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 | | Guides to the Evaluation of Disease and Injury Causation by J. Mark, M.D. Melhorn (Editor), William E., III, M.D. Ackerman (Editor) ISBN-10: 9781579479459 ISBN-10: 1-57947-945-6 ISBN-13: 9781579479459 ISBN-13: 978-1-57947-945-9 Paperback 2007-12-30 American Medical Association Press Find Lowest Price |
Editorials | ||
Product Description A source to provide a medically reasonable explanation of apportionment Designed to assist physicians, healthcare providers, ancillary services, legal and legislative agencies in determining individual causation for injury and work-related conditions using an evidence-based approach. Organized in three distinct parts discussing the background and history, methodologies and physical examination, and application of causation to specific medical conditions. | ||
Reviews | ||
Disease and Injury Causation Currently, it is a reference that compiles info from a multitude of sources and analyses the probable proximate relationship between the condition and causation. Well presented and referenced. | ||
Sobering A ridiculous number of "diseases" and "injuries" are attributed on a daily basis to an individual's employment despite a dearth of scientific evidence establishing such cause. Indeed, for many of the most commonly diagnosed "work-related" conditions there was until recently no studies of causation whatsoever. For many there remain none. This book offers a sobering account of the current state of the medical literature. Critics would be well served by filling in the scientific gaps with evidence-based medicine instead of experience-based medicine. It is impossible to prevent injury when the cause of the injury is unknown. | ||
"You must be joking, right?" Shania Twain, 1997. If You relied on the mental health chapter in court, you would get slaughtered. Here's my own summary for my own benefit. -------------- Guides to the Evaluation of Disease and Injury Causation ------------------ Foreword There is no scientific evidence that working on a railroad all your life causes anymore deterioration of the lumbar spine than would have occurred from natural history. The list of diseases and conditions that have thee inappropriately attributed to the workplace goes on and on... carpal tunnel... chronic back pain... depression caused by the stress of going to work. --------------------- 1. Introduction Link: the clinical findings, workplace exposure and the literature linking. Nonwork includes genetic, dietary, age-related, anthropomorphic and environmental. The final determination of work-relatedness is established by legal definitions. Fraud is deception made for personal gain and can be intentional or unintentional (apparently). Disability = alteration of a person's capacity to meet personal, social or occupational demands and is contingent on the environment. Impairment = loss, loss of use or derangement of any body part, organ system or organ function. Occupational exposures Nonoccupational exposures = include individual risk characteristics such as age, sex, hand preference, comorbid medical conditions such as diabetes, BMI, depression and hobbies. Aggravation = Exacerbation = Recurrence = similar to exacerbation, but it generally involves the reappearance of signs or symptoms attributable to a prior injury or illness with minimal or no provocation and does not necessarily occur related to work activities. Cause = an event, condition or characteristic that plays an essential role in producing an occurrence of the disease. Risk = probability that an event will occur. Risk factor = environmental, behavioural or biological factor confirmed by temporal sequence to increase the probability that a disease will occur. Risk factors are part of the causal pathway or expose the host to the causal pathway. Multiple risk factors are occupational and non-occupational. The presence of one risk factor does not negate other pathways with other causal roles. Causal models are complicated by differences in personal susceptibility and latency period. Several risk factors may combine in ways that are difficult to study and to understand. Aggravating factor or = causal factor. ---------------- 2. Understanding Work Relatedness Several quality scientific investigations that found little or no relationship between carpal tunnel syndrome and occupational hand use. Just because a condition is a work related disorder does not mean that work caused the disorder. Medical and legal causation are not the same things. Cause in fact = a cause where one thing brought about another. Direct cause = no other cause was necessary for the event to occur. Eg, blunt head trauma causing brain damage. Indirect cause = where some other factor is needed to also be present for the event to occur. Eg, poverty causing TB. Correlation = where a noncausative relationship exists between two things. Eg, gray hair does not (directly or indirectly) cause myocardial infarction. Post hoc ergo propter hoc. Proximate cause = legal cause = so closely linked that liability should be attached. Varies according to the legal area and according to the law. Can be because of convenience rather than science. Rebuttable presumption = burden of proof shifted to the party that the resumption applies to. Irrebuttable presumption = establishes a legal conclusion, once the basic facts are established. In WC, risk factors for osteoporosis or actual osteoporosis is not a factor for determining the outcome of a vertebral lifting fracture. Be aware of the level of certainty that is required in that particular legal area and the terminology used to communicate such concepts. ---------------------- 5. Apportionment Causation First consider all potential causes. Then decide which ones are probable and include them in the apportionment. Whether a preexisting condition is apportionable usually depends on the legal venue. Epidemiologic studies often use regression analysis to assess the relative contribution of potential causes, individually and in combination. In some states, a preexisting condition is not apportionable with respect to causation, disability and/or impairment unless it was symptomatic and partially disabling before the occurrence of an occupational injury or disease. In other states, only preexisting symptoms are required for apportionment. Sometimes neither preexisting symptoms nor disability are required for a preexisting condition to be apportionable. Apportionment by duration of exposure. Apportionment by dose of exposure. Apportionment by pain levels. Apportionment by more complex methods. Include rationale. Complex scenarios can occur where there is no rational basis for quantitative apportionment among multiple causes. When this happens, let the fact finder decide. Apportioning Evaluation and Treatment Generally the primary question is whether the evaluation and treatment in question would have been needed if the injury or exposure had not occurred. Apportionment occurs where treatment/evaluation was needed before the compensable injury and even more is needed after it. Eg if you needed two treatments a week before the injury and needed three after the injury, 67% is attributable to the old injury. Apportioning Disability Take into account the loss of function with normal ageing. Subtract, but it is difficult. Apportioning Impairment Subtract percentages. When Not to Apportion Apportionment is not warranted when only one probable cause exists, even if there are other possible causes. If there is no evidence of preexisting evaluation or treatment for a disability or impairment due to the condition in question, apportionment is probably not indicated. Confounders in Apportionment History, degeneration, alcohol, tobacco, exercise. Physicians ignorance, financial motives, advocacy. Don't be a parrot. ------------------------- 6. The Causality Examination This requires more insight into the events and exposures before, during and after the injury and onset of symptoms. At the time of the examination, the diagnosis has been established and treatment begun. Use the existing data as a springboard. Science requires all possibilities be considered. Law requires more likely than not. Additional time is required for this examination. Confirm the diagnosis. Make sure there is not a new separate diagnosis or a complication. Exclude abnormal illness behaviour, conscious or unconscious. Record Review Read the chart before you see the patient. Look for primary data rather than the conclusions of someone else. You might need to compel physicians to transcribe illegible records. Interview Details of the exposure should be compared to the record. A list of missing data should accompany the causality report, with an indication of its importance and how it might effect the examiner's conclusions. Current complaints are the next most important, and should be listed in the importance placed on them by the examinee. Elements: frequency, duration, intensity, pattern, ameliorating and exacerbating factors. Course since onset, and change temporary or permanent. Claims of no improvement or no response or worsening correlates with poor prognosis and behavioural issues. Estimate the severity of each symptom on a scale of one to 10. Note unlikely symptoms. Note attempts to hide behind claimed or real language, speech or hearing difficulties. Need to have a disinterested interpreter. Feelings, sensory symptoms and pain patterns do not cross languages easily. Physical Examination Note that there is not a complete dichotomy between objective and subjective. The ability to lift 10 pounds is objective but the inability to lift 15 pounds is subjective. Behavioural Symptoms Say "behavioural" as it is not pejorative, as are: nonphysiologic, nonorganic, functional, nonanatomic, inappropriate, and inexplicable. In moderation, they may be normal responses to trauma or a medical condition. Exaggeration can be conscious or unconscious. Illness behaviour can be for an illness that the person is not even undergoing the examination for. Some florid presentations can mask a genuine diagnosis. Expected illness behaviour starts soon after a trauma and gradually fades. Patients with chronic illness may develop a disease personality. For example, those with RSD/CRPS I present with an anxious demeanor, are passive and not usually demanding or critical. Florid behavioural signs are commonly seen in psychiatric disease that typically preceded the claimed causal injury. Psychiatric disease is unlikely to occur shortly after injury, although a person may want to connect the two - a more palatable alternative than conceding a preexisting mental condition. Can behaviour prompted by primary, secondary and tertiary gains. Musculoskeletal treatment might improve psychiatric conditions. You can observe a lot just by looking - Yogi Berra. Note the office etiquette. A large percentage of asymptomatic individuals have grossly abnormal spinal imaging. Torn menisci are ubiquitous in OA knees, too. Residuals are due to direct/indirect consequence of the condition and also due to other events or degeneration. Legally, any complication of appropriate or inappropriate treatment is considered to be causally related to the primary condition. Questions * Dx * Cause of Dx * Rx required * Rx help * Preexisting * Aggravation * Residuals * Subsequent modification * Permanence * ADL effect * Behavioural factors * Behavioural effects on residuals. ----------------------- 7. Report Writing Negligence + causation + damages = liability.] ----------------------- 16. Mental Illness "The things that make you go hmm, hmm, hmm." C+C Music Factory, 1991. | ||