Medical report writing series - by Dr John Wilson

Part 1 - When the report request arrives

As good doctors we are all about the art and science of good medicine, and anything that gets in the way of our healing duties is an impost on both ourselves and our patients’ well-being. Agreed!

So when some insurance company or solicitor sends a letter requesting (aka demanding) we set aside an hour or two of our scarce clinical time to answer their 25 stupid questions it is tempting to tell them to “f - off”. Agreed!

Now that we have got that lot off our chests, let us return to the realities of our earthly existence and settle into the inevitability that these reports do have to be done. They are an extension of the contractual obligation we have with our patients. The good news is that we are entitled to charge a fair fee for our effort – remember that!

If you think it is a dreary topic of which I write, I have spiced it up with some anecdotes and howlers, and even managed to slip in the occasional glass of riesling along the way.

This series of articles is not intended as a replacement of the standard advisory(1) texts on medico-legal matters; rather it is a series of articles that should be considered as an “add-on”.

The series will concentrate on issues surrounding reports requested from doctors in relation to patients they have treated. These are the reports requested by a third party, such as insurers, solicitors, and WorkCover. These articles relate to civil proceedings only and may not be relevant where criminal matters are involved.

It is good practice when a report request arrives, no matter how busy your practice is, to spend a couple of minutes reading the request letter, while having access to the patient’s case notes.

You normally have plenty of time to get the job done. Within one month(2) is regarded as good professional etiquette, however in some States there is an expectation by WorkCover that their reports are done sooner. My search of the websites of the former State medical boards has failed to reveal any consensus on what delay may be considered unprofessional or unreasonable. The consensus view that emerged out of discussion with fellow occupational physicians was that a doctor who deferred a report beyond two months was venturing into risky territory as far as the Medical Board was concerned.

Do not abuse that period of grace by shelving the file in the “to do tomorrow” basket. A bit of planning can make the job easier and generally result in a better outcome for your patient.

Read the questions. People who write report requests have a diversity of experience and training. Many are new to the job. Some insurers have a battery of standard questions, some of which may be irrelevant, and it is a constant problem to find “cut and paste” errors. As an example, a recent request asked me to justify my diagnosis of rotator-cuff pathology according to DSM - IV(psychiatric classification system)! If a question doesn’t make sense, ring the writer and ask for a translation. Document the name and date and refer to the matter in your report.

Do you have enough information to adequately answer the questions? Remember that the real purpose of the report is for you to convince the person at the “other end”. You may get away with a battery of Yes/No replies but don’t expect your report to be regarded as a treatise of unwavering credibility.

It may be that your opinion will be strengthened by an X-ray or pathology test, or there may be a case for getting a specialist opinion. Have your secretary contact your patient and explain the situation, to suggest making an appointment to discuss further investigations.

Need more time? Maybe you are about to go on holidays, or that specialist appointment will be six weeks away. Ring the person who requested the report. Again document the name and date. My experience in such situations is that the claim administrator will either agree to an extension of time, or will negotiate a quick reply, say to question 1, with replies to questions 2 to 25 to follow.

You need plenty of time and thought when the stars point to a “bad report”. This is where the report will not be to your patient’s advantage or liking. It is far better to discuss the potential problem with your patient prior to the report.

I recently had a patient who was an administrative worker, with an inguinal hernia discovered as an incidental finding, and without a history of specific injury. A WorkCover claim was made and the inevitable request arrived, begging my opinion as to the causation. I had the rooms make an appointment for the patient, and in the meantime accessed some recent journal articles on the subject, which I provided to my patient at the consultation. The outcome was that the patient admitted that there was a weak basis for the claim, which was promptly dropped. Crisis averted! The journal articles, incidentally, were even-handed regarding the work-causation of inguinal hernias.

It is important to know which side has requested the report. In most cases it is clear, but beware of making the assumption that a request from a law firm means that the firm is acting for your patient. When the letter states that the law firm “acts for the defendant” it normally means that, as far as your patient is concerned, this is the “other side”. To confuse matters further it could happen that it is your patient who is the defendant. An example could be in a civil claim made against your patient, and where a medical condition was being cited as part of the defence. For example, your patient may be a contractor (defendant) involved in an accident involving a sub-contractor (plaintiff), where it is alleged that some medical condition has contributed to the failure of the duty of care.

Have a nose for “fishy” requests. Most report requests represent no threat to the doctor, but there is the ever-present risk that a request for information about your patient is a veiled attempt by a solicitor who is gunning for you, to gather more information. If in the slightest doubt contact your medical defence organization.

There can be problems when you are dealing with an “impatient patient”. Worse still are the impatient ones who don’t want to pay (more about billing and payment issues in a future article).

There is no easy answer to the “impatient patient”. After a few days of pestering your receptionist, they will generally book themselves in for a consult. You can counter by telling them that their’s is not the only report in the queue. That may buy you a week of peace.

Has the patient signed an authority? This is stating the obvious, but you need to know that authorities come in different guises

Most authority documents are obtained by insurers when the claim form is lodged, and it may be years afterwards that you receive a request along with the photocopied stale authority. Mostly, these standard authority forms allow the insurer to get a medical report from any doctor, past or future. If you are treating the patient on a regular basis it is good practice to tell your patient that you have received an authority, and get their confirmation that it is in order to proceed. I generally make an entry in the case-notes to the effect that we have discussed the imminent report.

Be particularly wary of the report that is requested on a patient who is no longer under your care, and particularly where the authority document is old and does not specifically mention your name. It could be that the ex-patient was unhappy with some aspect of your care. In this situation it is appropriate to write to the insurer or solicitor requesting that the claimant signs a new authority, specifically with your name.

In a nutshell. Mostly, the task of writing medical reports invades our family time on evenings and weekends. That makes the task more unpalatable, but it is one that has to be done. A bit of planning can make the task a little easier. Unlike the consulting part of the day it’s OK to help it along with a glass of riesling, and remember that your fair fee for the job includes not only an hourly rate, but an extra slug for “insanity tax”.

In the next issue you will learn that a reefer is not always a marijuana cigarette. One of these other reefers was the subject of some skullduggery that has had a profound impact on the way we write our medical reports.

Stewart C., Kerridge I., Parker M., The Australian Medico-Legal Handbook, 2008, Elsevier Australia.
AMA South Australia and The Law Society of South Australia, Medico-Legal Joint Statement. May 2005. www.lawsocietysa.asn.au

Medical report writing series - by Dr John Wilson

Part 1 - When the report request arrives

Other articles in the Medical report writing series: