Mark Mullins, a consultant orthopaedic surgeon at the Morriston Hospital, Swansea, provides a brief overview of the role of medical evidence in a personal injury claim
The aim of a medical examination is to quantify the injuries and symptoms that can be attributed to the accident which the claimant has been involved in. It is important to remember that the examining doctor has a duty and responsibility to the Court and is an independent medical expert.
Prior to the assessment the claimant will usually be required to complete a questionnaire regarding the details of the accident, the subsequent symptoms which they have suffered and the treatments received. This questionnaire gives the claimant an opportunity to put down all relevant information in a quiet and focused manner, enabling them to retrieve relevant dates which may not be available during the course of the medical assessment itself.
The assessment usually takes around twenty minutes. Initially the claimant will be asked a series of questions, again focused on the effects of the injuries which have been suffered. Whilst we appreciate that many claimants have a large number of medical problems, the medical expert will attempt to focus on any relevant injuries sustained in the accident as these are the issues he has been asked to examine by the instructing solicitors. It is helpful to have a list of medications available but again the expert will attempt to focus on the relevant medication the claimant is taking and will probably not take into account any other medications, such as heart tablets, blood pressure or diabetic medication.
Following discussion of the symptoms, there will then be a physical examination of the relevant areas. This will be a focused examination looking for specific signs and features and therefore may be different to those which treating doctors may have undertaken previously. Should a claimant require a chaperone for any part of the examination they should feel free to ask.
At the end of the consultation the independent expert will probably summarise the situation. It is usual for a review of the medical records to be undertaken subsequent to the assessment. This may reveal further information about the case and any pre-existing medical condition that may have been previously omitted. The review of medical records will be incorporated within the medical report and form part of the contributing information to the opinion of the examining medical expert.
It may be that the assessment reveals long standing conditions the claimant is not aware of and that these may have been stirred up in the short term or the long term by the accident.
It is also important to remember that certain conditions, including headaches, neck pain and back pain, are present throughout the normal population even in the absence of an accident and the background rate of these conditions (how often they occur) has to be considered when assigning disability or suffering to a particular accident.
The medical report is then returned to the claimant’s solicitors. The solicitor will discuss the report with the claimant, when further queries can be raised and points clarified if required.
Overall it must be stressed that claimants should not be anxious about the medical examination and view it more in terms of a routine hospital out-patient appointment but with a particular emphasis on the recent injury and its effect.