What makes a good report?

I have twice, in the last few months, had feedback from irate case-managers, that they have not been happy with my reports.  In both cases they had asked for my opinion on a certain matter, yet I had stated that I was unable to provide the opinion that they sought, and then qualified that by providing several paragraphs of explanation of why (mainly due to the absence of appropriate medical imaging) I could not provide that opinion. To quote one of their missives “This is urgent – the point of us spending money on the consult is to get an opinion.”

It prompted me to invite comment at an informal gathering with a few colleagues, who all agreed that there was hitherto, no agreement on what made a good medical report. One suggested that in the particular situation I had described, it was more the case-manager that was bad than the report being bad.  This then begs the question of what are the respective needs and wants of the various parties who are involved in the medical report.  Over the subsequent few weeks, as the opportunity arose, I asked them what made a good medical report.

The Patient:  I did a quick informal survey of some of my long-term patients, who had in the past been the subject of a number of reports.  They wanted the report to be done promptly, written in plain language, and offering an opinion that was honest, and supportive of their claim.

The G.P.  Another quick survey, the GPs that I spoke to just wanted to get the file dispatched to the out-box.

The Occupational Physicians.  My colleagues take a pride in the quality of their medical reports. Some of the group said, that before answering the specific questions in a report, they constructed an “executive summary” or “global opinion” which summarises the key points, and “joins the dots” in linking the important  findings to explain the conclusions.

“A good report serves as an example for peers and trainees.”

“The insurer pays about $1,000 for a specialist report; for that money it should be done well.”

The Case-Manager. “we want a report that is fair and honest, and free from bias.  The days are past where the case-manager would seek out the most anti-worker doctor, and the union solicitor would then get a report from the doctor who could always be relied on to give a favourable worker report.”

The case-manager also stated that the main reason that insurers rely heavily on independent medical examinations is the poor quality of reports received from GPs.

There was agreement that the report should be:

In relation to this last point, it was agreed that the contents of a report could sometimes have the potential to adversely influence the well-being of the patient; as one put it, “write the report for the loser”.  If it is likely to be against the patient’s cause, go the extra mile, and explain why in clear English.

Realise that once the medical report has been sent to the recipient, it will pass through many photocopiers and go to destinations beyond your control and imagination.  Copies will go to the patient, who no doubt will seek opinion from relatives and neighbours.  Then there will be copies to the employers, superannuation funds, etc.  Your report will not only be spread widely in the geographical sense, but will travel in time and may still be circulating in medico-legal portfolios 25 years hence.  Be aware that there is nothing stopping the patient from circulating your report (or extracts thereof) on social media or blog sites. 

Pay attention to language and terminology.  Write, as far as possible, in plain English and if needing to use medical terms, provide a translation.  Don’t use legal terminology.

Avoid pejorative terms that may be perceived negatively by the patient or the court. There will however,  be times when this one trips you up. I got caught a few years ago when assessing a man, whose occupational history included several years operating a tattoo and piercing business.  One of the questions that was asked of me was whether he would still be able to perform that sort of work.  In my examination findings I reported that he was “heavily tattoo’d and had multiple piercings”.  He took offence, and complained to the insurer that had requested the report.  The matter was resolved with an apology.

People who carry too much weight generally take offence when the word “obese” appears in a report.  In my experience these people are comfortable with descriptors such as “BMI exceeds 45”, or “has experienced significant weight gain.”

Avoid emotive language,  such as, “my patient has become terribly stressed by the disputation surrounding this claim, and the tension in the household is affecting the family”.

Incorrect grammar can spoil an otherwise good report.  Put factual data in the past tense.  Put opinion in the present tense.  Avoid terms such as “I think” or “I feel”; these terms suggest a weakness of opinion. Be bold in stating your opinion.  But at the other extreme avoid using qualifiers like “obviously” or “clearly”. Use short sentences and short paragraphs.  If there are inconsistencies or contradictions, these need to be documented.

Use care in the use of terminology when referring to the addressee or your patient.  If, for example, the report has been requested by the worker’s solicitor, Mavis Smith, even though you may normally be on first name terms with her, address the report “Dear Ms Smith”. When referring to one of your own patients it is acceptable to use the first name, although preferable to refer to your patient as Ms White.  The use of less personal identifiers, such as “your client”, “the claimant” or “the worker” are best reserved for medico-legal reporting (independent medical examinations).

Prefix the history with “My patient said that...” and even though that may get to sound monotonous, it needs to be repeated  throughout the report.  You can occasionally dispense with the “he said/she said” if you have personally witnessed the event;  “On 20th March, at about 2.15pm, Mr  Jones slipped on the mat in my consulting room”

It should be stated near the front of the report, a summary of why the solicitor or insurer has requested the report. A good report will include a psychosocial and occupational history of the patient.  It will also be set out with headings: Past Medical History, History of Presenting Complaint, Present Symptoms, Examination, Imaging etc.  It will also include negative findings; for example if the report is about your patient’s knee condition, state that there is no past history of a knee injury. If you have been provided with other medical reports, these should be itemised. If there is anything special in one of those reports that supports or weakens your opinion, add a brief note to your report.

Use evidence-based conclusions, with references to (preferably recent) journal articles, where possible.  

Finally, a few things that flag a bad report:

Advocating for one side or the other.  Bias and partisanship are commonly seen in medical reports.  It is a topic that deserves a separate article on its own, and I shall deal with it in a subsequent edition.

Advertising: that is touting oneself or one’s practice;  “Over the last five years I have seen more than 100 patients with this condition”.

Bagging – of the person whose opinion or approach is disagreed.  It is understandable that there will often be times when there is a difference of opinion. If so, it should be aired in a professional manner.

In a nutshell.  The medico-legal arena is awash with reports that are either bad, or at best, just ordinary. Excellence in medical-report writing is a rarity, but it is achievable.