Academy of Chiropractic’s

Lawyers PI Program

#173

 From the Desk of:

 Mark Studin DC, FASBE (C), DAAPM, DAAMLP


"Chronology of Symptomatology - Part 2
The Final Narrative"

 

The "Chronology of Symptomatology - Part 1," written over 3 years ago, was one of the most significant pieces ever created about having a successful PI practice and letting the lawyer know in conversation that you are a true expert. It identifies an area so prevalent that once explained becomes a truism in the medical-legal world and will set you apart from the rest of the pack. Feedback from lawyers nationally has consistently, for 3 decades, embraced the concept with never a question because it is in both your patients' and their clients' interests from an honest and ethical perspective.
 
I have re-written the consultation, #14, to alter some of the timelines to reflect a more reasonable approach that will still accomplish what we need for our patients to reflect the true nature of their injury. Because this is so significant, I am reprinting for you Consultation #14 (it’s short and in BLUE) and afterwards, I will explain the critical problems with doing a final narrative and what needs to be done in handling the language of that examination. 
 
Lawyers PI Program

“Building a PI Practice”


#14

 From the Desk of:

 Mark Studin DC, FASBE (C), DAAPM, DAAMLP


"Timing of the Final Narrative & Chronologyof Symptomatology"
 
WARNING: If you have not read all previous consultations, then you stand the chance of being a "one-and-done" with the lawyers. You have to learn to speak their language of admissibility.
 
When a final narrative is requested by the patient’s attorney, it is usual and customary to comply with that request and render one. I don’t. It is for that reason that I have been able to use the refusal as a way of ensuring many more referrals. Before I go on to explain why, let’s look at the chronology of the injured patient in his/her rehabilitative process.
 
The patient:
1. Gets injured
2. Goes to the hospital or the doctor’s office
3. Gets evaluated and has diagnostic tests
4. Has a diagnosis rendered and in many instances, is taken out of work or put on light duty
5. Commences care with:
     a. Chiropractic
     b. Physical Therapy
     c. Medication
     d. Injection Therapy
     e. Massage Therapy
     f. Acupuncture
     g. Exercise Rehabilitation
6. Is taken out of his/her normal work and is no longer doing his/her repetitive occupation, i.e. no longer lifting, carrying, pushing, pulling, etc.
7. No longer doing housework, laundry, yard work, sports activities, etc…
8. Basically, for the length of his/her care, is relegated to getting treatment and watching Oprah.
9. Is then re-evaluated every 30-45 days, as per Medicare guidelines, documenting the progression of his/her recovery
10. Has an IME, 3-6 months later, or the doctor renders him/her as having met MMI (maximum medical improvement) and discontinues care, ordering him/her back to his/her normal life.
 
At this point the patient stops coming for active care and the last evaluation was either when the patient was released or more commonly, the last evaluation was the month prior to the last visit. The patient’s attorney then requests an evaluation and the information you rely on is the last evaluation. You are aware that the attorney can only argue for permanent damages and that is based upon residual problems after a course of care. I would venture to say that 99% of doctors nationwide create a narrative for lawyers based upon the last evaluation of the patient. In truth, it is 100%. That is the proper way to determine what residual problems the patient is left with post trauma. However, it isn’t accurate in documenting permanent residual problems resulting from the injury.
 
The problem is when the exit evaluation is performed. At the end of a few months of care, the patient is at his/her very best, perhaps for the balance of his/her life. The patient has been taken from his/her repetitive occupation, so he/she is not lifting, carrying, etc. No housework, getting massaged, adjusted, taking medication, being guided through exercise rehabilitation and overall, fluffed and puffed.
 
It is at this point you are basing your narrative and it is not an accurate portrayal of the true nature of the patient’s injury. The patient needs to go to work for 4-6 weeks minimum, back in his/her normal life with lifting, carrying, pushing, pulling, being stressed, and doing housework, not receiving active care 2-3 times per week, nor on anti-inflammatory drugs daily.
 
If there is a true injury where the supportive structure has been damaged (ligaments, discs, tendons, etc.), then the supportive structure of the human body will begin to fail when stressed both physically and mentally, rendering numerous signs and symptoms over time. These signs and symptoms will not have been present at the end of care because the patient was in an artificial state and not in his/her normal repetitive lifestyle.
 
Therefore, a subsequent evaluation needs to be done no sooner than 4-6 weeks subsequent to the last day of active care, preferably closer to 3 months for the true problems to surface. The best and most accurate way to objectively document this is through range of motion. In 30 years of practice (doing it wrong for 10) , following this standard of practice, the patient’s ranges of motion got significantly worse 99.9% of the time in the injured areas. In those areas not injured, the ranges were stable and were reported as such.
 
So…when a lawyer requests a final narrative on his/her client and it is at the end of care, have breakfast, bring the chart and explain the "chronology of the patient’s symptoms" to the lawyer. Then educate the lawyer as to why you want to wait 8-10 weeks minimum post care to perform the subsequent narrative. Should there be no benefits, bill private insurance, take a lien or do it as part of the care already rendered and chalk it up as goodwill.
 
Remember, we only want to bring out the truth of the injury. Once the lawyer understands, he/she will know that you get it…and that is the goal.
 
Other than amending the timing of the final narrative from 3-6 months to 3-4 weeks minimum because we found that was enough time once the patient re-integrated back into his/her repetitive stress environment, I changed the phrase "final narrative" to "subsequent narrative."
 
I received a call yesterday from a doctor who stated that his patient had a "final evaluation" last January (9 months ago) and has received no care since. The patient now experiences severe exacerbations. The question that now arises is how can a doctor do another evaluation as an exacerbation if that doctor already did a final narrative? You are probably saying this a semantic issue and not reality and you are 100% correct. However, admissibility is all about semantics and if you want to speak the language of the lawyer, then you have be consistent with the needs of the courts in an honest and ethical manner.
 
When doing your examination 3-10 weeks after the end of care, it is simply a re-evaluation. The word "FINAL" should never appear, as in truth, it is not necessarily a final evaluation, but an interim or subsequent evaluation. This issue has been brought up to me by 100’s of lawyers nationally as I have lectured through the years.
 
This one small issue can be huge in the courtroom and prevent you from bringing out the truth about your patient with a sharp opposing counsel. There should not be a title in the report. Just create the report and keep it very simple in format.