Reflections on Medical Decision-Making

I’m working on Part 2 of my blog series about IME Assessments, but have been ‘distracted’ over the last week or two by my involvement in an AMA Tasmania Committee considering issues relating to Tasmania’s Workers’ Compensation and Motor Accident Insurance Schemes.

I had the experience of  a meeting with the Tasmanian Government Minister responsible for WorkCover earlier this week. The committee members were explaining to the Minister the problems with the system from the perspective of doctors. I was providing some examples of situations in my own practice to illustrate the issues. I told the Minister about a case where the driver of a vehicle suffered neck injuries in a motor vehicle crash about 7 or 8 years ago. I had first seen this person some years ago for a medico-legal review. There was a disagreement then about whether there was a need for neck surgery. I had seen the same person again about a week earlier to provide an updated medico-legal opinion. His case was to be heard in the Supreme Court in a few months. It didn’t strike me how ridiculous the decision-making process was until I had to explain it to a non-medical person in that meeting.

It has taken 7 or 8 years for the legal system to determine whether a spinal operation is justified, presuming that a decision is forthcoming from the Court.

The legal decision-making process involves seeking opposing opinions. A learned non-medical person, the judge, makes a decision about which side is correct by weighing up the credibility of the evidence. Meanwhile the person with the injury waits in pain, suffers terrible psychological consequences and cannot move on with their life – not to mention the costs of lawyers and use of courts. This is what happens all too often in the workers compensation and motor accident compensation systems.

What normally happens in a health care setting? If a general practitioner doesn’t know what to do a referral is made to a suitable specialist. If the specialist doesn’t know what to do they might seek an opinion from another specialist they respect. If all else fails they would take the case to a panel of their peers or a multidisciplinary group for a ‘case conference’. While doctors can disagree, most of the time this process reaches a consensus of what to do in the patient’s best interests. The process might cost a few hours of doctor’s time and perhaps a few months, at worst, of waiting for the right specialist to be available. It certainly doesn’t take 7 or 8 years or cost anywhere near that of the legal process to reach a decision. The legal approach imposes a penalty on the person in terms of delay with continued pain and suffering. In many cases there is the additional cost of the development of depression and loss of personal relationships. This is in addition to the monetary costs of the legal system.

Doctors should make medical decisions. Legal processes should sort out disputes between parties or decide guilt about criminal activity. The legal system should rarely have to make decisions on medical matters and only where medical decision-making fails.

In the context of workers compensation or motor accident injuries, the best option is the use information from the treating doctors who know their patient the best. Where this is insufficient impartial medical panels of recognised practicing doctors in the relevant specialist field(s) of medicine should make decisions about diagnosis, reasonable treatment, prognosis, fitness for work, causation and impairment. The only issues that arise with this approach are how the panels are selected to ensure experienced and qualified doctors make the decisions and whether there are enough such suitable doctors to service the needs of the system.

The NSW Workers Compensation System is under review at present. The Tasmanian Workers Compensation System is overdue for review. Food for thought?





About Tasworkdoc

As an occupational physician in private medical practice in Hobart, Tasmania - the southernmost state of Australia, I see workers referred by their general practitioners with various types of work-related injuries and diseases. These are mostly musculoskeletal injuries, both of traumatic and gradual onset as well as various associated psychological disorders. With interaction with patients for treatment and providing advice about rehabilitation, I have the opportunity, first-hand, to observe interactions between individual patients and compensation systems. I also conduct independent medical assessments, including impairment assessments for musculoskeletal injuries and asbestos-related disease compensation. This provides another perspective of workers within compensation systems.
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2 Responses to Reflections on Medical Decision-Making

  1. Soula says:

    ‘Medico-legal’ should not be a word! Let’s begin there…

  2. Pingback: Reflections on Medical Decision-Making » The Injured Workers Support Network

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