Forensic Medicine: Overview and Responsibilities

1. C&P Mission Right Benefit Right Veteran Right Time Right Reason

2. Forensic Medicine: Overview Louisville, Ky. March 2015

3. Objectives • Describe key components of forensic medicine • Define key terms applicable to forensic medicine • Describe provider’s responsibilities • Describe the key components of a forensic medical report • Describe best practice in regards to a causality/opinion reporting

4. Forensic Medicine, Definitions • That science which applies the principles and practice of the different branches of medicine to the elucidation of doubtful questions in courts of justice, insurance claims and other compensation determinations • The branch of medicine that interprets or establishes the facts in civil or criminal law cases

5. Unique Challenges of CLCW cases • Unique provider skill set required • Highly technical toxicology evaluations • Detailed and complex exposure history required • Intimate knowledge of specific scientific reports and related literature • Melding of the above into a medically/legally defensible report requires excellent writing skill

6. Benefits of Subject Matter Experts • Greater consistency of evaluation of possible exposures • Greater reliability of opinions • Greater consistency of opinions bases on best medical evidence • Improved efficiency of provider opinions

7. Clinicians’ Role • Dual reporting relationship • Patient: life-threatening conditions and findings only • Agency • Provide a nexus decision in accord with the requirements of the requesting agency • Within the requisite burden of proof • Based on documented thorough review of the probative evidence • With supporting statements based on medical literature • Assess and document medical impairment and functional abilities in accord with the requirements of the requesting agency • Deferred to residual examination

8. Definition: Burden of Proof • The duty placed upon a party to prove or disprove a disputed fact • This does not equate to medical certainty

9. Burden of Proof • Beyond a reasonable doubt: “proof of such a convincing character that a reasonable person would not hesitate to act upon it in the most important of his own affairs" • Clear and convincing evidence: evidence that establishes the truth of a disputed fact by a high probability • Preponderance of the evidence: one side has more evidence in its favor than the other, even by the smallest degree • VA’s unique issue: Equipoise evidence, benefit of the doubt goes to the veteran

10. Causality (Nexus) Decision • Causality: based on review of the probative evidence of record, current clinical evaluation and applicable medical facts/principles • Probative evidence: • Tendency of a given item of evidence to prove or disprove a legal element of the case • Having the effect of proof, tending to proof, or actually proving • Association does not equate to causation

11. Type of Opinions • Primary Causality • Injury/illness sustained during documented time of military service • Secondary Causality • Injury/illness sustained as a result of a service connected condition or the treatment of a service connected condition

12. Causality Opinion • Burden of Proof: More likely than not with tie going to the veteran • Documented history of exposure • Record review • Supportable history • Bradford Hill Criteria

13. Bradford Hill Criteria • 1: Temporality: It is logically necessary for a cause to precede an effect in time. • 2. Strength of Association: The stronger the relationship between the independent variable and the dependent variable, the less likely it is that the relationship is due to an extraneous variable. • 3: Consistency: Multiple observations, of an association, with different people under different circumstances and with different measurement instruments increase the credibility of a finding.

14. Bradford Hill Criteria • 4: Theoretical Plausibility: It is easier to accept an association as causal when there is a rational and theoretical basis for such a conclusion. • 5: Coherence: A cause-and-effect interpretation for an association is clearest when it does not conflict with what is known about the variables under study and when there are no plausible competing theories or rival hypotheses. In other words, the association must be coherent with other knowledge.

15. Bradford Hill Criteria • 6: Specificity in the causes: In the ideal situation, the effect has only one cause. In other words, showing that an outcome is best predicted by one primary factor adds credibility to a causal claim. • 7: Dose Response Relationship: There should be a direct relationship between the magnitude of the risk factor (i.e., the independent variable) and severity of the disease variable (i.e., the dependent variable).

16. IME Process: Keep the end in mind • History adequate to support diagnosis and nexus decision • Physical examination adequate to support diagnosis, nexus decision and any applicable disability rating • Diagnosis • Causality opinion (Nexus decision) • Supporting rational • Statement of function (impairment)

17. Exposure History • Is Agent Present? • Is there a Route of Exposure for Agent? (air, dust, water, food) • Acute Vs. Chronic exposures • Did Agent get Into or On the Body? • Date(s) of exposure • Length of exposure • Amount of exposur • If in the Body, did Agent Cause Effects?

18. History gathering • Before Service • Rule out pre-existing injury/illness • During Military Service • Mechanism of injury/exposure • After Military Service • Rule out intervening/interceding events • Other exposures to same compounds • Other exposure which can cause condition of record

19. Record review • Does it support or refute individual’s history? • Adequacy of previous work up and diagnosis • Does the secondary data support the individual contention? • Is there consistency between veterans report of exposure and military service records

20. Physical Examination • Generally the same approach as non IME examinations • Documentation of current symptoms if active disease • Documentation of residuals findings if no active disease present • Significant negatives are very important • Help with adjudication of future claims

21. Diagnosis • Is there adequate evidence of record to support current of past claimed diagnosis? • Normal examination, No diagnosis/ No Residuals

22. Bradford Hill Criteria • 8: Experimental Evidence: Any related research that is based on experiments will make a causal inference more plausible. • 9: Analogy: Sometimes a commonly accepted phenomenon in one area can be applied to another area. Hill, B.A. (1965). The environment and disease: Association or causation? Proceedings of the Royal Society of Medicine, 58, 295-300.

23. Final Report Submission • Must be able to withstand appellate review • Must be understandable by non-medical reviewer • Must use applicable legal burden of proof • Must possess internal validity • Facts must be supportable by history, record review • Conclusion must be based on current applicable medical science • Consider your potential eventual audience—a Judge