Dr. McDiarmid s Personal Injury Report

Frank McDiarmid, D.C., FRCCSS (Canada) (email: frank@quadrachiropractic.com) Quadra Chiropractic City Centre Chiropractic 2602 Quadra Street 2832 Leigh Road Victoria, B.C. Langford, B.C. V8T 4E4 V9B 4G3 Tel: 250-386-8887 Tel: 778-440-1828 Fax: 250-360-0966 Fax: 250-360-0966 Dr. McDiarmid s Personal Injury Report PART 2 CROSSEXAMINING MEDICAL DOCTORS Welcome back! I hope you found part 1 insightful into the lack of training your average medical physician has when it comes to neuromusculoskeletal injuries. I am certain that the scientific based approach makes much more sense than a hunt-and-peck exam/no subjective questionnaires/a waste basket catch-all diagnosis/no photos/ two or three affidavits attesting to the person being in pain/pain ledger/negative imaging (typically because the doctor does not know what to order-more on that another time) medical testimony to just go get more therapy and exercise (if it did not help over the 2-3 years between the collision and the trial, I doubt it s going to help now), all that still in 2013. In a rear or side-impact collision, these photos are vital. Any practitioner, being called to give testimony should be able to recite that person s normal range of motion in all 6 degrees of freedom, for their gender and age range. A good 2013 example is He found that she had a full range of motion in the lumbar spine with some tenderness

2 when her back was extended. After hearing that I would be most interested in what is normal for that person s gender and age category. To have tenderness, with extension, is to load the passive holding elements and is a clear indication of injury to the passive holding elements. So why is there no further questioning about how said doctor would differentiate active versus passive elements? Follow-up questions about how to differentiate a muscle injury from a facet injury prove most enlightening. Remember, the neck s facet joint is the most highly researched pain producing structure to date and is believed to be responsible for up to 67% (depending on the study) of long-term pain in late whiplash. I ve sent out 2 earlier PI Reports that go in-depth on this very topic. If you never got them, email me and I ll resent them to you. Have them quote a single study (there are a number of them) that demonstrated the large number of injuries not visible when imaged (Xray,CT Scan,MRI) with cadavers and were subsequently microcryotomed thereby revealing the injuries (rim lesions, hemorrhages, internal disc tears or separation of the disc from the vertebrae, etc.). Failure to be able to answer these questions, the basics concerning these types of cases, will reflect most unfavourably upon the doctors skills. Be it, the plaintiff s physician or a defense funded IME performed by a physical medicine rehabilitation physician (PMRP), it is all fair game. Remember to check on the PMRP doctors actual qualifications. It s no secret Cultural Authority plays a BIG part in this arena. The majority of medical doctors do not have the formal training to differentiate musculoskeletal injuries. Because their training is in diseases (viruses and bacteria), re. pathology, they over-rely on vital signs, x-rays, and the pain described by the patient. Ten major Canadian universities medical schools the average amount of time devoted to pain management was just 16 hours, over 4 years training. Veterinary medical students received approximately 87 hours mandatory training. By the time settlements are being discussed the case is well into the chronic pain timeline.

3 In all fairness to the family doctor, they do the best they can. Unfortunately, a nice summary of what one of Vancouver s most highly respected Orthopedic Surgeon s (taken from a TLABC seminar I attended in 2009) had to say about modern medicine s standard approach for a typical complaint. It starts out with the acute injury, a history is taken and a physical examination is performed, diagnostic tests are performed and ordered, a treatment plan is determined, therapeutic Thunderbolts (his words, not mine) are administered, Cured! That approach is the standard for all medical training. As he stated, the problem comes with chronic pain, which is traditionally recognized as any condition lasting longer than approximately 3 months. Here, the model just described, breaks down. The pathophysiology is unknown, the majority of any tests ordered or performed are normal, and when they aren t normal, the doctor doesn t know what to order. A perfect example is ordering a high radiation CT Scan when an MRI (no radiation) was more appropriate. All too often the medical doctor will default to a psychosocial diagnosis. A nice comparison was the BC Whiplash Inintiative (BCWI) from some years back. It was a traveling road show, it went throughout the province, and only medical physicians were allowed to attend. It consisted of 4 Modules and basically spun organic injury into a psychological illness, all paid out of yours and mine insurance premiums. Finally defaulting to what the good doctor termed was his profession s Bacon Saver (again, his words-not mine) that of Cultural Authority. Your typical medical doctor s formal training, regarding injuries we are discussing here, is minimal at best. Probably the best comparison I heard was that Canadian (internationally for that matter) medical school s training in injuries, such as we are discussing here, is about the same as they get in dentistry. Therefore, when I review a medical legal report and I see one of the more popular waste basket Catch-all diagnoses,

4 i.e. Myofascial Pain Syndrome, Chronic Pain Syndrome, Myofascitis, Whiplash, Soft tissue Injury, to name but a few, my crap detector starts going off, regardless of who wrote it. It s for that reason lines such as He assessed her condition as a persistent mild soft tissue injury. are more amusing than informative. The term `soft tissue injury is so nebulous and trivializing of a wide variety of injury types ranging in severity from symptoms of a few days to a lifetime of debilitating pain that it should be completely abandoned. Dr. Michael Freeman, PhD (Epidemiologist) As far back as 1993, the following was published in the journal Sports Medicine Injuries and diseases of the musculoskeletal system account for more than 20% of patient visits to primary care and emergency medical practitioners. However, less than 3% of the pre-clinical medical school curriculum is devoted to teaching all aspects of musculoskeletal disease, and only 12% of medical schools require mandatory training in musculoskeletal medicine during the clinical years of undergraduate medical education in Canada. Here s something to consider, in a 2005 edition of the prestigious American Journal of Bone and Joint Surgery an article regarding medical training and musculoskeletal conditions was published. It involved 334 volunteers consisting of medical students, residents and staff physicians. The average score was 45% of which 79% of the participants failed. Another study, also published in the American Journal of Bone and Joint Surgery, took place at the University of Pennsylvania, School of Medicine. The article pointed out, the topics with which all physicians should be familiar. The participants were medical school residents on their first day of residency. The passing grade was 73.1% of

5 which 82% failed. The article summed it up failed to demonstrate basic competency in musculoskeletal medicine. On a final note, the University of Pennsylvania was redone only this time at the Flinder s School of Medicine in South Australia. Three of the questions had to be reworded because Aussies speak a little differently. On a personal note, having spent 2 years living down there I can attest to that fact, and I mean that in the nicest of terms. This time the exam was given to 31 practicing orthopedic surgeons and 66 interns. The passing grade was 73.1% and only 68% passed. To spare anyone crying foul, re. lack of clinical experience, the test was also mailed to 100 of the communities general medical doctors. Only 47 completed and returned the exam questionnaire. Of the 47 respondents, only 32 (68%) were able to reach a competency level of 73.1%. As stated in the Facet Injury article I sent earlier, the facet joint is the most highly researched, pain producing, structure in the spine, regarding injuries such as those we are discussing here. Back pain is not a disease, we re not talking Cauda Equina here. Have them explain how they would examine someone to determine the difference between a muscle v. a facet joint injury, what s the difference between IDD and a herniation, what s the standard ROM for the plaintiff, name any of the risk factors for acute and late whiplash, how much formal training did they receive in chronic pain and or neuromusculoskeletal injuries, can they diagram chronic pain (easy stuff-it has 3 components; receptive field enlargement, synaptogenesis and wind-up, more on that another time), ask why a low back injury occurs 30-50% of the time in rearimpact collisions (dust off the 2 PI Reports I sent out earlier covering this very topic) with minimal to no damage, why do women have twice the vulnerability to injury than men, how does a seatbelt contribute to being injured, etc, etc. I should mention that Myofascial Pain Syndrome continues to enjoy a significant degree of popularity, particularly with those formally trained in pathology (re. disease-virus and bacteria), not in

6 neuromusculoskeletal injuries. It s basically a generic, theoretical basis for chronic pain stemming from muscles in many regions of the body. Yes, it is a recognized diagnosis, but not at the frequency it s reported. Even myofascial experts have difficulty agreeing on the presence of trigger points, as far back as 1992. The presence of tenderness does not in and of itself make a trigger point. Here s something to think about the next time you see this popular diagnosis, the so-called trigger point overlies the facet joint! Ask the doctor to describe the trigger point s pain pattern, because they are pretty much identical to the referred pain patterns of the facet joints. Then pull out a trigger point referral chart and a facet referral chart for all to see. Recall from the earlier PI Reports I ve sent out, facets are the number one injured structures when it comes to the types of collisions we are talking about here. Enquire how they differentiated the two, having already viewed their clinical notes knowing they never did along with having no formal education in these injuries, makes for an interesting line of questioning. Remember, a point of tenderness does not make a trigger point or a primary myofascial diathesis. Just turn to the diagnosis and rest is easy. How many continuing education seminars have they attended, in the last year v. 3 years v. 5 years, addressing injuries such as we are discussing here? Ask why they would prescribe an anti-inflammatory when they are documented to actually delay healing (reduce chondrocyte migration, reduce blood flow, etc.) and quote the multitude of possible side-effects) and the death rate, which is actually quite scary. A site I like is www.rxisk.org. It s free to register and will really bring you up to speed regarding medications. Factually speaking Tylenol is the #5 medication for mortality, in terms of numbers. If the medical legal reveals a common waste basket diagnosis, and there was no mention in the examination section of having specifically isolated/reproduced the complaint(s) with the test names, I would be very interested in having them demonstrate exactly how they performed the examination. If the examination section mentions nothing more than palpable tenderness, range of motion guesstimations to an end point of

7 pain, muscle spasms (Dr. Morgan s testimony comes to mind), not to mention a number of other commonalities, chances are you ve got, or are up against, a case based on nothing more than hunt-and-peck. At that point it would be most interesting to immediately follow it up with a demonstration of how to perform a thorough examination, including verbal narration and what each test means, easy. How one can offer an opinion for long-term prognosis and not have the formal training, not knowing how to perform an examination, not know how to take a thorough history, order incomplete or incorrect imaging, offer up waste-basket catch-all diagnoses, not know the difference between an accident and a collision, not utilize a single subjective questionnaire (or repeat them), not be able to recite any of a number of different peer-reviewed references regarding long-term prognosis, etc. etc., is truly beyond me not to mention why it s hardly if ever challenged. If imaging has been ordered then check the specific views requested to see if cervical spine flexion and extension views were performed. They are vital in traumatically induced injury, beyond your routine series of AP and lateral. If it s too painful to be positioned for them, when acute, then ask why they weren t sent back for them at a later date. Also, for every 10 sets of X-rays ordered, related to collision induced injuries, how many also get flexion and extension films and what are they ordered for? The answer is to rule out ligamentous instability. Side note, if you have a client complaining of neck pain >1 year, of enough intensity it compromises their lifestyle to any degree, you might want to send them out for the films and subsequent report. In Victoria anyways, there is an over reliance on CT Scans. I suspect it s more to do with ease of availability than being an imaging modality of choice, but that s just my opinion. In the arena of soft tissue injury, the imaging modality of choice is the MRI. A CT Scan is ordered to eliminate boney involvement, i.e., fracture, tumor. When you understand that an abdominal CT Scan exposes the patient to the equivalent amount

8 of radiation of approximately 500 standard abdominal radiographs, it makes for a good line of questioning why a physician would expose his or her patient to so much ionizing radiation regarding why it was ordered and exactly what they were looking for (or to rule out). The average person receives about 3 millisieverts a year, via daily background radiation, v. an astrounaut who is permitted to be exposed to 1000 millisieverts over their entire career. Specifically how would the results have changed the direction of care, and why was an MRI not ordered considering it doesn t involve ionizing radiation. It s documented that if the ionizing radiation, from CT Scanners, was reduced by as little as 5% we d save approximately 125 Canadian s lives a year. Speaking of ionizing radiation, it might be worth mentioning that the dosage involved in BC hospitals varies by 8X! Again, there s more, but we ll save it for another time. If you have a trial pending, and would like a sample of questions to ask a health care provider, call me. My training qualifies me to discuss how the collision itself contributed to the injury(s), the biomechanics of how the injury(s) occurred, and the clinical component itself. That said, I m thinking of holding a 4 hour seminar, covering most of the material that have made up the these Reports to this point; i.e. apportioning today s pain/impairment to before and after the collision or between 2 separate collisions, photos to take, how to tell what s a thorough exam v. hunt-and-peck, imaging (when, how and why), my 10 favorite questions for a healthcare provider, who s formally trained and how to tell the difference, exactly how a low back and shoulder are injured in a rear/side impact collision, how a seatbelt/shoulder harness actually compounds these injuries, how the IAR is the principle behind these injuries, why someone is injured yet their maximum range of motion is never exceeded, etc. If I get 10 people interested, I ll hold it. The cost would be minimal. Email a reply if interested and I ll set it up for a time convenient to most.

9 I m also available to speak to your firm, which would qualify for those necessary continuing education credits, and allow me to meet the members of your firm. We re all getting together far too seldom nowadays, one of the downfalls of technology I guess. If this interests you, I would suggest you also invite office staff, because the better informed they are the better off your clients will be. The purpose of the Personal Injury Report is to keep you updated on relevant academic concepts pertaining to side/rear impact whiplash injury patients. I hope that the information is useful in terms of enhanced understanding, as well as helpful for the personal injury attorneys to deal with insurance claim adjusters, healthcare providers and adverse medical experts. Let s start to introduce some actual science into these cases. My hope is that this, and earlier PI Reports, will help us on the road to less reliance on Cultural Authority and more reliance on peer reviewed literature. Additionally, your law firm has access to daily phone consultation (or email) with me, to discuss any pertinent issues you might face, on a particular case. That applies as much to defense as plaintiff counsel. Frank McDiarmid, DC, FRCCSS (Canada) Email directly: frank@quadrachiropractic.com