Attorney Request, Causation Opinion, and a Prior Neck Pain Note
A 38-year-old patient is 6 weeks post rear-end motor vehicle collision. He has neck pain and an MRI showing a 4-mm C5-C6 disc protrusion without cord signal change. His attorney sends a letter requesting the complete file and a narrative report stating that the collision 'caused the disc herniation.' The radiologist's report says 'degenerative changes present; causation cannot be determined from imaging alone.' The patient asks you to 'write it strong so I get a fair settlement.' Your records contain a note that he had neck pain 3 years ago after sleeping awkwardly, for which he did not seek care.
1. How do you respond to the attorney's request? Address authorization, scope of release, and the requested causation wording.
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I would first confirm that the attorney has a valid signed authorization from the patient, or a subpoena that complies with state law. I would release only the records covered by that authorization, following the minimum-necessary principle, and I would not send unrelated parts of the file. I would send a copy, keep the original, and document the date and scope of release.
I would not write the sentence the attorney requested. Imaging cannot establish causation; a disc protrusion with degenerative changes may have predated the collision. My narrative report would describe the history, examination findings, diagnosis, treatment, and response, and it would state the limits of the imaging. If appropriate, I could say the collision is a plausible aggravating factor for a pre-existing degenerative condition, but I would not state that it caused the herniation. I would include the prior note of neck pain 3 years ago because withholding it would make the report misleading.
2. What is required before you can offer a causation opinion, and what are the ethical and legal pitfalls in this chart?
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A defensible causation opinion requires a complete history, a documented pre-injury baseline, a consistent temporal relationship, a plausible mechanism, and an explanation for alternative causes. Here the prior neck pain note weakens a simple 'caused by the collision' opinion, and the MRI report itself notes degenerative changes. I would need to review the prior records, the crash details, and the clinical course before offering even a qualified opinion. I should also distinguish aggravation of a pre-existing condition from new injury.
The ethical pitfalls are bias, advocacy, and misrepresentation. Writing a causation statement to support a settlement would be dishonest and could expose me to licensure and civil liability. Legally, I must follow privacy rules, release only authorized records, avoid altering records, and avoid ex parte communications that state law prohibits. I should not let the patient's financial interests dictate the medical opinion. If I am asked to testify beyond my expertise, I should say so.
3. The patient pressures you to 'write it strong.' Script your response and state what you document.
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I would say: 'I understand that a fair settlement matters to you, and I will write a complete and accurate report. I can describe your symptoms, the examination, and the treatment you received. What I cannot do is say the MRI proves the crash caused the disc problem, because the radiologist has already noted degenerative changes and you had neck pain before. If the evidence supports an aggravation of a pre-existing condition, I will say that. I have to include the earlier note because leaving it out would make the report misleading.'
I would document the request, my response, and the patient's acknowledgment. I would also document the records released, the authorization, and the content of the narrative report. If the patient continues to pressure me to alter the opinion, I would note that as well and consider ending the discussion. The record should show that the report was objective and not influenced by settlement considerations.