- Email: [email protected]
Medical reports bore me, too
MEDICAL REPORTS BORE ME, TOO G. Vice President
LESTER
and Genera1 CIaim Manager, American BOSTON,
MutuaI LiabiIity Insurance
Company
MASSACHUSETTS
RESUMABLY the word “bore” doesn’t begin to express the feeIings of the physician who is required to make out a medica report and anyone eIse who in the course of his duties must read it. With humbIe apoIogies to the “Stroud twins” we might go on to say that medica reports not onIy bore a11who have anything to do with them but they dispIease, annoy, troubIe, perplex, rag, tire, irk and so on, ad i&&urn. Not Iong since, I Iearned that at a meeting of a hospital board a physician was caIIed upon tb report on a case which he had in the hospita1. He was a weII-trained physician of Iong experience, chairman of the Board of HeaIth in the particuIar IocaIity in which the hospita1 was Iocated. He opened his remarks reIative to the case with the foIIowing words: “GentIemen, this is not a very good record of the case. I hate to write medica reports just as much as you a11 do.” Is not this statement indicative of the reason perhaps why the writer has been asked to prepare this article? But, why shouId this be so? WhiIe it has been agreed that medicine is not an exact science, medica men do represent a highIy trained and reasonabIy scientific profession. Perchance the answer to this question may, after aI1, be reIativeIy simpIe, e.g., that no one has previousIy taken the time and troubTe to expIain what “a11 the shooting” is about when the business of insurance compIains that medica reports are a bore. No one has explained to the medical profession the use to which these reports are put or expIained how vaIuabIe from the standpoint of the patient, the administering accident boards and commissions, and insurance carriers, these reports actuaIIy are.
P
MARSTON
Some physicians may feel that the insurance companies have IittIe right to require as a precedent to the payment of physicians’ biIIs an adequate medica report, or in fact question if the insurance carrier has any right to a report at aI1. In business, and presumabIy in the professions, a11 parties strive to pIease vaIued customers or clients. According to Best’s Insurance Reports for 1937, we may we11 assume that between 45 and 50 miIIion dolIars annuaIIy are being paid out by the stock and mutua1 insurance companies to physicians and hospitaIs for professiona services rendered in compensation cases. In addition to this vast sum, miIlions more are presumabIy paid out by the empIoyers who do not insure their compensation IiabiIity, and if we were to venture outside of the fieId of compensation insurance and consider the amount paid by casuaIty companies in other forms of coverage and by the Iife companies in their Iife extension work, etc., etc., we think that possibIy we have made out a case proving that the business of insurance is a worthwhiIe cIient whose request for codperation shouId not fal1 upon deaf ears or sightIess eyes. The aim of this articIe is not to be controversial or argumentative, but heIpfu1. After nearIy forty years’ experience the author stiI1 feeIs that the diffIcuIty in adequate and proper securing prompt, medica reports is due to Iack of understanding, on the part of the medica profession, of the probIem. We may break this subject down into severa parts. First, why are satisfactory medical reports diffIcuIt to obtain? Let us revert to the yesterdays of a quarter of a century ago when compensation Iaws were 490
NEW SERIES VOL.. XLII,
No. 3
Marston-MedicaI
first being considered by the IegisIatures of some of the states; to that time when this great piece of socia1 IegisIation appeared to be so very simpIe of administration, so devoid of procedura1 diff]cuIties, when it seemed that folIowing an injury arising out of and in the course of empIoyment all that wouId be necessary for the empIoyer or his insurance carrier to do was to pay the amount of compensation to which the injured man was entitIed, as decreed by the Iaw and defined as respects period of time and amount. Because this law which pIaced upon industry financia1 obIigations without regard to the question of fault, a thing aItogether unheard of up to that time in this country, it estabIished an entireIy new reIationship and additional responsibility as between the empIoyer and the empIoyee, the doctor and his patient. The safety movement already in existence received enthusiastic impetus, but always lagging behind in the progress of this socia1 IegisIation has been the deveIopment of a proper medica program of co6peration. It would serve no usefu1 purpose at this time to hoId an inquest to determine who was to blame or to attempt to narrate seriatim the progress which has been made to date. Exception to this might be made to pause briefly in our discourse to pay tribute to those whose breadth of vision conceived and brought into being a new branch of surgery, or speciaIty if you wiI1, generalIy referred to as industria1 surgery. Though it seemed heresy to some of the medica profession even to consider that surgery as appIicabIe to industria1 injuries couId possibIy be any different from the surgery which aIways had been, much credit is due the forward-Iooking members of the American CoIIege of Surgeons for their championing of the cause of this phase of surgery and especiaIIy for their progressive program as respects the treatment of fractures which has aIways been a serious and expensive probIem to carriers of compensation insurance.
Reports
American
Journal
of Surgery
49’
We have referred to the change in the reIations between the physician and his patient. Under the Workmen’s Compensation Law it was necessary that the physician must reveaI to some third person, e.g., the empIo?er or the insurance carrier, the facts reIatmg to the injuries suffered by his patient, i.e., their seriousness, the prognosis as respects disabiIity and his estimate of any permanent impairment that might reasonably result. So, it may we11 be that the faiIure to appreciate or unwiIIingness to conform to this changed reIationship may be to some considerabIe extent responsibIe for the dificuIties which we experience in adequate and proper securing prompt, medica reports in compensation cases. Why are medica reports necessary? Who uses them and how? They are necessary because in accordance with the provisions of a11 compensation Iaws no compensation is due the injured man, generaIIy speaking, unIess he has suffered a disabling injury requiring his absence from work or a permanent impairment which might possibIy resuIt from an injury in which there was no disabiIity (although such a situation in these days wouId be extremeIy rare). It is necessary that these reports be rendered promptIy due to the fact that compensation is in part presumed to take the pIace of the pay envelope whose arriva1 usuaIIy ceases with the beginning of absence from work. Who uses them? First of aI1, the empIoyer or the insurance carrier must have them for the foIIowing reasons: First, to determine if the injured workman wiI1 be disabIed a suficient Iength of time to entitIe him to the benefits provided by the Workmen’s Compensation Law. Second, to determine the probabIe Iength of that disabiIity. Third, to determine if their wiI1 be any permanent impairment, e.g., amputations, stiff joints, etc. Fourth, that the carrier may at the earhest possibIe moment erect a suit-
492
American
Journal
of Surgery
Marston-MedicaI
abIe reserve-Iater on we will refer to what this reserve is. Now the second group that are interested in the prompt receipt of an accident report are the industria1 accident boards or commissions whose responsibiIity it is to administer the Iaws of their respective states. Some of these boards or commissions require that medica reports be fired with them. IncidentaIIy, some require that medica bi1Is be referred to them for approva1 before payment. It is the function of these boards or commissions to satisfy themselves that the injured employee has been justIy deaIt with, that he has received the compensation which is provided for by the compensation Iaw. These groups oftentimes arrange that impartial examinations be made of the injured in order to satisfy themseIves impartiaIIy that the medical facts are as have been presented by the carrier or the empIoyer. Who eIse is interested in these reports? In serious cases probably the most interested individuaI is the medica or surgica1 director of the carrier who must, through the picture painted in the report, determine if there is anything that the carrier can do through its medica department to assist the attending physician-and, we are happy to say that through the years there has been a growing incIination or wiIIingness on the part of the medica fraternity to cons& with and ask for suggestions from the medica departments of the Iarger companies writing compensation insurance, an indication of co6peration which is indeed cheering and promises much for the future. Perhaps the next phase we shouId consider is the form to be used by the physician in making out the medica report. A few boards or commissions have a stock form of report which they require shaI1 be used. In most cases that form was mereIy for the convenience of a11 concerned, but as time went on and our interest in medical matters improved or grew, the inadequacy of those reports was recognized not onIy by the carriers, but by the InternationaI kssocia-
Reports
DECEMLIER,
1938
tion of IndustriaI Accident Boards and Commissions. Each group appointed a Committee on Forms part of whose duty was to attempt to standardize the many forms required by each state in the administration of this Iaw. With a fine spirit of co6peration these Committees met separateIy and Iater in joint conference and among other forms attempted to standardize on a medical report form. The standard form for surgeons’ reports known as “Standard Form 2” was approved by the joint committee and Iater adopted by the InternationaI Association of IndustriaI Accident Boards and Commissions at their convention in Columbus, Ohio in 1932. This conforms more or Iess in its details to the requirements of most of the states; it has been offIciaIIy adopted by many states and others, whiIe they have not adopted the form, have not objected to its use. We shaI1 attempt Iater on to expIain the reasons how and why this report should be compreted, but before doing so, and to sustain further our contention as respects the need for adequate medica reports, we should Iike to give some iIIustrations that have come to our attention from time to time which have so cIearly indicated the need for complete, adequate and accurate medica reports.. WhiIe the cases are from our own records, for obvious reasons they wiI1 not be identified in this paper. CASE I. In this case the Physician’s Report (Form SF2) stated in answering question 6: “Crushing of second fmger on Ieft hand. End of finger back to the first joint entirely amputated.” Upon that information, compensation in accordance with the provisions of the Iaw was paid to the injured man. SubsequentIy, we Iearned from information obtained from the doctor who made out the first report that onIy the tip of the bone of the termina1 phalanx was actuaIIy Iost and therefore there was no compensation due. CASE II. This was a coIored boy who had sustained a broken ankle. He was taken to the hospita1 where he was cared for by his physician. After the patient had been in the hospitaI about a month he was discharged and a coupIe of weeks Iater the physician sent in a report
NEW SERIES VOL.XLII, No. 3
Marston-MedicaI
that the patient was all. we11 and was able to return to his usual work. The injured boy was advised to this effect and he tried to go to work, in fact he did work two or three days, although suffering considerabIe pain. SeveraI weeks later the young man reported to his empIoyer that he was unabIe to work because the ankle was still bothering him. Later on x-rays revealed the fact that the ankle was entireIy unreduced, that it was not united, and that at the time the case was closed by his attending physician the patient was in no way able to return to his work. The result was that the patient had to be turned over to another doctor, the fracture rebroken and many months of disability ensued. This meant increased cost insurance company, pain to the empIoyer, and suffering to the injured man. This we11 iIIustrates the difficulties caused by a report that was too optimistic. CASE III. This was a patient with a broken hip. The physician took x-rays and found that everything was all right, but three or four without checking his months afterwards, results by x-rays, he allowed the patient to get out of bed. The patient waIked about, suffering a moderate amount of pain. There were optimistic reports from the physician. At the end of a year the patient had not yet returned to work, but stiI1 the reports were optimistic on his condition. Examination by a. second physician reveaIed that there was no union and that the patient had been a11 of the time walking about on an ununited fracture of the neck of the femur. Result-extensive, Long treatment had to be done, which took a great deal of time and caused a great dea1 of expense. CASE IV. This patient had his arm injured in some gears, sustaining fracture of the hand, wrist, elbow and shoulder. He was under the care of a busy, active surgeon. Repeated efforts were made to secure a medical report from him. We were put off for a period of three or four months. The doctor was taken sick and died before the initia1 medica report came through on a very sick patient. This was four months after the time of injury. CASE v. This patient had a septic hand. After severa weeks of treatment, the hand was getting worse although the medica reports were very optimistic. It was brought out after a Iong time and many requests for reports that the patient was suffering from diabetes and
Reports
American Journal of Surgery
that this was the reason that the disabiIity so prolonged.
493 was
If these cases indicate the faiIure of compIete and prompt and accurate medica reports, then their citing has been we11 worth whiIe. As doctors you have heard a great dea1 about the insurance company reserves, and it may be of interest to you to Iearn that one of the tests of the financia1 stabiIity of any casualty insurance company is the adequacy of its reserves, and that the state insurance departments under the Iaw and in the interest of the public good are constantly on the alert to determine that the companies doing business are soIvent. GeneraIIy speaking, in every other business a reserve is an asset but in the business of insurance it is a IiabiIity. Because it takes the place of a potentia1 debt, socaIIed, the amount set aside to Iiquidate this debt shouId at a11 times be adequate. In order to accompIish this, each claim when it comes into the insurance company offices is given a money vaIue called a reserve. If you were to buiId a house and your architect toId you it wouId cost ten thousand doIIars, you would see to it that you had that sum of money in the bank to pay for it. The fmancing of a compensation case is no different from that of financing a house and instead of reIying upon the plans of architects we must reIy on doctors and surgeons to furnish specifications in the form of medica reports in order that the potentia1 cost of that case can be properIy determined. Each case is a separate bookkeeping account against which amounts are drawn for the purpose of making compensation, medica and expense payments. In order that this account may at a11 times be soIvent, we reIy to a Iarge extent upon your fuII coijperation as respects furnishing us with the information requested in the medical reports. HOW TO MAKE OUT THE REPORT We hope that in this preambIe we have aroused sufficient interest to justify the
American
494
Journal
Marston-MedicaI
of Surgery
Reports
DECEMBER, 1938
m-m I%. L 1. 1
STANDARD FORM FOR
SURGEON'SREPORT b'-*db'L*.LLRC
:....._ ..__-_.__-___.__. ..._..._ :..._. ........-_..-__..._.__...__ ._ ......_._
(The spaces above not to k filled io by Employer)
ZL.,
1. Nama of fnjmd P.rsm:.__ ........._..._ _. ....._..._ _....._......._.........._...._................_..........Age: . .._I._....__. Se:. .... _...... _.___. ..... --.-._--._.State..._. ...__. ... 2. Address: No. mod St.. ..._....._...__.._...._I._.._ .._......___. ........._ .._....... City or Town.. ................ 3. Name md Ad&.. , of lL,&,er:...._..._..._..__._ .._ ...._...._. ........I ...._.................._................I.. .._.......___._....._ ......_.._.....................
%a .oddmt
4. Date of acsidemt:.. . ......._..“” ...._........._.I___......... .Ho w ....................... hf. Date disability began ............. ..__“._ .......................... ;” _...... 5. State in patie& own words where ad how occident occurred : ............... _.................................................. ___.-......._......._ ....................
.................... .._.....“. ... _...__....” ................ _^_._ ..._.....“..._..................................... ...“........... ..^........................................ -........... ................ ............... ......... .._...._.__................” ...._...._.......... _......... _...._........................... _...._......................................... .._. ............ ......... _............... _.................................. -6. Give accurate &acriptie~ of naturead extantof injury ad statsyew objective hndfn~:..._ .._....................................... ...................... ....”.............................. _................ . .........._...._................ _............................... _................... .._..........._......_ ......_......“...........................
....... _......... _..“....._..._............................... _“.....“.......... _........................... _.._._ ..“............ _.................................. _............... _................. .......... ...... ‘ha &rv
7. Will the injury result in (a) Permaocnt defect?. ......................... If so, what?. ............_ ....._........._........ - _.__....-. .._............................. (b) Facial or head disfi,ement.? ... .............~................ _.._........ ......................._..___ _ ........._.....................”....... (Pernuncntdisabilitysuchan lossof wholeor parts of ngerr. Iacul Orheaddwfiguurcment, etc nwlt be accwatet~0urLd 011chart on reve*scsld uf this rcpoct.> ., 8. Ir accident above referred to the only cause of patlmt s condltlon?. ........................... If not, state contributing cases: ........................
...._.......... . .__.“. ............ _...._.......... _“__. .... _....... _...-.._ _..._..._....._........ _.._. ............................... ..“................ ...... _....__. ...._.._. ............................... 9.
Is patient suffering from not due to this a&cot?.. .........._.....“.__...........“...._. ... IO. Has patient any physxal
sny disease of the hurt, lungs, brain, kidneys, blood, vascular system or any other disabling conditio ..._......_...........Give particulrs:. ........_....._.................................... _............_..........____........................................... ............ -. ..._....._.-. ..._.._.._ ..........I. .... -..............-................................................. _. .....“.......................................... . . . lmpalrment due to prmous acadent or disease?. ......._................ Gwe partxulars :..._.....................................
...._............... _......... ...“. ...._._........ “_...._...._. -. ...I._- _..._ .....“....... .._.._ ............ ...“........... ..“.......................... _................................................... 11. Hasnormal recovery been delayed for any reason ?_.._.................... Give particulars :.......................... _................ _................... .................. .......... _........ ..“............ “.__..._. ........_...“....... .._....- .._.............. ..“............. ...... .._.......... ...”......................... ..“...... .._.._......__“. ............................. 12. Dateof yourfirsttreatment :_........ _........................ .._....... Who engaged your services?. ....................... __.____ _.......................... ___ 13. Des&k treatment given by you: .......... _.................. _................................................................................................... _...... _................................. IYtm.mt ...._...._........................ _...._........................ . ........ I......................... ..-.......................................................................................... __................................ 14. Were X-Rays taken? ................ By whom?. ......._.......__.........._...............” ...._.........._.................................................... -When? ........................ @&n,cmd Address) 15. X-by
d,agnosr,:_. ..................... _.................................................... -. ................................................................ _.........._............................................. whom? ................................................. ..”............................ _.__Whm?..._ .._................... (Name md Add.&
16.Waspatient treated by anyone else?. ............... By
17. Was patient hospitalized7 ........................ Name and address of hospital :-..-...-..._........._..._......_ ...._ -_“-. 18. Date of ad&ion to hospital :.......................... ..~.............~ ..._.......... . _.....Dat e of discharge:. ...._..._....._.-__._. ,p. 1~ further treat,neot needed?...._...._...._............ __.................. . For how long?. .._................. _....I ........._..____-
inability
20. Patient $be
able
..._...._ ..._................ ........_. ..._-. ....._..... _...._...._............... _...
to remmm ngdu r~& ow_..........................-......”..............._ ......... _...._..I....._..-...._...-.._. ...... .._ .._.._...... or,:. .................................................................................. _ ...I .._.._ .._ ......................._......_..
above) .I_......I................” .....-. ............. .._...._...__._-._I__ ..._............._...............
\it\r
SERIES
VOL. XLII,
No.
3
Marston--MedicaI
hope that the folIowing attempt to analyze 3r expIain in detail the reasons for the questions asked on this report wiI1 be care-
Reports
American
Journal
495
of Surgery
abiIity must be judged in many cases by the type of report you make to the carrier or empIoyer. MARK FACIAL OR Hhhb DISFIGUREMENT
RIGHT
FOOT
RIGHT
HAND
SKULL
,
A
STATE RIGHT
WHETHER
OR
LEFT EYE
INDICATE WHETHER RIGHT OR LEFT ARM
fulIy read and thoroughIy digested. We fee1 sure that if they are, medica reports will no Ionger bore the maker or the reader. Remember, doctor, that your work and
For your convenience, we have facsimifes of the front and reverse the Standard Form of the Surgeon’s known as Standard Form 2. (Figs.
inserted sides of Report I and 2.)
496
American
Journal
FIRST
of Surgery
Marston-MedicaI
SECTION
The Patient. Let us consider together the first section reIating to the patient. I. Name of Injured Person. Write the name Iegibly in ink, for this is the soIe means of identifying the injured person and enabIes the carrier to connect promptIy the report to the proper fiIe. Age. Too much cannot be said about the importance of giving the age, for any Iayman knows that a broken ankIe in a man of 20 and the same broken bone in a man of 70 may have vastIy different consequences. Furthermore, it frequentIy happens that the age given by a patient to his physician is his true age whereas the age given to his empIoyer may have been different. Sex. Important oftentimes because the Christian name does not aIways indicate sex. For iIIustration, in the South particuIarIy the names of women sometimes are quite mascuIine, e.g., Johnnie, Johnsie, WiIIie, etc. 2. Address: Number and Street. This is important for the purpose of identifying and Iocating the employee. FrequentIy we find that the empIoyee has not registered his Iatest address with his empIoyer. The address shouId be compIete, giving both the number and street and the name of the city, town and state. Many times in the Iarger centers there are streets of the same name within a few miIes of each other; perhaps we shouId say in the adjacent suburban communities. If the insurance carrier has not the correct address of the injured man, it may be diffIcuIt for it to forward compensation when due. 3. Name and Address of Employer. This is most important in identifying the employer of the injured man as records in most insurance companies are fiIed by the name of the empIoyer. Therefore, this information assists many times in making a prompt investigation. FrequentIy the medical report is the first notice of an name and injury, and if the empIoyer’s address are not given. the report is returned to the physician for completion.
Reports
DECEMBER,1938
SECOND
SECTION
The Accident. 4. Date of Accident: Hour. The date of the accident and the definite hour of occurrence are of great importance, as this information heIps to determine whether the accident occurred during working hours and during the poIicy period. In some states, if the accident occurs late during the working period, the compensation period does not start unti1 the folIowing day. In other states it is otherwise. The date of the accident and the hour of the accident are aIso important because many times the making of a claim aIIeging an accident is an afterthought on the part of the cIaimant and it becomes very important to check the statements given to the physician. Many times there is a discrepancy which heIps us to determine whether the accident is a Iegitimate one or not. Date Disability Began. The date disabiIity began is equaIIy important with the date of the accident because in many instances there are deIayed disabiIities of perhaps days, weeks or months foIIowing the aIIeged accident. The date of disability is aIso important, possibly in determining the causa1 reIationship between the aIIeged accident and the condition found by the physician. This information is becoming increasingIy important in view of the widening of the scope of many Acts to incIude occupationa diseases. In such cases we have no date of disability or accident unIess it is given by the physician. In occupational diseases it is important to indicate the date the man quits work and the date he actuaIIy became disabIed. They may be two absoIuteIy different dates. We a11 recognize that a man may Ieave work because there is no work for him to do and later on he discovers that he has an occupationa1 condition on account of which he makes cIaim. 5. State in Patient’s Own Words Where and How Accident Occurred. It is aIways vaIuabIe and useful to put down in the first person just exactIy what the patient said
NEW Smrss Var. XLII,
Marston-Medical
No. 3
to the physician as to how the accident happened, e.g. : “I shpped on some water and feII down, Ianding on my back.” Such a statement contains the facts of what caused the faII and the part of the man’s anatomy which was injured. In most instances the physician is the first one to see the cIaimant foIIowing the injury and therefore the claimant is more IikeIy to give an accurate statement then than after talking with reIatives and friends. After all, what we are searching for in anv investigation is the truth. Many times “in compensation hearings the history given to the physician may be the pivota point on which the decision of the referee or commissioner hinges. It is of great importance to a11 claim examiners and medica or surgica1 advisers in determining the question as to whether the condition actuaIIy resuhed from the alleged injury or not. THIRD
SECTION
The Injury. 6. Give Accurate Description of Nature and Extent of Injury and State Your Objective Findings. When we come to this question we are impressed with the fact that this form of report appears to be a great record for a minor injury and a very smaI1 record for a Iarge or serious injury. In the Iatter case the information must be suppIemented by a more compIete report. Yet it must be aIways borne in mind that this is a physician’s story told to a Iayman and the avoidance of technica terms so far as possibIe is much to be desired. However, with a IittIe practice and thought, the description of the injury can be boiIed down to a few cornminuted words, such as “compound fracture of the right tibia in the mid third,” “right inguina1 hernia, indirect, scrotal, reducibIe.” If there isn’t room on the report, use an extra sheet of paper, for this is one of the most important items on the report. Upon this description depends the evahration of the case. It aIso assists greatIy in determining the question of whether the disabiIity is being unduIy proIonged. The
Reports
American
Journal
of Surgery
497
objective findings are of the utmost importance in determining the question of causa1 reIationship between the aIIeged injury or accident and the condition found by the physician. In’s great many instances the objective lindings reported by the physician fai1 absoIuteIy to bear out the diagnosis which he makes. For i1Iustration: we recently read a medica report in which the patient had received an injury. Physical examination described him as entireIy norma1 and described no abnorma1 or pathoIogic things about it. Then at the end in his opinion the physician said, “I believe this man is incapacitated from doing any work.” These are the things that bore, bother and annoy. 7. Will the Injury Result in (a) Permanent Defect (b) Facial or Head Disfigurement? If So, What ? Again a proper answer to these questions is of great importance in determining the value of the case, not onIy from the standpoint of temporary tota disability but from the standpoint of permanent impairment or dishgurement. Furthermore, with the vast experience which the medica departments of insurance companies are having in this highly speciaIized work, it is quite possible that there may be some treatment which they have Iearned about through experience in other cases which might Iessen or entirely eliminate the disabiIity or improve the end resuIt; and, in connection with question 7, attention is caIIed to the mannequin on the reverse side of the report by the use of which the doctor may indicate the exact point of amputation, injury or disfigurement. Accuracy in making this indication is of great importance because of the difference as respects the provisions of the Iaws of the various states. It is aIso important in answering this question to indicate whether there is any restriction and to what extent that restriction extends and where it is located. 8. Is Accident Above Referred to the Only Cause of Patient’s Condition? If Not, State Contributing Causes. Important because
498
American
Journal
of Surgery
Marston-MedicaI
some states do not recognize the aggravation by an injury of a previousIy existing systemic condition, compensation in such states being payabIe onIy for a disabiIity normaIIy to be expected froth that type of injury. 9. Is Patient Su$ering from Any Disease of the Heart, Lungs, Brain, Kidneys, Blood, Vascular System or Any Other Disabling Condition Not Due to This Accident? Give Particulars. We a11 know, even a layman, that fractures and injuries generaIIy do not cIear up readiIy if a patient is suffering from syphiIis or diabetes. The disabiIity wiI1 be proIonged if the patient has an arterioscIerotic condition, kidney troubIe or a bad heart, or any one of a number of diseases. It is therefore important that the attending physician, the surgica1 director and the cIaim examiner have the fuIIest information so that they may coijperate together in shortening the period of disabiIity. IO. Has Patient Any Physical Impairment Due to Previous Accident 07 Disease? Give Particulars. This is important, too, in that faiIure to give an accurate answer might invoIve the insurance carrier or empIoyer in making a payment for a permanent impairment or amputation which had previousIy been paid for. I I. Has Normal Recovery Been Delayed for Any Reason? Give Particulars. This question is cIoseIy reIated to questions 8 and 9 and affords the physician an opportunity further to expIain the reason, if there is such, for the deIay in reaching norma recovery. For iIIustration: A few years ago it was discovered in New York City that among a certain group of empIoyees of a particuIar nationaIity there were many injuries of a definite type for which there seemed to be no IogicaI expIanation; neither was there any discoverabIe reason why recovery was so Iong deIayed. It was Iearned that these injuries were seIf-inff icted and serf-perpetuated and that the entire racket was being carried on by a we&organized group. This fraud cost the insurance carriers and
Reports
DECEMBER,1938
the empIoyers hundreds of thousands of doIIars. Therefore, the importance of this question and the answer thereto. Again, we want to point out that under “The Injury” questions 6 to I I inclusive contain pretty nearIy a11 the Iaw and the gospe1 as respects the problem of determining the actua1 loss cost of the case and the relation of the condition to the aIIeged accident. FOURTH
SECTION
Treatment. 12. Date of Your First Treatment. Who Engaged Your Services? This is of extreme importance, particularly in cases where treatment has been deIayed and possibIy an infection has gained the upper hand. Oftentimes this date is important as it may indicate treatment prior to the actua1 date of this accident. Again, it might invoIve the question of which of two carriers, there having been a change in carriers by the empIoyer, is responsibIe for the aIIeged injury and ensuing disabiIity with consequentia1 expense. This might be important in a case, as we understand it, of the foIIowing type : A man has an uIcer within the eye. The sensation of its breaking through the surface might be the same as a foreign body entering the eye, and in such a case there is a great responsibiIity upon the doctor to determine whether there is a causa1 connection between the condition which he finds and the story of the accident as given by the patient. The second part to this question-“who engaged your services”-is important in many states because of certain provisions of the Iaw. 13. Describe Treatment Given by You. It is heIpfu1, in fact essentia1, for the medical or surgicaI director to know exactIy the kind of treatment rendered by the attending physician in order to determine whether rt is proper treatment for the injury or condition, whether it is the most up-to-date treatment or perhaps an outmoded treatment which has been found absoIuteIy useIess or aTmost useIess in treatment of the
NEW SERIES VOL. XLII, No. 3
Marston-Medical
condition present compared with modern treatment. Also, if there was a wound, was it sutured? Was it drained? Was it cIeaned up? If there was a hernia, was there an operation? If there was a fracture, was it reduced? Was it sprinted? What was the nature or kind of sphnt? Was a satisfactory reduction obtained? 14. Were X-Rays Taken? Very important in certain types of injuries. B
Reports
American
Journal
of Surgery
499
been and is being given for the condition described in the report. Investigation sometimes discIoses that the injury was not of sufficient severity to require hospitaIization. This means unnecessary and addiand reffects upon the tiona1 expense judgment of the physician. 18. Date of Admission to Hospital? Date to the insurance of Discharge? Important carrier and empIoyer in checking up biIIs received from the hospita1. The answer aIso has the same vaIue as respects the answer to question 12. 19. Is Further Treatment Needed? For How Long? This, too, is vitaIIy important in determining reserve figures and aIso the question of whether speciaIized treatment which might be recommended by the physician wouId shorten or eIim1nate the disabiIity. Very important that we know the period of further treatment if such is recommended. FIFTH
Disability.
20.
SECTION
Patient tyl
be Able
to
Resume Regular Work On? was 2 I. Patient will be Able to Resume Light Work On? W’hiIe these two questions may not be the most important on the report, they are equa1 in importance to any that appear thereon, for upon the answers to these questions depends the date on which compensation shouId cease. They serve to satisfy the various boards or commissions that the insurance carrier, or empIoyer, is warranted in stopping compensation on that date. The physician shouId bear in mind that while questions 20 and 21 are tied together, at the same time they are absoIuteIy different questions. Question 20 reIates to the fact that the empIoyee was abIe to resume his regular work and 2 I indicates that he was able to resume Iight work. The answers to these questions are of vaIue to the empIoyee, insurance carrier, empIoyer and the administering board or commission.
PO
A~nerican Journal
of
Surgery
Marston-MedicaI
22. If Death Ensued, Give Date. This question is obviousIy a very important one for record purposes.
SIXTH
SECTION
Reports
DECEMBER,,938
a11 suspected industria1 cases. Here again a11 that is sought is to bring out the facts. Quite recentIy we had the case of a patient who died suddenIy foIIowing a Ieg fracture after three and one-haIf months’ disabiIity. It was the opinion of the attending physician that the patient had died of heart disease. The post-mortem examination, however, discIosed that the patient died of a puImonary emboIus and, therefore, that the death was the resuIt of the origina injury. To the contrary, in another case it was supposed that the patient had died of siIicosis and the post-mortem reveaIed that there was no evidence of siIicosis, that the patient had reaIIy died of pneumonia. Such examinations suite often satisfactoriIy soIve a11 exist&g doubts as to the cause of death.
The Iast group of questions, particuIarIy “Remarks” wiI1 quite IikeIy serve no good purpose if the physician has carefuIIy and thoroughIy answered a11 the foregoing questions. It may be used to eIaborate on answers to previous questions or where a physician feeIs that the injured man is abIe to Ieave the hospita1 and the injured man has a contrary view. HospitaIs very often make very satisfactory boarding pIaces to men without homes. The questions which foIIow immediateIy in this section reIate to the persona1 history of the physician and are required in some states and are of vaIue in a11 states. Of course, the report shouId be signed CONCLUSION personaIIy by the physician-by no one eIse. In some states the Iaw requires that So, we come to the cIose of this articIe the reports be attested as they may be with the hope that what we have tried to used in evidence. present wiI1 be vaIuabIe in improving the The information which may be contained type of report furnished by the medica in this section of the report is aIso of great profession to insurance companies in comvaIue to the experienced surgica1 director pensation cases. It may promote a better of a company in assisting young physicians understanding between the two groups, so who have recentIy graduated from medica that, with the expIanations given, the SchooI and who, obviousIy, may not have physician wiI1 no Ionger fee1 that the had such experience as to justify the preparation of a medica report is a duII expectation that the end resuIt or end . and uninteresting proceeding, but that he treatment wiI1 be in every way as satisis rendering a worthwhiIe service to a factory as that at the hands of an oIder vaIuabIe cIient. Perhaps aIso, the insurance and more experienced man. And, again examiners wiI1 no Ionger be bored by the aIong this same Iine we wouId emphasize report in which the physician tries to be the desire of a11 medica departments to both lawyer and doctor; the verbose have the fuI1 cobperation, so far as the report in which there are Iong and eIaborate consuIting faciIities are concerned, in aI expIanations which say nothing; the report cases which have probIems connected with which leaves you, when you are through them. Teamwork is doing much in Iessenreading it, with no idea of what has haping disabiIities and obtaining better end pened to the patient, what is the matter resuIts, the aim of aI1 highly professional with him or what treatment he has remen and hospitaIs. ceived; the report which caIIs every case of a patient with a rifting back strain a POST-MORTEM EXAMINATIONS maIingerer; the report which is a11 opinion but does not give the facts upon which the It is generaIIy admitted that postmortem examinations shouId be heId in opinion is based.
LESTER
and Genera1 CIaim Manager, American BOSTON,
MutuaI LiabiIity Insurance
Company
MASSACHUSETTS
RESUMABLY the word “bore” doesn’t begin to express the feeIings of the physician who is required to make out a medica report and anyone eIse who in the course of his duties must read it. With humbIe apoIogies to the “Stroud twins” we might go on to say that medica reports not onIy bore a11who have anything to do with them but they dispIease, annoy, troubIe, perplex, rag, tire, irk and so on, ad i&&urn. Not Iong since, I Iearned that at a meeting of a hospital board a physician was caIIed upon tb report on a case which he had in the hospita1. He was a weII-trained physician of Iong experience, chairman of the Board of HeaIth in the particuIar IocaIity in which the hospita1 was Iocated. He opened his remarks reIative to the case with the foIIowing words: “GentIemen, this is not a very good record of the case. I hate to write medica reports just as much as you a11 do.” Is not this statement indicative of the reason perhaps why the writer has been asked to prepare this article? But, why shouId this be so? WhiIe it has been agreed that medicine is not an exact science, medica men do represent a highIy trained and reasonabIy scientific profession. Perchance the answer to this question may, after aI1, be reIativeIy simpIe, e.g., that no one has previousIy taken the time and troubTe to expIain what “a11 the shooting” is about when the business of insurance compIains that medica reports are a bore. No one has explained to the medical profession the use to which these reports are put or expIained how vaIuabIe from the standpoint of the patient, the administering accident boards and commissions, and insurance carriers, these reports actuaIIy are.
P
MARSTON
Some physicians may feel that the insurance companies have IittIe right to require as a precedent to the payment of physicians’ biIIs an adequate medica report, or in fact question if the insurance carrier has any right to a report at aI1. In business, and presumabIy in the professions, a11 parties strive to pIease vaIued customers or clients. According to Best’s Insurance Reports for 1937, we may we11 assume that between 45 and 50 miIIion dolIars annuaIIy are being paid out by the stock and mutua1 insurance companies to physicians and hospitaIs for professiona services rendered in compensation cases. In addition to this vast sum, miIlions more are presumabIy paid out by the empIoyers who do not insure their compensation IiabiIity, and if we were to venture outside of the fieId of compensation insurance and consider the amount paid by casuaIty companies in other forms of coverage and by the Iife companies in their Iife extension work, etc., etc., we think that possibIy we have made out a case proving that the business of insurance is a worthwhiIe cIient whose request for codperation shouId not fal1 upon deaf ears or sightIess eyes. The aim of this articIe is not to be controversial or argumentative, but heIpfu1. After nearIy forty years’ experience the author stiI1 feeIs that the diffIcuIty in adequate and proper securing prompt, medica reports is due to Iack of understanding, on the part of the medica profession, of the probIem. We may break this subject down into severa parts. First, why are satisfactory medical reports diffIcuIt to obtain? Let us revert to the yesterdays of a quarter of a century ago when compensation Iaws were 490
NEW SERIES VOL.. XLII,
No. 3
Marston-MedicaI
first being considered by the IegisIatures of some of the states; to that time when this great piece of socia1 IegisIation appeared to be so very simpIe of administration, so devoid of procedura1 diff]cuIties, when it seemed that folIowing an injury arising out of and in the course of empIoyment all that wouId be necessary for the empIoyer or his insurance carrier to do was to pay the amount of compensation to which the injured man was entitIed, as decreed by the Iaw and defined as respects period of time and amount. Because this law which pIaced upon industry financia1 obIigations without regard to the question of fault, a thing aItogether unheard of up to that time in this country, it estabIished an entireIy new reIationship and additional responsibility as between the empIoyer and the empIoyee, the doctor and his patient. The safety movement already in existence received enthusiastic impetus, but always lagging behind in the progress of this socia1 IegisIation has been the deveIopment of a proper medica program of co6peration. It would serve no usefu1 purpose at this time to hoId an inquest to determine who was to blame or to attempt to narrate seriatim the progress which has been made to date. Exception to this might be made to pause briefly in our discourse to pay tribute to those whose breadth of vision conceived and brought into being a new branch of surgery, or speciaIty if you wiI1, generalIy referred to as industria1 surgery. Though it seemed heresy to some of the medica profession even to consider that surgery as appIicabIe to industria1 injuries couId possibIy be any different from the surgery which aIways had been, much credit is due the forward-Iooking members of the American CoIIege of Surgeons for their championing of the cause of this phase of surgery and especiaIIy for their progressive program as respects the treatment of fractures which has aIways been a serious and expensive probIem to carriers of compensation insurance.
Reports
American
Journal
of Surgery
49’
We have referred to the change in the reIations between the physician and his patient. Under the Workmen’s Compensation Law it was necessary that the physician must reveaI to some third person, e.g., the empIo?er or the insurance carrier, the facts reIatmg to the injuries suffered by his patient, i.e., their seriousness, the prognosis as respects disabiIity and his estimate of any permanent impairment that might reasonably result. So, it may we11 be that the faiIure to appreciate or unwiIIingness to conform to this changed reIationship may be to some considerabIe extent responsibIe for the dificuIties which we experience in adequate and proper securing prompt, medica reports in compensation cases. Why are medica reports necessary? Who uses them and how? They are necessary because in accordance with the provisions of a11 compensation Iaws no compensation is due the injured man, generaIIy speaking, unIess he has suffered a disabling injury requiring his absence from work or a permanent impairment which might possibIy resuIt from an injury in which there was no disabiIity (although such a situation in these days wouId be extremeIy rare). It is necessary that these reports be rendered promptIy due to the fact that compensation is in part presumed to take the pIace of the pay envelope whose arriva1 usuaIIy ceases with the beginning of absence from work. Who uses them? First of aI1, the empIoyer or the insurance carrier must have them for the foIIowing reasons: First, to determine if the injured workman wiI1 be disabIed a suficient Iength of time to entitIe him to the benefits provided by the Workmen’s Compensation Law. Second, to determine the probabIe Iength of that disabiIity. Third, to determine if their wiI1 be any permanent impairment, e.g., amputations, stiff joints, etc. Fourth, that the carrier may at the earhest possibIe moment erect a suit-
492
American
Journal
of Surgery
Marston-MedicaI
abIe reserve-Iater on we will refer to what this reserve is. Now the second group that are interested in the prompt receipt of an accident report are the industria1 accident boards or commissions whose responsibiIity it is to administer the Iaws of their respective states. Some of these boards or commissions require that medica reports be fired with them. IncidentaIIy, some require that medica bi1Is be referred to them for approva1 before payment. It is the function of these boards or commissions to satisfy themselves that the injured employee has been justIy deaIt with, that he has received the compensation which is provided for by the compensation Iaw. These groups oftentimes arrange that impartial examinations be made of the injured in order to satisfy themseIves impartiaIIy that the medical facts are as have been presented by the carrier or the empIoyer. Who eIse is interested in these reports? In serious cases probably the most interested individuaI is the medica or surgica1 director of the carrier who must, through the picture painted in the report, determine if there is anything that the carrier can do through its medica department to assist the attending physician-and, we are happy to say that through the years there has been a growing incIination or wiIIingness on the part of the medica fraternity to cons& with and ask for suggestions from the medica departments of the Iarger companies writing compensation insurance, an indication of co6peration which is indeed cheering and promises much for the future. Perhaps the next phase we shouId consider is the form to be used by the physician in making out the medica report. A few boards or commissions have a stock form of report which they require shaI1 be used. In most cases that form was mereIy for the convenience of a11 concerned, but as time went on and our interest in medical matters improved or grew, the inadequacy of those reports was recognized not onIy by the carriers, but by the InternationaI kssocia-
Reports
DECEMLIER,
1938
tion of IndustriaI Accident Boards and Commissions. Each group appointed a Committee on Forms part of whose duty was to attempt to standardize the many forms required by each state in the administration of this Iaw. With a fine spirit of co6peration these Committees met separateIy and Iater in joint conference and among other forms attempted to standardize on a medical report form. The standard form for surgeons’ reports known as “Standard Form 2” was approved by the joint committee and Iater adopted by the InternationaI Association of IndustriaI Accident Boards and Commissions at their convention in Columbus, Ohio in 1932. This conforms more or Iess in its details to the requirements of most of the states; it has been offIciaIIy adopted by many states and others, whiIe they have not adopted the form, have not objected to its use. We shaI1 attempt Iater on to expIain the reasons how and why this report should be compreted, but before doing so, and to sustain further our contention as respects the need for adequate medica reports, we should Iike to give some iIIustrations that have come to our attention from time to time which have so cIearly indicated the need for complete, adequate and accurate medica reports.. WhiIe the cases are from our own records, for obvious reasons they wiI1 not be identified in this paper. CASE I. In this case the Physician’s Report (Form SF2) stated in answering question 6: “Crushing of second fmger on Ieft hand. End of finger back to the first joint entirely amputated.” Upon that information, compensation in accordance with the provisions of the Iaw was paid to the injured man. SubsequentIy, we Iearned from information obtained from the doctor who made out the first report that onIy the tip of the bone of the termina1 phalanx was actuaIIy Iost and therefore there was no compensation due. CASE II. This was a coIored boy who had sustained a broken ankle. He was taken to the hospita1 where he was cared for by his physician. After the patient had been in the hospitaI about a month he was discharged and a coupIe of weeks Iater the physician sent in a report
NEW SERIES VOL.XLII, No. 3
Marston-MedicaI
that the patient was all. we11 and was able to return to his usual work. The injured boy was advised to this effect and he tried to go to work, in fact he did work two or three days, although suffering considerabIe pain. SeveraI weeks later the young man reported to his empIoyer that he was unabIe to work because the ankle was still bothering him. Later on x-rays revealed the fact that the ankle was entireIy unreduced, that it was not united, and that at the time the case was closed by his attending physician the patient was in no way able to return to his work. The result was that the patient had to be turned over to another doctor, the fracture rebroken and many months of disability ensued. This meant increased cost insurance company, pain to the empIoyer, and suffering to the injured man. This we11 iIIustrates the difficulties caused by a report that was too optimistic. CASE III. This was a patient with a broken hip. The physician took x-rays and found that everything was all right, but three or four without checking his months afterwards, results by x-rays, he allowed the patient to get out of bed. The patient waIked about, suffering a moderate amount of pain. There were optimistic reports from the physician. At the end of a year the patient had not yet returned to work, but stiI1 the reports were optimistic on his condition. Examination by a. second physician reveaIed that there was no union and that the patient had been a11 of the time walking about on an ununited fracture of the neck of the femur. Result-extensive, Long treatment had to be done, which took a great deal of time and caused a great dea1 of expense. CASE IV. This patient had his arm injured in some gears, sustaining fracture of the hand, wrist, elbow and shoulder. He was under the care of a busy, active surgeon. Repeated efforts were made to secure a medical report from him. We were put off for a period of three or four months. The doctor was taken sick and died before the initia1 medica report came through on a very sick patient. This was four months after the time of injury. CASE v. This patient had a septic hand. After severa weeks of treatment, the hand was getting worse although the medica reports were very optimistic. It was brought out after a Iong time and many requests for reports that the patient was suffering from diabetes and
Reports
American Journal of Surgery
that this was the reason that the disabiIity so prolonged.
493 was
If these cases indicate the faiIure of compIete and prompt and accurate medica reports, then their citing has been we11 worth whiIe. As doctors you have heard a great dea1 about the insurance company reserves, and it may be of interest to you to Iearn that one of the tests of the financia1 stabiIity of any casualty insurance company is the adequacy of its reserves, and that the state insurance departments under the Iaw and in the interest of the public good are constantly on the alert to determine that the companies doing business are soIvent. GeneraIIy speaking, in every other business a reserve is an asset but in the business of insurance it is a IiabiIity. Because it takes the place of a potentia1 debt, socaIIed, the amount set aside to Iiquidate this debt shouId at a11 times be adequate. In order to accompIish this, each claim when it comes into the insurance company offices is given a money vaIue called a reserve. If you were to buiId a house and your architect toId you it wouId cost ten thousand doIIars, you would see to it that you had that sum of money in the bank to pay for it. The fmancing of a compensation case is no different from that of financing a house and instead of reIying upon the plans of architects we must reIy on doctors and surgeons to furnish specifications in the form of medica reports in order that the potentia1 cost of that case can be properIy determined. Each case is a separate bookkeeping account against which amounts are drawn for the purpose of making compensation, medica and expense payments. In order that this account may at a11 times be soIvent, we reIy to a Iarge extent upon your fuII coijperation as respects furnishing us with the information requested in the medical reports. HOW TO MAKE OUT THE REPORT We hope that in this preambIe we have aroused sufficient interest to justify the
American
494
Journal
Marston-MedicaI
of Surgery
Reports
DECEMBER, 1938
m-m I%. L 1. 1
STANDARD FORM FOR
SURGEON'SREPORT b'-*db'L*.LLRC
:....._ ..__-_.__-___.__. ..._..._ :..._. ........-_..-__..._.__...__ ._ ......_._
(The spaces above not to k filled io by Employer)
ZL.,
1. Nama of fnjmd P.rsm:.__ ........._..._ _. ....._..._ _....._......._.........._...._................_..........Age: . .._I._....__. Se:. .... _...... _.___. ..... --.-._--._.State..._. ...__. ... 2. Address: No. mod St.. ..._....._...__.._...._I._.._ .._......___. ........._ .._....... City or Town.. ................ 3. Name md Ad&.. , of lL,&,er:...._..._..._..__._ .._ ...._...._. ........I ...._.................._................I.. .._.......___._....._ ......_.._.....................
%a .oddmt
4. Date of acsidemt:.. . ......._..“” ...._........._.I___......... .Ho w ....................... hf. Date disability began ............. ..__“._ .......................... ;” _...... 5. State in patie& own words where ad how occident occurred : ............... _.................................................. ___.-......._......._ ....................
.................... .._.....“. ... _...__....” ................ _^_._ ..._.....“..._..................................... ...“........... ..^........................................ -........... ................ ............... ......... .._...._.__................” ...._...._.......... _......... _...._........................... _...._......................................... .._. ............ ......... _............... _.................................. -6. Give accurate &acriptie~ of naturead extantof injury ad statsyew objective hndfn~:..._ .._....................................... ...................... ....”.............................. _................ . .........._...._................ _............................... _................... .._..........._......_ ......_......“...........................
....... _......... _..“....._..._............................... _“.....“.......... _........................... _.._._ ..“............ _.................................. _............... _................. .......... ...... ‘ha &rv
7. Will the injury result in (a) Permaocnt defect?. ......................... If so, what?. ............_ ....._........._........ - _.__....-. .._............................. (b) Facial or head disfi,ement.? ... .............~................ _.._........ ......................._..___ _ ........._.....................”....... (Pernuncntdisabilitysuchan lossof wholeor parts of ngerr. Iacul Orheaddwfiguurcment, etc nwlt be accwatet~0urLd 011chart on reve*scsld uf this rcpoct.> ., 8. Ir accident above referred to the only cause of patlmt s condltlon?. ........................... If not, state contributing cases: ........................
...._.......... . .__.“. ............ _...._.......... _“__. .... _....... _...-.._ _..._..._....._........ _.._. ............................... ..“................ ...... _....__. ...._.._. ............................... 9.
Is patient suffering from not due to this a&cot?.. .........._.....“.__...........“...._. ... IO. Has patient any physxal
sny disease of the hurt, lungs, brain, kidneys, blood, vascular system or any other disabling conditio ..._......_...........Give particulrs:. ........_....._.................................... _............_..........____........................................... ............ -. ..._....._.-. ..._.._.._ ..........I. .... -..............-................................................. _. .....“.......................................... . . . lmpalrment due to prmous acadent or disease?. ......._................ Gwe partxulars :..._.....................................
...._............... _......... ...“. ...._._........ “_...._...._. -. ...I._- _..._ .....“....... .._.._ ............ ...“........... ..“.......................... _................................................... 11. Hasnormal recovery been delayed for any reason ?_.._.................... Give particulars :.......................... _................ _................... .................. .......... _........ ..“............ “.__..._. ........_...“....... .._....- .._.............. ..“............. ...... .._.......... ...”......................... ..“...... .._.._......__“. ............................. 12. Dateof yourfirsttreatment :_........ _........................ .._....... Who engaged your services?. ....................... __.____ _.......................... ___ 13. Des&k treatment given by you: .......... _.................. _................................................................................................... _...... _................................. IYtm.mt ...._...._........................ _...._........................ . ........ I......................... ..-.......................................................................................... __................................ 14. Were X-Rays taken? ................ By whom?. ......._.......__.........._...............” ...._.........._.................................................... -When? ........................ @&n,cmd Address) 15. X-by
d,agnosr,:_. ..................... _.................................................... -. ................................................................ _.........._............................................. whom? ................................................. ..”............................ _.__Whm?..._ .._................... (Name md Add.&
16.Waspatient treated by anyone else?. ............... By
17. Was patient hospitalized7 ........................ Name and address of hospital :-..-...-..._........._..._......_ ...._ -_“-. 18. Date of ad&ion to hospital :.......................... ..~.............~ ..._.......... . _.....Dat e of discharge:. ...._..._....._.-__._. ,p. 1~ further treat,neot needed?...._...._...._............ __.................. . For how long?. .._................. _....I ........._..____-
inability
20. Patient $be
able
..._...._ ..._................ ........_. ..._-. ....._..... _...._...._............... _...
to remmm ngdu r~& ow_..........................-......”..............._ ......... _...._..I....._..-...._...-.._. ...... .._ .._.._...... or,:. .................................................................................. _ ...I .._.._ .._ ......................._......_..
above) .I_......I................” .....-. ............. .._...._...__._-._I__ ..._............._...............
\it\r
SERIES
VOL. XLII,
No.
3
Marston--MedicaI
hope that the folIowing attempt to analyze 3r expIain in detail the reasons for the questions asked on this report wiI1 be care-
Reports
American
Journal
495
of Surgery
abiIity must be judged in many cases by the type of report you make to the carrier or empIoyer. MARK FACIAL OR Hhhb DISFIGUREMENT
RIGHT
FOOT
RIGHT
HAND
SKULL
,
A
STATE RIGHT
WHETHER
OR
LEFT EYE
INDICATE WHETHER RIGHT OR LEFT ARM
fulIy read and thoroughIy digested. We fee1 sure that if they are, medica reports will no Ionger bore the maker or the reader. Remember, doctor, that your work and
For your convenience, we have facsimifes of the front and reverse the Standard Form of the Surgeon’s known as Standard Form 2. (Figs.
inserted sides of Report I and 2.)
496
American
Journal
FIRST
of Surgery
Marston-MedicaI
SECTION
The Patient. Let us consider together the first section reIating to the patient. I. Name of Injured Person. Write the name Iegibly in ink, for this is the soIe means of identifying the injured person and enabIes the carrier to connect promptIy the report to the proper fiIe. Age. Too much cannot be said about the importance of giving the age, for any Iayman knows that a broken ankIe in a man of 20 and the same broken bone in a man of 70 may have vastIy different consequences. Furthermore, it frequentIy happens that the age given by a patient to his physician is his true age whereas the age given to his empIoyer may have been different. Sex. Important oftentimes because the Christian name does not aIways indicate sex. For iIIustration, in the South particuIarIy the names of women sometimes are quite mascuIine, e.g., Johnnie, Johnsie, WiIIie, etc. 2. Address: Number and Street. This is important for the purpose of identifying and Iocating the employee. FrequentIy we find that the empIoyee has not registered his Iatest address with his empIoyer. The address shouId be compIete, giving both the number and street and the name of the city, town and state. Many times in the Iarger centers there are streets of the same name within a few miIes of each other; perhaps we shouId say in the adjacent suburban communities. If the insurance carrier has not the correct address of the injured man, it may be diffIcuIt for it to forward compensation when due. 3. Name and Address of Employer. This is most important in identifying the employer of the injured man as records in most insurance companies are fiIed by the name of the empIoyer. Therefore, this information assists many times in making a prompt investigation. FrequentIy the medical report is the first notice of an name and injury, and if the empIoyer’s address are not given. the report is returned to the physician for completion.
Reports
DECEMBER,1938
SECOND
SECTION
The Accident. 4. Date of Accident: Hour. The date of the accident and the definite hour of occurrence are of great importance, as this information heIps to determine whether the accident occurred during working hours and during the poIicy period. In some states, if the accident occurs late during the working period, the compensation period does not start unti1 the folIowing day. In other states it is otherwise. The date of the accident and the hour of the accident are aIso important because many times the making of a claim aIIeging an accident is an afterthought on the part of the cIaimant and it becomes very important to check the statements given to the physician. Many times there is a discrepancy which heIps us to determine whether the accident is a Iegitimate one or not. Date Disability Began. The date disabiIity began is equaIIy important with the date of the accident because in many instances there are deIayed disabiIities of perhaps days, weeks or months foIIowing the aIIeged accident. The date of disability is aIso important, possibly in determining the causa1 reIationship between the aIIeged accident and the condition found by the physician. This information is becoming increasingIy important in view of the widening of the scope of many Acts to incIude occupationa diseases. In such cases we have no date of disability or accident unIess it is given by the physician. In occupational diseases it is important to indicate the date the man quits work and the date he actuaIIy became disabIed. They may be two absoIuteIy different dates. We a11 recognize that a man may Ieave work because there is no work for him to do and later on he discovers that he has an occupationa1 condition on account of which he makes cIaim. 5. State in Patient’s Own Words Where and How Accident Occurred. It is aIways vaIuabIe and useful to put down in the first person just exactIy what the patient said
NEW Smrss Var. XLII,
Marston-Medical
No. 3
to the physician as to how the accident happened, e.g. : “I shpped on some water and feII down, Ianding on my back.” Such a statement contains the facts of what caused the faII and the part of the man’s anatomy which was injured. In most instances the physician is the first one to see the cIaimant foIIowing the injury and therefore the claimant is more IikeIy to give an accurate statement then than after talking with reIatives and friends. After all, what we are searching for in anv investigation is the truth. Many times “in compensation hearings the history given to the physician may be the pivota point on which the decision of the referee or commissioner hinges. It is of great importance to a11 claim examiners and medica or surgica1 advisers in determining the question as to whether the condition actuaIIy resuhed from the alleged injury or not. THIRD
SECTION
The Injury. 6. Give Accurate Description of Nature and Extent of Injury and State Your Objective Findings. When we come to this question we are impressed with the fact that this form of report appears to be a great record for a minor injury and a very smaI1 record for a Iarge or serious injury. In the Iatter case the information must be suppIemented by a more compIete report. Yet it must be aIways borne in mind that this is a physician’s story told to a Iayman and the avoidance of technica terms so far as possibIe is much to be desired. However, with a IittIe practice and thought, the description of the injury can be boiIed down to a few cornminuted words, such as “compound fracture of the right tibia in the mid third,” “right inguina1 hernia, indirect, scrotal, reducibIe.” If there isn’t room on the report, use an extra sheet of paper, for this is one of the most important items on the report. Upon this description depends the evahration of the case. It aIso assists greatIy in determining the question of whether the disabiIity is being unduIy proIonged. The
Reports
American
Journal
of Surgery
497
objective findings are of the utmost importance in determining the question of causa1 reIationship between the aIIeged injury or accident and the condition found by the physician. In’s great many instances the objective lindings reported by the physician fai1 absoIuteIy to bear out the diagnosis which he makes. For i1Iustration: we recently read a medica report in which the patient had received an injury. Physical examination described him as entireIy norma1 and described no abnorma1 or pathoIogic things about it. Then at the end in his opinion the physician said, “I believe this man is incapacitated from doing any work.” These are the things that bore, bother and annoy. 7. Will the Injury Result in (a) Permanent Defect (b) Facial or Head Disfigurement? If So, What ? Again a proper answer to these questions is of great importance in determining the value of the case, not onIy from the standpoint of temporary tota disability but from the standpoint of permanent impairment or dishgurement. Furthermore, with the vast experience which the medica departments of insurance companies are having in this highly speciaIized work, it is quite possible that there may be some treatment which they have Iearned about through experience in other cases which might Iessen or entirely eliminate the disabiIity or improve the end resuIt; and, in connection with question 7, attention is caIIed to the mannequin on the reverse side of the report by the use of which the doctor may indicate the exact point of amputation, injury or disfigurement. Accuracy in making this indication is of great importance because of the difference as respects the provisions of the Iaws of the various states. It is aIso important in answering this question to indicate whether there is any restriction and to what extent that restriction extends and where it is located. 8. Is Accident Above Referred to the Only Cause of Patient’s Condition? If Not, State Contributing Causes. Important because
498
American
Journal
of Surgery
Marston-MedicaI
some states do not recognize the aggravation by an injury of a previousIy existing systemic condition, compensation in such states being payabIe onIy for a disabiIity normaIIy to be expected froth that type of injury. 9. Is Patient Su$ering from Any Disease of the Heart, Lungs, Brain, Kidneys, Blood, Vascular System or Any Other Disabling Condition Not Due to This Accident? Give Particulars. We a11 know, even a layman, that fractures and injuries generaIIy do not cIear up readiIy if a patient is suffering from syphiIis or diabetes. The disabiIity wiI1 be proIonged if the patient has an arterioscIerotic condition, kidney troubIe or a bad heart, or any one of a number of diseases. It is therefore important that the attending physician, the surgica1 director and the cIaim examiner have the fuIIest information so that they may coijperate together in shortening the period of disabiIity. IO. Has Patient Any Physical Impairment Due to Previous Accident 07 Disease? Give Particulars. This is important, too, in that faiIure to give an accurate answer might invoIve the insurance carrier or empIoyer in making a payment for a permanent impairment or amputation which had previousIy been paid for. I I. Has Normal Recovery Been Delayed for Any Reason? Give Particulars. This question is cIoseIy reIated to questions 8 and 9 and affords the physician an opportunity further to expIain the reason, if there is such, for the deIay in reaching norma recovery. For iIIustration: A few years ago it was discovered in New York City that among a certain group of empIoyees of a particuIar nationaIity there were many injuries of a definite type for which there seemed to be no IogicaI expIanation; neither was there any discoverabIe reason why recovery was so Iong deIayed. It was Iearned that these injuries were seIf-inff icted and serf-perpetuated and that the entire racket was being carried on by a we&organized group. This fraud cost the insurance carriers and
Reports
DECEMBER,1938
the empIoyers hundreds of thousands of doIIars. Therefore, the importance of this question and the answer thereto. Again, we want to point out that under “The Injury” questions 6 to I I inclusive contain pretty nearIy a11 the Iaw and the gospe1 as respects the problem of determining the actua1 loss cost of the case and the relation of the condition to the aIIeged accident. FOURTH
SECTION
Treatment. 12. Date of Your First Treatment. Who Engaged Your Services? This is of extreme importance, particularly in cases where treatment has been deIayed and possibIy an infection has gained the upper hand. Oftentimes this date is important as it may indicate treatment prior to the actua1 date of this accident. Again, it might invoIve the question of which of two carriers, there having been a change in carriers by the empIoyer, is responsibIe for the aIIeged injury and ensuing disabiIity with consequentia1 expense. This might be important in a case, as we understand it, of the foIIowing type : A man has an uIcer within the eye. The sensation of its breaking through the surface might be the same as a foreign body entering the eye, and in such a case there is a great responsibiIity upon the doctor to determine whether there is a causa1 connection between the condition which he finds and the story of the accident as given by the patient. The second part to this question-“who engaged your services”-is important in many states because of certain provisions of the Iaw. 13. Describe Treatment Given by You. It is heIpfu1, in fact essentia1, for the medical or surgicaI director to know exactIy the kind of treatment rendered by the attending physician in order to determine whether rt is proper treatment for the injury or condition, whether it is the most up-to-date treatment or perhaps an outmoded treatment which has been found absoIuteIy useIess or aTmost useIess in treatment of the
NEW SERIES VOL. XLII, No. 3
Marston-Medical
condition present compared with modern treatment. Also, if there was a wound, was it sutured? Was it drained? Was it cIeaned up? If there was a hernia, was there an operation? If there was a fracture, was it reduced? Was it sprinted? What was the nature or kind of sphnt? Was a satisfactory reduction obtained? 14. Were X-Rays Taken? Very important in certain types of injuries. B
Reports
American
Journal
of Surgery
499
been and is being given for the condition described in the report. Investigation sometimes discIoses that the injury was not of sufficient severity to require hospitaIization. This means unnecessary and addiand reffects upon the tiona1 expense judgment of the physician. 18. Date of Admission to Hospital? Date to the insurance of Discharge? Important carrier and empIoyer in checking up biIIs received from the hospita1. The answer aIso has the same vaIue as respects the answer to question 12. 19. Is Further Treatment Needed? For How Long? This, too, is vitaIIy important in determining reserve figures and aIso the question of whether speciaIized treatment which might be recommended by the physician wouId shorten or eIim1nate the disabiIity. Very important that we know the period of further treatment if such is recommended. FIFTH
Disability.
20.
SECTION
Patient tyl
be Able
to
Resume Regular Work On? was 2 I. Patient will be Able to Resume Light Work On? W’hiIe these two questions may not be the most important on the report, they are equa1 in importance to any that appear thereon, for upon the answers to these questions depends the date on which compensation shouId cease. They serve to satisfy the various boards or commissions that the insurance carrier, or empIoyer, is warranted in stopping compensation on that date. The physician shouId bear in mind that while questions 20 and 21 are tied together, at the same time they are absoIuteIy different questions. Question 20 reIates to the fact that the empIoyee was abIe to resume his regular work and 2 I indicates that he was able to resume Iight work. The answers to these questions are of vaIue to the empIoyee, insurance carrier, empIoyer and the administering board or commission.
PO
A~nerican Journal
of
Surgery
Marston-MedicaI
22. If Death Ensued, Give Date. This question is obviousIy a very important one for record purposes.
SIXTH
SECTION
Reports
DECEMBER,,938
a11 suspected industria1 cases. Here again a11 that is sought is to bring out the facts. Quite recentIy we had the case of a patient who died suddenIy foIIowing a Ieg fracture after three and one-haIf months’ disabiIity. It was the opinion of the attending physician that the patient had died of heart disease. The post-mortem examination, however, discIosed that the patient died of a puImonary emboIus and, therefore, that the death was the resuIt of the origina injury. To the contrary, in another case it was supposed that the patient had died of siIicosis and the post-mortem reveaIed that there was no evidence of siIicosis, that the patient had reaIIy died of pneumonia. Such examinations suite often satisfactoriIy soIve a11 exist&g doubts as to the cause of death.
The Iast group of questions, particuIarIy “Remarks” wiI1 quite IikeIy serve no good purpose if the physician has carefuIIy and thoroughIy answered a11 the foregoing questions. It may be used to eIaborate on answers to previous questions or where a physician feeIs that the injured man is abIe to Ieave the hospita1 and the injured man has a contrary view. HospitaIs very often make very satisfactory boarding pIaces to men without homes. The questions which foIIow immediateIy in this section reIate to the persona1 history of the physician and are required in some states and are of vaIue in a11 states. Of course, the report shouId be signed CONCLUSION personaIIy by the physician-by no one eIse. In some states the Iaw requires that So, we come to the cIose of this articIe the reports be attested as they may be with the hope that what we have tried to used in evidence. present wiI1 be vaIuabIe in improving the The information which may be contained type of report furnished by the medica in this section of the report is aIso of great profession to insurance companies in comvaIue to the experienced surgica1 director pensation cases. It may promote a better of a company in assisting young physicians understanding between the two groups, so who have recentIy graduated from medica that, with the expIanations given, the SchooI and who, obviousIy, may not have physician wiI1 no Ionger fee1 that the had such experience as to justify the preparation of a medica report is a duII expectation that the end resuIt or end . and uninteresting proceeding, but that he treatment wiI1 be in every way as satisis rendering a worthwhiIe service to a factory as that at the hands of an oIder vaIuabIe cIient. Perhaps aIso, the insurance and more experienced man. And, again examiners wiI1 no Ionger be bored by the aIong this same Iine we wouId emphasize report in which the physician tries to be the desire of a11 medica departments to both lawyer and doctor; the verbose have the fuI1 cobperation, so far as the report in which there are Iong and eIaborate consuIting faciIities are concerned, in aI expIanations which say nothing; the report cases which have probIems connected with which leaves you, when you are through them. Teamwork is doing much in Iessenreading it, with no idea of what has haping disabiIities and obtaining better end pened to the patient, what is the matter resuIts, the aim of aI1 highly professional with him or what treatment he has remen and hospitaIs. ceived; the report which caIIs every case of a patient with a rifting back strain a POST-MORTEM EXAMINATIONS maIingerer; the report which is a11 opinion but does not give the facts upon which the It is generaIIy admitted that postmortem examinations shouId be heId in opinion is based.