Source: https://www.finkellaw.com/Published-Works/The-Pain-Physicians-Role-in-Legal-Proceedings.aspx
Timestamp: 2019-04-24 11:58:24+00:00

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Pain is a medical concept. Pain and suffering is a legal concept. Although some legal commentators have attempted to create an ephemeral distinction between the concepts of pain and suffering, these attempts have been unsuccessful. Pain is the sensation of the body, while suffering is the consequence of pain to the individual. However, pain and suffering are so inextricably linked that it is often impossible to determine where one ends and the other begins. Therefore, courts treat pain and suffering as one concept with different components- past and present physical pain, future pain, and mental suffering.
The experience of pain has two consequences: 1) the overt behavior of pain, and 2) the subjective experience of pain. 1 The job that faces physicians is determining the source of the pain and treating the pain. The job that faces the attorney is to help the patient, now the plaintiff, to be compensated for this pain. What is problematic for both professionals is the subjective nature of the pain. How does the physician separate the malingerer from the pain stricken? How does the attorney explain to the jury the subjective feeling of pain?
Physicians, like attorneys, often times face the daunting task of assessing the legitimacy of their patient’s, or client’s, claims of pain. The physician’s job in assessing the validity of these claims is primarily to diagnose and treat the underlying pathology. The physician, however, shares with the attorney, albeit secondarily, the task of assessing the legitimacy of these claims for the purpose of litigation. The attorney knows the law. The physician knows the medicine. Together, they can prove this pain. Thus, the physician, not only occupies the unique position of healer, but also holds the financial future of the patient in her hands.
What makes this process somewhat easier is the growing recognition in the medical community of the concept of pain management. The multi-disciplinary approach to pain helps to alleviate in part the skepticism which used to accompany chronic pain. Although the alleviation of pain is still seen by some physicians as secondary to diagnosis and treatment of the underlying pathology, there are signs that the medical community may soon recognize the alleviation of pain as a primary duty. For example, the Joint Commission of Accreditation of Healthcare Organizations has proposed pain management standards. Standard PE 1.4 provides: “Pain is assessed in all patients.” 2 Examples of implementation of this standard include the suggestions that physicians determine pain intensity through the use of a rating scale; “the onset, duration, variations and patterns;” “alleviating and aggravating factors;” and “effects of pain (impact on daily life, function, sleep, appetite, relationships with others, emotions, concentration, etc.).” 3 The very same factors that the physician must have in order to adequately treat the plaintiff’s pain, the attorney must have to prove pain and suffering.
The purpose of this chapter is to bring to the practice of medicine the practical realities of the court room- how pain and suffering is proved, what is admissible, to what may the physician testify, what can physicians include in medical records that may later help the patient prove his pain and suffering? To these ends, the chapter examines briefly discusses several studies which attempt to analyze the jury decision-making process in pain and suffering cases. The chapter then discusses the basic legal principles, of which physicians should be cognizant in order to help the patient in proving pain and suffering.
The decision- making processes of juries is difficult to quantify, especially when it comes to the elusive concept of “pain and suffering.” The same characteristics of pain which frustrate doctors and lawyers also frustrate laymen jurors who are often given few guidelines in assessing the legitimacy of pain and in assigning a monetary value to it. Social scientists and legal commentators have attempted to quantify the mindset of the jury. What information, what details, influence juries’ decisions? Although these questions are impossible to answer with absolute certainty, studies are helpful for attorney and lawyer alike in understanding how this complicated decision is made.
The study showed although litigators typically use the “making whole”perspective in pain and suffering litigation, the more lucrative approach is the “selling price” perspective. 9 The latter approach is disfavored by attorneys and courts alike, and may, in fact, be inappropriate in some jurisdictions. 10 Thus, although this information may little direct practical application in litigation, it does demonstrate the very important point that jurors’ perceptions of pain and suffering are not static and can be influenced.
Valuation of pain and suffering is within the sole province of the jury. Much of the criticism of pain and suffering awards seems to stem in part from many legal commentators’ fear of the jury and their seemingly omnipotent power. Many worry that laymen jurors, when confronted by the savvy and sleek plaintiff’s attorney, will disregard evidence and follow their hearts, ultimately awarding more than the pain and suffering is really worth. This fear is exacerbated by fact that there is no real method to place a dollar amount on pain and suffering.
However, as will be discussed later in this chapter, such testimony often appears self-serving to the jury. Thus, additional testimony will be needed to buttress plaintiff’s claims regarding the pain and suffering.
Only the injured person can recover pain and suffering damages in a personal injury suit. 4 2 Although the injury and the resulting pain and suffering of the plaintiff obviously impact the plaintiff’s family, the pain and suffering award is not a vehicle through which to compensate these people. Rather, causes of action such as loss of consortium are tailored toward such a goal. However, the pain and suffering award is meant to compensate the plaintiff for the pain that he has to endure through no fault of his own.
Traditionally, courts denied infant plaintiffs the right to recover mental pain and suffering awards. 4 3 However, courts today recognize that although a child may be unable to articulate their suffering as adults can, a child’s pain is often clear and perhaps more poignant than the pain of an adult. Although a child may be too young to express this pain, it is often evidenced by crying and other outward manifestations of pain and discomfort. The pain is real even though the child cannot articulate it in the same way as an adult can, and the child is deserving of a monetary award for pain and suffering in the same way that an adult plaintiff is.
If the actor’s conduct is negligent as creating an unreasonable risk of causing bodily harm to another otherwise than by subjecting him to fright, shock, or other similar and immediate emotional disturbance, the fact that such harm results solely from the internal operation of fright or other emotional disturbance does not protect the actor from liability.
(1) One who by extreme and outrageous conduct intentionally or recklessly causes severe emotional distress to another is subject to liability for such emotional distress, and if bodily harm to the other results from it, for such bodily harm. (2) Where such conduct is directed at a third person, the actor is subject to liability if he intentionally or recklessly causes severe emotional distress (a) to a member of such person's immediate family who is present at the time, whether or not such distress results in bodily harm, or (b) to any other person who is present at the time, if such distress results in bodily harm.
Valuation of pain and suffering, as previously discussed, presents the jury with the unique job of placing a value upon the subjective feeling of another. Besides the requirement of reasonability, there appears to be no consensus as to how the jury is the reach its decisions. However, certain methods of valuation are common. Perhaps the most common is the per diem method.
1. There is no evidentiary basis for converting pain and suffering into a monetary sum.
2. Suggesting monetary equivalents for pain and suffering is tantamount to giving testimony or expressing an opinion not disclosed by the evidence.
3. The per diem approach put the defendant at the disadvantage of having to rebut an argument that has no basis in evidence.
The per diem approach involves the determination of two figures. First, the life expectancy of the plaintiff must be determined. Mortuary tables establish life expectancy based on statistical information of the population. Thus, the age of the plaintiff is subtracted from the life expectancy reflected in the mortuary table. 7 0 Second, a value must be placed upon some unit of time – a minute, hour, or day. 7 1 These two numbers are multiplied to theoretically place a value upon the plaintiff’s pain and suffering.
Multiply the value by 365 in order to place a monetary value of one year.
Testimony given by the family members will likely include the plaintiff’s initial reaction to his injury, what complaints he made directly following the injury, and the duration of his recuperation. 8 3 The family member will also testify to plaintiff’s activity level and hobbies before the injury in comparison to now. 8 4 The family member will also testify as to the strain that plaintiff’s injury has placed on other areas of his life and the family’s welfare, including the financial situation of the family and the effect of plaintiff’s pain on his relationships with family members. 8 5 Co-workers can similarly testify as to how the injury has effected plaintiff in the context of the workplace.
The physician is perhaps the most important and credible witness the plaintiff can offer. The reason is obvious. Unlike the plaintiff and his family, who may have a motive to lie or exaggerate, the physician stands to receive no economic benefit from the ultimate verdict. Additionally, physicians, unlike other professions, are perceived by society as honest professions bound by morality and their Hypocratic Oath to do good.
The importance of the physician’s testimony cannot be overstated. Given this importance, the physician should remain cognizant of certain legal principles in order to offer the best testimony possible.
1.The Physician’s belief in the patient’s pain and suffering is vital.
2.Another’s Expressions of Pain to prove the existence and severity of pain.
As already discussed, the great difficulty in proving pain and suffering is lies in the subjective nature of pain. As suggested by the Wissler study, jurors tend to better understand the pain and suffering associated with severe injury as opposed to less severe injury. 9 5 Thus, although a physician cannot prove with certainty that a plaintiff’s pain is genuine, that physician may testify as to the objective manifestations of pain by the plaintiff. 9 6 These objective manifestations are particularly important when the patient appears relatively “physically sound.” 9 7 Such objective findings include tears, perspiration, moaning, facial expressions such as grimacing, limitations in motions, and changes in vital signs. 9 8 Thus, the physician and staff should include such objective behavior in the medical record of the patient.
(4) Statements for Purposes of Medical Diagnosis or Treatment. Statement made for purposes of medical diagnosis or treatment and describing medical history, or past or present symptoms, pain, or sensations,or the inception or general character of the cause or external source thereof as reasonably pertinent to diagnosis and treatment.
4.Referral to Pain Management Treatment strongly speaks to the physician’s belief in the legitimacy of the plaintiff’s pain.
B.Although the physician’s belief is vital, objective tests should be conducted to reinforce the physician’s opinion.
As discussed above, a significant impediment to a truly effective claim for pain and suffering is the public perception that those suffering from pain and suffering are using the legal system to extort money from defendants. Although there are among the body of plaintiffs malingerers, such a perception ignores the medical reality that individuals have varying thresholds for pain. 10 8 The defense will attempt to exploit this perception by offering medical evidence that the plaintiff is malingering. 10 9 Therefore, the physician should be prepared to address the pain threshold issue 11 0 and should include in the medical record any pain threshold tests conducted.
Physiological factors, cultural factors, personality characteristics, and lifestyle factors contribute to the varying thresholds of individuals. Differences in the chemical make-up of individuals, as in the production of endorphins and serotonin, contribute. 11 1 Also, one’s culture, for example, whether one’s culture teaches to maintain a stiff upper lip, contributes. 11 2 Personality traits, such as how one handles stress, contribute. 11 3 And, finally, lifestyle choices, such as one’s level of physical fitness, contribute. 11 4 Thus, a patient’s complaints of pain cannot be dismissed because they seem out of proportion to the injury actually sustained.
Aside from determining the patient’s pain threshold, the physician should undertake some objective tests to determine the existence of pain. Because pain is a subjective complaint, the jury may be unpersuaded by the plaintiff’s testimony if no concrete medical evidence is presented to back up the plaintiff’s claims. Thus, the physician should undertake objective tests, not only for her own purposes of diagnosis of pain and referral to pain management, but also to aid the patient’s claim for pain and suffering.
Although such a step is obvious to the physician, what is not readily apparent is that objective test undertaken may or may not be admissible, depending on the test’s purported reliability and acceptance within the medical community. Thus, a new, experimental procedure may be an excellent diagnostic source and, yet, be inadmissible in court.
It is important for the physician to understand the criteria by which these procedures will be evaluated. Depending on the court, the objective test will have to pass muster with one of the following tests.
Under Frye, the test must be one that has crossed this line. Although, this case offers little guidance in the way of factors to which one should look in order to determine whether the line has been crossed and the test has become an accepted procedure, a test commonly used by doctors will undoubtedly pass this test.
Although relevant evidence may be excluded if its probative value is substantially outweighed by the danger of unfair prejudice, confusion of the issue, or misleading the jury, or by consideration of undue delay, waste of time, or needless presentation of cumulative evidence.
If scientific, technical, or other specialized knowledge will assist the trier of fact to understand the evidence or to determine a fact in issue, a witness qualified as an expert by knowledge, skill, training, or education, may testify thereto in the form of opinion or otherwise, if (1) the testimony is based upon sufficient facts or data, (2) the testimony is the product of reliable principles and methods, and (3) the witness has applied the principles and methods reliably to the facts of the case.
Stated simply, evidence must be relevant, and even then it may be excluded in the face of time constraints or the possibility of prejudice.
The application of rules 401 and 403 requires a balancing by the court of relevance versus the possibility of unfair prejudice or delay. Some courts have articulated factors which may be considered when making this balance. 12 3 The Williams court considered the potential rate of error, 12 4 the existence and maintenance of standards, 12 5 and “the care and concern with which a scientific technique has been employed, and whether it appears to lend itself to abuse,” 12 6 and “the presence of ‘fail-safe’ characteristics” 12 7 as factors of reliability. Thus, the physician would be well-advised to consider these factors when deciding which objective tests to use.
Thus far, we have discussed areas of testimony that are relevant for establishing the existence and severity of the plaintiff’s pain. Other areas of testimony include, the duration of treatment and future treatment that will be required. 13 0 Future pain and suffering, as a general rule, must be established with medical testimony. Testimony regarding the duration of treatment and the future treatment required tend to help establish future pain and suffering damages with a reasonable certainty. Additionally, the physician should be prepared to explain to the jury the pain management approach.
In proving pain and suffering, the attorney faces the complicated task of making the jury understand what cannot be quantified or empirically shown. The attorney, in essence, must tell the story of the plaintiff’s pain and suffering. Like all great story-tellers, attorneys must not only give the facts, but must also create the picture of pain. Attorneys use a number of devices in telling this story. First and most obviously, attorneys put the plaintiff on the stand to explain his pain and the effect that it has had on his life. The attorney also puts family, friends, and co-workers on the stand to testify as to what the plaintiff has said and how the pain has impacted his life and his relationships with others. However, the testimony of friends, family, and co-workers may be limited by the hearsay rule. Additionally, both the testimony of the plaintiff and his family and friends may be doubted by skeptical jurors. Thus, the physician’s testimony is vital in bolstering the plaintiff’s claims. Additionally, attorneys use demonstrative aids such as blown-up medical records and blown-up pictures of objective tests, such as the thermograph.
2 Http:// www.jcaho.org/standard/pm.html (Visited Jan. 22, 2001).
4 Mark Geisfeld, Placing a Price on Pain and Suffering: A Method for Helping Juries Determine Tort Damages for Nonmonetary Injuries, 83 Calif. L. Rev. 773, 776 (1995). See also Oscar G. Chase, Helping Jurors Determine Pain and Suffering Awards, 23 Hofstra L. Rev. 763 (1995).
5 Mark Geisfeld, Placing a Price on Pain and Suffering: A Method for Helping Juries Determine Tort Damages for Nonmonetary Injuries, 83 Calif. L. Rev. 773, 776-77 (1995).
7 See DAN B. DOBBS, HANDBOOK ON THE LAW OF REMEDIES 545 (1973); Oscar G. Chase, Helping Jurors Determine Pain and Suffering Awards, 23 Hofstra L. Rev. 763, 769 (1995).
8 J. Kahneman & Matthew L. Spitzer , Framing the Jury: Cognitive Perspectives on Pain and Suffering Awards, 81 Va. L.Rev. 1341 (Aug. 1995).
1 0 Id. at 1375.
1 3 Id. at 1372.
1 4 Roselle L. Wisser, et al., Explaining “Pain and Suffering” Awards: The Role of Injury Characteristics and Fault Attributes, 21 Law and Hum. Beh. 181 (1997).
1 5 Id. at 188.
1 6 Id. at 199.
1 8 Id. at 199-200.
1 9 Id. at 201.
2 0 31 Am Jur 2d Damages § 264.
2 1 See Id. at §§260, 1023.
2 2 Conscious Pain and Suffering is not a Matter of Degree, 74 Marq. L. Rev. 289, 302 (1991).
2 4 Id. at 304.
2 5 22 Am Jur 2d Damages §245.
2 7 Conscious Pain and Suffering is not a Matter of Degree, 74 Marq. L. Rev. 289, 311 (1991).
2 9 See Conscious Pain and Suffering is not a Matter of Degree, 74 Marq. L. Rev. 289, 310 (1991), quoting Diemel v. Weirich, 58 N.W.2d 651, 652-52 (1953).
3 1 22 Am Jur. 2d Damages §915.
3 2 22 Am Jur. 2d Damages §1006; 9 PERSONAL INJURY: ACTION, DEFENSES, DAMAGES §3.04[c] (Louis R. Frumer & Melvin I. Friedman, eds. 1998).
3 3 9 PERSONAL INJURY: ACTION, DEFENSES, DAMAGES §3.04[c] (Louis R. Frumer & Melvin I. Friedman, eds. 1998).
3 4 Id.at § 3.04[c].
3 6 22 Am Jur.2d Damages §251.
3 9 9 PERSONAL INJURY: ACTION, DEFENSES, DAMAGES §3.04[ii] (Louis R. Frumer & Melvin I. Friedman, eds. 1998).
4 0 Id. at §3.04[ii].
4 2 RALPH C. MCCULLOUGH, CIVIL TRIAL MANUAL II 788 (1980).
4 3 Id. at 789.
4 4 103 Cal.Rptr. 856, 858.
4 5 Id. at 860.
4 6 Cases allowing children to recover pain and suffering damages: Reale v. Wayne Tp., 332 A.2d 236 (N.J. Super. 1975); Hiraldo v. Khan, 699 N.Y.S.2d 456, 267 A.D.2d 205 (2 Dept. 1999); Williams v. Williams, 641 N.Y.S.2d 408, 226 A.D.2d 710 (2 Dept. 1996); Reid by Reid v. County of Nassau, 627 N.Y.S.2d 396, 215 A.D.2d 466 (2 Dept. 1995).
4 9 10 PERSONAL INJURY: ACTION, DEFENSES, DAMAGES §1.02 (Louis R. Frumer & Melvin I. Friedman, eds. 1998).
5 0 Id. at §1.02.
5 1 Id. at §1.02.
5 3 10 PERSONAL INJURY: ACTION, DEFENSES, DAMAGES §3.02 (Louis R. Frumer & Melvin I. Friedman, eds. 1998).
5 4 RALPH C. MCCULLOUGH, CIVIL TRIAL MANUAL II 788 (1980).
5 5 9 PERSONAL INJURY: ACTION, DEFENSES, DAMAGES 3.04[b][vi](Louis R. Frumer & Melvin I. Friedman, eds. 1998).
5 7 Id. at 3.04[b][vii].
6 0 RESTATEMENT (SECOND) OF TORTS §46, Cmt. d.
6 1 See e.g., Giant Food v. Satterfield, 603 A.2d 877, 879 (Md.App. 1992).
6 3 See e.g., Pool v. Bell, 209 Conn. 536, 551 A.2d 1254 (1989); Henne v. Balick, 51 Del. 369, 146 A.2d 394 (1958); Ferry v Checker Taxi Co., 165 Ill.App.3d 744, 117 Ill.Dec. 382, 520 N.E.2d 733 (1987); Steel v Bemis, 121 N.H. 425, 431 A.2d 113 (1981); Cox v. Valley Fair Corp., 83 N.J. 381, 416 A.2d 809 (1980); Tate v. Colobello, 58 N.Y.S.2d 84, 459 N.Y.S.2d 422, 445 N.E.2d 1101 (1983); Ilosky v. Michelin Tire Corp., 172 W.Va. 435, 307 S.E.2d 603 (1983); Affect v. Milwaukee & S.T. Corp., 11 Wis. 2d 604, 106 N.W.2d 274 (1960).
6 4 See e.g., Beagle v. Vasold, 65 Cal.2d 166, 53 Cal. Rptr. 129, 417 P.2d 673 (1966); Paduach Area Public Library v. Terry, 655 S.W.2d 19 (Ky. App. 1983); Streeter v. Sears, Roebuck & Co., 533 So.2d 54 (La. App. 1988); Giant Food v. Satterfield, 603 A.2d 877 (Md. App. 1992); Cafferty v. Monson, 360 N.W.2d 414 (Minn. App. 1985); Higgins v. Hermes, 89 N.M. 379, 552 P.2d 1227 (1976).
6 5 See, e.g., Johnson v. Brown, 75 Nev. 437, 447, 345 P.2d 754 (Nev. 1959). See also 22 Am Jur 2d §265.
6 6 See supra note 65.
6 7 See e.g., Debus v. Grand Union Stores of Vermont, 621 A.2d 1288, 1290 (Vt. 1993).
6 8 22 Am Jur 2d Damages §266.
6 9 Debus v. Grand Union Store of Vermont, 621 A.2d 1288,1290 (Vt. 1993).
7 0 RALPH C. MCCULLOUGH, CIVIL TRIAL MANUAL II 790 (1980).
7 3 DAN B. DOBBS, HANDBOOK ON THE LAW OF REMEDIES 545 (1973).
7 5 9 PERSONAL INJURY: ACTION, DEFENSES, DAMAGES 3.04[e] (Louis R. Frumer & Melvin I. Friedman, eds. 1998).
7 7 RALPH C. MCCULLOUGH, CIVIL TRIAL MANUAL II 790 (1980).
7 8 9 PERSONAL INJURY: ACTION, DEFENSES, DAMAGES 3.04 (Louis R. Frumer & Melvin I. Friedman, eds. 1998).
8 1 See 22 Am Jur 2d Damages §246; 9 PERSONAL INJURY: ACTION, DEFENSES, DAMAGES 3.04[b] (Louis R. Frumer & Melvin I. Friedman, eds. 1998).
8 3 8 Am Jur PoF3d 91 §§21-23.
8 6 See generally Admissibility in Civil Action, apart for res gestae, of Lay Testimony as to Another’s Expressions of Pain, 90 ALR2d 1071 (1963); Neil Sugarman & Charlotte Glinka, Explaining Pain: how you do it, who can help, Trial, 30 (Nov. 1994).
8 7 See generally 90 ALR2d 1071 §2.
9 2 Neil Sugarman & Charlotte Glinka, Explaining Pain: how you do it, who can help, Trial, 30 (Nov. 1994).
9 3 Expert and Opinion Evidence, 31A Am Jur 2d §§265-66.
9 5Neil Sugarman & Charlotte Glinka, Explaining Pain: how you do it, who can help, Trial, 30 (Nov. 1994).
9 7 Neil Sugarman & Charlotte Glinka, Explaining Pain: how you do it, who can help, Trial, 30 (Nov. 1994).
9 8 31A Am Jur.2d §266.
9 9 Neil Sugarman & Charlotte Glinka, Explaining Pain: how you do it, who can help, Trial, 30 (Nov. 1994).
1 02 Id. at 309-10.
1 03 Id. at 310-11.
1 04 Id. at 311.
1 05 Id. at 312.
1 06 Neil Sugarman & Charlotte Glinka, Explaining Pain: how you do it, who can help, Trial, 30 (Nov. 1994).
1 07 See generally Lawyers’ Medical Cyclopedia of Personal Injuries and Allied Specialties §44A.41( Richard M. Patterson, ed.).
1 09 Id. at §8.
1 15 Lawyers’ Medical Cyclopedia of Personal Injuries and Allied Specialties 314 §44A.41 (Richard M. Patterson, ed.).
1 20 Richard J. Byrne, Thermography: The Double- Edged Sword Which can Either Corroborate the Existence of Pain or Weed out the Malingerer, 38 Drake L. Rev. 355, 380 (Winter 1989).
1 23 See, e.g., United States v. Williams, 583 F.2d 1194 (2 nd Cir. 1978), cited in Richard J. Byrne, Thermography: The Double- Edged Sword Which can Either Corroborate the Existence of Pain or Weed out the Malingerer, 38 Drake L. Rev. 355, 382-83 (Winter 1989).
1 24 Id. at 1198.
1 26 Id. at 1199.
1 31 Neil Sugarman & Charlotte Glinka, Explaining Pain: how you do it, who can help, Trial, 30 (Nov. 1994).

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