Unexplained symptoms are very common in clinical practice1,2,3, and in the normal population4. They often feature to greater or lesser degree in medical litigation Actions, both medical malpractice and general personal injury.
Fatigue typifies symptoms that are common and for which there is frequently no medical explanation. Fatigue is highly prevalent in primary care patients, in out-patient consultations and in surveys of the normal population5 [full text].
To the patient, fatigue may cause not only disability but considerable alarm. For the doctor, it is generally not diagnostically useful, in that fatigue commonly does not discriminate between possible causes of the accompanying symptoms. However, to remain credible the caregiver needs to provide a palatable explanation that results in strategies to alleviate the symptom. It is useful to conceptualise and tackle contributory factors as 1) predisposing to, 2) triggering or 3) maintaining the medically unexplained fatigue5 [full text].
From the medical malpractice perspective, certain elements of history, examination and investigation must be explored before a serious physical cause can be confidently and competently excluded. Even when this is done, a patient's dissatisfaction with the caregivers explanations or attitude may trigger an ill-advised lawsuit.
Practice PointA persistent symptom was not necessarily a clue to a missed diagnosis nor Causally related to an injury |
From the general personal injury perspective, there is little correlation between the nature or extent of an injury and the resulting pain and suffering6.
Doctors and their patients have different concepts of disease.
Although body-mind split continues to pervade the thinking of both patients and physicians, the groups differ in their concepts of pathology. Medical training causes doctors to reject the predominantly mechanistic model of disease that is embraced by most patients (and many lawyers).
Patients generally conceptualise illness as arising in much the same fashion as a mechanical fault develops in a car - the defect simply needs to be accurately identified and fixed.
Western scientific medicine by contrast views the healthy body as constantly subjected to a barrage of derangements and threats, in response to which the body is continually self-correcting and self-healing. Cancer cells daily develop by spontaneous mutation in the healthy body7, and are detected and eliminated by the competent immune system.
Acute illness or impairment generally arises when a unitary change overwhelms those compensating mechanisms, resulting in a cascade of physiological derangements.
Practice PointAbility to self-heal results in ability to self-destruct |
Even when it is possible to "fix" the fundamental error, this commonly does not cure the illness, because that is caused by the cascade of secondary effects that may persist when the original cause is gone. Sepsis and Adult Respiratory Distress Syndrome complicating (usually major) trauma are examples well-known to Personal Injury counsel8.
Just as the derangements are diverse, so the various therapeutic interventions may have little or no relationship to the original injury or disease process.
Individual physical and psychological response to injury is more important than the injury itself.
The concept that unifies is that personal injury is at least as much to do with the soil as with the seed. Going beyond the litigation notion of "thin skull", personal injury occurs in a biomedical, psychosocial and cultural context, and its consequences in the individual claimant cannot be predicted or understood without that context. Withholding pre-accident clinical records from Defence counsel may have its merits in medical law, but it makes no sense in legal medicine.
Practice PointThe injured are more variable and unpredictable than the injuries |
Copyright © 2008 Electronic Handbook of Legal Medicine