Medical report writing series - by Dr John Wilson

Part 3 - DVDs and Malingerers

In an average week in my practice, I get to see two or three new cases who have been involved in motor vehicle accidents. These are not the people who have sustained catastrophic injuries, but generally ones who have been involved in suburban bingles.

The mathematics would suggest that throughout my career, I have seen thousands of these patients.

There is one other common thread that unites my informal series. Invariably the accident has been the fault of the “other driver”. Not that I even ask that question. I don’t need to. The issue of culpability always emerges fairly early once the history-taking begins.

The issue of fault and blame also loom large when we are dealing with occupational injuries. Persons injured in these circumstances view themselves as having been wronged, and (wrongly) perceive the compensation process as being a vehicle for retribution.

The litigation process and the expectation of secondary gain have long been recognized as modifiers of disability. This process usually generates a spectrum of descriptors (note that I have deliberately used the term “descriptors”) where the patient’s description of disability does not comfortably fit with either the mechanism of injury or the examination findings.

The feature that set the last three apart is that the disability is switched off when there is no need for it. There are no clear medical tests that can tell who is and isn’t, and it is usual for these claimants to enjoy the benefit of the doubt from experienced clinicians.

One of the more challenging exercises in medical-report writing emerges when the letter of request is accompanied by a DVD.

My intro to the world of licensed enquiry agents was way back in 1975 when I was working as a raw “factory doctor”, and had a call from the “compo manager” to join him for a quick drive out to the next suburb. We were met by a somewhat ebullient private detective called George, whose tools of trade were a large panel van (with ladders on the roof rack), within which was a 16mm movie camera. The ladders, I learnt served no other purpose than creating the illusion that the van was something to do with phone lines or electricity wires. We were bundled into the back of the van, for a quick trip around the block to behold, from a slight distance down the street, one of my factory-worker patients engaged in full toil, as George aimed his camera through the tinted windows of the van.

The technology has changed a lot in 40 years. They still have their vans, and I suspect their ladders too, but now they have miniature cameras with incredible zoom power and the ability to almost see in the dark. And they are very portable and innocuous cameras that have extended the territory of their operators into shopping malls and supermarkets.

These operators can be amazingly tenacious. One of the more adventurous booked a ticket on the same Ghan trip as one of my patients, and then managed to join her for the walk up Uluru – filmed along the way!

Expect to see the outside of your surgery feature on the video. Case managers seem to know where and when their claimants attend appointments. They pass this information on to the surveillance agents, firstly to help them identify the claimant (and car). It also helps the agent to get a tail on the claimant, as in many cases once your patient has left your rooms, he or she will then go to the adjacent shopping centre.

In earlier times the agent would book an hour or two of one’s consulting time, and set up the projector in the rooms. Nowadays a DVD is delivered by courier, and you get to watch it at home.

There are traps to avoid when viewing surveillance DVDs.

Firstly be absolutely sure that you can identify the person on the screen as being the correct person. Often filming is done from great distance, and can be blurred. Is the person wearing the same clothes, is it their car or house? There is also the ever-present risk that your patient has a twin brother or sister.

Be aware of mirror-images. I have seen films that were taken by pointing the camera into the mirror of the car. If you see cars being driven on the wrong side of the road it could mean that what you think is the patient’s left hand is actually the right hand.

If there is one hour of video, expect it to consume about two hours of your time, as you will need to reverse and replay on occasions, not to mention the pauses to make notes.

You are being asked to view the DVD and write a report, because at some earlier stage you have written a certificate or report supporting your patient having a disability. It is understandable that you will feel angry about the fact the both you, and your patient, have been disbelieved. You may be angry that you have set aside an hour or two to watch the video. Try to cool-off your emotions a bit before preparing the report. I will write more in a future article about the problem of emotions working their way into medical reports – it is known as affective bias.

On the other side of the equation it is possible to be swayed by the reasoning that, as the insurer has expended a considerable sum in surveillance that there must be more to it than just what is on the video.

Prior to watching the video, revisit your case-notes and know exactly what it is that your patient said they could and couldn’t do. Importantly did they have good days and bad days? That will become the yardstick by which their credibility is measured.

Most of the DVDs that I get to watch are a boring itinerary of daily activities that are quite consistent with what the patient says they can and can’t do. But there are others that fully justify the great time and expense that the insurer has expended.

On a couple of occasions in the past I have found myself in the unfortunate situation of being the one who had to front the patient with the news that they had been caught out. I am wiser now. My advice is to avoid getting caught in this situation. Here is my method of handling the situation now.

If my rooms receive a DVD and report request relating to a present patient I check the correspondence to see if there is an accompanying report from an independent medical examiner. If the case manager has been doing his or her job there should have been an independent assessment after the filming, and the independent examiner would report on both the examination and video evidence. In that situation the report and a copy of the DVD would have been provided to the claimant (or their solicitor).

As the treating doctor, I just file the DVD and report request in the “slow in-tray” and wait for the patient or their solicitor to open the batting. When they do, I can acknowledge receipt of the material but add that I haven’t yet had the time to view it.

Finally, a word about malingerers. The term is defined as an individual who deliberately feigns an injury. My impression regarding my own patients who have been “caught-out” is that most had a legitimate injury in the first instance but have become embroiled in grievance during the recovery process. Therefore they cannot be defined as malingerers. It is dangerous to use the term “malingerer” in a medical report.

In a nutshell. It is normal to feel angry about having to watch a video of your patient, and then write a report on what you have seen. You may be angry that the insurer has not believed you, or be angry that you have been duped by your patient. In this situation, you need more than glass of riesling to get you through the viewing. I’d recommend a robust shiraz.

In the next issue I will tell you of the unfortunate pickle that one of my close colleagues got into when he made an innocent but silly mistake when writing a medical report.

Medical report writing series - by Dr John Wilson

Part 3 - DVDs and Malingerers

Other articles in the Medical report writing series: