PI Brief Update

Generalist PI expert's Role in Serious injury - Dr Mark Burgin

17/05/19. Dr. Mark Burgin BM BCh (oxon) MRCGP explains how a generalist expert can use their expertise to assist the court in PI cases involving serious injury.

GPs and orthopaedic surgeons have different areas of expertise from their experience as Orthos follow up complex fractures but refer patients with other injuries back to their GPs.

Acute investigation of injuries and acute management of fractures are largely performed by A and E specialists who then discharge to GPs or orthos for longer term follow up.

Generalist experts (GPs and physios) have a role to ensure that all necessary evidence is available and transcribed before they decide if an expensive specialist is necessary to settle the case.

Generalist experts are usually cheaper, quicker, better with large volumes of evidence, diagnosing non-orthopaedic conditions and trials of treatment than an Ortho expert.

Injury details

The symptoms both at the time of the injury and currently should be described using SOCRATES as a guide to ensure all details are recorded.

Many NHS orthopaedic consultants state that there is no tenderness (meaning that the fracture is not unstable) but fail to detail the patient’s minor ongoing symptoms.

The GP description may include issues such as aching in the cold or cosmetic problems or small areas of numbness that would appear unimportant to a specialist.

Susceptibility conditions can explain an injury’s susceptibility or why it occurred at all and whether there are risks to recovery from e.g. Vitamin D deficiency.

The claimant’s description of the forces can be compared with any objective evidence such as engineering evidence, CCTV or black box data.

Confirming fractures

The radiologist’s report on an x-ray fairly frequently does not confirm the claimant’s version of the injury perhaps due to miscommunication at busy NHS clinics.

The treatment given would be expected to be immobilisation for 6 weeks and where lesser or no treatments have been given is inconsistent.

Review of the records for contemporaneous examination findings can suggest alternative explanations or confirm clinical fracture diagnoses (ribs or toes).

If a claimant has ongoing symptoms from an undisplaced fracture treated by immobilisation that did not involve the joint by 6 months it does not require an ortho to say they are permanent.

Pre-existing problems in the area

It is not unusual for an injury to occur in the area of a previous injury (the injury goes to the area of weakness) even if previously asymptomatic.

Past medical histories are not as reliable as medical records review but many claimants will confirm a history of heavy lifting or contact sports which supports their honesty and reliability.

X-ray reports from consultant radiologists typically deal with both the type of injury present and whether there are changes consistent with pre-existing problems.

Generalist can claim expertise in reading medical records from recognising the limits of specialist letters to reading between the lines of GP medical records.

Specialist opinions

Almost all significant fractures will have a specialist opinion in the form of a letter to the GP and often confirming that it no longer requires specialist care.

NHS specialist opinions are in some ways more reliable as they are not influenced by the legal process and therefore can be relied upon by the generalist expert.

Some claimants require a second specialist consultant opinion when the NHS specialist role does not answer a material question but often such a report is unnecessary or disproportionate.

Chronic pain cases typically require a course of NHS treatment to determine the eventual prognosis as it can be difficult to predict how effective the treatment will be.

Disability

GP experts with expertise in disability analysis can identify areas of difficulty that the claimant may not be aware of and assist the instructions of other experts.

Serious injuries can take months or years to adjust to and even 6 months after the event the claimant may not have returned to some activities.

Functional restrictions describe the claimant’s disability in an organised way so that the causes and the likely consequences can be spelled out to the court.

The Biopsychosocial Model of the GP is a better fit to understanding a claimant’s disability than the Biomedical ‘diagnosis’ model but less good at predicting future complications.

Conclusions

Neither GP experts nor orthopaedic specialist experts have all the answers in cases of serious injury but if they work together, each within their area of expertise, they can assist the court.

The GP expert should ensure that all the material evidence is in an organised form and non-orthopaedic issues are recognised and dealt with in the generalist report.

The GP expert can recognise when a specialist opinion is already available and repetition is inappropriate and take a holistic view of how obtain material evidence.

Solicitors recognise the GP expert’s role in a serious injury case is investigating the details rather than writing a report recommending several expensive specialist reports.

The importance of GP experts’ professionalism in their duty to assist the court to keep costs down to that which is necessary is perhaps most evident in serious injury cases.

Doctor Mark Burgin, BM BCh (oxon) MRCGP is on the General Practitioner Specialist Register.

Dr. Burgin can be contacted on This email address is being protected from spambots. You need JavaScript enabled to view it. and 0845 331 3304 website drmarkburgin.co.uk

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