E01: Diagnosis & Causation with Dr Michael Dooley

(upbeat music) - Welcome to Medico Legal Mastery. The experts guide to Medico Legal Reporting. I'm Jess Marshall, and on today's episode, we're exploring one of the fundamental and most contested aspects of Medico Legal Work, diagnosis and causation. Uncertainty of diagnosis is if you can't actually say what that knee pain or elbow pain is due to, I just say that this person describes a scenario where they may have sustained a soft tissue injury say to their shoulder, and I will say the exact nature of which is not clear. I can't make a firm medical diagnosis. - In a Medico Legal Context, doctors are asked to form opinions when symptoms, imaging and history, don't line up. Thanks to Melbourne Medical Legal, we were able to get in touch with one of Melbourne's most experienced experts. - One of my modalities to the residents and students he's never saying ever, never saying always. - Dr. Michael Dauley is an expert with 30 years experience, predominantly as an orthopedic surgeon working out of St Vincent's public hospital. Michael, thanks so much for joining me on the podcast. - Thank you for having us. My first question for you is when symptoms, imaging and history don't align, where do you start? - In the setting of seeing someone for a medical legal assessment, you're not a treater, and often before we see a patient we send documentation, it may include reports from other doctors during previous examinations, you know, various information. I try not to read over and above, say, "The general practitioner knows beforehand, "because other reports can influence the way you might think about someone." So I'll have a look at that. Then you go through your history examination, review of the X-ray reports you might have, and then you form your diagnosis and opinion, ray management, causation, etc. How do you translate or transmit your view that you might think the person's pain is disproportionate to their injury or illness. I think really is a patient straight out lying, exaggerating with malicious intent, I suppose you might call it. I mean, growing up you'd watch current affair and you'd see a guy in a neck brace being filmed and they'd shown playing, you know, heading a goal and said, "After" and the soccer, I think that sort of stuff's rare, but I think again, every physical injury, dash illness is accompanied by psychological reaction, that will vary in its degree, depending on all those factors we've talked about. I think the reason for their constancy, intensity of their pain being greater than you might expect is this psychological component. Others can accept that or not accept that. I just try and give my point of view. You know, I try to be reasonable and I suppose sometimes I'll use code words, "I think this patient is a sensible and genuine historian," which means, you know, I think they're pretty rigid-idge. But the important thing also in that regard is, if you've got a patient that you think set a significant psychological reaction, their ongoing pain means it's usually not going to respond to conventional treatments. It's probably not going to respond to further treatment. I saw a lady the other day in the clinic at St Vincent's because I've seen her with a crookip. She's now had four operations on her thumb. First four operations haven't worked. The fifth one that's being contemplated is unlikely to improve her in that setting. So you're actually trying to help the patient, you can't treat the patient, but you try to help the process to say, maybe enough's enough. So when you are looking at the images and then you have the clinical assessment in front of you, what weight do you put on either one of those? So you've got the imaging and you've done the assessment. Always my weight is on the clinical assessment, history and examination. The difficulty, okay, if you've got some of this fallen over and broken their arm or ankle, and there's an X-ray with a broken arm or ankle, that's pretty straightforward. Problem is you've got someone who said, I've been to over a work three years ago, and I hurt my back and I've had constant ongoing pain since, and I can't do the chores at home, 32 other things. Then the imaging shows almost certainly in a middle age to slightly older person. It's going to show a degeneration of the lumbar spine, which we know is a very common finding on imaging. So you're going to say, okay, so does everyone else, I'd say, Juran 60. So you would just note that the X-ray show degenerative change, but they do not explain the intensity of the ongoing pain and the patient's claim disability. Yeah, so you reference the imaging based on what you can see, but then you'll put more emphasis on, this is what I've seen today in the consultation. Yeah, and partly also using that based on your experience of treating the same condition in a lot of other situations and a lot of other people. So first of all, we've got to say, have I miss something? We now have a situation where people talk about chronic pain and neuropathic pain, but I don't think they're really operational in most of the patients I see. Yeah, so you've been in medical legal for 30 years. You're also a practicing orthopedic surgeon. When you're seeing a day-to-day clinical practice patient versus a medical legal patient, how does the diagnosis differ? Because you're looking at a different angle, right? You're looking at a different angle maybe in the way that diagnosis was sustained, but the diagnosis is still the diagnosis. Again, all you can do is your history examination, view of investigations and make a diagnosis based on that in general in terms of medical legal by the time I'm seeing patients, it's become a static situation. They've usually completed whatever treatment they're going to have and it's sometimes down the track. You might be seeing patients who have had complications or unsuccessful treatments, but not so much evolving diagnosis. Okay. And what factors do you consider most important when linking an injury or condition to an incident? Look, again, you're going strongly on the patient's history and the actual diagnosis. So people might know in a sporting context, they've seen someone playing football. They get grabbed, they get twisted on a wrench knee and they get a rupture of their anterior cruciate ligament. People jumping from a small height and their ankle inverts and they hear a crack and they get a badly sprained ankle. So mostly, if the patient's able to give you a describe making some of injury, you can pretty quickly say, "Yes, that's consistent." I suppose Kanundrum comes with it's going to be low back, lumber conditions, low back pain. So the patient says, "I sat for too long, my chair's not good at work, I sit awkwardly, I bent over and lifted, and now I've got back pain." We all know that's consistent with potential strain or sprain of the back. And then you have to work out, well, in most contexts and we've all done those sort of things to it agree, you might have a lot of initial pain, but fairly quickly over the period of several weeks and by six weeks you've substantially recovered and off you go again. When you left with a scenario that the person bent over and lifted or whatever happened and six years later, some doctor's going to say, "Well, look, yes, I see patients who six years later have still got bad pain and I'm happy to accept that's their view, I might not agree with it." But look, probably, are you might want to hear this just from, when we're about 18 or 20, we degenerate muscular skeletally. That's what studies show, MRI studies, cadavric studies show. Because, I don't know how many hundred years ago, what was our lifespan 40 to 50 years? So now with medicine, whether it's a good or bad thing, we all live longer. So, degeneration comes into play. If we take that person that twists and gets a crook back, so to speak, we know age 50 or 60, they've got a lot of degeneration in their long-spin. What have they done in that injury? Did they exacerbate their underlying condition? Did they cause it to have heightened effect? Yes, probably some of those things, but why is it ongoing? And in nearly everyone, there'll be pre-existing. Degeneration. And it can be difficult to apportion culpability in that sense of was it the episode naturally occurring to generation? Again, people have their views, somewhat based on experience, somewhat based on their bento gases towards going on. So, what advice would you give to doctors starting out in the medical legal work? Very cynical answer would be, "Don't, but I can't do that." Look, I think starting out with medical legal type work is treating it just like seeing any other patient. The process is still the same. Look, it can be more difficult. There's an in-biter comers more paperwork involved in certain situations that can lead you having to appear in court as a so-called expert witness. And that's a pretty challenging and stressful situation for most doctors. You know a thousand times more medicine than anyone in that room. But if you think that's going to protect you from saying dumb things, stupidity, being a bit of a smarty pants watch out because the barrister's job is to make you look doubtful of your integrity, so to speak. So I think in all those scenarios you just treat it a normal situation, be respectful, don't overstate things. But I think it can be an enjoyable area of medicine. I'm a bit fortunate in that some of the cases I'm asked to see, it is a causation. It's been suggested this person should have this surgery or not. What do you think? So I probably get asked to review case histories and files in relation to medical negligence, which again is academically interesting. It's challenging and you do your best, but it reminds you that you need to be on the ball and you have to be thinking about that. And would you say someone you coming into the medical legal world focus on a key area? Did you go that way or did you just see what came across your desk? I think pretty much sore all comers. And then I think in time you will get asked to see those causation and negligence issues. I think there are some surgeons who are going to be called plaintive surgeons and there are some surgeons who get called defendant surgeons. And that's not a good thing. I think as you try to see each and every patient openly, to me, the idea of that system is okay, if you're a motor vehicle accident or if I get hurt at work, what I would want is fair and reasonable system where I receive excellent medical care and fair and reasonable compensation. What we're seeing now in a lot of aspects, I think, is where the system's been extrapolated and it doesn't always treat people and things fair and reasonably. And looking in certain situations, if I worked in a lousy job and had a lousy employer and I'm working in a factory and everyone's nasty to me and I'm 62, I might get a bad back and think, you know, what the last two or three years of my life, I think, I'll coast on the system. That shouldn't be, it's not ideal and it's not what we have the system for, but I guess like most things, we're not going to change things over now. If you have someone coming into your practice and say they have, they've been on this medical legal journey for sometimes 24 months, even longer and they walk into your practice, how do you approach that appointment? I think, look, you've got to use all the skills and experience and certainly I have patients like that and I understand why they're unhappy, initially unfriendly, fed up with the system. I mean, it's like most systems, it does weigh you down. So I think my role in that is I've still got to see the patient when I think they're balanced and giving a good history rather than just monosyllabic answers. So I do try and explain to them, I understand your frustration, I understand where you're at. I know you might want to do that today and perhaps I don't want to do that today, but this is our task. Let's work at it together and mostly you can bring the patient around and you will have, I mean, I can't remember just off the top of the head, but I'm sure I've had patients who have remained disgruntled monosyllabic and I've mentioned that in the report, I'll say, look, the Mr or Mrs Smith was unhappy today, it was clear that I wasn't getting a troops perspective on things. I'll say I've reviewed all the documentation that I've been seeing, I've reviewed all the investigations. This is what's most likely happened even in time, you would like me to see the patient again, well happy to do so. Have you had people come into your practice that have given you issues and do you mind sharing any examples? I haven't had anyone that I've feared physical assault or anything like that for around 15 years, I worked as the orthopedic surgeon to Port Phillip Prison in Leverton. So I guess I had a bit of experience in treating patients who potentially could be somewhat hostile or threatening, but of interest, most are pretty good, fairly grateful for getting some treatment. And again, I was perhaps able to use that experience to learn how to manage patients who before I saw them, I might have feared verbal or physical abuse. And I think that's one of the good things. You never quite know when you open the door so to speak, which patients are going to come in. Any of all you were, if you have a whole practice involved, private practice and you saw what I'm not termed two rectos, you're going to have a pretty boring clinical practice in life. So I'm happy with all that, but it does require an element of consideration, tact, and in your head, well all this is happening on the run, you've got to form a plan as to how I'm going to manage this situation. Yeah. Another question for you is uncertainty acceptable in medical legal reporting? And if so, how should it be handled? I think we know from ordinary clinical practice, there's uncertainty. So in the medical legal setting, that might be taint to diagnosis, management, treatment. Sometimes as I said, we're asked to call me on a plan treatment. And we have scenarios where often I'll say to the patient, I might think a certain treatment will be helpful in your situation, but if I'm asked, is it possible, then usually the answer is yes, because most things are possible. I suppose actually uncertainty of diagnosis is if you can't actually say what that person's knee pain or all both pain is due to, I just say that. I say this person describes a scenario where they may have sustained a soft tissue injury say to their shoulder, I can't make a firm medical diagnosis. Some sort of injury occurred, but I can't delineate that. So I'm always happy to say, I can't give you an exact diagnosis. I'm not sure what a treatment should be. And I think that's far better than making a diagnosis that's not really accurate, or you can't justify on clinical or investigation grounds. What are the biggest traps doctors fall into when diagnosing in this setting? All the traps are being over certain when you can't be rigid as I said before, you know, I never say never, never say always. This condition has been 100% caused by, or 100% has not caused by, I think you want to stay away from extremes. But equally, you've got to be able to justify your view as an evidence-based situation. You can't just say things without being able to back them up. So otherwise, I think you leave yourself open to criticism that you've gone over and beyond what really you should be doing. So my last question, and I always like to ask this at the end of an episode, is we have Mr Stephen Doig, who I believe you may know on our next episode, what is one question you would ask him? Yes, I do know Mr Stephen Doig and there are plenty of questions I could ask him. But what I would ask you, Stephen, in the medical legal setting is, as you know, often we're provided with documentation before we see a patient that might include GP records, other reports, letters or statements from their legal representatives. And the question I'd ask is how much credence do you place upon that information versus the history that you obtained for the patient when you ask them, tell me what happened in your own words and in your own way, and on your clinical examination findings versus all of the formal documentation that you receive. And then the other question I would ask is, it's since you're much older than me, why is you still working in the medical legal area? And perhaps just like the St Kielder Football Club, how do you think the Melbourne Football Club will go this year? Well thank you so much for your time today Michael. This has been very insightful and I'm sure I could ask a lot more questions, but I will let you go for now, but I appreciate you coming on the podcast. Thank you very much Jess. I'm Mark and Napier Tifeh for podcast. Thanks.