Saturday, 16 October 2010

SBS: medical experts

I would invite any interested party to examine the history of testimony provided by all who have opined on this matter in court. You will find demagogues, on both sides of the issue, but principally among the most vocal, active, and highly compensated perennial "experts." You will find nuanced thoughtful and balanced analysis countered by demagoguery. You will find opinions that pop up regardless of the actual facts of the case. You will also find what Ms. Tuerkheimer seemed most concerned with in her original legal review article, simplistic analysis unchallenged by capable opposing experts; something that should concern us all. While you will find overly simplistic analysis based on the presence of a "triad", more commonly you will see careful analysis dismissed using the trojan horse of fealty to a "triad." Only by looking at the real experience, and history of those that opine, will you be able to judge their opinions. Alternatively you will need to check all your presumptions and your personal vested interests at the door, and start from square one with first hand data. This is a remarkably arduous task, and has been the life's work of many of the doctors who posted on the original blog strain.
The post by Illum starts, "Doctors are not God and they do not have all the answers; they are not infallible. An expert in any field is only as good as their experience, their education, and their knowledge and understanding of on-going non-bias studies and information." This is certainly true and I welcome this sort of analysis! Doctors are not asked to testify as God, however. They are asked to testify "to a reasonable medical certainty." This is not a standard taught in medical school. It is a term of art of the legal profession, yet one that lawyers, and commonly judges, decline to define for the doctors who must adhere to it. Only once has a judge defined it for me. I was shocked to hear him say it was simply "more likely than not." I would suggest that your anger should not be with doctors, but with the legal system that consumes, constrains and attempts to influence, bias, dismiss, distort and otherwise use their opinions in the pursuit of legal victory.
As to the comments of Innis. I have never seen a case of abusive head trauma proceed without looking carefully at clotting. The few cases where OI has presented with retinal hemorrhage or symptomatic subdural hemorrhage hardly justify universal OI testing, but most cases are carefully assessed for clinical evidence of OI and many are assessed for laboratory evidence. I would challenge him to document clear evidence that trace mineral and vitamin deficiencies are anything more than a red herring or very rare contributor to this issue. This post magnifies fascinating, unfortunate, and truly rare cases to the status of major diagnostic pitfall.
Unfortunately, we are in a stage similar to global warming science research years ago. Though the great bulk of science may agree, a band of vociferous opponents who manufacture disagreement and magnify the natural disagreements in a developing scientific field, trumpeted by a news hungry press, and capitalized upon by lawyers and politicians hungry for victory, can mislead the public into seeing controversy where little exists. Hopefully our science is still growing. Hopefully opinions of tomorrow will have differences from opinions of today. But please don't dismiss what you do not want to hear because a century ago someone with my same degree bled his patient. The case for shaking only starts with John Caffey, and has faced, and adapted to valid scientific challenges in the subsequent forty years.
It would be nice if as much care was shown in the public discourse, defense, and prosecution related to this topic as professionals like Dr Block show in their clinical work. I fight to take that degree of care in my work as well, as do all of the professionals I know who have made this the focus of their clinical life. Shaking injury appears to be a real issue. it is not present every time the "triad" is present, nor is it invoked every time a baby is injured. There are many other ways, both abusive and otherwise to injure a baby. The careful clinician understands the odds, the alternatives, the uncertainties, and testifies to them, no matter how disturbing or inconvenient the answer.

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