Tales from the Couch

Seeing the patient from psychiatry’s perspective

Break an Ankle, Become Schizophrenic

In court, an expert must rely on real life experience and sound principles

Testifying in court can be a trying experience for an expert witness, whether you’re a forensic pathologist, engineer or psychiatrist.

 Early in my career, I was asked by a defense attorney to evaluate a plaintiff in a lawsuit. He was a 30 year old man, who, while walking across the lobby of an office building, slipped on a freshly waxed floor and fractured an ankle. The physical injury was indisputable and was caused  by the accident. I was certain the plaintiff would be claiming a consequential depression as being causally-related to the fall.

 To prepare for the examination, in addition to reading the medical records, I also reviewed legal documents, including the Bill of Particulars—a document that among other things, alleges various injuries deriving from the incident in litigation. Surprisingly, there was nothing about depression or lost wages. Rather, to my astonishment, the document claimed that John B had developed schizophrenia as a direct result of having sustained a fracture to the ankle.

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 This assertion by the plaintiff’s attorney was being made despite its medical implausibility, and in the face of the medical records indicating John B. had been maintained on anti-psychotic medication for 5 years before the accident, and hadn’t worked in three years. His last job had been as a messenger.

 When I saw John B in forensic consultation, he was sweating profusely; was disheveled; and spoke rapidly. At times, his words made little sense. In addition, a paranoid coloration permeated his thinking and verbalizations. He was indeed quite disturbed.

 I submitted a detailed report of my findings and opinion. The report concluded that indeed the fractured ankle had caused pain and distress for John, and may have temporarily caused his condition to have worsened; but could not be considered causative in his severe and very likely, lifelong condition.

 When I testified in court, I explained to the jury that schizophrenia is a chronic disorder, with periods during which it will wax and wane; has a biogenetic basis; persists throughout life; and John would have presented as he did had the accident never occurred. His disorder was not caused by his having sustained a fractured ankle.

 On cross examination, the plaintiff’s attorney was belligerent, loud, abrasive, and tried to undermine my testimony by pointing out I’d only been in court three times previously. He then produced an obscure journal of social psychology and asked me if it was authoritative. I was familiar enough with courtroom procedure to know an attorney could read to the jury from such a document, only if the expert on the stand deemed it “authoritative.”

            “I’ve never heard of the journal,” I said.

            “Could it be authoritative?” he asked.

            “What does authoritative mean?”

            “That you would rely on it, Doctor.”

            “No, I wouldn’t rely on a journal to make decisions about a patient.”

            “Would you rely on a journal for scientifically valid information?\

            “No I wouldn’t.”

            “Would you rely on any journal?”

            “No, I would not.”.

            “Then, what do you rely on to make a diagnosis?”

            I rely on my training, education and on my experience with patients.”

            He grew increasingly frustrated and pulled out another obscure journal—this time, a pamphlet.

            The same line of questions and answers ensued.

            Finally, I said, “Nothing is authoritative since nothing is etched in stone. Science proceeds every day with new findings and research. What was dogma one day is refuted the next.”

            “So you rely on nothing…” the attorney said, growing red in the face.

            “I already testified about what I rely on,” I replied.

            “So you think it’s impossible that my client’s fractured ankle caused his schizophrenia?”

            “That’s correct.”

            “How can you know that?”

            “Claiming a fractured ankle causes schizophrenia is like saying a broken wrist causes diabetes.”

            Seething with frustration, and seeing the jury’s obviously positive reaction to my common-sense and medically sound testimony, the plaintiff’s attorney turned to the judge and muttered, “I have no further questions, Your Honor.”

 

Mark Rubinstein

Author of Mad Dog House, Love Gone Mad and The Foot Soldier

Mark Rubinstein, M.D., is a former professor of psychiatry at Cornell. His most recent book is the novel Mad Dog House.

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