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CHAPTER 8

Clash of cultures in the field of brain injury

CLINICIANS, ATTORNEYS, AND various entities face the challenge of agreeing upon what constitutes an injury and when the effects of such an injury disappear. This is more so for the case of the milder forms of brain injury i.e. concussion. Most persons with concussion are 80–90% back to their baseline and functioning normally within 7–10 days but may take longer in children and adolescents (McCrory 2005, McCrory 2013).

While this statement is partially true, it is most relevant when treating patients in a static environment where they fit a certain profile. As there are always two sides to a story, our society has developed a sort of climate polarization, and we now think only in terms of the plaintiff (injured) and the defense. Employees and consumers are more adept to the liabilities that arise from the negligence caused by faulty products, construction, and situations that put an individual at risk for injury. Recognizing the fact that the US is a country of rights and countries all around the world are now focusing on human rights, we as a society have become litigious. There is now an entire industry developed around trauma, and that includes TBI/concussion. The significantly easy access to the legal system and insurance coverage available to pay for damages are driving both sides of the divide. The issues of workers’ compensation addressing return to work, liabilities, and personal injury lawsuits have been shaping for the past few decades the way we evaluate and manage individuals with TBI and concussion. Consumerism has forced us to redefine what a concussion is and when people can be classified as experiencing the signs and symptoms of such a condition. Whether you are on the plaintiff or the defense side, employer or employee side of the issue, we are all now at a time and place in the TBI/concussion world where economic drives on both sides have clouded our ability to truly predict outcomes following injuries and determine whether the effects of injury persist. I have also seen providers of health care miss important diagnoses due to inherent beliefs held by certain health care workers. One such belief or view says that if patients are not truthful about one thing, they are not truthful about all things. On the patient side, the idea of secondary gain (i.e., utilizing one’s illness or perceived illness to acquire a benefit that is not deserving in the context of the injury) can be a major driver of illness. I have experienced treating patients who put on a charade of symptoms to continue in a sick role for secondary gains and at times demonstrate a condition referred to as malingering – the conscious knowledge of making up conditions that do not exist or exaggerating their condition beyond the actuality. If you are a purist, most patient whom you suspect to be exaggerating their condition or providing falsities about their described symptoms and their clinical and neuropsychological exam are considered not to be ill. Well, many times, if the key issues of focus are finding ways to trap the patient and determining whether they are really ill, clinicians can miss important facts about the patient’s illness. The fields of neuropsychology and neurology spend a considerable amount of time looking for inconsistencies within a level or sub-dimensions of test conditions. In this context, the clinician neuropsychologists and sometimes the neurologists perform different tests to evaluate the same function.

As an example, say, we carry out a test assessing short-term memory using more than one test measure. Assuming that the condition is legitimate, the results of short-term memory should be similar to two or more tests. While these measures can be taken to determine the legitimacy of a condition, caution should be maintained in interpreting the results as conditions such as pain, fatigue, anxiety, emotional instability, and fear, and yes, a secondary gain can influence consistency when different neuropsychological tests are administered for the same function.

I know a neuropsychologist (let’s call him Dr. Silva) who performs two different memory tests, each of which evaluates the same memory function, i.e., short-term memory. If there is a more than 40% deviation from the scores on the different tests of short-term memory, the neuropsychologist immediately assumes that the patient is malingering or exaggerating their symptoms. Neuropsychologists clearly carry out various tests before they can draw those conclusions.

(Case # 3)

I was hired by a plaintiff’s attorney to testify about the validity of the neuropsychological tests from the neuropsychologist, Dr. Silva. The attorney wanted me to testify regarding the legitimacy of the symptoms of a patient (Mr. Dalbert) who suffered a cerebral concussion. Neuropsychological tests performed by Dr. Silva determined that there was an inconsistency between the two neuropsychological tests of short-term memory with an over 40% difference between the results of the two. As a result, Dr. Silva declared in his conclusion that the patient was malingering. What was not evident to Dr. Silva was that Mr. Dalbert was a diabetic and had taken a dose of insulin in the morning before coming to take the tests. In addition, Mr. Dalbert was so nervous about the neuropsychological tests that he did not eat his breakfast before taking the test. Upon questioning the patient about the conditions surrounding the occasion when he took the second short-term memory neuropsychological test, the patient indicated that he was feeling very bad during the test. It was fortunate that the patient was very meticulous about checking his blood sugar; he provided us with his log of blood sugar levels. He had a finger-stick blood sugar test performed shortly after taking his insulin, and that was 2 hours before taking the second part of the neuropsychological test. He then did a follow-up blood sugar finger-stick test when he completed the second neuropsychological test because he was feeling lousy. My medical scribe who was reviewing his blood sugar log found that the patient was running low blood sugar. The results of his blood sugar before he completed the second neuropsychological test was 42 with normal being between 60–100 range, whereas the one performed 2 hours before the first neuropsychological test showed normal results. Months after seeing this patient, I was providing legal testimony in a deposition as to the legitimacy of the neuropsychological test performed on Mr. Dalbert. I was able to point out that a blood sugar of 42 would significantly compromise the patient’s cognitive function and affect his performance on memory test. I later received a call from the neuropsychologist administering the test. In that phone conversation, he made a declaration that he had learned an important lesson from this experience and pledged to be more cautious in interpreting the inconsistencies on neuropsychological testing, as many factors including low blood sugar could influence the results.

The history of cerebral concussion and more recently the history of the development of the chronic traumatic encephalopathy (CTE) diagnosis has faced significant controversy over the years. Until recently, the definitions of concussion required that there be a loss of consciousness, and we now know that this is not a necessity. Due to the applications of this loss of consciousness standard for research and other clinical evaluation tools, concussions have been largely underreported and underdiagnosed over the years.

Like the case of the tobacco industry which for years denied the link between smoking and lung cancer, the world has finally understood the link between the effects of repeated hits to the head during sporting activities, such as football, and concussion (Stieg 2014, Gardner 2015, Washington 2016).

This issue of the denial of the existence of a concussion has come with a price tag close to $1 billion in a court settlement for the National Football League (NFL). We now know that concussion is also linked to CTE despite the major denials over the years (Stieg 2014, Gardner 2014).

(Case # 4)

I once saw a patient, Alfonzo Grant, who was involved in a workers’ compensation situation where he genuinely fell off a roof while working as a roofer. I saw him approximately 10 years after the injury. After spending 2 hours listening to his litany of symptoms, I had a list of over 42 complaints. If you are a physician, you must have had the experience of such an encounter with a patient, having to sit through all the gory details and the plethora of complaints. Patients must understand that doctors are humans too; we can get impatient. My favorite manner of dealing with such patients is asking them to rank in order what bothers them the most. I finally asked Mr. Grant to tell me the one thing that bothered him the most. The patient answered, “My wife does not believe or understand the problems that I am having, and she expects me to do things that I cannot do.” Getting to really know this patient after several visits and meeting and understanding his wife’s perspective, I soon realized that the patient did have real symptoms, which were proved through clinical exams. Most of his complaints were rooted in the fact that his wife gave him little attention and made it a rule in the house that if he did not perform certain tasks, she would not allow him certain privileges. These included not receiving an allowance, having sexual intercourse, and not being permitted to drive his car. The patient soon realized that being sick at least got him sex because his wife paid more attention to him when he complained of feeling sick. Given that the patient was in a workers’ compensation situation, he had been seen by a neuropsychologist on the request of the insurance company. The neuropsychologist noted that he had various inconsistencies on the neuropsychological test, like what was noted the case of Mr. Dalbert. Various neurologists who saw Alfonzo had similar conclusions. Therefore, he was diagnosed as “malingering”. With this diagnosis given by his neuropsychologist, Alfonzo was forced to go back to work under the threat of his workers’ compensation financial benefits provided by the insurance carrier being cut off. The patient had important “drivers” that made him continue the sick role, and in my opinion, he utilized them well. Clearly, the clinicians came to this patient with a lot of biases and failed to understand the drivers of his pain, emotional state, and physical limitations. It took me some time spent with the patient’s attorneys, the workers’ compensation carrier, the patient, his wife, and employer to address the issue. At the end of the day, everyone agreed that the patient had a real condition and had suffered a real injury. The patient had regressed to a stage earlier than his stated age, causing him to emulate immature and childish coping behavior driven by his emotional needs. Today, the patient is working as a productive individual providing for his family. Saving this patient involved bringing all the parties together to eliminate the biases that we all have. Having put aside our biases, we were able to develop a treatment plan that made sense while addressing the patient’s situation. This patient had a real problem that was easily treated with medications and input from another neuropsychologist skilled in the management of such situations. We must realize that many patients who are considered to be malingering or exaggerating their symptoms do so but sometimes actually have real conditions. We, as clinicians, do a disservice when we fail to look for the real conditions that can be treated and introduce our personal biases because we believe that the patient has been untruthful in their symptoms or exaggerate their clinical exam situation for various reasons. It takes special skills as a clinician to distinguish fact from fiction and to even talk to patients and their families when such situations of malingering exist. If at the end of such a discussion, you have a satisfied patient or they are willing to have you follow up on them, you can be really impressed with yourself as a clinician. You will surely not win every case, as some patients’ beliefs about their condition are so ingrained that it may not be possible to assist them out of a situation in which they are malingering or exaggerating their symptoms. However, there are some tools we can employ to help determine the validity of the patient’s reporting and our findings on clinical assessment. The following tools are helpful in this situation:

Table # 7 – Establishing validity in patient reporting

Consistency on neurocognitive and neurological exam; perform tests of malingering that can be useful	The field of neuroscience utilizes testing tools that are generally consistent across patient population and disease conditions based on our classification of diseases. Any significant variation on what is expected often introduces concerns of legitimacy that should not be ignored. It takes a knowledgeable and experienced clinician to be able to administer and interpret these exams/tests.
Evaluation of the incentive and drivers of playing the sick role, if any	This can be driven by a parent, spouse, family members, friends and issues of obligation, fear of a particular outcome or a reward.
Purging yourself from biases as a clinician	Assuming that the patient is guilty until proven otherwise is not the best approach to the patient’s situation.
Listening to all sides before drawing conclusions	Information provided by all parties can be misleading. A smart clinician knows the right questions to ask to get the information needed and utilizes such information to analyze a patient’s situation.
Clinicians’ knowledge of what they treat	Before attempting treatment, a clinician must be certain as to what they are treating. As a rule of thumb, it is not a good idea to treat something you do not know or understand.

In the USA, the entire system of jurisprudence is strictly polarized down the middle; physicians and neuropsychologists are defined as either supporting the plaintiff or the defense side. We must realize that at times money/economics are the major drivers at play here.

Beyond workers’ compensations and personal injury, the US has been through one of the largest settlements seen between the National Football League and the retired players only to be matched by the tobacco settlement. Irrespective of where you find yourself, perplexing questions central to this issue of compensation for the retired injured player are as follows: Who is injured and who is not? Who is healed and who is not? The National Football League (NFL) world has been rocked by controversy on this question when an injury occurs, defining the post-concussion sequelae of such injury and finally determining if the symptoms persist. Even after a billion-dollar settlement with the former players, setting up a way of objectively making those determinations with the former players has been challenging. While there have been consorted efforts by all parties, professional biases by specialty physician groups, neuropsychologists, and the legal community and pressure from the players, their advocates, and NFL representation can limit clinicians’ ability to objectively answer the fundamental question as to who should qualify for the settlements.

For soldiers returning from recent military conflicts, the question as to who is injured and who remains with symptoms and signs have been at the forefront. During my training years, I spent time in a Veterans Hospital and had the opportunity to see and evaluate veterans of war from the Vietnam War. Sure enough, I was looking at brain injuries and concussions that went untreated. For all practical purposes, this is a generation of persons with TBI/concussion, who have been lost in the community with little attention from the medical system. Returning soldiers and their families, as in the case of football players, have been living in the shadow, as they have largely gone undiagnosed and untreated.

Another issue where there is a clash of cultures is that of post-traumatic stress disorder, otherwise known as PTSD. PTSD is commonly seen in soldiers and following traumatic events, such as accidents (Morissette 2011). Most persons with this condition have knowledge of the accident and often re-live the experience in many ways. In PTSD, the key feature of the condition is heralded by what is known as “anniversary reaction.” Individuals are often reminded of the experience (anniversary) consciously and unconsciously where they re-live the experience of the accident when they are exposed to days that seem like the day of the event, anniversary periods such as the time and circumstance of the accident, or in seeing others with similar fate. These experiences can be anxiety-producing and can create fear and apprehension. For years, soldiers were not taken seriously about having this condition until the military realized that these individuals became highly dependent due to crippling symptoms. Today, the US military has developed an entire system to deal with patients who have witnessed horrifying experiences, including trauma from blast incidents and direct blow to the head (Morissette 2011).

A group of patients who develop PTSD that we often forget are patients in intensive care units (ICUs), who experience the terror of certain procedures and experiences. They may vividly recollect those experiences and feel trapped. Nurses and doctors are often insensitive about the issue of pain-producing procedures carried out without enough anesthesia or sedation or the terrifying hallucinations or nightmares that patients may experience in the ICU. Sideris (2019) presented a paper on the case of a patient who developed PTSD due to terrifying hallucinations and nightmares in the ICU. Like the cases seen in the returning soldiers, these cases of PTSD in trauma and ICU settings may be more common than we previously recognized.