Report writing, however much some dislike it, is an inescapable fact of medical life
Report writing, however much some dislike it, is an inescapable fact of medical life, whatever field one works in.
There are several reasons doctors resist doing reports when requested, or at the very least defer them for as long as possible.
Firstly, there is the organisational issue. Setting aside time from clinical work and having to dig through a lengthy file is at variance with the daily flow of practice. Secondly, the stylised format required for a report is a challenge to some who find this type of writing difficult – and brings back memories of the relentless, and mostly pointless, form filling that is a feature of modern practice.
As many reports are for compensation or third-party claims, some practitioners do not wish to be involved with these matters (or dislike patients who submit claims). However, this is a legal requirement which cannot be avoided. For others, there is a fear of being shown up. Reports, after all, enter the public domain with judges, lawyers and even the media being free to comment.
Doctors work in a clinical cocoon. Their work is seen by the patient, ancillary staff and a few colleagues, in most cases. A report is an opportunity to show the outside world the skilled assessment that makes your work valid, if not distinctive. In short, a boost to the professional self esteem.
To this can be added that there is a fee for reports which is a useful addition to the Medicare-restrained income.
The fear of being shown up or criticised is understandable but should not be a factor. Doctors have qualified privilege in writing reports. That is, they cannot litigated for providing a professional opinion, only if they are shown to engage in blatant misconduct – eg. deliberately lying to influence the outcome of the judgment.
It is natural for any clinician to want to assist their patient in the report. However, it is not uncommon for the treating doctor to go overboard in promoting their patient’s claim. This tendency should be strongly resisted. Courts are well aware of this, which is why they also use independent reporters.
Being seen as an advocate essentially renders your report worthless. Equally, criticism by a judge of a sloppy or biased report is not a good look under any circumstances and every practitioner would want to avoid this.
The best way to overcome these inhibitions is to set up a routine that ensures the process runs smoothly. Many doctors put aside a regular time for preparing reports when they are not distracted by patients. Word processors are a huge asset. There is nothing wrong with using a report template, provided the work produced does not look stereotyped and provides the required information.
In preparing a report, the natural tendency is towards brevity. Follow this rule but remember that assertions need to be supported by facts; for example, generic statements about pain, anxiety or depression must be supported by descriptions of the underlying symptoms. Alternately, lengthy anecdotal accounts, rather than a precise history, are equally likely to antagonise those reading the end result.
Jargon is the biggest enemy of the report writer. It annoys the reader and devalues the case being put forward. This is a special problem with psychiatric cases where the court may share the public misunderstanding of these issues and need correct terminology to avoid getting the wrong idea; confusion, it can be said with certainty, will not assist the reception of a report.
With criminal cases, certain rules must be followed. Careful notes should be kept and direct quotations of significant statements used where possible. Threats or reports of violence or self-harm must be documented.
At the same time, when quoting secondary sources, such as aggrieved spouses making accusations, it is important to be objective, rather than uncritically list what they say as factual. At the very least, indicate that you are objectively documenting their comments without reaching a judgment.
This is of special importance in Family Court and child-abuse matters which can lead to cross-examination in court.
Psychiatric reports pose a special problem for the non-specialist. Vague terms such as “stress” send a shudder through the legal reader, with “anxiety” or “depression” no better. The laws for workers’ compensation and third-party claims insist on diagnoses from approved classifications eg, DSM or ICD.
On the other hand, it is unfair to expect the non-specialist to have a detailed understanding of these categories (to say nothing of the whirlwind of controversy that surrounds DSM-5). There is plenty of information available about the diagnostic categories on the internet and that should provide sufficient guidance for the non-psychiatric reporter.
In this regard the courts have reasonable tolerance for what can be expected from the non-specialist.
Whereas in the past compensation claims were largely based on physical injuries, the shift has been to psychiatric injuries such as post-traumatic stress disorder (PTSD) with claims of bullying or harassment escalating dramatically. Such claims can be highly subjective.
The treating doctor is obliged to accept the account from their patient but they should be aware that there is often a radically different view of the situation from the employers. Uncritical acceptance of the history should always be tempered by consideration of this possibility.
The commonest diagnosis made for psychiatric claims is adjustment disorder, a condition that did not exist before 1980, essentially referring to anxiety and depression arising from a known external stressor. Because the criteria for adjustment disorder are poorly defined, doctors should appreciate that there is a distinction between the clinical state and emotional distress that is a normal reaction to the situation (such as a workplace problem). This is often the chief point of dispute in settling the claim and should be considered by the writer.
There are many misconceptions about the use of PTSD as a diagnosis, to say nothing of continuing differences over its application between clinical and forensic psychiatrists.
It is important to remember that “Criterion A”, the requirement to have experienced an event outside the normal range of human experience, refers to issues such as war, assault or rape – not minor altercations, distressing arguments or witnessing incidental events.
The same considerations apply to cases of “nervous shock”, usually grief reactions in close relatives of someone who dies in an accident. There is a tendency to list persisting symptoms of bereavement after a year as being a pathological (meaning assessable) bereavement. After a sudden and unexpected loss, normal grieving can go on for several years before it becomes a clinical disorder.
Report writing, in summary, is an unavoidable part of medical practice. Overcoming inhibitions, setting up a routine and having a positive attitude will take out much of the pain and produce an excellent result which puts the writer in the best light.
And in the current contentious consumer-driven medical environment don’t we all need this?
Robert M Kaplan is a forensic psychiatrist and spends much of his time reading reports
