevant case law. At this time, the following modules will be introduced:

i.   Ontario (ON) – including SABS, Tort Principles and WSIB legislation

ii.  Quebec (QC) – includes CSST, Tort principles and an overview of the auto insurance framework, and Retraite Quebec disability and pension plan

iii. British Columbia – includes Part 7 auto benefits, the general Tort system and the worker’s compensation framework

3.5.   At any time, based on legislative changes or demand from membership, the CMLE Board of Examiners may opt to introduce additional modules as required with 90 days’ notice to its membership and prior certificates.

ELIGIBILITY

4.1.   An individual is eligible to qualify to write the CMLE examination provided all of the following criteria are met:

i.    Qualification and current registration: The candidate must provide documentation of having completed an official accredited training program within their area of clinical expertise and documentation of applicable registration status at their respective governing College. The candidate must also demonstrate that they are currently in good standing with their respective college and hold autonomy to practice with no limitations at the time of examination.

ii.    CMLE Training: In order to qualify for the CMLE examination, the candidate must have completed the CMLE IME Foundations Training program – Parts I and II (8 hours per course for a total of 16 hours) in the prior 12 months at the time of application. No substitutions for this training will be accommodated in any circumstance.

iii.    IME Report Review: As a key component of completing their CMLE certification, the candidate must demonstrate competency in IME assessments and reporting. The reports will be reviewed by the Examination Committee through a blind peer review process, and scored together as pass or fail. Both reports must receive a passing grade in order to qualify for certification. In addition, the candidate will be required to complete a self-evaluation on the reports pertaining to quality factors, an analysis of elements of bias and medicolegal principles applied.

There are two options to satisfy this criteria: 

a.    The candidate provides 2 full IME reports (without patient identifying information) of their own writing to the Examination Office for review at least 45 days prior to the date of the intended written examination.

b.     If the candidate does not have prior IME reports for submission, the candidate will have up to 6 months from the examination date to submit their reports for review. Credentialing will not be granted until after the review of these reports and a passing grade achieved.

4.2.   The number of examination attempts by candidate will be limited to three times within a three year period.

MAINTENANCE OF CERTIFICATION

5.1.   The successful CMLE candidate will be required to provide the Examination Office with evidence of completion of continuing education in the field of independent medicolegal evaluations annually by the 31st December of each calendar year. This includes:

i.      Completion of a minimum of 15 hours per calendar year of continuing education directly relating to or relevant to the field of independent evaluations and disability management. This might include conference and/or webinar participation, research publication, or formal course work. Any other proposed educational activities will require review by the credentialing committee on special request and with full documentation.

ii.    All related clinical and legal topics are eligible. Any questions regarding eligibility should be forwarded to the CMLE Examination Office in advance of completion of the session/course.

APPLICATION PROCEDURES

6.1.   Dates of Examinations shall be published in the Examinations Calendar of CSME and CAPDA

6.2.   Application forms for admission to the Examination will be available online through the CMLE Examinations Office. Applications must reach the Examinations Office before the published closing date for the relevant sitting.

6.3.   An application must be accompanied by the appropriate fee, 2 full IME reports and proof of registration, training and current practice as per Section 4 above. Only electronic file attachments will be accepted via the secure online CMLE portal.

NOTE: Individuals with diverse learning styles and needs are welcome to participate in the credentialing program.  In particular, if you have a disability/health consideration that may require accommodations, please feel free to approach the CMLE Examination Office at 416 640 1211 prior to the examination to assess specific needs, provide referrals and arrange appropriate accommodations.

6.4.   Requests for examination deferrals to a future examination date will be entertained up until two (2) weeks prior to the exam date without penalty. After that time, formal documentation detailing the exceptional circumstances will be required to be submitted to the CMLE Examination Office for review and approval.

6.5.   All approved deferral requests received later than 2 weeks prior to the examination date will be subject to a $100.00 administration fee.

6.6.   All unsuccessful deferral requests received as well as no-shows will be subject to the full cost of the examination without refund.

EXAMINATION REPORTING, ARCHIVING & APPEALS

7.1.   Results from each CMLE examination will be reported to participants within 4-6 weeks following the date of the examination by formal letter and via secured portal access. A grade of “pass” or “fail” will be indicated for each module of the examination as well as an overall score. Please refer to section 4.1(iii) above regarding the process and procedures surrounding the additional IME Report Review requirement.

7.2.   A candidate, or a duly authorized person on behalf of that candidate, wishing to make representations in respect of the conduct of an examination or to appeal against any result, must make such representation or appeal to the CMLE Board of Examiners in writing, within 30 days of the impugned results being published. The Examination Committee will consider representations and appeals. The appellate decision by the examination committee shall be final and it not subject to any further appeals or reconsiderations.

7.3.   A candidate who is unsuccessful in an examination may, subject to the provisions of the regulations below, enter for the next or any subsequent sitting of that Examination. A candidate may not sit for the examination on more than three (3) occasions in a three-year period.

7.4.   The CMLE Board of Examiners will document clearly all aspects of the (practical) organisation of the CMLE examinations, and keep archives of these documents (electronically wherever practical) for a period of at least five years.

7.5.   A permanent electronic and properly secured database of the successful candidates will be maintained by the CMLE office. The minimum information to be included within this database comprises full name, province, clinical specialty and area of practice as well as date of successful Certification completion. On successful completion of the Certification program, the examinee will have the opportunity to make part or all of this information available to industry stakeholders and colleagues via a secured portal should they so choose.

INFRINGEMENTS

8.1.   For reasons of privacy as well as protection of copyright, unauthorized video or audio recording in Foundation Training Programs is prohibited.

8.2.   Candidates are not permitted to bring any materials or information, which may assist them including electronic devices, computers and mobile telephones into the examinations. Failure to comply with these examination regulations may result in disqualification from the whole of that examination sitting.

8.3.   Academic integrity is essential to the pursuit of learning and scholarship, and to ensuring that credentialing from the CMLE Board is a strong signal of each individual academic achievement. As a result, the CMLE Board treats cases of cheating and plagiarism very seriously. The CMLE Board of Examiners will investigate all suspected cases of academic dishonesty. If you have questions or concerns about what constitutes appropriate academic behaviour, you are expected to seek out additional information on academic integrity from various institutional resources (see http://www.utoronto.ca/academicintegrity/ as reference).

8.4.   The Faculty may refuse to admit to an examination or proceed with the examination of any candidate who infringes any of the regulations, or who is considered by the presiding examiner to be guilty of behaviour which prejudices the proper conduct and management for the examination or who has previously been found guilty of such behaviour. If, in the opinion of the Faculty, any examination result has been secured by cheating, deception or fraud of any kind whatsoever, the Faculty may nullify the result of any qualification resulting from it and withdraw the Certification so obtained

APPENDIX 1

Certification in Medicolegal Expertise (CMLE)

Examination Structure

Assessment Venue

For the organisation of examinations, a suitable venue is essential. Special attention will be paid to the security issues of the venue, not only in respect of standard precautions such as fire, but also in terms of security of the examination materials.

Assessment Structure and Duration

Multiple choice questions (MCQ) related to all concepts related to the IME process will constitute the examination: including the referral process and mandate, informed consent and regulatory framework, conduct of IME, data analysis, opinion formulation and causal analysis, report writing and testifying in the legal context.

  1. The examination will be comprised of up to 100MCQ’s, many of which relate to a clinical case stem, and up to 20 MCQ’s relating to the specific legislative provincial module (if applicable).
  2. There will be no negative marking for candidates who choose the wrong answer.
  3. Candidates will be allowed 3 hours to complete the entire examination.

The examination questions will be set to reflect a broad curriculum and will be weighted to represent the importance of an area of the curriculum as viewed by the examination faculty.

The following statistical parameters are traditionally calculated when performing the primary statistical validity analysis of questions:

  1. level of difficulty of the questions;
  2. degree of discriminative power of the questions;
  3. general reliability (internal consistency) of the assessment.

At this time, three versions of the examination and Certification will be offered to accommodate for different regional expectations for the successful candidate:

  1. Ontario (ON) – including SABS, Tort Principles and WSIB legislation
  2. Quebec (QC) – includes CSST, Tort principles and an overview of the auto insurance framework, and Retraite Quebec disability and pension plan
  3. British Columbia (BC) – includes Part 7 auto benefits, the general Tort system and the worker’s compensation framework

Examination Results

Results from each CMLE examination will be reported to participants within 4-6 weeks following the date of the examination by formal letter and via secured portal access.

A grade of “pass” or “fail” will be determined in connection with mastery grading for each module of the examination as well as an overall score. The grading rubric will follow a percentage grading based on percent correct on the exam coupled with norm referenced, mastery and absolute standards grading whereby pass or fail percentages will be mediated by comparison to others and whether performance reaches a level of performance with reference to pre-established content standards (i.e., CMLE IME Foundations Training program – Parts I and II).

APPENDIX 2

Curriculum Guideline for the Certification in
Medicolegal Expertise (CMLE
)

 

1.     The Expert and The Independent Medical Examination

IME Process Overview

  •  Conflicts of interest
  • Core assessment components and processes
  • Interview
  • Examination
  • Psychometric and functional testing
  • File material review
  • Informed consent
  • Risk assessment
  • Administrative forms and documentation
  • Special needs &accommodation
  • Records management and privacy 

Duties of experts

  •  Restriction on expert evidence
  •  Form of expert evidence
  •  Classification and criteria for expert evidence (e.g., Daubert, Frye, Mohan standards)
  •  Third party assessment vs therapeutic role vs dual role (includes navigating scenarios with conflicting responsibilities)

Structure and function of expert assessments and reports

  • Report structure:
    • Overview of key assessment and report components based on scenario/specialty, including paper/file reviews and in-person assessments
    • Written questions to experts and format for response utilizing principles of neutrality
    •  Documenting rationale and reasoning underlying the expert’s opinion
    •  Rebuttals/Amendments to reports
    •  Joint expert assessment and reports
  • Proof
  • Civil standard of proof and its application
  •  Decision-making in civil litigation
  •  Applying “the balance of probabilities”
  •  Establishing proof
  •  Causation of Damage
  • Competing causes of injury
  •  Material contribution
  • The “Thin Skull” and “Crumbling Skull” Doctrines and Causation
  •  Use of percentages
  • "Acceleration”, “Aggravation” and “Exacerbation”
  •  Industrial disease claims and “Material contribution”
  •  “But for” test of causation
  • Prognosis and Future risk
  • Consequences of Injuries
  • Addressing consequential loss
  •  Consequences to assess
  •  Pain and suffering and loss of amenity
  •  Medical or therapeutic treatment
  •  Care, rehabilitation and accommodation
  •  Current/future employment
  •  Non-vocational loss
  •  Life expectancy
  •  Loss of Care, Guidance and Companionship (Family Law Reform Act)

Presenting and defending expert opinions

  •  Importance of a commitment to unbiased, fair and non-partisan principles
  •  Avoiding biases, interpretive errors and reasoning errors
  • Making science understandable to the trier of fact
  • Expert witness qualification and cross-examination preparation
  • Peer Review
  •  Tiers of standards of evidence based opinion as it relates to research (e.g., from quantitative meta analyses, to case studies)
  •  Industry and commercial implications of litigation and evident skills

Legal Context of Personal Injury Claims

  • Purpose of a civil claim for damages
  • Legal basis of a claim

o   Breach of duty

o   Injury, loss or damage

o   Causation

o   Contributory negligence

  • Adversarial litigation process
  • Proof / Law of evidence
  •  Damages: definition and assessment
  •  Types of claim for damages

o   Non-pecuniary loss

o   Pecuniary loss

o   Death

o   Possible future complications and provisional damages

  •  Valuation of the claim

3.     Biostatistics and Evidence Based Medicine

  • Data sources
  • Vital records, reportable diseases, surveys, registries, morbidity, census, national health surveys
  • Study design
  • Meta-Analysis, Experimental studies, Quasi-experimental studies, Observational studies
  • Measurements of morbidity and mortality
  • Rates, ratios and proportions, Life expectancy, Population pyramids, Measures of disability
  • Describing data
  • Frequencies and distributions, Measures of central tendency, Measures of variation, Probability, Standard scores, P-values
  • Epidemiologic associations and data interpretation
  • Causality, Bias (systematic error), Generalizability, Hypothesis testing, Meta-analysis

 

  • Approach to reviewing Evidence Based Medicine literature/analyses:
  • Rational conclusions drawn from different types of studies – including retrospective, prospective, case studies and randomized controlled trial (including double blinding), Understanding sources of bias, Understanding basic concepts in data analysis, Types of outcome measures/measurement – interval, ratio, etc., Appropriate use of parametric/non-parametric analyses and recognition of commonly used tests, Understanding of statistical expressions of results (e.g., relative risk, odds ratio, absolute risk reduction)

4. Clinical Competency

Focus on core principles for each functional area including:

 

  1. Definitions and core terminology
  2. Common workplace/traumatic injuries and outcomes
  3. Evidence-based investigations and treatment pathways
  4. Commonly encountered medicolegal implications, pitfalls and controversy

 Musculoskeletal (e.g., spinal, upper extremity, lower extremity disorders)

  • Strains, sprains and tears
  • Fractures, dislocations and contractures
  • Tendonopathies, bursitis
  • Arthritis – osteoarthritis and inflammatory arthropathies
  • Whiplash grading and outcomes
  • Spinal disc pathologies
  • Repetitive strain injuries
  • Various pathologies responsible for pain in different joint regions
  • Metabolic, autoimmune and infectious musculoskeletal disorders
  • Postoperative considerations and complications
  • Musculoskeletal pathology/injury unique to children
  • Appropriate investigations and imaging modalities for all of above
  • Physical, medical and surgical management

Neurological:

  • Traumatic Brain Injuries – including severity grading, outcomes, complications and moderating factors, and evidence based prognosis
  • Episodic/chronic tension-type headaches, cervicogenic headaches
  • Peripheral nerve dysfunction/injury – sciatica, carpal tunnel syndrome etc.
  • Spinal cord injuries
  •  Stroke/CVA patterns and rehabilitation/outcomes
  • MS, GBS etc. – diagnosis and outcomes/recovery
  • CRPS/RSD – classification, treatment and outcomes
  • Dementia (Pre-existing and Post-Facto)
  •  Vertigo

Mental Health:

  • Formal clinical disorders as per the DSM-5, with reference to their presentation, differential diagnosis, treatment pathways and functional impact on daily life activities and employment capabilities.
    •  PTSD, adjustment disorder, somatic symptom disorders, depression, anxiety disorders, bipolar disorder, ADHD, autism spectrum disorders and schizophrenia
    •  Personality disorders/traits: e.g., paranoid personality disorder, borderline personality disorder, narcissistic personality disorder, histrionic personality disorder, obsessive-compulsive personality disorder; and intellectual disabilities.
    • Mild and Major Neurocognitive Disorders
    • Somatic Symptom and Related Disorders
    • Trauma- and stressor-related disorders
    •  Substance-related and addictive disorders
  • Psychological and Neuropsychological Testing.
    •  Psychometrics; Reliability, Validity, Standardization, Normative comparison
    •  Indexes of Feigning: Performance Validity Test Measures, Symptom Validity Test Measures, Embedded Validity Test Measures Sympton
  • Feigning, Malingering, Conversion, Exaggeration (symptom magnification), Poor Effort

Multifactorial and Pain Management

  • Chronic Pain/Somatic Symptom disorder
  • Fibromyalgia
  • Substance abuse addictions/disorders
  • Chronic fatigue syndrome
  • Pain Management:
  •  Understanding of musculoskeletal, neurological, and psychological components of pain and chronic pain
  • Appreciation of broader concepts of chronic pain models (neuropathic, central sensitivity syndromes, Chronic pain syndrome etc.)
  • Clinical scales and assessment tools utilized for evaluating pain and chronic pain
  •  Pain management and risks of treatment/ addiction/ dependence
     

 Internal/Occupational Medicine:

  • Common and serious medical symptom/disease state presentations including co-morbidity implications:
  • Cardiopulmonary conditions and functional testing
  •  Diabetes Mellitus
  • Thyroid condition
  • Arthritis (inflammatory, rheumatoid, osteoarthritis etc.)
  • Multiple chemical sensitivities
  • Toxicology – exposures, prevention and best practices
  • Substance-related and addictive disorders, including best current best practices for screening and considerations for safety-sensitive occupations

Impairment and Disability Assessment

  • Definitions (activities of daily living, impairment, disability, restrictions, limitations) of general classification systems for injuries/illness and work abilities.
  •  Assessment tools for work/functional abilities and work option planning
  • Functional capacity evaluations and validity indicators
  •  Job site analysis/physical demands analysis
  •  Occupational therapy assessments
  •  Vocational evaluations
  •  Common assessment scoring tools and general principles (AMA Guides 4/5/6 etc.)

Ontario Legislative Module:

SABS

  • General framework and principles
  •  Medical/Rehabilitation benefits and processes
  •  Disability benefits (Pre/post-104, IRB, NEB, attendant Care etc.)
  •  General overview of Catastrophic criteria
  •  FSCO, the LAT and case law considerations

 Tor

  • General framework and principles
  • The threshold definition
  • Form 53 and other procedures
  • Current accepted tort principles and doctrine
  • Ontario case law and evolving trends

WSIB

  • General framework and principles
  • Key policy definitions
  • The WSIAT model and case precedent

 

Sample References:

Ontario Protocol For Traffic Injury Management Collaboration, “Enabling Recovery From Common Traffic Injuries: A Focus On The Injured Personhttps://www.fsco.gov.on.c/en/auto/Documents/2015-cti.pdf

The Joint OPA/CAPDA Guidelines for Best Practices in Psychological Insurer Examinations (2016)

3.                Independent Medical Examinations for Insurance and Legal Reports, 2nd Edition. Michel Lacerte & Pierre G. Forcier. 2003. LexisNexis Canada

4.                AMA Guides to the Evaluation of Permanent Impairment – 4th Edition

5.                AMA Guides to the Evaluation of Permanent Impairment – 5th Edition

6.                AMA Guides to the Evaluation of Permanent Impairment – 6th Edition

 

Note: Additional references will be circulated to participants closer to the training and examination

 

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