The Challenges Experts May Face When Undergoing Assessments from Home
Mr Peter Gray considers the best practice in relation to the COVID-19 pandemic and medico-legal report writing in ophthalmology.
The COVID-19 pandemic created an unprecedented challenge which has been the catalyst for the development of new modalities of delivering healthcare in order to maintain social distancing and minimising the potential spread of infection, especially in high risk specialities such as ophthalmology where there is close contact when the patient is examined. The Royal College of Ophthalmologists, following advice from Public Health England, recommended that all non-urgent face-to-face clinical work should be postponed. This includes medico-legal reports.
If a face-to-face consultation cannot take place, what are other options are available for experts?
Prior to undertaking any consultation for all medicolegal reports, it is my practice to thoroughly review the letter of instruction, any witness statements and the medical records – from general practice and hospital; the optician’s records are invaluable as they will detail the ‘pre-event’ visual status and more recent observations. Further, many opticians now perform retinal photography and sometimes OCT scans. Ideally, this should be supplied electronically as image quality is superior and to prevent contamination, which can occur in the postal system.
The recent meeting of G7 leaders regarding COVID-19 was successfully held virtually and virtual court hearings have been satisfactorily conducted.
This represents the knowledge base for all consultations and will enable both the expert and the patient to engage with each other on all occasions whilst staying safe. An introductory telephone call is favoured because this will be a familiar modality for all patients; consider a future video consultation, discussing informed consent regarding confidentiality and GDPR. This might be sufficient for the expert report to be drafted without the need for a face-to-face consultation.
How effective are virtual consultations? How much can you rely on video calls to achieve objective results?
The recent meeting of G7 leaders regarding COVID-19 was successfully held virtually and virtual court hearings have been satisfactorily conducted. The General Medical Council’s guidance is that telemedicine (remote consultations via a telephone or video link) can improve patient access. Both telephone and video consultations have been increasingly conducted in routine clinical practice in the COVID-19 pandemic and have been widely accepted by patients. A video link further facilitates the verification of the patient’s identity by showing photographic ID to the camera. The patient’s location should be confirmed which should be with no other person present, in private, and not in their lawyer’s office.
There is a need to balance the risks associated with the patient travelling against the benefits of undergoing the face-to-face examination or postponing it to a later date.
The history will be taken as in a face-to-face consultation together with the interpretation of the patient’s body language, facial expressions and tonal changes, as well as how the patient responds to visual prompts. A full ophthalmological examination cannot be performed virtually.
The patient’s visual acuity can be determined with a ‘sight test chart’ downloaded and printed from the internet, as discussed at the initial telephone consultation, and attached to a wall at a prescribed distance which can be verified during the video consultation. This recreates the scenario with which the patient will be accustomed when they are asked to read the lowest line that can be seen.
The patient can be asked to make directed eye movements and facial movements which can be directly observed. The expert has the facility to enlarge the images of the external eye on the video image, but the examination of the inner eye can only be practically performed at a face-to-face examination if this is possible and the patient is not ‘shielding’. Although, the expert will have reviewed the images in the disclosed medical records which may be adequate. Because a full history will have been taken during the virtual consultation, the time required for the face-to-face examination will be reduced which will increase the safety for both the expert and the patient. Other factors, such as reducing the number of patients seen and of the time spent in the clinic environment and exposure to other potentially sick patients, will also play a part here. The client should also wear a face covering and the expert PPE for this examination. There is a need to balance the risks associated with the patient travelling against the benefits of undergoing the face-to-face examination or postponing it to a later date.
The expert’s review of the medical records bundle affords a good approximation to the anticipated findings during a face-to-face or virtual consultation
What could be the impact if the assessment is not as accurate? How can experts mitigate this risk?
The expert should specifically state in their report the modality in which the consultation was conducted and if investigations, such as retinal photographs or visual field plots, in the clinical records are interpreted by the expert, the date of the investigation and where it was performed should also be stated. If the expert considers that more up-to-date investigations are required, a provisional report could be drafted with the recommendation that a final report would be produced when the investigation(s) has been performed, when possible, according to Public Health England’s guidelines.
The expert’s review of the medical records bundle affords a good approximation to the anticipated findings during a face-to-face or virtual consultation; if there is a discrepancy, then this is an indication for further assessment, but if the patient complains of a significant change in their clinical status, they should be referred via their GP to the ophthalmology department for management, because the role of the expert is to prepare the report for the court and not to manage the patient’s condition. A provisional report should be drafted in such circumstances.
Will these methods change the way you assess clients post-pandemic?
Challenges drive innovation and virtual consultations have rapidly developed in clinical ophthalmology because of the constraints of COVID-19. This modality will become the norm in the future, but there will still be the need for investigations and clinical examination which can only be performed during a face-to-face appointment. The initial virtual consultation, as described between the expert and their patient will streamline their interaction and a face-to-face appointment will only be made if indicated. This will also facilitate the assessment of those clients who have difficulties in attending a consultation in person because of health issues, the distance involved, or the availability of transport; the performance of a virtual consultation will be beneficial to such cases, as well as optimising the expert’s time management.
Mr Peter Gray, MA, LLM, FRCS, FRCOphth, MFFLM, DMCC is a respected and experienced ophthalmologist who, having worked in many prestigious centres of excellence in the United Kingdom, is proficient in all aspects of ophthalmology, especially in relation to ocular chemical injuries and has particular expertise in the ocular damage caused by the CS incapacitant spray deployed by the British Police. He has a Master’s Degree in Law in the “Legal Aspects of Medical Practice” and has worked as a medico-legal adviser to the Defence Medical Services. He is a Director of Eye Law Chambers®