Host: We have a special treat today. We have Dr. Bash. He’s going to be on here in a minute. He’s taking care of tying up some loose ends, but he will come in and talk about his Bash Bulletin. This bulletin will cover the importance of getting an independent medical opinion when you have your VA claim. He’ll tell us all about that good information, and we will discuss spinal cord injuries in the next part of the show. Just bear with us, and Dr. Bash will be here in just a couple of minutes. Dr. Bash, how are you doing today, buddy?

Dr. Bash: Well, I’m doing all right, John. I stayed out of the weather. I went to the doctor this morning and just made it home, and it started raining, so I’ve stayed indoors ever since.

Host: Oh, don’t want to go back out. I think Dr. Bash has finally made it back. Are you with us, Dr. Bash?

Dr. Bash: Yeah, I’m back. I’m back.

Host: Okay, okay. We’ve already started discussing the topic. We’re going to talk about your Bash Bulletin, the one that deals with the importance of getting independent medical opinions or examinations when doing your VA claim.

Importance of Independent Medical Opinions

Dr. Bash: Right, right. For the examination, yeah. Do you have a specific question?

Host: Basically, just an overview based on your bulletin itself. The importance of getting an evaluation, what to look for, and what type of evaluation a person needs, what type of doctors and things like that—just general information.

Dr. Bash: Yeah, those C&P examinations or DBQs are important because that’s how the VA provides the Nexus. The DBQ and the exam are basically the rating percentage, and the Nexus is the linkage. The VA can hurt you on both sides; they can downplay the exam and the Nexus. The best idea is to be prepared when you go in, and one way to be prepared is to get as much testing as you can. For example, if you have a spine injury that has worsened over the years, a repeat x-ray or MRI scan showing it got worse is good evidence that the VA has to consider instead of just relying on a physical exam that might be better on some days than others. This applies to kidney disease, hearing tests, and everything else. Try to get testing to document what’s going on.

I also talk about finding out who the examiner is. Sometimes they have nurse practitioners and PAs, and those guys often don’t have the depth of knowledge. I had a patient last week with all kinds of problems: weight loss, arrhythmias, and hair loss in service. Later, she ended up with thyroid disease. When you put it all together, she had thyroid disease back in service, and it was part of that hair loss problem. Nurse practitioners and PAs often can’t deal with all those complicated aspects of the medical part, so they just take a little piece of it. The VA might say, “Look at the person’s spine” or “Just look at their hair loss,” but it’s like the old story of the elephant: someone feels the trunk, someone feels the tail, and someone feels the side, but they don’t realize it’s an elephant when you put it all together.

The Puzzle of Medical Diagnosis

Medicine and diagnosis are like a puzzle. Make sure you have good lay letters done first. I always recommend getting an IME (Independent Medical Examination). Get yourself a Nexus letter before you go to the exam. At the exam, they won’t let you enter new evidence, so make sure you get that stuff uploaded a few days before. That way, the examiner has to read it and has a chance to look at it. If they don’t look at it or integrate it, that’s an automatic appealable thing because it’s an error not considering all the evidence.

Host: Dr. Bash mentioned the term IME, folks. That’s a very important term. You’ve got an IMO, which is an independent medical opinion, but an IME is an independent medical examination. The VA takes a little more weight to that examination versus an opinion. That’s a good point, Dr. Bash.

The Importance of IMEs

Dr. Bash: Yeah, the IME is a big deal. I had a guy the other day with five issues, and the VA only did one IME on a personal DBQ. I wrote my DBQs, and sometimes they take them, sometimes they don’t. But when I do a DBQ, it forces the VA to do DBQs on their side. They had to go back and examine him for the four or five leftover issues, and then we can compare notes. Those IMEs are important. The X-ray is kind of an IME, and lab tests are kind of an IME because all those data points match up to help the claim get rated.

Also, think about the worst-case scenario, which is really the idea of a flare-up. The VA has a lot of rules about flare-ups, and the examiner is supposed to talk to you about flare-ups. Many patients are stoic and don’t want to talk about them. They take pain meds before the exam. I tell them not to take their pain meds and to make sure they talk about the worst-case day with flare-ups. The examiner might give you leading questions like, “You feel great today?” or “You feel normal, right?” The patient might say, “Yeah, I feel great,” and the examiner writes down “normal,” even though the patient might have chronic pain.

Preparing for Your Exam

Make sure you take your crutches, wheelchair, cane, or braces to the exam. Often, if the exam only takes 10 or 15 minutes and they don’t see a crutch, cane, or wheelchair, they won’t mark it down. Use all those devices.

Host: We had a guy here who went to a C&P exam, got his cane out of his car, struggled into the VA, went through his exam, and then put his cane back in his trunk and walked off like nothing was wrong. They used that against him because they had him on video.

Dr. Bash: Yep, I always tell patients that the exam starts in the car and ends in the car. I’ve had examiners look at people through windows and stuff like that. Also, think about using a walker. For example, if you go to Walmart and lean on the shopping cart, that’s really a walker. Describe things in a way the examiner can understand.

Thoughts on DBQs

Host: What is your opinion on the DBQs now? Do you like the format, or do you think it could be improved?

Dr. Bash: They could always be improved. I’ve got them memorized now, so I don’t worry about the format as much, but they are a broad brush. There’s a lot of stuff in each DBQ that doesn’t apply to the specific rating. Some of it doesn’t even apply. For the knee, for example, the rating is based on range of motion and stability, and there are eight pages of questions that don’t match up with the rating schedule. The DBQs are confusing because the way we were taught to do exams and evaluations is in a different order and logic pathway. They are more legal documents than medical documents, making it hard to mesh them.

Host: Wouldn’t the DBQ be better if it had a place for you to write an opinion?

Dr. Bash: Yes, exactly. The DBQ usually has a tiny space for history and an even smaller space for comments or rationale. It’s almost a setup for failure because it doesn’t give the doctor a chance to explain themselves.

Host: When the C&P examiner writes an opinion, they often say it would be speculative.

Dr. Bash: The VA has its own special website for DBQs, and the forms the VA doctors use look different from the ones on the website. The VA forms have sections for rationale and opinion, making it easier for VA doctors to provide detailed explanations.

Importance of Accurate Diagnoses and Ratings

Many of the VA’s internal forms are more comprehensive. Veterans might get the wrong DBQ, or the wrong one might be filled out. The whole system is weighted in favor of the VA. Veterans with complicated diseases might see nurse practitioners and PAs who don’t have as much experience, making it harder to get accurate diagnoses and ratings.

Host: That’s why it’s important to have good doctors like yourself to navigate this system. How many years have you been doing this now?

Dr. Bash: More than 20 years. I did my first one probably in 1986, so about 30 years now. It’s important to have that perspective and understand how the VA has changed over time. The rules that applied 30 years ago still apply under CUE and so on. It’s nice to have that perspective and align my thinking with the DRO because they have seen the same changes over time.

Changes in VA Regulations

The VA has gotten into the habit of straining cases, using the schedule against the patient. For example, they might rate lumbar spine strain instead of arthritis, limiting the rating. This is confusing for patients who don’t realize they’re being rated for a lesser condition.

Host: Would scoliosis fall into that program of arthritis or rheumatoid arthritis?

Dr. Bash: Scoliosis is just a description of a little bit of a curve, like an S-curve. A lot of people have a little bit of a leg length difference, causing a bit of a spine twist over time. Scoliosis can be pathologic, caused by things like arthritis or vertebral body fracture. They’re using large pieces of parachute cord with screws to straighten the curve under elastic tension. This is a less invasive procedure than using rods, a new little twist in treatment.

Host: What about atrophy in your shoulder if you have a situation where it wastes away?

Dr. Bash: Atrophy can be caused by not using a muscle or by nerve or muscle damage. The VA asks a lot of questions about atrophy. It’s a sign you can see, but you have to figure out the cause. Nerve damage often causes atrophy because the muscle isn’t being used or isn’t getting any juice.

Challenges with DBQs

The DBQs don’t cover enough, especially for neurological issues. Spinal cord injuries have multi-function problems, and the DBQs don’t talk about neurogenic bowel and bladder issues, which can be huge problems. They also don’t talk about skin breakdowns, decubitus ulcers, contractures, or erectile dysfunction, which are all important aspects of spinal cord injuries.

Host: Thank you all for listening. That ends this show, and now I’m going to zoom off.