This article outlines the use of medical literature to support a physiatrist’s expert opinion in the development of a life care plan and proposes a basic ethical code of conduct in performing medicolegal work.
Key points
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Providing life care planners with evidence-based recommendations requires a thorough knowledge of how to search, read, and critically apply literature findings to the individual patient.
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Knowledge of available databases, as well as how to determine the relevancy and validity of research findings, is key to providing evidence-based recommendations.
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The physiatrist performing medicolegal work must be aware of their ethical duties.
Introduction
The soundness of any life care plan depends on how thoroughly it addresses an individual patient’s or client’s needs. Accuracy in a life care plan requires establishing a proper foundation of opinion for recommended services. Physiatrists who provide expert opinion for life care plans should be guided by the recognition that recommendations for the long-term needs of permanently injured or impaired persons must be based solidly on medical evidence. In turn, the life care planner should incorporate the physiatrist’s recommendations in a comprehensive manner and be consistent in his or her methodology. The physiatrist providing recommendations to the life care planner can help bolster his or her opinion on the long-term care needs of the individual by applying findings from relevant, peer-reviewed literature. Fundamental elements of evidence-based life care planning include a commitment to a frequent review of relevant literature to stay informed about current research, as well as developing criteria for determining research acceptability. Advantages of evidence-based life care planning include defensibility of opinions given in plans and in testimony, the minimization of errors and omissions in determining care needs, and better treatment guidelines for patients to follow, leading to optimal medical and rehabilitation outcomes.
Introduction
The soundness of any life care plan depends on how thoroughly it addresses an individual patient’s or client’s needs. Accuracy in a life care plan requires establishing a proper foundation of opinion for recommended services. Physiatrists who provide expert opinion for life care plans should be guided by the recognition that recommendations for the long-term needs of permanently injured or impaired persons must be based solidly on medical evidence. In turn, the life care planner should incorporate the physiatrist’s recommendations in a comprehensive manner and be consistent in his or her methodology. The physiatrist providing recommendations to the life care planner can help bolster his or her opinion on the long-term care needs of the individual by applying findings from relevant, peer-reviewed literature. Fundamental elements of evidence-based life care planning include a commitment to a frequent review of relevant literature to stay informed about current research, as well as developing criteria for determining research acceptability. Advantages of evidence-based life care planning include defensibility of opinions given in plans and in testimony, the minimization of errors and omissions in determining care needs, and better treatment guidelines for patients to follow, leading to optimal medical and rehabilitation outcomes.
Searching the literature
A variety of databases index literature useful in determining long-term care needs and research related to life care planning. Examples of such databases include the following:
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CINAHL via EBSCOhost: a database of more than 3000 journals for nursing and allied health research, with more than 610 being free full-text titles
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APA PsycNET: a database that indexes and delivers American Psychological Association content and offers institutional site licenses as well as individual access to articles on behavioral science research
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PubMed: a free database that primarily accesses MEDLINE, a database of references and abstracts on the life sciences and biomedical topics; PubMed contains more than 22 million records for biomedical literature
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Elsevier: a publishing company that publishes around 1250 journals and close to 20,000 books and major reference texts related to science and health information
Another database resource for physiatrists and life care planners is FormPro, a resource created by Reg Gibbs, one of the authors of this article. This database is designed specifically to collect evidence-based information on a variety of common diagnoses that are often encountered when preparing a life care plan. The articles cited in FormPro focus on the long-term care needs of the individual. FormPro includes peer-reviewed articles and resources that pertain to such needs and can be searched by keyword, injury type, and pediatric and adult age groups. FormPro’s database includes journal articles, books, clinical practice guidelines, and Web sites that provide evidence to support case-related recommendations. FormPro is a valuable resource for life care planners and medical professionals commenting on long-term care needs, because the database screens out research that is not relevant or of good quality, such as studies on animals and studies on acute care needs or treatment strategies for individuals (in this article, these studies are referred to as acute studies). FormPro’s database allows users to search by additional criteria to narrow results and to conduct specific searches for longitudinal studies, resources on life expectancy, resources that discuss the need for attendant care, and resources on employment after injury.
FormPro can also create questionnaires and checklists specifically for evidence-based life care planning. A Patient Care Needs Questionnaire can be created using specific criteria, including a patient’s age, gender, and injury type. The questionnaire lists common medical services, surgical and procedural treatments, and diagnostic tests associated with a specific medical condition, as well as addressing a variety of other concerns applicable to the needs of a permanently impaired individual. The questionnaire has several sections that allow a provider or consultant to rate a patient’s capacity for activities of daily living and their need for functional assistance. A comprehensive list of complications of the specified injury appears near the end of the form, and the provider or consultant has the opportunity to rate each of them as potential, probable, or already present. A rating greater than 10% for any of the care needs, tests, complications, and so forth is the threshold level for inclusion on the form. A 10% threshold was believed to be adequate for inclusion for most circumstances, but additional comments are allowed, as noted in the forms. The FormPro checklist evolved from a desire to be thorough but also to eliminate undue influence by the life care planner.
The FormPro questionnaire and checklist system are flexible, allowing the user to add specific services warranted by a patient’s needs and to omit any service deemed unnecessary. A key benefit of this flexibility is the ease with which a single questionnaire or checklist can be created to address more than 1 injury. If a patient has both a mild brain injury and complete paraplegia, for example, the user does not have to create a separate form for each condition. Instead of recording the opinions of physicians, consultants, and other care providers with the aid of documents created ad hoc, FormPro offers a standardized, repeatable, and comprehensive way of recording opinions for every case.
Determining Relevancy of Literature
Not all literature is of equal quality, and it is important to determine if an article is relevant to the case in question. In developing a life care plan, it is important to avoid animal studies, acute studies, and case studies. Animal studies are generally conducted as an initial step in experimental drug/procedure studies or to understand a process not yet understood in humans. The rational for conducting animal research is that it is safer or more ethical to test on animals before moving to humans; however, any information gleaned from animal studies would have to be confirmed by human studies to be empirically accepted as relevant in a human population. Although animal studies can be an important first step in research, they are not sufficient to make recommendations in a life care plan.
Acute studies often deal with short-term complications that resolve with time and treatment, or issues that are not present in an individual who is at maximum medical improvement. For example, many acute studies on traumatic brain injury focus on life-saving techniques, surgeries, therapies, and medications that are not relevant once 2 years has elapsed since the date of the person’s brain injury. Although a certain therapy may prove beneficial during the acute stage, it may not be useful or provide any benefit once the acute stage of injury has passed. Case studies are generally useful only for rare disorders or injuries. For example, few if any large studies have been conducted on the long-term care needs of individuals with hemipelvectomy. Because the injury that requires a hemipelvectomy is itself rare, as is survival after the injury, a large population is not available to study for long-term care needs. Thus, in instances such as this, a case study may be able to provide the physician with some guidance where they would otherwise have little or none.
The ideal research investigation to support long-term care needs is a study with a large sample of individuals with the same injury at maximum medical improvement. Superior research chooses the appropriate design for the type of research being conducted. A sample that is as similar as possible to the individual being assessed is ideal, and matching demographic variables such as race, income level, and educational level make for an even more accurate fit. Literature reviews and meta-analyses are also good for synthesizing and assessing literature quality and applicability. Guidelines are statements to guide clinicians in decision making for a specific diagnosis or injury. Guidelines usually include a review of the literature as well.
Greenhalgh discusses the hierarchy of evidence when reviewing literature. At the top of the hierarchy and carrying the most weight are systematic reviews and meta-analyses. After systematic reviews are randomized controlled trials, cohort studies, case-control studies, and cross-sectional surveys. At the bottom of the hierarchy and carrying the least weight are case reports. However, not all studies lend themselves to a randomized controlled trial design, and not all randomized controlled studies are designed well. Some may have serious methodological flaws, limiting their applicability to a patient’s specific condition.
The physiatrist as a consultant
Rehabilitation physicians are uniquely qualified to provide expert opinion for a life care plan by nature of their medical specialty. Through training, experience, and ongoing education, a physiatrist often provides lifelong care to individuals who have sustained an injury or illness that has resulted in a permanent impairment(s) and subsequent disabilities. Once a physiatrist enters into a patient-physician relationship, they should be informally computing both the short-term and long-term care needs of the patient. In addition, physiatric care of a patient often overlaps and interfaces with care from multiple other health care providers, such as other physicians, allied health care providers, and complementary/alternative care practitioners. Accordingly, physiatric understanding of the holistic needs of a medically compromised patient arguably exceeds that of any other health care professional. Given their experience and qualifications, physiatrists are often sought by and develop professional relationships with life care planners, or in some cases even become life care planners. Incorporating skillful and knowledgeable physiatric expert opinion in a life care plan is a first step in ensuring that the plan is comprehensive and has appropriate medical foundation. For this article, it is assumed that the physiatrist is acting as a consultant to a life care planner, although the principles set forth here certainly are also applicable to physiatrist life care planners.
By acting as a consultant to a life care planner, the rehabilitation physician is providing expert opinion. Acting in such a capacity, the physiatrist typically falls into 1 of 4 categories. First, the physiatrist can be hired by a company or third party as an employee or more commonly as an independent contractor. The physiatrist in the later role characteristically is asked to perform an independent medical examination (IME) and then provide expert opinion based on that evaluation. Usually, such an arrangement occurs when the physiatrist has been hired on behalf of the defense. Second, the physiatrist may be hired by the plaintiff or injured party’s representatives to provide expert opinion on their client’s rehabilitation and therapy needs. Third, as a treating physician, the physiatrist may be asked to provide expert opinion on the current and future abilities and care needs of their patient. Fourth, and less frequent, the physiatrist may occasionally be hired by the court or by both parties involved in a medicolegal dispute to provide expert opinion commensurate with their expertise. In providing recommendations to a life care planner, it is assumed that the physiatrist has expertise in the area of dispute and provides opinions and conclusions without bias or prejudice. For this discussion, all but the treating physiatrist is referred to as the hired expert or simply as the expert, whereas the treating physiatrist is referred to as the treater.
As a treating physician, it is assumed the physiatrist has some level of expertise in the areas being addressed regarding their patient. As a consequence, the credential standards for the treating physician are not as rigorous as they are for the hired expert, who has not developed a treating relationship with the patient, client, or evaluee, but has been hired instead primarily for their ability and expertise in resolving a forensic matter. At a minimum, the hired expert should be in active medical practice, in which at least 50% of their time is spent in clinical practice, addressing the ongoing care needs of patients. The expert should be board certified and in good standing, with an unrestricted license. The expert also must have some level of clinical experience with the forensic matter on which they have been asked to provide opinions. A more detailed discussion of this topic is in Appendix 1 on proposed model code of conduct.
Ideally, the recommendations provided by either the treating physician or the hired expert are supported by the medical literature. However, often there may be a paucity or lack of applicable literature regarding a specific recommendation or opinion. Further, there may be no literature on a topic because the problem may be rare or difficult to study or, alternatively, the answer to the problem is self-evident. For example, it is self-evident to a physiatrist that a teenaged ambulating below-knee amputee requires a replacement leg or that a stroke survivor benefits from a shower chair and grab bars, thus no literature is needed to support these conclusions. If the opinions of the physiatrist related to a particular question deviate from accepted practice or findings in the literature, such opinions should be supported with rational foundation, so that anyone else considering the same question would come to the same conclusion more likely than not. That is, if the conclusions of the treater or expert differ from the literature or accepted practice, the expert should be prepared to explain the methodology on which they have relied to develop their conclusions. In the absence of good scientific data to support a particular conclusion or opinion, appropriate scientific methodology can be used instead. The physiatrist must have a basic understanding of the scientific method to formulate such conclusions.
Ethical Duties of the Physiatrist
One of the greatest pitfalls that the physiatrist may encounter when making recommendations for a life care plan is not recognizing leading questions or directly answering them. An example of a leading question is, “Wouldn’t it be beneficial for Mr X to have a handicap-accessible van with adaptive equipment?” Certain assumptions need to be met for this to not be a leading question. For instance, is Mr X capable of driving, is Mr X incapable of performing a car transfer, and are attendants always available who can assist Mr X in his car transfers? Arguably, anyone who is a paraplegic would benefit from a handicap-accessible van, and why would one not outfit it with adaptive equipment, even if the paraplegic person cannot drive, because this person may have friends or peers who will use such equipment? However, not all paraplegics use handicap-accessible vans or require them. When confronted with such a question, the physiatrist should ask themselves whether such a vehicle is more likely than not medically necessary. Avoiding blanket approvals of such leading questions only strengthens the position of the treater or expert. Using a checklist, like those available through FormPro, eliminates the potential for bias or undue influence of the life care planner on the consulting physiatry expert. In addition, for those physiatrists who also prepare life care plans, using the FormPro checklist underscores the methodology that physiatrists use when thinking about their patient’s or client’s long-term care needs and when formulating a treatment plan. FormPro puts on paper the thought process that good physiatrists use when they interview and examine a particular patient.
When providing opinions and conclusions, the physiatrist obviously relies on their skill, knowledge, training, education, and clinical experience. However, what matters most in the medicolegal world is scientific data to support these conclusions. Thus, solely keeping current on the literature is insufficient. The expert and treater must have a thorough understanding of the literature as it applies to the forensic matter at hand, and they should understand the scientific merits of each applicable study and the particular strengths and weakness of the investigators’ conclusions.
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