What did the GP say? Making sense of a claimant's self-report about care received
Drs Hugh Koch, Faye Fraser, Chris Harrop, and Elizabeth Boyd discuss the importance of careful analysis of GP records in forming a robust expert opinion
A robust psychological opinion is based on five sets of data: the claimant's self-report of history and complaints, the expert's observation of the presentation and mental state of the claimant, any objective psychological or behavioural testing data, the claimant's medical records, and any other collateral sources of information (see 'The importance of medical records in psychological cases', B Leckart, WETC Psychology Newsletter (April 2013)). Medico-legal postulates (as discussed in 'Robust opinions need robust reasoning: 15 medico-legal postulates', HCH Koch) have clearly illustrated the importance of careful analysis of GP records, which increases the robustness of expert opinion (postulates V, VIII, and XII).
Prior medico-legal reports
Within the context of the ongoing litigation, it is likely that there will be at least one or two medico-legal reports in existence from a GP, orthopaedic surgeon, or A&E specialist. These will indicate possible areas of psychological difficulty, as well as describing the index event and its general 'medical' consequences, including GP attendance at or around the time of the index event. Such reports, typically commissioned between six and 18 months after the index event, will indicate whether the psychological symptoms are persisting at the time of interview.
These pre-existing reports are invaluable in setting the scene for subsequent psychological investigation. As with any expert, it is incumbent on the GP or orthopaedic expert to keep conclusion and opinion within their own field and not stray into conjecture outside their expertise. This is especially important in the area of chronic pain, and is also important in the management of claimant expectations, for example erroneously telling a claimant that the psychological expert will recommend treatment.
Vignette: The claimant reports that he had not attended his GP at any time prior to the index car accident to discuss any type of psychological problem and had never been involved in a prior road traffic accident. He went on to state that, following the index accident, he attended his GP during the first week, discussed his stress, and was given antidepressants and referred for counselling, which took place over the next six months. He denied any other road accident since the index accident.
The assessing psychological expert will initially listen to and note all the above statements. However, in order to develop a robust opinion which is based on validated evidence, it is essential to see and review the claimant's GP records referring to attendances both prior to and following the index event. This information will allow the expert to confirm, disconfirm, or clarify the four statements made by the claimant in the example vignette above.
Taking each statement in turn:
1. Prior GP attendance for psychological problems: Claimants can omit important details of their prior history for conscious (wish to mislead or distract) or unconscious (lack of recall or misinterpretation of question) reasons. A key time frame is the 12-month period immediately prior to the index accident. Larger time frames may point to a predisposition, vulnerability, or 'thin skull', but the 12-month period points to the possibility of a 'crumbling skull', which may significantly affect the causation and hence the resulting quantum decision (see 'Thin and crumbling skulls', HCH Koch et al).
2. Prior road accidents: It is probable that a previous road accident in which the claimant was injured and brought a personal injury claim would be remembered during questioning, either in the interview or in a pre-interview questionnaire. Apart from a test of reliable recall, the relevance of a prior accident is when injuries are ongoing, especially in terms of anxiety or depression. Occasionally, a claimant will explain the lack of information by stating, 'I didn't think this was relevant.' Clear instruction about recall and provision of full historical factors is important at the outset of an interview. GP records provide the factual and accurate data against which the claimant's recall can be tested.
3. GP attendance immediately post accident: Confusion may arise over recall of the type of consultation (physical/psychological), medication (antibiotics/antidepressants), and treatment (physiotherapy/psychotherapy). GP records will clearly state what was discussed and what treatment was recommended. GP notes are typically of high quality and reliability, and any significant fact raised in the consultation by the claimant is likely to be noted in the contemporaneous GP attendance entry.
4. Subsequent road accidents: With the claim and associated interview focusing primarily on one index event, it is not uncommon for claimants to be overfocused on this event and not 'recall' any subsequent similar event. The factors described in (2) above also pertain to this issue. GP records will hopefully 'fill the gap' of forgotten information, which can result then in a further discussion and assessment of post-index event problems, causation, and duration.
In a previous publication ('Reviewing medical notes', HCH Koch, B Leckart, K Shannon, and J Hetherton, Expert Witness Journal (Autumn 2014)), we outlined a number of factors which illustrated the importance of reviewing GP records carefully. These included:
• How GP data helps opinion formulation;
• Categorising GP entries;
• Reasons why claimants visit their GP:
a. Attendance and non-attendance reasons;
b. Severity and GP attendance;
c. Delayed attendance post accident;
d. Interpretation of GP attendance notes; and
e. When medical notes say post-traumatic stress disorder (PTSD).
• Pre-accident depression; and
• Technical problems with GP records.
This follows on from previous publications of this topic ('Perfect attendance' (January 2006) and 'GPs: The primary port of call for the anxious patient?' (November 2006), HCH Koch et al, Legal and Medical). The reader is referred to these papers for a full exposition of these factors.
A robust psychological opinion requires careful and rigorous analysis of GP records, whether the purpose/context is the preparation of an assessment report, a joint opinion discussion, or a court hearing attendance. In some cases, no GP records will be available. This may reduce the robustness of an expert's opinion. However, where these are in existence and available, the lawyer is best advised to obtain a legible chronology of GP attendance to clarify with the claimant what occurred and to highlight to the expert the 'facts' of pre-litigation and post-litigation attendance. The expert can make asignificant contribution to the legal process by carefully considering the meaning of different GP attendance records, thus reducing unnecessary ambiguity. The GP, meanwhile, soldiers on, and can make an invaluable contribution with accurate records keeping and clinical observation untainted by lawyer or expert.
Although GPs are not trained in either psychology or psychiatry, and therefore cannot be expected to obtain the detailed types of data that one would typically obtain from a psychologist or a psychiatrist, the GP's timely and reliable records are invaluable to the court's deliberations.
Dr Hugh Koch, pictured, is a chartered psychologist and director of Hugh Koch Associates. Drs Faye Fraser, Chris Harrop, and Elizabeth Boyd are also chartered psychologists at the firmTags: