On January 6, 2011, in San Antonio TX, Dr. Mark Melhorn will be lecturing at the 2011 Advanced Skills Course of the American Academy of Disability Evaluating Physicians, on his book Guides to the Evaluation of Disease and Injury Causation.  Dr. Melhorn will also be lecturing at AADEP’s Annual Scientific Session, January 7, on the evaluation of hand and wrist claims.  Additionally, another seminal book that he has edited, A Physician’s Guide to Return to Work, will also be the focus of a session during AADEP’s 2011 Advanced Skills Course.

Dr. Melhorn’s Causation book is perhaps the most important book ever written for medical-legal work, because it addresses the issues which are the foundation of workers compensation and personal injury legal systems.  Workers’ compensation was created to address health problems specifically of a work-related nature, and the personal injury court system was created to address injuries. Unfortunately, discrepancies have emerged between these purposes and modern reality. As has been explained in Dr. Melhorn’s book, there are many clinical issues that find their way into those legal systems despite the fact that there is little to no scientific support for claiming that those issues are work-related or injury-related. Examples include carpal tunnel syndrome, complex regional pain syndrome type 1, posttraumatic stress disorder, and chronic back pain. Conversely, Dr. Melhorn’s book also explains that the potential work-relatedness of some conditions may go unrecognized because of the less than obvious nature of the relevant occupational risks.

One factor in the development of such discrepancies is the dominant tendency for legal systems to allow doctors to offer opinions, rather than limiting doctors to a discussion of facts. Reviews of workers’ compensation files (such as a review of files that was undertaken specifically in conjunction with the creation of Dr. Melhorn’s book), reveal that doctors develop opinions regarding work-relatedness in an idiosyncratic, haphazard, and even cavalier fashion. Similarly, a Florida workers’ compensation insurer surveyed its panel of doctors about how they determine work-relatedness, and the prevailing response was that they do not — they simply assume work-relatedness based on the fact that the patient came to see them in the context of a workers’ compensation claim.  Based on such reviews and reports, one might develop the impression that there are no professional standards for evaluating work-relatedness or injury-relatedness.

Dr. Melhorn’s Causation book was published in 2008 with the goal of eliminating such impressions. It specified scientific and clinical standards for causation analysis. Given the information in this text, claims of relatedness from any individual case can be scrutinized to determine whether the doctors who offered the conclusions did so in a manner that is factually based, scientifically credible, and consistent with professional standards.

Two points from the preceding paragraph warrant emphasis: Factual basis and scientific credibility. The first, factual basis, is dependent on the second, scientific credibility.  Dr. Melhorn’s book explains that scientific causation analysis involves a search for facts. The text highlights the discrepancy between this and legal causation, which, instead of being based on facts, is rooted in subjectivity — the subjective claims of the patient, the subjective opinions of doctors, and the subjective judgment of decision-makers. Because legal systems are so thoroughly plagued by subjectivity, people who work within those systems might never have realized that causation determinations could potentially be based on facts.

Health science is the source of the facts that are needed for making credible causation determinations. Unfortunately, this critical portion of the process is usually ignored.  Doctors’ opinions frequently develop in the absence of any consideration of the relevant health science.  Dr. Melhorn’s book repeatedly emphasizes that a claim of relatedness, even for a single case, should primarily be based on a presentation of scientific research which specifically and credibly analyzed the possibility of a causative link between the presumed cause and the claimed clinical presentation. 

In other words, it is appropriate for a doctor’s causation analysis in an individual case to start with a review of the relevant scientific literature.  Dr. Melhorn’s book actually provides such reviews of the relevant science for many issues that enter into medical-legal claims. For example, for claims of post-traumatic stress disorder (PTSD), a review was provided of studies that examined the possibility of a causative relationship between traumatic civilian experiences in adult life, and the development of PTSD symptoms.  Such studies have repeatedly revealed a lack of causative relationship — the syndrome of PTSD did not occur at higher rates in groups of people who had experienced trauma, compared to groups of people who had not experienced trauma. The repeated replication of such scientific findings creates a significant obstacle to credibly concluding that PTSD is caused by civilian trauma in adult life. Such scientific findings allow a doctor in any individual case to address relatedness based on facts (e.g., the fact that scientific findings have failed to support claims of relatedness), rather than based on subjective claims and opinions.

In addition to such reviews of the scientific literature, Dr. Melhorn’s book provides examples of how doctors can conduct a causation analysis for any individual case, and how the results of that analysis can be documented. The text additionally addresses many of the benefits of a credible approach to evaluating causation, such as  sparing patients from unjustifiable exposure to the reliably harmful health effects of involvement in medical-legal claims, identifying relatedness that might be overlooked if a scientifically credible approach is not used, combating the tendency for misdirected claims of relatedness to cause more important causes to be overlooked, minimizing the unnecessary adversarialness of medical-legal systems by providing a factual basis for claim resolution, and controlling the explosively increasing costs of workers’ compensation.

AADEP is honored and thankful that Dr. Melhorn is willing to lecture at the 2011 Advanced Skills Course and Annual Scientific Session.   His contributions to AADEP (serving as program chair repeatedly, holding a variety of offices including President, and a long history of faculty duties) have been a major factor in AADEP becoming a leading source of medical education in credible health science.

Information about AADEP and its educational offerings can be found at www.aadep.org, or by calling 312/663-1171.

Meeting Information:
24th Annual Scientific Session
January 7-8, 2011
JW Marriot Hill Country
San Antonio, Texas

Click HERE to view the Annual Meeting brochure.