Clash of cultures in the field of brain injury
CLINICIANS, ATTORNEYS, AND various entities face the challenge of agreeing upon what constitutes an injury and when the effects of such an injury disappear. This is more so for the case of the milder forms of brain injury i.e. concussion. Most persons with concussion are 80–90% back to their baseline and functioning normally within 7–10 days but may take longer in children and adolescents (McCrory 2005, McCrory 2013).
While this statement is partially true, it is most relevant when treating patients in a static environment where they fit a certain profile. As there are always two sides to a story, our society has developed a sort of climate polarization, and we now think only in terms of the plaintiff (injured) and the defense. Employees and consumers are more adept to the liabilities that arise from the negligence caused by faulty products, construction, and situations that put an individual at risk for injury. Recognizing the fact that the US is a country of rights and countries all around the world are now focusing on human rights, we as a society have become litigious. There is now an entire industry developed around trauma, and that includes TBI/concussion. The significantly easy access to the legal system and insurance coverage available to pay for damages are driving both sides of the divide. The issues of workers’ compensation addressing return to work, liabilities, and personal injury lawsuits have been shaping for the past few decades the way we evaluate and manage individuals with TBI and concussion. Consumerism has forced us to redefine what a concussion is and when people can be classified as experiencing the signs and symptoms of such a condition. Whether you are on the plaintiff or the defense side, employer or employee side of the issue, we are all now at a time and place in the TBI/concussion world where economic drives on both sides have clouded our ability to truly predict outcomes following injuries and determine whether the effects of injury persist. I have also seen providers of health care miss important diagnoses due to inherent beliefs held by certain health care workers. One such belief or view says that if patients are not truthful about one thing, they are not truthful about all things. On the patient side, the idea of secondary gain (i.e., utilizing one’s illness or perceived illness to acquire a benefit that is not deserving in the context of the injury) can be a major driver of illness. I have experienced treating patients who put on a charade of symptoms to continue in a sick role for secondary gains and at times demonstrate a condition referred to as malingering – the conscious knowledge of making up conditions that do not exist or exaggerating their condition beyond the actuality. If you are a purist, most patient whom you suspect to be exaggerating their condition or providing falsities about their described symptoms and their clinical and neuropsychological exam are considered not to be ill. Well, many times, if the key issues of focus are finding ways to trap the patient and determining whether they are really ill, clinicians can miss important facts about the patient’s illness. The fields of neuropsychology and neurology spend a considerable amount of time looking for inconsistencies within a level or sub-dimensions of test conditions. In this context, the clinician neuropsychologists and sometimes the neurologists perform different tests to evaluate the same function.
As an example, say, we carry out a test assessing short-term memory using more than one test measure. Assuming that the condition is legitimate, the results of short-term memory should be similar to two or more tests. While these measures can be taken to determine the legitimacy of a condition, caution should be maintained in interpreting the results as conditions such as pain, fatigue, anxiety, emotional instability, and fear, and yes, a secondary gain can influence consistency when different neuropsychological tests are administered for the same function.
I know a neuropsychologist (let’s call him Dr. Silva) who performs two different memory tests, each of which evaluates the same memory function, i.e., short-term memory. If there is a more than 40% deviation from the scores on the different tests of short-term memory, the neuropsychologist immediately assumes that the patient is malingering or exaggerating their symptoms. Neuropsychologists clearly carry out various tests before they can draw those conclusions.
(Case # 3)
I was hired by a plaintiff’s attorney to testify about the validity of the neuropsychological tests from the neuropsychologist, Dr. Silva. The attorney wanted me to testify regarding the legitimacy of the symptoms of a patient (Mr. Dalbert) who suffered a cerebral concussion. Neuropsychological tests performed by Dr. Silva determined that there was an inconsistency between the two neuropsychological tests of short-term memory with an over 40% difference between the results of the two. As a result, Dr. Silva declared in his conclusion that the patient was malingering. What was not evident to Dr. Silva was that Mr. Dalbert was a diabetic and had taken a dose of insulin in the morning before coming to take the tests. In addition, Mr. Dalbert was so nervous about the neuropsychological tests that he did not eat his breakfast before taking the test. Upon questioning the patient about the conditions surrounding the occasion when he took the second short-term memory neuropsychological test, the patient indicated that he was feeling very bad during the test. It was fortunate that the patient was very meticulous about checking his blood sugar; he provided us with his log of blood sugar levels. He had a finger-stick blood sugar test performed shortly after taking his insulin, and that was 2 hours before taking the second part of the neuropsychological test. He then did a follow-up blood sugar finger-stick test when he completed the second neuropsychological test because he was feeling lousy. My medical scribe who was reviewing his blood sugar log found that the patient was running low blood sugar. The results of his blood sugar before he completed the second neuropsychological test was 42 with normal being between 60–100 range, whereas the one performed 2 hours before the first neuropsychological test showed normal results. Months after seeing this patient, I was providing legal testimony in a deposition as to the legitimacy of the neuropsychological test performed on Mr. Dalbert. I was able to point out that a blood sugar of 42 would significantly compromise the patient’s cognitive function and affect his performance on memory test. I later received a call from the neuropsychologist administering the test. In that phone conversation, he made a declaration that he had learned an important lesson from this experience and pledged to be more cautious in interpreting the inconsistencies on neuropsychological testing, as many factors including low blood sugar could influence the results.
The history of cerebral concussion and more recently the history of the development of the chronic traumatic encephalopathy (CTE) diagnosis has faced significant controversy over the years. Until recently, the definitions of concussion required that there be a loss of consciousness, and we now know that this is not a necessity. Due to the applications of this loss of consciousness standard for research and other clinical evaluation tools, concussions have been largely underreported and underdiagnosed over the years.
Like the case of the tobacco industry which for years denied the link between smoking and lung cancer, the world has finally understood the link between the effects of repeated hits to the head during sporting activities, such as football, and concussion (Stieg 2014, Gardner 2015, Washington 2016).
This issue of the denial of the existence of a concussion has come with a price tag close to $1 billion in a court settlement for the National Football League (NFL). We now know that concussion is also linked to CTE despite the major denials over the years (Stieg 2014, Gardner 2014).
(Case # 4)
I once saw a patient, Alfonzo Grant, who was involved in a workers’ compensation situation where he genuinely fell off a roof while working as a roofer. I saw him approximately 10 years after the injury. After spending 2 hours listening to his litany of symptoms, I had a list of over 42 complaints. If you are a physician, you must have had the experience of such an encounter with a patient, having to sit through all the gory details and the plethora of complaints. Patients must understand that doctors are humans too; we can get impatient. My favorite manner of dealing with such patients is asking them to rank in order what bothers them the most. I finally asked Mr. Grant to tell me the one thing that bothered him the most. The