What Legal Idioms Mean in Medicine

When he went to court in expert opinion, this doctor discovered that legal
idioms abound.
"Do you know where 'let the cat out of the bag' came from?" asked my
patient, with a grin. Sitting in my clinic office, he wasn't demonstrating
tangential thought process, just setting me up for my next lesson in idioms.
"It came from a place where pigs were sold in the marketplace and placed in
burlap bags for transport," he continued. "Crooked salesmen would substitute
cats for the pigs after the sale. The unsuspecting customers would return
home to find they'd been swindled -when the cat was let out of the bag!"
Mr. Smith (not his real name) had written the book on idioms-literally.
During my three years as his physician, I discovered how ubiquitous these
expressions are in the English language.
Medically themed idioms, like "take two aspirin and call me in the morning,"
and "an apple a day keeps the doctor away," abound. Idioms are about as
well, lawsuits. Where else are accident victims followed by "ambulance
chasers"?
As in medicine, a myriad of idioms litter the legal system-phrases like
"brush with the law" and "throw the book at him." But in the courtroom, one
expression stands apart: that literal, unambiguous query, "Do you swear to
tell the truth, the whole truth and nothing but the truth, so help you God?"
Posed to me twice in recent months, this simple question asked of anyone who
is about to give legal testimony truly "hits home."

Should I play the role of "hired gun"?
I "took the plunge" into the pool of medical litigation when I was asked to
serve in expert opinion. But before I agreed to testify, I sought advice
from senior faculty members at my teaching hospital. Some thought I should
pass on the job. One said he "wouldn't touch it with a 10-foot pole."
Others, including my chairman, thought it would provide an excellent
education in the medico-legal process-a subject our medical schools devote
little or no time to despite malpractice's status as every physician's
"Achilles' heel."
My role as an internal medicine/psychiatry expert was to review a case on
behalf of a physician I'll call Dr. Jones, who had been practicing medicine
for nearly as long as I've been alive. He'd seemingly been pulled "out of
the frying pan" of his busy practice and thrust "into the fire" of
litigation. I read through his deposition, starting with: "Do you agree to
tell the truth . . ." It proved a fitting preamble to a series of
unforgettable lessons.
The plaintiff was a patient committed to a psychiatric hospital for
evaluation and treatment of psychosis. At the nearby community hospital,
police officers had to wrestle him to the ground because of his erratic
behavior. Once in the psychiatric facility, he allegedly hallucinated and
hit his head against a metal-grated window in a seclusion room. Dr. Jones, a
consulting internist, was summoned after the patient refused to get up off
the floor. His preliminary diagnosis: hysterical paralysis. The
intervention: intramuscular normal saline. After the patient lay on the
seclusion room floor for two days, the diagnosis was changed to quadriplegia
secondary to cervical fracture. The intervention: neurological surgery.
Trying not to play "Monday morning quarterback," I learned three valuable
lessons from this case-lessons that have made me a better physician and
clinical educator.

What I learned in expert opinion
Lesson 1: It's "better to be safe than sorry." Lack of proper medical
documentation in this case was a liability. The physical exams, assessments,
and treatment plans were charted with minimal detail, making it difficult to
evaluate the clinician's thought processes. Whenever I'm tempted to omit
details of my evaluations-especially late in the day when my kids want to
know when Daddy's coming home-I remember Dr. Jones' case and stay a few
extra minutes to complete my notes. I may never know the legal impact these
extra words would have, but I do know they help me sleep better at night.
Lesson 2 "Don't talk the talk if you can't walk the walk." The initial
psychiatric diagnosis in this case was made by an internist, clearly acting
outside his area of expertise. I've since become acutely aware of the
far-too-narrow boundary that surrounds my own knowledge base. Fortunately,
whenever I start to venture beyond it, the "hairs on the back of my neck
stand up." Fear of overstepping my medical bounds keeps my nose in the
medical literature and my ears trained on the opinions of my expert
consultants.
Lesson 3: Avoid the "blame game"-which is easier said than done. Pinning
blame on colleagues in the midst of a crisis does little good; and it raises
stress levels and detracts from the efforts of the treatment team, as it did
in this case.
That's not to say that reporting medical errors should be avoided in order
to protect those who've erred. Quite the opposite. The credo "first do no
harm" was hammered into all of us during medical training. But if harm does
occur, it must be promptly reported, without finger pointing.

How preparation pays off
I learned another valuable lesson when, under notice of deposition, I was
subpoenaed to testify on behalf of a quadriplegic patient in my outpatient
psychiatry clinic. He was suing the primary care physician who had treated
his neck pain and arm paresthesias. Mr. Brown (not his real name) was
conservatively treated with cyclobenzaprine-until he couldn't walk. It was
later discovered that he had a cervical small-cell lymphoma causing spinal
cord compression. I was treating Mr. Brown, a former dance champion, for
depression related to his resultant quadriplegia.
I was in a "Catch-22" situation-testifying for my patient at the expense of
a fellow physician. I hadn't anticipated being a consultant in litigation
involving Mr. Brown. But when it came time to review my medical
documentation, I was relieved to find I had "all my ducks in a row." This
was quite a comfort, as I watched the lawyers dissect every sentence I had
ever written about Mr. Brown.
Fortunately, I had included data from clinical rating scales in my
notes-something I did frequently before this case, but now do without fail.
So when I was questioned about how I assessed and treated Mr. Brown for
depression, I was able to produce hard numerical data on symptom severity.
These numbers made it easy for the jury to understand both the patient's
symptoms and his response to treatment.
The lesson I learned from this case extends beyond psychiatry. I'm more
careful in my medical practice now when it comes to obtaining and
documenting data on patients with pneumonia, fibromyalgia, and
cardiovascular mortality risk, to name a few.
"Knock on wood," these lessons will go a long way in helping you, too, avoid
the "slings and arrows" of malpractice litigation. But if you do find
yourself involved in a case, I hope you'll be armed with the unfettered
confidence that comes with preparedness.
As they say, "forewarned is forearmed!"