When Words Are Not Just Words

This post continues our discussion of strategies to eliminate cognitive biases and improve strategic decision making.  Brewer’s fourth strategy is interesting and does not seem, at first, to be intuitively important or useful: 

 Recognize that words are symbols of ideas and not the ideas themselves.  Recognize the necessity of using only words of prior definition, rooted in shared experience, in forming a new definition and in avoiding being misled by technical jargon.

This seems abstruse and postmodern, the worst sort of crypto-theoretical drivel…  However, it makes sense when you think about it for a moment.   As part of the medico-legal world, words are our currency.  The value of a claim may be expressed in dollars based on percentages estimating the likelihood of success, but the way we get there is through words.  Even when a claim is rife with photos, videos, diagnostic imaging studies, etc. the images lack meaning without narrative support, which is established through the use of language.  Words create, establish, color, taint, destroy, or bolster what the images mean.  Words are the firmament out of which the images of a claim shine (or are obscured). 

A good example of the critical need to differentiate between word and idea and to use words of prior definition is the presence of subchondral bone marrow edema in knee injury cases.  “Subchondral bone marrow edema,” also referred to as “subchondral edema,” “bone marrow edema,” and “bone marrow edema syndrome” is the term used to describe fat cell changes to the subchondral bone marrow observed on MRI that suggest swelling in the bone below the articular cartilage.  When this phenomenon was first observed during the introduction of MRI machines to hospitals in the mid-1980s, the phenomenon was referred to as a “bone bruise” and was thought to be the result of acute trauma.  As the use of MRI machines became ubiquitous in orthopedic practices a funny thing happened:  radiologists and orthopedists began observing subchondral bone marrow edema in a significant number of patients with no history of knee trauma.  This group of patients broke down into roughly two categories:  those with degenerative changes (osteoarthritis) and those with inflammatory conditions (rheumatoid arthritis, septic arthritis).  The new findings demonstrated that the term “bone bruise” was not an apt term for subchondral bone marrow edema because in most cases the finding was not related to trauma and hence could not be described as “bruising” in any conventional or commonly understood sense.

When considering the importance of using words of prior definition, consider an administrative law judge dealing with an alleged work-related knee injury and MRI findings that demonstrate the presence of subchondral bone marrow edema.  If one does not establish a clear definition of what “subchondral bone marrow edema” is and what its presence on an MRI scan suggests, an administrative law judge could conflate the MRI evidence with the concept of bruising and use that erroneous understanding to find that the employee sustained a traumatic, work-related knee injury.  Instead, when handling a claim with MRI evidence of subchondral bone marrow edema, the claim administrator may wish to take the opportunity that the independent medical examination affords to establish the limits of what the MRI evidence means.  A series of targeted questions and references to academic consensus on subchondral bone marrow edema can help set the parameters for what conclusions can be drawn from the presence of subchondral bone marrow edema.

For example, a well-regarded study from researchers and the University of Wisconsin Hospitals and Clinics noted:

[T]he histologic diagnosis of bone marrow edema is relatively crude and relies on secondary signs such as the presence of swollen fat cells and the incipient disintegration of fat cells.

This finding is one of general consensus among radiologists.  Others with even more concision report, “[t]he pathophysiological event that triggers BMES (bone marrow edema syndrome) is still a complete enigma.”  Still other researchers report, “[b]one marrow edema is non-specific and can be seen in degenerative disease or traumatic injury.”   

Despite the difficulty of determining the etiology of subchondral bone marrow edema, there are, however, some characteristics specifically associated with traumatic injury.  “If the cartilage defect has well-defined right angle margins, with marrow edema deep to the defect, this suggests a traumatic etiology.”  Also, traumatic changes tend to be focal.  “Characteristic changes include focal cartilage defect or fissure, subchondral linear-branching pattern, focal edema, and cortical impaction or bowing.”  Non-focal changes suggest a degenerative condition rather than a traumatic cause.

From a claims administration perspective, this information can be used to establish what MRI findings of subchondral bone marrow edema mean in the context of our hypothetical knee claim.  When crafting an IME letter, a claim administrator may wish to point out to the independent medical expert that the MRI evidence demonstrates subchondral bone marrow edema and then ask a series of targeted questions such as the following to demonstrate that the MRI findings suggest a degenerative rather than traumatic etiology:

  • According to the best available evidence, is it possible in most cases to determine the pathophysiological event that triggers subchondral bone marrow edema?
  • According to the best available evidence, is subchondral bone marrow edema a non-specific finding that is found in both degenerative disease and traumatic injury?
  • According to the best available evidence, do traumatic changes tend to be focal rather than diffuse? 
  • According to the best available evidence, does a cartilage defect with well-defined right angle margins and marrow edema deep to the defect suggest a traumatic etiology?  Were any of these findings present here? 
  • According to the best available evidence, are traumatic changes characterized by such findings as focal cartilage defect or fissure, subchondral linear-branching patter, focal edema, and cortical impaction or bowing?  Were any of these findings present here?

Obviously, the form of the question may need to be altered based on local evidentiary standards and the facts of the claim, but the bottom line is that claims are handled more effectively when we recognize that words and the ideas they represent can often pose problems if we allow the relationship of work and idea to be loose, ambiguous, or vague.  Instead, we should carefully limit definitions to established fact whenever possible so that decisions, whether our own in handling claims or those of the trier of fact, are based on terms of consensus and limited definition.  The independent medical examination represents an excellent opportunity to use an expert to establish the limits of medical terms that could otherwise be used to justify the compensability of a claim when the actual medical records and imaging studies do no such thing.  

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