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DOCTOR IN THE BOX
838 DOCTOR IN THE BOX "
WHICH of the many injuries sustained by the claimant caused chronic alcoholism: answer Yes or No ? " Thus may run the doctor’s nightmare before his appearance in court in a case in which he has, wittingly or otherwise, become involved in a professional respect; for there are few who view such a public ordeal with complete equanimity. In British courts, the evidence on fact and opinion elicited by counsel’s questions in the examination-in-chief is open to be tested by cross-examination, when a witness may be questioned closely and persistently. Once in the witness-box the doctor is, therefore, likely to find that a straightforward examination-in-chief will be followed by questions which will require knowledge and rapid but careful thought if helpful and clear answers are to be given. And all this in public, with the full attention of the court and Press, so that incautious remarks are apt to resound far more than similar remarks made in the seclusion of the consulting-room. The doctor’s peace of mind may be further disturbed by the sight of a steady succession of notes being passed to cross-examining counsel by the medical adviser for that side, making it quite clear that any deficiencies of medical knowledge on the part of the lawyer are constantly being made good. Merliss et aLl emphasise how important it is to keep complete and detailed records, so that, if litigation arises, reliable reference may be made to the documents. Abbreviations in records are a hazard, unless their use can really be justified, for counsel are not slow to seize upon possible ambiguities or any other apparent defects in case-records, sometimes using them with devastating effect in cross-examination. Bias and sympathy on the doctor’s part may easily lead to an impulsive and rash opinion, and if lawyers proceed on the assumption that that opinion is correct then the doctor may find himself in court unhappily learning that the objects of cross-examination include the destruction of his assertions and the strengthening of the opinions of the other side, while someone, more unhappily still, faces an adverse verdict and costs. This kind of disaster can usually be averted if no opinion is ever given without deliberation and reference to authoritative literature. At no time should a doctor be drawn into professing an opinion to lawyers on the understanding, expressed or implied, that he will not at any time be called to the witness-box to give evidence: either the opinion is to be regarded as worthy of repetition and test in court, or it should not be given at all. In the court with the heaviest demands on doctors’ time, the coroner’s court, there is no cross-examination, but the coroner’s questions may be followed by counsel’s, often designed to lay emphasis in some special direction, and these additional questions can be as probing and as difficult as any in a thoroughgoing cross-examination in other courts. Quite often the most junior member of a hospital clinical team is sent to the coroner’s court to give evidence, even though his comprehension of the case may be imperfect, and it is scarcely surprising that this can result in counsel’s questions not always being answered with the clarity, accuracy, or determination of which a senior clinician might have been capable. The worth of medical evidence elicited by crossexamination is often questioned after the hearing of a sensational case in court, when both doctors and the general public express doubts about the merits or even 1.
Merliss, R. R., Gelfand, L., Magana, R. New Engl. J. Med. 1959, 261, 175.
relevance of statements given during what is a stressful ordeal. From time to time suggestions2 are made to the general effect that it would be an advance if conflicting medical evidence were to be heard and assessed by a panel of experts, or else that expert witnesses should be examined by the judge rather than by opposing counsel. The expert panel could well be a time-saving device and a guarantee that the evidence given at a trial is genuine and truly expert; but it is sufficiently far from established British practice to cause uneasiness about defeating the object of allowing justice to be seen to be done. It might be safer to continue to hear all the evidence in court and put it to a judge or a jury in such a way that they could form their own opinions of the whole matter, for they, after all, are the final arbiters. If the testifying doctor gives an honest and sincere opinion, and if he is prepared to support his views with reasonable references to textbooks and articles, then he will not be likely to confuse the court or to run into serious difficulties in the cross-examination. One thing is certain-a doctor should not withhold useful evidence just because he is afraid of having a bad time in court. As Merliss et al. remark, " Cross-examination is a rigorous test for any doctor to undergo. Yet, unless he is willing, and unless he delivers testimony effectively, he fails in an important service to his community and to his patient " THE SALIVA IN DEPRESSION
THE need for some objective measure of mood-change is clear enough: clinical detection of the suicidal risk is a baffling problem. Depression, at times, is a normal condition if not too severe or long-continued; and much of the recent symposium on this subject 3 was taken up with questioning as to what was meant by the word. Over twenty years ago Strongin and Hinsie4 observed that, while the salivary excretion-rate in schizophrenia is somewhat higher than normal, it is greatly reduced in depression. Peckhas replaced the cumbersome technique with a suction cup over the parotid duct by a more practicable one in which standard dental rolls of cottonwool are weighed after lying for two minutes over the duct orifices. This procedure has become known as the S.H.P. (or Strongin-Hinsie-Peck) test, and the results with it are interesting. Clearly significant differences beyond the 0.01 level were found between normals and depressives, irrespective of sex, age, and race; but among those under 19 years of age this difference became lost in a generally higher level of secretion, and Negroes gave relatively higher readings in both normal and depressive groups. Body-weight and smoking habits did not seem to interfere with the results; but gum-chewing did, and intercurrent fever lowered the readings. In some a diurnal fluctuation was noted, with greater secretion in the evening; and Peck suggests a possible relation to the well-known diurnal changes of mood. As he observes, the overlap between the normal and depressed subjects is such that no cut-off point can be identified, and much remains to be done before this test can be usefully used for diagnosis.
Psychosomatic accompaniments to depressive illnesses have long been observed,6 but their measurement has not, hitherto, been very helpful clinically. 2. See Lancet, 1956, i, 427. 3. See ibid., Oct. 3, 1959, p. 509. 4. Strongin, E. I., Hinsie, L. E. Amer. J. Psychiat. 1938, 94, 1459. 5. Peck, R. E. A.M.A. Arch. gen. Psychiat. 1959, 1, 35. 6. See, e.g., Cleghorn, R. A., Curtis, G. C. Canad. psychiat. Ass. J. 1959,
4, suppl. (McGill University Conference States); p. S13.
on
Depression and Allied
WHICH of the many injuries sustained by the claimant caused chronic alcoholism: answer Yes or No ? " Thus may run the doctor’s nightmare before his appearance in court in a case in which he has, wittingly or otherwise, become involved in a professional respect; for there are few who view such a public ordeal with complete equanimity. In British courts, the evidence on fact and opinion elicited by counsel’s questions in the examination-in-chief is open to be tested by cross-examination, when a witness may be questioned closely and persistently. Once in the witness-box the doctor is, therefore, likely to find that a straightforward examination-in-chief will be followed by questions which will require knowledge and rapid but careful thought if helpful and clear answers are to be given. And all this in public, with the full attention of the court and Press, so that incautious remarks are apt to resound far more than similar remarks made in the seclusion of the consulting-room. The doctor’s peace of mind may be further disturbed by the sight of a steady succession of notes being passed to cross-examining counsel by the medical adviser for that side, making it quite clear that any deficiencies of medical knowledge on the part of the lawyer are constantly being made good. Merliss et aLl emphasise how important it is to keep complete and detailed records, so that, if litigation arises, reliable reference may be made to the documents. Abbreviations in records are a hazard, unless their use can really be justified, for counsel are not slow to seize upon possible ambiguities or any other apparent defects in case-records, sometimes using them with devastating effect in cross-examination. Bias and sympathy on the doctor’s part may easily lead to an impulsive and rash opinion, and if lawyers proceed on the assumption that that opinion is correct then the doctor may find himself in court unhappily learning that the objects of cross-examination include the destruction of his assertions and the strengthening of the opinions of the other side, while someone, more unhappily still, faces an adverse verdict and costs. This kind of disaster can usually be averted if no opinion is ever given without deliberation and reference to authoritative literature. At no time should a doctor be drawn into professing an opinion to lawyers on the understanding, expressed or implied, that he will not at any time be called to the witness-box to give evidence: either the opinion is to be regarded as worthy of repetition and test in court, or it should not be given at all. In the court with the heaviest demands on doctors’ time, the coroner’s court, there is no cross-examination, but the coroner’s questions may be followed by counsel’s, often designed to lay emphasis in some special direction, and these additional questions can be as probing and as difficult as any in a thoroughgoing cross-examination in other courts. Quite often the most junior member of a hospital clinical team is sent to the coroner’s court to give evidence, even though his comprehension of the case may be imperfect, and it is scarcely surprising that this can result in counsel’s questions not always being answered with the clarity, accuracy, or determination of which a senior clinician might have been capable. The worth of medical evidence elicited by crossexamination is often questioned after the hearing of a sensational case in court, when both doctors and the general public express doubts about the merits or even 1.
Merliss, R. R., Gelfand, L., Magana, R. New Engl. J. Med. 1959, 261, 175.
relevance of statements given during what is a stressful ordeal. From time to time suggestions2 are made to the general effect that it would be an advance if conflicting medical evidence were to be heard and assessed by a panel of experts, or else that expert witnesses should be examined by the judge rather than by opposing counsel. The expert panel could well be a time-saving device and a guarantee that the evidence given at a trial is genuine and truly expert; but it is sufficiently far from established British practice to cause uneasiness about defeating the object of allowing justice to be seen to be done. It might be safer to continue to hear all the evidence in court and put it to a judge or a jury in such a way that they could form their own opinions of the whole matter, for they, after all, are the final arbiters. If the testifying doctor gives an honest and sincere opinion, and if he is prepared to support his views with reasonable references to textbooks and articles, then he will not be likely to confuse the court or to run into serious difficulties in the cross-examination. One thing is certain-a doctor should not withhold useful evidence just because he is afraid of having a bad time in court. As Merliss et al. remark, " Cross-examination is a rigorous test for any doctor to undergo. Yet, unless he is willing, and unless he delivers testimony effectively, he fails in an important service to his community and to his patient " THE SALIVA IN DEPRESSION
THE need for some objective measure of mood-change is clear enough: clinical detection of the suicidal risk is a baffling problem. Depression, at times, is a normal condition if not too severe or long-continued; and much of the recent symposium on this subject 3 was taken up with questioning as to what was meant by the word. Over twenty years ago Strongin and Hinsie4 observed that, while the salivary excretion-rate in schizophrenia is somewhat higher than normal, it is greatly reduced in depression. Peckhas replaced the cumbersome technique with a suction cup over the parotid duct by a more practicable one in which standard dental rolls of cottonwool are weighed after lying for two minutes over the duct orifices. This procedure has become known as the S.H.P. (or Strongin-Hinsie-Peck) test, and the results with it are interesting. Clearly significant differences beyond the 0.01 level were found between normals and depressives, irrespective of sex, age, and race; but among those under 19 years of age this difference became lost in a generally higher level of secretion, and Negroes gave relatively higher readings in both normal and depressive groups. Body-weight and smoking habits did not seem to interfere with the results; but gum-chewing did, and intercurrent fever lowered the readings. In some a diurnal fluctuation was noted, with greater secretion in the evening; and Peck suggests a possible relation to the well-known diurnal changes of mood. As he observes, the overlap between the normal and depressed subjects is such that no cut-off point can be identified, and much remains to be done before this test can be usefully used for diagnosis.
Psychosomatic accompaniments to depressive illnesses have long been observed,6 but their measurement has not, hitherto, been very helpful clinically. 2. See Lancet, 1956, i, 427. 3. See ibid., Oct. 3, 1959, p. 509. 4. Strongin, E. I., Hinsie, L. E. Amer. J. Psychiat. 1938, 94, 1459. 5. Peck, R. E. A.M.A. Arch. gen. Psychiat. 1959, 1, 35. 6. See, e.g., Cleghorn, R. A., Curtis, G. C. Canad. psychiat. Ass. J. 1959,
4, suppl. (McGill University Conference States); p. S13.
on
Depression and Allied