Over To You

Expert reports

I am writing to say how much I enjoyed reading your article “A guide to writing expert reports” in the Ireland edition of Casebook 22(3), September 2014 .

I think that all of the important aspects of report writing were well covered in the article apart from one.

To be comprehensive and complete the article should have mentioned that, having supplied a written report, there is a small but definite chance that the expert may be called to give evidence and stand over the opinions expressed and the conclusions reached in either the Circuit or the High Court.
 
The expert will normally be led through his report but may then expect a sometimes rigorous cross-examination by the other side.This may include but not be limited to questioning the expert’s qualifications, impartiality, experience, opinions and conclusions.

A cross-examination, particularly one from an experienced, clever and sometimes deprecating barrister, is rarely an enjoyable experience but one that an expert should expect to undergo from time to time. Writing a report is one thing. Standing over it in a court of law is a part of the totality of being an expert and should, I feel, have received at least a mention in an otherwise excellent article.

Dr Stephen Murphy
The Park Clinic, Dublin  
 

Responses

I completely agree with the point you make regarding cross-examination in the context of formal legal proceedings. The article was intended to apply more widely to expert reports in general, many of which are written for purposes other than litigation. 

The role of an expert in the litigation process (depending on the jurisdiction of course) can be considerably wider and may involve attendance at conferences, provision of supplementary reports and opinions, and meeting the expert for the other side with a view to reaching an agreed, joint position. 

I will ask the author of the original piece to see whether a follow-up article, dealing with some of these other issues, might be helpful. Thank you once again for your comments.

Missed cauda equina

You report a case of a GP missing a cauda equina syndrome in a patient with a slipped disc (page 17, Casebook September 2014). I do not believe this is within the expertise of a GP and is not even within the expertise of many specialists. 

I have seen several of these cases not from slipped disc but from anaesthesia either by inserting a needle into the lumbar spine or from the insertion of a plastic catheter to anaesthetise the abdomen or legs. Most anaesthetists claim the procedure is harmless and that ‘soft’ catheters can’t harm. It may be rare but it is completely false to assume it is harmless. 

I recently saw a previously completely healthy middle-aged businesswoman who had weak legs and disabling and permanent urinary and faecal incontinence immediately postoperatively, after she had ‘soft’ catheter cauda equina anaesthesia. 

Various alternative explanations were given but the timing of her signs and symptoms were indisputable and occurred immediately after surgery. 

Other neurological colleagues I have discussed this with have had similar experiences. I suggest that spinal catheters should be avoided whenever possible. 

John W Norris
Emeritus Professor, Clinical Neurosciences
St Georges Medical School, London
  

Response

Thank you for your letter. Our case report was, as you point out, concerned with the care provided by the GP, and was settled on the basis of expert opinions from a GP and a neurosurgeon. 

Our GP expert was of the view that the care provided by the GP was in this case substandard, and the neurosurgeon was of the view that an earlier admission would have (on the balance of probabilities) led to a more favourable outcome. 

I quite agree that cauda equina syndrome may arise in a number of circumstances, but the key issue in this case was the delay in the GP recognising the “red flag” symptoms, and consequently failing to take
appropriate timely action.

High expectations

I am rather puzzled by “High Expectations”, in the September 2014 issue. From the description of the case, it sounds very likely that this was indeed a case of post viral fatigue syndrome (also known as Myalgic encephalomyelitis or chronic fatigue syndrome). 

No explanation is given of the basis of the probable possible diagnosis of chronic fatigue or what management was given for the condition. Post viral fatigue syndrome is a common condition probably affecting about 1% of the population. It is not difficult to diagnose as there are clear diagnostic criteria available today and it would be interesting to know whether this patient fitted the diagnostic criteria or not. 

They do indeed seem so bizarre to doctors that I feel a misdiagnosis would be unlikely if the criteria were properly used. In addition, in the following paragraph it is stated that the patient “… was convinced that there was a physical cause for his symptoms…” as if this rebutted the specialist opinion. 

However it is well-known today that chronic fatigue is indeed definitely an organically-based physical condition. This was clearly shown at the last conference of 2014 in the United States and it is no longer considered acceptable to consider a non-organic basis for the disease. 

It is probably a chronic encephalitis but this has not been definitely proven. There is management available for chronic fatigue syndrome. In my opinion, it is indeed negligent to miss this diagnosis in a patient who fits the criteria for it (eg, Carruthers et al 2003 and 2011 – these are the criteria I use). In addition the patient’s prognosis can be adversely affected if proper management including management of activity scheduling is not instituted as soon as possible. 

Unfortunately, at least in South Africa, this disease now occupies the same space as mental illnesses did in the dark ages and as multiple sclerosis did at the turn of the last century (“Faker’s Disease”). 

Patients generally do not have the energy or financial means to pursue their cases against doctors regarding this diagnosis but in my opinion it certainly should be a source of litigation because of the poor diagnostic skills of most practitioners in this regard, the ignorance about management and the stigma which doctors attach to this disease, greatly increasing the significant suffering of patients.

Dr Elizabeth Murray
Rondebosche Medical centre, Mediclinic Constantiaberg
UCT Private Academic Hospital,South Africa
  

Response

Thank you for your letter of 21 September, regarding the case report “High Expectations”. 

By necessity, our case reports are a summarisation of the actual case, where the documents often run into many hundreds of pages. This does mean that we are only able to focus on the most salient features of the case from a medicolegal perspective. 

In this particular case, even after the involvement of a number of specialists, the diagnosis was not completely certain. The claimant alleged a failure to make the diagnosis (probably a variant of chronic fatigue syndrome), as well as a failure to arrange vestibular rehabilitation. This will have been based on the advice of his solicitors and, in all probability, an expert opinion.

However, the expert opinion obtained by MPS on behalf of our member was supportive, as explained at the end of the article. It is important to bear in mind that the standard to be applied here is that of a responsible body of general practitioners, and not any higher, or different, standard. 

It is also the case that where there might be more than one school of thought on a particular issue, a doctor will not be negligent for choosing one over the other, as long as the option he chooses is supported by a responsible body of practitioners, skilled in that particular specialty, even if that is a minority opinion.

In this case, the claimant withdrew their claim before the matter came to court, which generally indicates that their solicitor (with the help of their expert) has advised them that their case is unlikely to succeed. Of course, medicine is constantly changing and advancing, and what would have been acceptable practice five years ago may no longer be supportable. 

In the context of medical negligence litigation, the standard which applies is, of course, that which applied at the time in question.

The elusive diagnosis

Re: “The elusive diagnosis”, Casebook September 2014

I am very surprised from the evidence given that the claim for late diagnosis of diabetes (presumably mellitus) was successfully defended. The failure to test the plaintiff’s urine is inexcusable. Many years ago the late Professor Peter Jackson estimated that in Cape Town there were an estimated 20,000 asymptomatic people with undiagnosed diabetes mellitus. Since then the provincial facility at which I used to practise has tested the urine of every new and returned patient for glucose et al. We were newly diagnosing two to three diabetes mellitus patients every week. 

Dr Stephen A Craven
Hon Lecturer in Family Medicine, University of Cape Town, South Africa

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I read “The elusive diagnosis” (Casebook 22(3), September 2014) with great interest, in particular the mention during two presentations of penile symptoms, described as “sore scratch on L-side of penis” and "a rash on the glans penis”.

Some years ago I submitted with a medical student a paper to the BMJ in the hope it would be published as “Lesson of the week”. We reported case histories of four men, aged 26, 34, 40 and 51 years, who presented to our department of genitourinary medicine in the month of July 2008 and were found on examination to have balanoposthitis, while three of them also had fissuring of the penile skin. All gave a history of or had a tight prepuce at presentation. 

None had a previous diagnosis of diabetes but all four were found at their first attendance to have glycosuria, with random blood sugars of 28.8 mmol/L, 14.8 mmol/L, 24.3 mmol/L and 17.5 mmol/L, in order of their ages as above. The 26-year-old gave a ten-month history of self-use of anabolic steroids for bodybuilding and was subsequently diagnosed with Type 1 diabetes requiring insulin. 

All four had their diabetes managed by their GPs and at least two were prescribed metformin. These patients all presented with balanoposthitis and at some stage appeared to have associated phimosis. It has been previously suggested that the sudden appearance of these symptoms in a patient without a prior history justifies investigating such patients for possible diabetes.¹

The paper was not accepted for publication as it was felt that the association with balanoposthitis and diabetes was well-known, although interestingly the 40 and 51-year-old had been advised to attend our department by their GPs. It is difficult from the description of the penile findings in the case presented in “The elusive diagnosis” to fully assess their relevance in regard to missing the diagnosis of diabetes in this case but balanoposthitis (and vulvitis particularly when recurrent) certainly warrant at least checking the patient’s urine for glycosuria. 

Dr Mike Walzman
Consultant in Genitourinary Medicine, George Eliot Hospital
Nuneaton, UK
  

Response (to both letters):

Thank you for your correspondence about this case. 

The chronology of the symptoms relating to the skin in this case was of a sore scratch to the penis (possibly infected) in June 2006, and of a rash on the hand and penis eight months later, in February 2007. Whether a doctor would be considered negligent in not considering diabetes in such circumstances revolves around whether their actions would be supported by a responsible body of medical opinion, skilled in the relevant specialty. In this case, the relevant specialty is general practice, and the GP expert instructed by MPS was supportive of our member’s actions.

It is important to realise that where there might be differing views as to the appropriate steps to take in an individual case, a doctor is not negligent for choosing one option over another, as long as the option he or she chooses would be supported by a responsible body of opinion. It was on the basis of the supportive opinion that MPS decided to defend the case. Subsequently, the claimant discontinued his case, presumably on the advice of his solicitors and any expert opinions they had obtained.