Assessing medical disability for the courts

Assessing Medical Disability for the courts

Mr Vaikunthan RajaratnamMBBS(Mal),AM(Mal),FRCS(Ed),FRCS(Glasg),FICS(USA),MBA(USA),

Dip Hand Surgery(Eur),Dip MedEd(Dundee),FHEA(UK),FFST(Ed),FAcadMEd(UK).

Senior Consultant Hand SurgeonAlexandra Health, SINGAPORE

Credentials

• 35 years clinical practice and teaching• Qualifications in medical education• Experience in instructional design and technology (on going Masters)• Publications and research in surgical education• Senior Clinical Examiner(UG) – Birmingham/ Singapore• Examiner PG Ortho Exit exams – Indonesia/Malaysia/Singapore• Examiner Royal College of Surgeons, Edinburgh• Quality Assurance Panel of Visitor in PG ME&T, UK• Core Faculty Member Orthopaedic Surgery – ACGME-I, Singapore• Core Faculty Member Hand Surgery Residency, ACGME-I, Singapore• Fellow - HEA UK, Academy Medical Educators (UK), Faculty of Surgical Trainers Edinburgh• Reviewer for Educational Research Grants HEA,UK• Member of Alexander Health, Research in Education, Singapore• Member of Alexander Health, Medical Ethics Board, Singapore• Visiting Consultant Bangabandhu Sheikh Mujib Medical University, Bangladesh and

Children Surgical Center, Cambodia• Failed medical and digital entrepreneur x 6• Medical Fraud Consultancy/Education – City State Liberty Mutual, Gerling Re and NIAM• 1600 written expert opinion for personal injury in UK (2002-2011)

Learning OutcomesAt the end of this lecture you will be able :-

• Understand the cognitive basis for your judgments

• Understand the science behind measurement and assessment used in medicine

• Understand the tools and process of assessment of medical disability and its limitation

Judiciary Perspective

The Bangalore Principles of Judicial Conduct 2003

• Judicial independence

• Impartiality - skill to recognize and detach from emotional reactions

• Integrity

• Propriety

• Ensuring equality of treatment to

• Competence and diligence

Bangalore Principles of Judicial Conduct were initiated in 2001. The Bangalore principles arose from a United Nations initiative with the participation of Dato’ Param Cumaraswamy, UN Special Rapporteur on the Independence of Judges and Lawyers.

“It is a judge’s professional duty to do what he reasonably can to equip himself to discharge his judicial duties with a high degree of competence.”

Lord Bingham of Cornhill

Responsible for planning, organizing and conducting training programs and courses for judges of the

Superior Courts. 33 “Superior Courts” include the Federal Court, Court of Appeal, High Court in Malaya,

and High Court in Sabah and Sarawak.

Judicial Academy

2014 “Senior Management & Professional” programme

1. Course on Protocols, Social and Dining Etiquette 2. Workshop on Negotiation Skills 3. Workshop of Handling and Discipline Management 4. Workshop on Writing Grounds of Judgement 5. Course on Creative Thinking in Problem Solving 6. Course on Middle Managers’ Worklife and Academic Strategic Planning 7. Course of Time and Stress Management 8. Course on Mind Transformation, Motivation and Leadership 9. Course for Magistrates 10. Seminar on Judicial Ethics 11. Seminar for Industrial Court Chairman 12. Seminar on People Skills – Empowerment and Positive Influence at The Workplace 13. Course on Government’s Transformation Plans 14. Seminar for Sessions Court Judges 15. Workshop on Arbitration

A Knowledge and technical skill B Communication and authority C Decision-making D Professionalism and integrity E Efficiency F Leadership and management

How abilities would be demonstrated

• Undertakes necessary preparatory work. • Properly applies appropriate legal principles to issues before the court. • Appropriately conducts proceedings in accordance with current procedural rules. • Identifies critical issues. • Rapidly absorbs and analyses complex and competing factual and legal material. • Clarifies uncertainty. • Weighs relevant issues and matters of law to formulate reasoned and coherent decisions. • Concentrates for long periods. • Stays up to date with changes to law and procedure. • Broadens and extends knowledge.• Remains detached and manages own reactions and emotions.

Assessing Medical Disability Decision science




Decisions dynamically evolve from a sequential sampling and accumulation of evidence/preference process that continues until a threshold criterion is reached

Brain and Mind

• Cognition• Ego

• Memory• Senses & Motor

TEMPOROPARIETEAL LOBE

HIPPOCAMPUS

PREFRONTAL CORTEX

DORSOLATERAL PREFRONTAL

CORTEX

The brain is the organ of the mind the lungs are the organs for respiration

Four basic mind states

fighting, fleeing, feeding, and f……g

function of the hypothalamus

Stimuli Identification Recall Understand

AssociationKnowledge

creationWIIFM

Affective change

Life change

JudgementA heuristic technique (/hjʉˈrɪstɨk/; Greek: "Εὑρίσκω", "find" or "discover"), sometimes called simply a heuristic, is any approach to problem solving, learning, or discovery that employs a practical methodology not guaranteed to be optimal or perfect, but sufficient for the immediate goals. Where finding an optimal solution is impossible or impractical, heuristic methods can be used to speed up the process of finding a satisfactory solution. Heuristics can be mental shortcuts that ease the cognitive load of making a decision. Examples of this method include using a rule of thumb, an educated guess, an intuitive judgment, stereotyping, profiling, or common sense.

Sir Francis Buller, an English judge, for allegedly ruling that a man may legally beat his wife, provided that he used a stick no thicker than his thumb

http://en.wikipedia.org/wiki/Help:IPA_for_English

http://en.wikipedia.org/wiki/Help:IPA_for_English#Key

http://en.wikipedia.org/wiki/Help:IPA_for_English

http://en.wikipedia.org/wiki/Polytonic_Greek

http://en.wikipedia.org/wiki/Rule_of_thumb

http://en.wikipedia.org/wiki/Ansatz

http://en.wikipedia.org/wiki/Profiling

http://en.wikipedia.org/wiki/Common_sense

The Bolam Test vs The Bolitho Test

• he or she has acted in accordance with a practice accepted as proper and responsible by a responsible body of medical practitioners skilled in that particular art.

• if the management by a body of responsible doctors was not demonstrably reasonable, it would not necessarily constitute a defence.

Plato & AristotleRationalism vs. Empiricism

• “Is truth and knowledge to be found within us (rationalism) or is it to be found by using our senses to discover what is outside of ourselves (empiricism)?”

• As a rationalist, Plato developed the belief that knowledge and truth can be discovered by self-reflection. Socrates also believed strongly that certain knowledge was only attainable through reason. He developed the dialectic method of discovering truth through conversations with fellow citizens (Monroe, 1925)

• Aristotle, the empiricist, suggested that we use our senses to look for truth and knowledge in the world outside ourselves.

• The Romans emphasized education as vocational training, rather than as training of the mind for the discovery of truth

Assessing Disability - the empiricist approach

Hawthorne effect (also referred to as

the observer effect) is a type

of reactivity in which individuals improve an

aspect of their behaviour in response to

their awareness of being observed

The Dr. Fox effect is

a correlation observed between teacher

expressiveness, content coverage, student

evaluation and student achievement

Emotion and Decision Making: Multiple Modulatory Neural CircuitsAnnual Review of NeuroscienceVol. 37: 263-287 (Volume publication date July 2014)

Assessing Medical Disability Defining Disability




Disability and Damage

Injury/Illness Treatment Intervention Outcome

Defining•

Impairment: any loss or abnormality of psychological, physiological or anatomical structure or function.

•Disability: any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being.

•Handicap: a disadvantage for a given individual that limits or prevents the fulfilment of a role that is normal

•As traditionally used, impairment refers to a problem with a structure or organ of the body; disability is a functional limitation with regard to a particular activity; and handicap refers to a disadvantage in filling a role in life relative to a peer group.

World Health Organization (1980) in The International Classification of Impairments, Disabilities, and Handicaps:

43 year-old female, right-handed, cook

Traumatic amputation of right thumb and index finger

Unreplantable thumb

Underwent right thumb reconstruction

with right big toe osteoplastic wrap-

around flap 1 week post-injury, after

counseling and consenting

Toe wrap based on

dorsalis pedis

Assessing Medical Disability Guides




http://www.mom.gov.sg/Documents/safety-health/GATIOD-Fifth-Edition.pdf

worker's capacity to perform duties that are part of the physical demands at work ……..

……….in cases of discrepancies between disability determined by the doctor to the patient's complaints and participation.

Ratzon, N. Z., Amit, Y., Friedman, S., Zamir, S., & Rand, D. (2015). Functional capacity

evaluation: Does it change the determination of the degree of work disability? Disability

and Health Journal, 8(1), 80–85. http://doi.org/10.1016/j.dhjo.2014.08.004

Assessing Medical Disability Psycometrics




Psychometrics and Metrology

construction and validation of measurement instruments such as questionnaires, tests, and

personality assessments

Classical test theory• reliability and validity.

– Pearson correlation coefficient, and is often called test-retest reliability.

– index of reliability is Cronbach's α

• concurrent validity; predictive validity, construct validity, Content validity

Quality of Assessment• Traceability,

• accuracy,

• precision,

• systematic bias

• evaluation of measurement uncertainty

International Classification of Functioning, Disability and Health

(ICF)• classified from body, individual and societal

perspectives

• measuring health and disability at both individual and population levels

• shifting the focus from cause to impact

• the social aspects of disability

– http://apps.who.int/classifications/icfbrowser/

http://apps.who.int/classifications/icfbrowser/

Assessing Medical Disability WHO DAS II




WHODAS II• ISBN 978 92 4 154759 8

• (NLM classification: W 15)

• © World Health Organization 2010

• http://p.ideaday.de/104.2/icf/en/index.html

Conclusion: disability can be measured and compared using WHODAS 2.0.

http://p.ideaday.de/104.2/icf/en/index.html

WHODAS II

• generic assessment instrument

• standardized method for measuring health and disability

• developed from a comprehensive set of International Classification of Functioning, Disability and Health (ICF)

• Cross cultural applicability, utility, reliability and validity

Why is disability assessment important?

• “there are no diseases, but patients”

• There are no disabilities but people with problems that affect their lives

Why develop a method to assess disability?

• “a decrement in each functioning domain”

– Body, person and society

• International Classification of Functioning, Disability and Health (ICF) – impractical for daily use

• WHODAS 2.0 – practical, reliable and valid

Why learn and use a disability measure?

• patient’s needs

• level of care

• outcome of the condition

• length of hospitalization

• receipt of disability benefits

• work performance

• social integration

Disability assessment

• identifying needs

• matching treatments and interventions

• measuring outcomes and effectiveness

• setting priorities

• allocating resources.

Why use WHODAS 2.0?

• sound theoretical underpinnings

• good psychometric properties

• numerous applications

• direct link to the ICF

• Cross-cultural comparability

• Ease of use and availability

WHODAS 2.0practical, generic assessment instrument measuring health and disability

• 1: Cognition – understanding and communicating

• 2: Mobility – moving and getting around

• 3: Self-care – attending to one’s hygiene, dressing, eating and staying alone

• 4: Getting along – interacting with other people

• 5: Life activities – domestic responsibilities, leisure, work and school

• 6: Participation – joining in community activities, participating in society.

WHODA II contd

• common metric

• generic measure

• possible to design and monitor interventions

• etiologically neutral

• focus directly on functioning and disability

• full version has 36 and the short version 12 questions

WHODAS and WHOQOL

• WHODAS 2.0 measures functioning (i.e. an objective performance in a given life domain), while WHOQOL measures subjective well-being (i.e. a feeling of satisfaction about one’s performance in a given life domain).

• Does vs Feel

36-item version

• interviewer-administered, self-administered and proxy-administered

• most detailed

• 20 minutes.

12-item version

• brief assessments of overall functioning

• interviewer-administered, self administered and proxy-administered.

• explains 81% of the variance of the 36-item version

• five minutes.

Psychometric properties

• Test–retest reliability and internal consistency - Cronbach’s alpha levels 0.98

• Most questions fitted in their assigned domains, confirming the unidimensionality of domains

• summary change scores were unaffected by sociodemographic factors

• Face , construct and concurrent validity

THANK YOU

[email protected]

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Assessing medical disability for the courts

Health & Medicine