The Medicolegal Challenges of Assessing Prognosis and Degree of Disability

Once causation has been established in a medical negligence or personal injury case, the amount of compensation awarded to the claimant is dependent upon the injuries suffered and the long-term effects of these injuries on daily life. In an ideal world, all claims would be settled when an injury has fully resolved and any lasting functional impairment can be more accurately assessed. In reality, however, settlement is often reached before recovery is complete. In these cases, predicting the patient’s prognosis and likely degree of disability, if any, become crucial: the claimant should be fairly compensated for any injuries suffered, but the defendant should not be required to pay out an unnecessarily high amount. Unfortunately, predicting the ultimate outcome and degree of disability the patient is likely to suffer from in the future is extremely challenging. 

For most injuries, there is a typical expected recovery time, after which symptoms should be fully resolved in the majority of people. However, as this is based on average recovery times, it will not be accurate for everyone. The severity of the original injury often predicts the outcome: more serious injuries are usually associated with longer recovery times and higher rates and degrees of residual disability. However, even with relatively mild injuries such as whiplash, around 15–20% of patients will subsequently develop a chronic pain condition that may limit their participation in daily activities. In addition, the treatment received and individual responses to treatment, which are often genetically determined, will both influence the healing process. Other factors that can affect the prognosis include age, gender, family and social support, pre-existing comorbidities, psychiatric symptoms and the patient’s willingness to engage in treatment plans and rehabilitation programmes. 

Another issue that can impact the assessment of likely prognosis is the tendency for symptoms associated with some conditions to fluctuate over time. This is particularly true of some chronic pain conditions, where sufferers describe ‘good’ and ‘bad’ days. Predicting how frequently these flare-ups will occur, and exactly how they will impact the patient’s life is extremely difficult, and makes determining the appropriate amount of compensation more challenging. 

One crucial aspect of evaluating injury outcome is distinguishing between impairment and disability. An impairment is any deviation or loss of any body function or structure, while disability is characterised by a limitation or reduction in an individual’s ability to participate in their normal daily activities due to disease or injury. It is important to understand that these two states are not necessarily directly dependent on each other. For example, a person who loses an arm would be considered to have a significant impairment but would not be considered severely disabled if they were still able to participate in the majority of their daily tasks. Conversely, an impairment that appears minor can be extremely disabling if it significantly interferes with normal activities. This may be the case for someone with an arthritic joint that restricts their ability to work, and thus confers an economic burden as well as a physical one.  

For some patients, the promise of financial gain may provide sufficient motivation to exaggerate or falsify their symptoms in order to receive a worse prognosis or establish a higher level of disability and thus receive more compensation. Involvement in litigation or a compensation claim is known to influence the reporting of symptoms, with patients typically describing more symptoms over a longer time period. The phenomena of exaggeration, compensation neurosis and malingering are often grouped together under the banner of compensation syndromes, although the precise motivation that drives each of them is different. Exaggeration normally results from a desire to be believed, while malingering is a deliberate attempt to deceive. Compensation syndromes may occur after an injury or disease if the patient believes there is a reasonable prospect of financial compensation, but identifying the minority of patients who display this behaviour is difficult and rarely possible simply from a medical examination, although suspicion may be raised if the symptoms reported bear little relation to the injury sustained. Often, surveillance is needed to record the patient undertaking an activity they have previously claimed to be unable to do. 

A typical patient evaluation should ideally include a physical and psychological examination, an assessment of the likely causation of the symptoms and a credibility assessment. This last aspect is not designed to serve as a judgment about the character of the patient, but rather to determine the consistency of the allegations and give a more accurate portrayal of the patient’s condition. In reality, functioning and disability are context-dependent and can vary according to geographical, social, economic and cultural factors. 

Further reading:

Davis KL, Davis DD. Disability Determination and Impairment Rating. 2022 Sep 26. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–.

Hanks RA, Rapport LJ, Seagly K, Millis SR, Scott C, Pearson C. Outcomes after Concussion Recovery Education: Effects of Litigation and Disability Status on Maintenance of Symptoms. J Neurotrauma. 2019 Feb 15;36(4):554-558.