You are a common law lawyer who works on personal injury and/or medical negligence file/s, which may contain clinical notes, medico-legal reports, hospital records and treatment records etc. Do you require a medical or nursing degree or background to decipher the medical information and its meaning in the context of law? Will a “reputable” medical dictionary and/or medical texts provide you with sufficient knowledge and skill to run the matter successfully? Common law lawyers, aren’t required to be medically trained, however, some are ex practicing doctors, nurses or have been employed in medicine, with many more having no medical background. How do common law lawyers, with no medical background, get a “handle on” medical terminology, abbreviations in documentation, procedures, tests, surgery and medical culture so as to run files confidently and successfully? What tips can be employed to assist and better understand medical documents in personal injury and medical negligence matters?
I was employed in medicine for 15 years prior to entering law. Before I was employed in medicine, I completed a 9 month “Language of Medicine” course which assisted me to understand medical terminology, body systems and associated diseases and traumas, clinical procedures, lab tests, radiology, nuclear medicine, pharmacology and abbreviations related to each body system and pronunciation of the correlated medical terms.
When I was employed in medicine, I organised patient procedures and surgeries, accompanied surgeons to theatre and observed operations, their outcomes, good and poor prognoses and usual treatment regimes in a wide variety of specialties. As a result of the course I completed and my diverse experience in medicine, I have gained extensive knowledge of “medicine” and these tips are provided to assist common law lawyers working on PI and/or med neg files, who do not have a medical background. It must be remembered that understanding medical terms, procedures, abbreviations etc takes time, its like becoming fluent in a foreign language. First things to remember:
- Knowledge of how to divide medical words into their component parts, for example, “the root, the combining vowel and the suffix is a very useful start.
- The prefix is the word beginning
- The root is the foundation of the term i.e. haemat (blood), gynaec (woman/female), gastr (stomach) encephal (brain), enter (intestines) etc
- The combining vowel is usually ‘o’ with it being used to combine one word part to another i.e. haemat/o, gynaec/0, cephal/0 or multiple root words – gastr/0 /enter/0 etc
- The suffix is the word ending i.e. logy (study of), itis (inflammation), gram (record), ic (pertaining to) etc
- When combined haemat/o/logy means study of the blood, gynaec/o/logy means study of females/women, gastr/itis means inflammation of the stomach, encephal/itis means inflammation of the brain and gastr/o/enter/o/logy means study of the stomach and intestines.
Three General Rules:
- Read the medical term from the suffix back to the beginning of the term
- Drop the combining vowel (usually ‘o’) before a suffix beginning with a vowel i.e. gastr/itis not gastr/o/itis, encephal/itis not encephal/o/itis (inflammation of the brain)
- Keep the combining vowel between 2 roots i.e. gastr/o/enterology not gastr/enterology
A Few Common Medical Terms
- aden/o = gland
- cardi/0 = heart
- cephal/o = head
- cerebr/0 = largest part of the brain
- cis/o = to cut
- cyst/o = urinary bladder
- erythr/0 – red
- hepat/o = liver
- neur/o = nerve
- oste/o = bone
- sect/o = to cut
Some Common Prefixes & Suffixes:
- Oma = tumour or mass (i.e. lymphoma – tumour of the lymph nodes)
- opsy = process of viewing (i.e. biopsy – viewing of tissue under a microscope)
- ic & al = pertaining to (ie cerebral – pertaining to the head)
- in = into (i.e. incision – cut into to)
- ex = out (i.e. excision)
- re= back (i.e. resection i.e. a gastric resection is stomach removal)
- cis = to cut (excision, incision)
- ion = process
- scopy = process of visual examination (i.e. gastroscopy – visual examination of stomach)
Some Common Gynaecological Abbreviations (Birth Cases)
- AFP = alpha-fetoprotein – chemical found in the amniotic fluid of foetuses with severe nervous system developmental abnormalities. Can be tested for with amniocentesis.
- C-section = caesarean section
- CS = caesarean section
- Cx = cervix
- FHT = foetal heart tones
- G – gravida (pregnant)
- LMP – last menstrual period
- NB = newborn
- UC = uterine contractions
This is a very small sampling of medical terms and abbreviations. Unfortunately, I’m unable to address medical terminology, diseases, procedures, traumas, surgeries etc in this limited blog space. However, a more detailed discussion at a “lunch and learn” for your law firm to gain additional education on the subject could be arranged by contacting me at firstname.lastname@example.org Suffice to say, it takes time and experience to understand and assimilate what is written in medical documents contained in a PI or med neg files so that a practitioner is able to determine what is important to consider and what is superfluous so as to decide whether the tort of negligence has been satisfied. A very good understanding of medical terminology is only the beginning to understanding medical documents as there are many “layers and levels” to understand “medicine” . Everyone has a starting point i.e. we all started out without knowledge in any given field, however, I would suggest endeavouring to have a competent understanding of medical terminology is the best “first step“!
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