By Deborah Cho
As a student in the Disability Litigation Clinic, one of the many fantastic clinics here at Harvard Law school, I’ve come to appreciate the value of hands-on experience as an essential component of legal education. One issue that we as students are often faced with, however, is a lack of familiarity with the particular subject matter we are assigned to work with. Now, I know that topic-specific knowledge typically comes on the job, but I’m starting to see that many of us trying to practice law touching the medical field never really have a chance to learn the basics of the medical world and just how essential that basic knowledge really is.
As a short introduction to this post, I will say that I spent several of my college years volunteering and doing research at various hospitals and clinics, went to medical school for two years, have an M.A. in Bioethics (noting this to add to my hours spent in a hospital), have interned in the health care division in state government, have interned in a health law nonprofit firm, and, as noted above, am enrolled in the Disability Litigation Clinic right now. All that to say, please take everything I write here with a grain of salt. I am by no means an expert on this, but have found that this information has helped me throughout my healthcare-related legal experience so far and I hope that this will spark dialogue and interest on this subject.
Over the past few months, I’ve noticed a few things about the medical field and health care providers that I think may help law students (or maybe even lawyers) who are interested in any type of health or medical law.
- Always refer to a physician as “Dr.” This is a really obvious one, but it has to be said, especially if you plan on working with the physician on your case. Think of an MD or DO as more like a Judge or Honorable than a JD in terms of the importance of the title. In medical school, I once saw Dr. S return an e-mail addressed to “Ms. S” saying only, “Why does it say Ms. S?” It was as if she thought the e-mail had reached her in error. Ms. S was not her name.
- As a corollary, any other health care provider with a doctorate should also be referred to as a doctor. This means those with a PhD, PsyD, DNP, DDS, OD, etc. If you don’t know if a health care provider is a nurse (non-doctorate) or a doctor, you should probably just call them doctor until they correct you.
- In law, we give medical records significant weight as evidence because we believe that people generally tell the truth to their providers since that is in their best interest. As such, you should know how to read and interpret common terms in the records as a starting point in understanding your clients and cases.
- First, as the wife of a physician, I can personally attest to the fact that writing, typing, or dictating medical charts is not a physician’s favorite activity. Because of this, you will find numerous abbreviations and acronyms littered throughout the records. While you don’t need to know or memorize what each of these mean, you may need to know how to look them up. Unfortunately, the same set of letters can often stand for many very different things, so you’re will need to do more than just search the abbreviation or acronym itself. For example, search “PE medical acronym” may not get you the correct answer. You should include the words around the term itself and what type of file it was in to get more accurate results. Searching “PE emergency room” versus “PE annual check up” will help your quickly determine whether your client had a life-threatening embolism or a routine physical exam. Sounds silly, but you might be surprised at how often one-word searches are done in this context and how unreliable they can be.
- Here are some of the basic headings that you will find in a medical chart and what they mean:
CC – chief complaint. This is the patient’s main issue.
HPI – history of present illness. This is essentially the patient’s answer to the question, “So what brings you in today?”
PMH/PSH – past medical/surgical history.
ROS – review of systems. This is when the provider asks the patient questions upon questions pertaining to how he feels generally, if he’s had any changes in weight, any coughing, any pain, etc.
PE – physical exam. This will probably be followed by several other acronyms or other half-words. If it looks like there are only acronyms, such as “HEENT PERRLA CVP RRR CTA,” then the findings were probably all normal. If there was something abnormal you should, in theory, be able to read about it in plain English. WNL means “within normal limits,” but, and this is my bioethics side kicking in here, it is sometimes disparagingly also referred to as meaning “we never looked.” Thus, it might be a good idea not to have your entire case turn on one WNL in the record. This is doubly true if the provider simply circles the entire physical exam form and writes one large WNL.
A – assessment. This is where the provider writes what she thinks is going on, including a differential diagnosis (DDx). The differential diagnosis is the list of possible causes of the patient’s symptoms (what the patient reported) and signs (what the provider noticed or measured). The patient is not necessarily being diagnosed with everything, or anything, listed.
P – plan. Here, the provider notes what she and the patient are going to do to treat the patient’s condition. The provider may note that she is recommending a certain prescription, but it does not guarantee that the patient filled or took that medication. - One term of art that is crucial to understand is the use of the word historian. When a provider describes what type of historian a patient is, she is making a credibility assessment. For example, if your client was noted to be a poor historian, then you should take everything he reported as suspect unless corroborated elsewhere. He may be a poor historian due to age, drugs (prescription or otherwise), mental impairment, or because his story to his provider was obviously inconsistent. This term is used without any attempt to make a normative judgment on his character. It is simply a way to communicate to others reading the report the possibility that not everything the patient reported is true.
Next week, I will add a few other tips to this list, including what search engines you should consult first in any quests for medical information.