Abbreviations--- Summary of paper (including list of pitfalls)--- Introduction to paper--- Pitfalls #1-7--- Pitfalls #8-15--- Discussion--- References
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1. Making an unsupported medical diagnosis (looking for a "quick fix")

Settlement of an occupational lung disease claim takes time. The treating physician may want to oblige his or her patient by making a quick (unsupported) diagnosis in the chart or in a letter to plaintiff's attorney. Although an unsupported diagnosis may help initiate a claim it will only get in the way if the claim is contested.

A 56 year-old man with a long smoking history was being treated for exacerbation for chronic obstructive pulmonary disease (COPD). Noting that the patient "works in a foundry," his family physician wrote in the chart: "Dx. COPD - occupational asthma." A worker's compensation claim was filed, supported solely by the physician's statement (reiterated on the claim form without any supporting information). Ultimately the claim was disallowed, but only after two year's of legal wrangling and several experts had independently evaluated the patient.

If the treating physician cannot be the patient's advocate all the way through a claim, the patient should be referred to someone who can. The above claim might not have been filed had the treating physician referred the patient to a specialist from the beginning.

The "quick fix" pitfall sometimes occurs when the claimant's physician is asked by an attorney to certify OLD "so Mr. C. can pursue his claim." Even though the physician never considered OLD in Mr. C., he feels an obligation to help and, with some prompting by the attorney, writes: "It is more probable than not that my patient, Mr. C, has occupational asthma." If uncontested, such a statement may be all that is needed to pursue a scheduled award. If contested, however, the following facts will emerge: the doctor is not an expert in the field; he has treated the patient on numerous occasions but never made any connection between asthma symptoms and OLD before the claim; his first mention of OLD appears in his letter to the claimant's attorney. The result in such a situation is usually nullification of the treating doctor's testimony and delay in resolving the patient's claim.

This type of pitfall also occurs when a physician is hired specifically to certify a diagnosis in multiple claimants with similar exposure history. To save time the physician may adopt a "uniform" approach, in which every letter reads the same, irrespective of the facts of the case.

A large number of ex-foundry workers were sent to one physician to certify that they had OLD from their remote foundry work. Since most of the workers had no lung disease of any type, certification required coming up with a quick-fix diagnosis. Thus every letter from the physician included the following boilerplate statement, irrespective of the evidence: "His symptoms, clinical examination, employment history, and chest x-rays are consistent with the diagnosis of Asbestosis and or Asbestos exposure related disease." In fact, in almost every case nothing about the patients' exams, test results or chest x-rays were consistent with the stated diagnoses. Lacking evidence to support these conditions, no claim was allowed at the administrative level. When a few of these cases were adjudicated in the courts, the identical nature of the letters harmed the physician's credibility.

2. Echoing an unsupported diagnosis made by someone else

Many diagnoses appear on the chart without adequate documentation, only to have the never-substantiated diagnosis repeated over and over throughout the patient's clinical record.

A patient with COPD had a brief history of foundry work. His physician wrote "R/O asbestosis" on a chest x-ray request form. A radiologist read the film as: ". . .Severe COPD...some fibrotic streaks not typical of asbestosis but cannot rule out that diagnosis." The patient was later hospitalized and at some point "R/O asbestosis" simply became "asbestosis" in the hospital chart. This unsubstantiated diagnosis was echoed by numerous other physicians and listed along with "COPD," "Cor Pulmonale" and, ultimately, "Respiratory Failure." The patient died of COPD-related respiratory failure. No autopsy was done. A claim was made for asbestosis as the cause of death. Repetition of the incorrect diagnosis in the hospital chart gave the impression that asbestosis had been established. Review of the records showed the diagnosis traceable to the single radiology report. There was never any radiologic evidence for asbestosis.

A form of ECHO diagnosis also occurs when a patient receives compensation for a disease not present by the usual medical criteria. For example, the medical and legal criteria for coal worker's pneumoconiosis are different (Richman 1989; Richman 1982; Hansen 1988). Under the 1969 Federal Coal Mine Health and Safety Act, many coal workers met criteria for compensation only because they smoked cigarettes or had non-respiratory disability such as heart disease, hypertension or obesity (Morgan 1980). The result is that many ex-miners hospitalized for exacerbation of COPD with clear lung fields on chest x-ray are erroneously noted throughout the chart as having "coal worker's pneumoconiosis." This type of ECHO diagnosis fosters confusion about terminology and clinical causation.

3. Inadequate clarification of 'impairment' and 'disability'

Impairment is purely a medical condition, such as loss of physiologic function or anatomic loss, e.g. percent decrease in FEV-1 or loss of a limb. Disability is a broader term, meaning overall effect of impairment on the individual and his or her ability to work and function in society (ATS 1986). A worker with respiratory impairment may or may not be disabled for a particular job. Two workers with identical impairment may have varying degrees of disability, by virtue of factors such as age, sex, education and socioeconomic status (ATS 1986).

Notwithstanding the accepted definitions, the two terms are often used inter-changeably and have at times generated much confusion (Richman 1980). The physician should not be faulted for using one term when he or she means the other. Rather, the pitfall comes from using either term as a substitute for clearly stating the worker's limitation or characterizing the patient's impairment/disability in some useful fashion.

A physician evaluating a patient for "percentage of disability" found the FEV-1 approximately 15% below predicted. He wrote that the patient had "15% impairment of the body as a whole," implying a modest degree of fixed impairment and therefore disability. However, he did not address the fact that the patient: a) was taking daily bronchodilator medication, without which the FEV-1 would likely have been much lower; b) had much worse lung function during exacerbations, as documented in emergency department records; and c) was completely disabled for gainful employment because of airway hyper-responsiveness and lack of any skill outside the dusty trades. The physician substituted a precise but limited statement on impairment for a fuller characterization of the patient's true disability.

A related pitfall is stating a percentage of impairment (or disability) on an arbitrary basis. Workers' compensation agencies frequently ask for "the amount of disability stated in a definite percentage." Physicians evaluating pulmonary disorders can use lung function tests (FEV-1, FVC, diffusing capacity), resting arterial blood gases and/or exercise test results as a guide (ATS 1986; AMA Guides). Alternatively, the degree of bronchial hyper-responsiveness and/or the documented minimal amount of medications necessary to control asthma symptoms can be used (Chan-Yeung 1987). Some physicians, unfortunately, seem to just pull a percentage out of 'thin air.'

A patient was evaluated by two different physicians a month apart; each had access to the same data, and the patient's clinical status was unchanged in the interval. One physician found the claimant to have "20% permanent partial disability;" the other found "80% permanent partial disability." Neither physician explained the stated percentage.

After evaluating a patient with chronic rhinitis who also had some history of occupational dust exposure, an otolaryngologist wrote: ". . .it is reasonable to assume that a component of her nasal problems is due to her occupational exposure . . . it is, in reality, a multifactorial problem . . . I feel the chronic irritative environmental exposure would account for 60-70% of her nasal symptoms." The physician provided no explanation as to how he arrived at "60-70%."

4. Ignoring or minimizing relevant medical history

This is perhaps the most common pitfall. Medical history that would be prominent in a routine clinical presentation is often ignored in an occupational claim.

A patient alleging silicosis had a documented history of congestive heart failure (CHF), with CHF-related pleural effusions; she used three different cardiac medications. Her chest x-ray showed cardiomegaly with some vascular redistribution of blood flow and nothing to suggest pneumoconiosis. The physician evaluating her as an outpatient, on the question of OLD, read her chest x-ray as showing "interstitial disease" and concluded she had "silicosis." In an otherwise detailed report the physician made no mention of her cardiac history.

Medical history that appears in a physician's treatment records often disappears when that same physician is asked to certify an occupational illness.

A physician at a tertiary referral center saw a 38-year-old female patient in 1983 for what he noted in the chart to be "shortness of breath and chronic nonproductive cough x 2 yrs. . ." Similar complaints had been recorded by other physicians. No specific diagnosis was made and the patient was lost to followup. Between April 1984 and February 1987 the patient worked for Company X soldering computer boards. During this period her cough continued, on occasion exacerbated by exposure to epoxy fumes. Two methacholine challenge tests were normal and at no time did she manifest airway obstruction or wheezing. Her complaints continued after leaving the company, without any objective evidence for asthma. After re-evaluating the patient in 1989 this same physician wrote her attorney that the diagnosis was "asthmatic bronchitis...of occupational origin" from work at Company X. He made no mention of having evaluated her for identical symptoms in 1983, before she ever started working for the company.

Selective reporting is particularly common as regards smoking history. I have encountered several situations where patients were diagnosed as having occupationally-induced chronic obstructive lung disease with no mention made of an extensive smoking history.

In September 1987 a 55-year-old man was hospitalized for what his physician noted in the chart as: "Exacerbation of chronic obstructive pulmonary disease. . . He has a 30 pack year history of smoking and quit two or so years prior to this admission." The patient had worked in a paper mill for several years and lately had become bothered by fumes at work. After discharge from the hospital an occupational claim was made. In October 1987 the same physician completed a Workers' Compensation 'Statement of Occupational Disease' form for his patient. Under "What is the Diagnosis?" the physician wrote: "Occupational asthma; chronic bronchitis, COPD." Under "What in your opinion is the cause of the disease?" the physician wrote "Allergen at work." No mention was made of the smoking history, or of how an "allergen" might have caused the COPD.

5. Arguing against yourself

This is a rare pitfall, but one that can trap the unwary expert.

A 59-year-old man died in 1985 of pulmonary fibrosis. He had a documented history of extensive work exposure to asbestos during the 1960s and 1970s. Pulmonary fibrosis first became manifest in 1975, in a pattern typical of asbestosis. The autopsy revealed extensive pulmonary fibrosis and at least one asbestos body per high power field. The patient's employer, who was sued on the claim of asbestosis, stated through experts that the claimant died of "idiopathic pulmonary fibrosis." In 1988 the company's pathology expert wrote that he found "A single ferruginous body, possibly an asbestos body was demonstrated [but] the overall [histologic] pattern is that of an end stage lung with fibrosis of a nonspecific nature...on the basis of the evidence I do not consider this disease process to be asbestosis...the pulmonary disease should be placed in the category of idiopathic pulmonary fibrosis...[the diagnosis] is...clearly...not...asbestosis."

This same expert had previously published, in a specialty medical journal (statement paraphrased):

asbestos bodies are not always observable because they are cleared from the lung and undergo dissolution with time, and therefore particle counts do not correlate directly with the severity of pulmonary parenchymal disease.

The pitfall in this case was the expert's conclusion, directly contrary to his own published work (as well as others; see Churg 1986), that the available data indicated a diagnosis 'clearly not asbestosis.' Unchallenged, such a statement would seem to be conclusive. Critically challenged (principally by citing his own published work), defendant's expert appears highly biased. One wonders what this expert would have written had he been retained by the plaintiff's attorney.

6. Ignoring the possibility of a rare or unusual diagnosis

A 59-year old man developed pneumoconiosis from close exposure to mica while working for a gun shell manufacturer between 1975 and 1982. Prior to this job he had no respiratory history and was a non-smoker. Chest x-ray showed bilateral interstitial nodular infiltrates consistent with pneumoconiosis (lung scarring from inhaled dusts, such as asbestos and silica). Pulmonary function studies showed moderate to severe restrictive impairment; after three minutes of treadmill exercise his oxygen saturation fell from 98% to 87%. An open lung biopsy in 1983 showed "severe interstitial fibrosis [with] honeycomb asbestos body is identified." Electron microscopic analysis of the lung tissue revealed "elemental composition of aluminum, potassium, and silicon [as] found in mineral silicates, commonly referred to as mica." Thus the diagnosis was unequivocal mica pneumoconiosis, of which a few cases had been reported up to that time (Pinmental 1978; Davies 1983). Despite this evidence, a prominent expert hired by the company wrote in October 1984: "Although [the patient's] history would appear to clearly indicate a significant degree of mica dust work exposure, I must say that from my own years of experience as a lung specialist, his physical and x-ray findings are to me classically those of a non-occupational work problem which is defined by some as idiopathic pulmonary fibrosis...This non-occupational condition has caused a marked degree of impairment of [his] lung function and does limit his present work ability . . ."

Taking advantage of the relative rarity of pure mica pneumoconiosis, this expert attempted to use his own prominence to refute an obvious case of occupationally-related interstitial fibrosis. (An article appeared the following year reporting 66 cases of apparent mica pneumoconiosis; the authors found causation by mica exposure alone reasonably convincing in 26 of the cases [Skulberg 1985].) The expert compounded his mistake by claiming that the alternative diagnosis, idiopathic pulmonary fibrosis (IPF), is "classically" characterized by certain "physical and x-ray findings," yet the literature available at the time strongly emphasized the non-specificity of these findings (Crystal 1984).

Along the same line, some experts erroneously rule out the possibility of occupational asthma (OA) because no familiar causative compound is identified. About one patient with classic symptoms of OA who worked around several identified chemicals, an expert wrote: "I know of nothing this patient was exposed to that can cause asthma." Over 200 chemicals and compounds have been implicated in occupational asthma (Chan-Yeung 1986; Chan-Yeung 1990; Smith 1990) and the list grows yearly (Cullen 1990). In many cases a specific sensitizing agent cannot be identified (Smith 1990). For the individual patient, finding a specific agent is less important than documenting temporal changes in lung function that implicate some causal factor from which the patient can be removed (Cullen 1990).

7. Not obtaining or reviewing independent chest x-rays and reports

The vast majority of physicians today rely on independent radiologists to both take and interpret chest x-rays on their patients. However, some non-radiology trained physicians operate x-ray machines in their office and then formally interpret the claimant's chest x-ray. This practice can lead to over-interpretation.

In a letter to an attorney a pulmonologist formally interpreted his patient's outpatient chest x-ray as showing interstitial lung disease from pneumoconiosis; there was no interpretation by a radiologist. During the same year the claimant had other chest x-rays during a hospitalization; all were read as normal by independent radiologists ignorant of the occupational claim.

Sometimes a chest x-ray already interpreted by a hospital-based radiologist will be reinterpreted without reference to the radiologist's report. Certainly there can be honest differences of opinion. More often, however, the 're-interpreter' has simply ignored the radiology report rather than disagreed with it.

A 70 year old man with severe COPD had a series of chest x-rays over five years. All films were read, by various radiologists, as consistent with bullous emphysema; a few "fibrotic streaks" were noted and commented on as consistent with bullous emphysema. No mention was made in the radiology reports of interstitial lung disease (ILD), OLD, or pneumoconiosis. (Also, no mention was made in the clinician's brief history, provided on the x-ray request forms, of any ILD or occupational lung concern.) A pulmonary expert was asked by the claimant's attorney to evaluate the patient and all his chest x-rays. The physician wrote the attorney that the "chest x-rays are indicative of interstitial fibrosis and [occupationally-related] pneumoconiosis." The physician made no mention of the formal radiology reports or of any difference of opinion he had with the radiologists' interpretations.

Often a "B-reader" will be hired by plaintiff's attorney to "prove" a patient has pneumoconiosis. A B-reader is a physician (not necessarily a radiologist) who has taken a course on reading pneumoconiosis x-rays according to the standards of the International Labor Organization (ILO), and passed a timed x-ray interpretation test. Since interpretation of all x-ray films is partly subjective, it may be difficult to argue with a reading of "minimal" pneumoconiosis (1/1 or 1/0 on the ILO scale). However, if a B-reader ignores extant x-rays reports he might enter a pitfall as did the radiologist and pulmonologist in the next case.

On March 4 Dr. W., a certified B-reader, interpreted a PA and lateral chest x-ray as showing interstitial lung disease of profusion 1/1, consistent with occupational pneumoconiosis. Based on this interpretation, a pulmonologist wrote plaintiff's attorney a letter stating the patient had asbestosis. However, both the radiologist and the pulmonologist ignored records readily available (in their own hospital), which included 15 prior chest x-rays and 3 chest CT scans. None of the prior x-rays or CT scans were interpreted as showing any interstitial lung disease, which meant that the condition was unequivocally non-existent. More damaging to the plaintiff's case, however, was the fact that one of the earlier chest x-rays and one of the chest CT scans had actually been interpreted as negative by the same B-reader expert - Dr. W.

Continue with Pitfalls #8-15


Abbreviations--- Summary of paper (including list of pitfalls)--- Introduction to paper--- Pitfalls #1-7--- Discussion--- References
Return to Pulmonary Division home page