Assessing medical disability for the courts v2

Assessing Medical Disability
for the courts
Mr Vaikunthan Rajaratnam
MBBS(Mal),AM(Mal),FRCS(Ed),FRCS(Glasg),FICS(USA),MBA(USA),
Dip Hand Surgery(Eur),Dip MedEd(Dundee),FHEA(UK),FFST(Ed),FAcadMEd(UK).
Senior Consultant Hand Surgeon
Alexandra Health, SINGAPORE

Credentials
• 35 years clinical practice and teaching
• Qualifications in medical education
• Experience in instructional design and technology (on going Masters)
• Publications and research in surgical education
• Senior Clinical Examiner(UG) – Birmingham/ Singapore
• Examiner PG Ortho Exit exams – Indonesia/Malaysia/Singapore
• Examiner Royal College of Surgeons, Edinburgh
• Quality Assurance Panel of Visitor in PG ME&T, UK
• Core Faculty Member Orthopaedic Surgery – ACGME-I, Singapore
• Core Faculty Member Hand Surgery Residency, ACGME-I, Singapore
• Fellow - HEA UK, Academy Medical Educators (UK), Faculty of Surgical Trainers Edinburgh
• Reviewer for Educational Research Grants HEA,UK
• Member of Alexander Health, Research in Education, Singapore
• Member of Alexander Health, Medical Ethics Board, Singapore
• Visiting Consultant Bangabandhu Sheikh Mujib Medical University, Bangladesh and
Children Surgical Center, Cambodia
• Failed medical and digital entrepreneur x 6
• Medical Fraud Consultancy/Education – City State Liberty Mutual, Gerling Re and NIAM
• 1600 written expert opinion for personal injury in UK (2002-2011)

Learning Outcomes
At the end of this lecture you will be able :-
• Understand the cognitive basis for your
judgments
• Understand the science behind measurement
and assessment used in medicine
• Understand the tools and process of
assessment of medical disability and its
limitation

The Bangalore Principles of
Judicial Conduct 2003
• Judicial independence
• Impartiality - skill to recognize and detach
from emotional reactions
• Integrity
• Propriety
• Ensuring equality of treatment to
• Competence and diligence
Bangalore Principles of Judicial Conduct were initiated in 2001. The Bangalore principles arose from a
United Nations initiative with the participation of Dato’ Param Cumaraswamy, UN Special Rapporteur on
the Independence of Judges and Lawyers.

“It is a judge’s
professional duty
to do what he
reasonably can to
equip himself to
discharge his
judicial duties
with a high
degree of
competence.”
Lord Bingham of Cornhill

Responsible for planning, organizing and conducting
training programs and courses for judges of the
Superior Courts. 33 “Superior Courts” include the
Federal Court, Court of Appeal, High Court in Malaya,
and High Court in Sabah and Sarawak.
Judicial Academy

2014 “Senior Management & Professional” programme
1. Course on Protocols, Social and Dining Etiquette
2. Workshop on Negotiation Skills
3. Workshop of Handling and Discipline Management
4. Workshop on Writing Grounds of Judgement
5. Course on Creative Thinking in Problem Solving
6. Course on Middle Managers’ Worklife and Academic Strategic Planning
7. Course of Time and Stress Management
8. Course on Mind Transformation, Motivation and Leadership
9. Course for Magistrates
10. Seminar on Judicial Ethics
11. Seminar for Industrial Court Chairman
12. Seminar on People Skills – Empowerment and Positive Influence at The Workplace
13. Course on Government’s Transformation Plans
14. Seminar for Sessions Court Judges
15. Workshop on Arbitration

A Knowledge and technical skill
B Communication and authority
C Decision-making
D Professionalism and integrity
E Efficiency
F Leadership and management

How abilities would be demonstrated
• Undertakes necessary preparatory work.
• Properly applies appropriate legal principles to issues before the court.
• Appropriately conducts proceedings in accordance with current procedural rules.
• Identifies critical issues.
• Rapidly absorbs and analyses complex and competing factual and legal material.
• Clarifies uncertainty.
• Weighs relevant issues and matters of law to formulate reasoned and coherent
decisions.
• Concentrates for long periods.
• Stays up to date with changes to law and procedure.
• Broadens and extends knowledge.
• Remains detached and manages own reactions and emotions.

Decision science

Decisions dynamically evolve from a sequential sampling and
accumulation of evidence/preference process that continues
until a threshold criterion is reached

Brain and Mind
• Cognition• Ego
• Memory• Senses & Motor
TEMPORO
PARIETEAL LOBE
HIPPOCAMPUS
PREFRONTAL
CORTEX
DORSOLATERAL
PREFRONTAL
CORTEX
The brain is the organ of the mind
the lungs are the organs for respiration

Four basic mind states
fighting, fleeing, feeding, and f……g
function of the hypothalamus

Stimuli Identification Recall Understand
Association
Knowledge
creation
WIIFM
Affective
change
Life change

Judgement
A heuristic technique (/hjʉˈrɪstɨk/; Greek:
"Εὑρίσκω", "find" or "discover"), sometimes
called simply a heuristic, is any approach to
problem solving, learning, or discovery that
employs a practical methodology not
guaranteed to be optimal or perfect, but
sufficient for the immediate goals. Where
finding an optimal solution is impossible or
impractical, heuristic methods can be used to
speed up the process of finding a satisfactory
solution. Heuristics can be mental shortcuts that
ease the cognitive load of making a decision.
Examples of this method include using a rule of
thumb, an educated guess, an intuitive
judgment, stereotyping, profiling, or common
sense.
Sir Francis Buller, an English judge, for allegedly ruling that a
man may legally beat his wife, provided that he used a stick
no thicker than his thumb

The Bolam Test vs The Bolitho Test
• he or she has acted in accordance with a practice
accepted as proper and responsible by a
responsible body of medical practitioners skilled
in that particular art.
• if the management by a body of responsible
doctors was not demonstrably reasonable, it
would not necessarily constitute a defence.

Plato & Aristotle
Rationalism vs. Empiricism
• “Is truth and knowledge to be found within us (rationalism) or is it
to be found by using our senses to discover what is outside of
ourselves (empiricism)?”
• As a rationalist, Plato developed the belief that knowledge and
truth can be discovered by self-reflection. Socrates also believed
strongly that certain knowledge was only attainable through
reason. He developed the dialectic method of discovering truth
through conversations with fellow citizens (Monroe, 1925)
• Aristotle, the empiricist, suggested that we use our senses to look
for truth and knowledge in the world outside ourselves.
• The Romans emphasized education as vocational training, rather
than as training of the mind for the discovery of truth
Assessing Disability - the empiricist approach

Hawthorne effect (also referred to as
the observer effect) is a type
of reactivity in which individuals improve an
aspect of their behaviour in response to
their awareness of being observed
The Dr. Fox effect is
a correlation observed between teacher
expressiveness, content coverage, student
evaluation and student achievement
Emotion and Decision Making: Multiple Modulatory Neural Circuits
Annual Review of Neuroscience
Vol. 37: 263-287 (Volume publication date July 2014)

Defining Disability

Disability and Damage
Injury/Illness Treatment Intervention Outcome

Defining
•
Impairment: any loss or abnormality of psychological, physiological
or anatomical structure or function.
•
Disability: any restriction or lack (resulting from an impairment) of
ability to perform an activity in the manner or within the range
considered normal for a human being.
•
Handicap: a disadvantage for a given individual that limits or
prevents the fulfilment of a role that is normal
•
As traditionally used, impairment refers to a problem with a
structure or organ of the body; disability is a functional limitation
with regard to a particular activity; and handicap refers to a
disadvantage in filling a role in life relative to a peer group.
World Health Organization (1980) in The International Classification of
Impairments, Disabilities, and Handicaps:

 43 year-old female, right-handed, cook
Traumatic amputation of right thumb and index finger


Underwent right thumb reconstruction
with right big toe osteoplastic wrap-
around flap 1 week post-injury, after
counseling and consenting

Toe wrap based on
dorsalis pedis

Guides

http://www.mom.gov.sg/Documents/safety-health/GATIOD-Fifth-Edition.pdf

worker's capacity to perform duties that are part
of the physical demands at work ……..
……….in cases of discrepancies between disability
determined by the doctor to the patient's
complaints and participation.
Ratzon, N. Z., Amit, Y., Friedman, S., Zamir, S., & Rand, D. (2015). Functional capacity
evaluation: Does it change the determination of the degree of work disability? Disability
and Health Journal, 8(1), 80–85. http://doi.org/10.1016/j.dhjo.2014.08.004

Psycometrics

Psychometrics and Metrology
construction and validation of measurement
instruments such as questionnaires, tests, and
personality assessments

Classical test theory
• reliability and validity.
– Pearson correlation
coefficient, and is often
called test-retest
reliability.
– index of reliability
is Cronbach's α
• concurrent
validity; predictive
validity, construct
validity, Content validity

Quality of Assessment
• Traceability,
• accuracy,
• precision,
• systematic bias
• evaluation of measurement uncertainty

International Classification of
Functioning, Disability and Health
(ICF)
• classified from body, individual and societal
perspectives
• measuring health and disability at both
individual and population levels
• shifting the focus from cause to impact
• the social aspects of disability
– http://apps.who.int/classifications/icfbrowser/

WHO DAS II

WHODAS II
• ISBN 978 92 4 154759 8
• (NLM classification: W 15)
• © World Health
Organization 2010
• http://p.ideaday.de/104.2/i
cf/en/index.html
Conclusion: disability can be measured and compared using WHODAS 2.0.

WHODAS II
• generic assessment instrument
• standardized method for measuring health
and disability
• developed from a comprehensive set of
International Classification of Functioning,
Disability and Health (ICF)
• Cross cultural applicability, utility, reliability
and validity

Why is disability assessment
important?
• “there are no
diseases, but
patients”
• There are no
disabilities but
people with
problems that
affect their lives

Why develop a method to assess
disability?
• “a decrement in each functioning domain”
– Body, person and society
• International Classification of Functioning,
Disability and Health (ICF) – impractical for
daily use
• WHODAS 2.0 – practical, reliable and valid

Why learn and use a disability
measure?
• patient’s needs
• level of care
• outcome of the condition
• length of hospitalization
• receipt of disability benefits
• work performance
• social integration

Disability assessment
• identifying needs
• matching
treatments and
interventions
• measuring
outcomes and
effectiveness
• setting priorities
• allocating resources.

Why use WHODAS 2.0?
• sound theoretical underpinnings
• good psychometric properties
• numerous applications
• direct link to the ICF
• Cross-cultural comparability
• Ease of use and availability

WHODAS 2.0
practical, generic assessment instrument measuring health and disability
• 1: Cognition – understanding and communicating
• 2: Mobility – moving and getting around
• 3: Self-care – attending to one’s hygiene, dressing,
eating and staying alone
• 4: Getting along – interacting with other people
• 5: Life activities – domestic responsibilities, leisure,
work and school
• 6: Participation – joining in community activities,
participating in society.

WHODA II contd
• common metric
• generic measure
• possible to design and monitor interventions
• etiologically neutral
• focus directly on functioning and disability
• full version has 36 and the short version 12
questions

WHODAS and WHOQOL
• WHODAS 2.0 measures functioning (i.e. an
objective performance in a given life domain),
while WHOQOL measures subjective well-
being (i.e. a feeling of satisfaction about one’s
performance in a given life domain).
• Does vs Feel

36-item version
• interviewer-administered, self-administered
and proxy-administered
• most detailed
• 20 minutes.

12-item version
• brief assessments of overall functioning
• interviewer-administered, self administered
and proxy-administered.
• explains 81% of the variance of the 36-item
version
• five minutes.

Psychometric properties
• Test–retest reliability and internal consistency
- Cronbach’s alpha levels 0.98
• Most questions fitted in their assigned
domains, confirming the unidimensionality of
domains
• summary change scores were unaffected by
sociodemographic factors
• Face , construct and concurrent validity

THANK YOU
vaikunthan@gmail.com
This work is licensed under a Creative Commons Attribution 4.0 International License.

Assessing medical disability for the courts v2

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