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Shrewsbury, NJ - Main office

655 Shrewsbury Ave, Suite 314

Shrewsbury, NJ 07702

Monday to Friday - 8:30am -5:30pm

Evening and weekend appointments 

available upon request



Freehold, NJ

25 monument  St Freehold, NJ 07728

Monday to Friday - 9:00am -5:00pm
















© 2018 Shebell & Shebell LLC. All Rights Reserved.

Disclaimer |  Privacy Policy |  Awards Methodology 

Tom Shebell, Esquire

May 14, 2019

Tom Shebell, Esquire

May 14, 2019

FUNDAMENTALS OF MEDICAL RESEARCH FOR LAWYERS

When I first began trying injury cases back in 1991, my father gave me an eight-hundred page medical-legal textbook, entitled “Trauma and Disease”, by Moritz and Helberg. “Read this book—in order to try cases involving medical testimony, you need to know the medicine cold,” he emphasized. True statement, no doubt. 


“Trauma and Disease” is beautifully bound in leather, well-written, and contains many of the medical-legal analyses that are still relevant today. The problem is that that book was used by my grandfather in workers’ compensation court and was published in 1959. Yes, 1959 -- an era well before the advent of CT and MRI imaging, before minimally-invasive surgical interventions, before the development of thousands of medication therapies for various diseases, and the like.


Imagine trying to cross-examine an expert in 1991 with a book published back in 1959. Not happening… My father was right -- I needed to learn medicine, thoroughly and quickly, with current medical information. From that point forward, I sought to build an extensive medical library with textbooks in every conceivable area of medicine. I subscribed to JAMA, the New England Journal of Medicine, the Journal of the AAOS…


And then came the internet and Google. Suddenly, hundreds of thousands of medical articles, abstracts, peer-reviewed and open-source articles became available to the public. Every day, new medical studies, theories, treatment options, and medications are published on the internet. Are textbooks outdated before publication? How reliable are the sources of medical information contained on the internet? How can we, as lawyers, use medical resources that are ever-evolving in our daily lives and in our practices? 


I.    A GOOD STARTING POINT


The proverb “a little knowledge is a dangerous thing”, ascribed to Bacon or Pope -- for our purposes, should be reframed to state “a little [medical] knowledge is better than no knowledge at all.” For our own health, as patients, and to adequately represent our clients, we need to learn the fundamentals of medicine. Harrison’s Principles of Internal Medicine, now in its 20th edition, is an excellent two-volume textbook that addresses core principles of medicine. Although written for physicians, I recommend that every lawyer and judge own a copy for his or her own reference. The preface to the 20th edition of Harrison’s, referencing the first edition, succinctly states the ever-developing expansion of medical and scientific thought as “an explosion of scientific information”, which is “[o]ngoing and accelerating.”



Will select portions of Harrison’s be admissible as “reasonably reliable” on direct or cross-examination of a medical expert, under N.J.R.E. 803©(18) and Jacober v. St. Peter’s Medical Center, 128 N.J. 475 (1992)? Although most experts will agree that Harrison’s is a good foundational resource on basic internal medicine, some will disagree that the text is “reasonably reliable” on a specific topic, usually on the topic at issue in the case. 


In my experience, the current consensus is that the electronic app and internet-based resource Up To Date is used by most physicians on a daily basis, and few will challenge the “reasonable reliability” of that source. I will discuss Uptodate.com in greater detail below.


There are countless free internet medical resources available. Wikipedia is, not surprisingly, the most commonly-used site by patients who are researching medical issues. Shockingly, Wikipedia is also the most commonly-used wiki in the medical community. According to a 2014 article by CL Ventola, “Social Media and Healthcare Professionals: Benefits, Risks, and Best Practices ”, Wikipedia “is often used as a reference by clinicians, despite its known shortcomings, such as errors and narrow breadth of information. One study found that 35% of 1,056 pharmacists used Wikipedia, although only 19% trusted it. In another survey of more than 1,000 pharmacists, one in five respondents said they trusted Wikipedia, but only one in four knew that anyone could edit the site (emphasis added).”

The author also cited a study that found that “70% of 35 junior physicians used Wikipedia to find medical information during a week-long period, with 93% citing ease of use as their primary motivation”.

In my view, use Wikipedia at your own risk. Alternatively, I recommend six free, reasonably-reliable sources that are available that contain current and archived medical research. First, Google Scholar is a good resource for general and specific full-text and abstracts of peer-reviewed source materials. Many of the articles will refer you to other websites, such as nejm.org or researchgate.net. Google Scholar is a good, free starting point. Merck Manual Professional Version, found at merckmanuals.com/professional, is another solid, free source to learn about current drug information and medical research. 


Perhaps the best, free source for current and archived medical literature is available at www.ncbi.nlm.nih.gov/pubmed. PubMed and PubMed Central is the largest medical and scientific database from the Central National Library of Medicine at the U.S. National Institutes of Health. A large majority of the publications may be downloaded in PDF format or are available as an abstract (which you can later access from other sources). PubMed is an invaluable resource, particularly when researching the accuracy and legitimacy of medical expert witness citations contained on CVs.


Next, the Centers for Disease Control and Prevention provide excellent resources and medical guidelines for physicians that are reliable and current, at www.cdc.gov/DiseasesConditions/. The U.S. Food and Drug Administration offers free, fully searchable resources concerning drug safety, approvals, warning letters, adverse event reporting, and drug research, at www.accessdata.fda.gov/. Finally, The Wiley Online Library is a great resource for peer-reviewed journals in medicine, as well as other fields, at onlinelibrary.wiley.com. Although the site contains a great many free, full-text medical articles, some publishers require charges to download a PDF. 


II.    SOMETIMES MEDICAL RESOURCES ARE WORTH THE COST 


I am a huge coffee drinker. Six to ten cups a day. If you go Rook or Starbucks, you’re spending $3.00 to $4.00 for a “venti” or “bigger” cup. Multiply that number times, say six cups a day, times 365 days…you can see where I’m going with this time-unit argument. You can make the same argument for a bottle of water, beer, wine, or other beverage of choice.


For $1.77 per day, less than one cup of coffee, you can obtain full access to UpToDate. UpToDate is a web and/or application-based subscription service, available for Iphone, Ipad, Android, or computer. Over 90% of the academic medical centers in the United States and over 1.7 million physicians are currently using UpToDate as a medical reference and to make clinical, evidence-based decisions. 


The App offers current, peer-reviewed discussions of most all medical conditions, providing summary and recommendations for treatment, clinical manifestations, laboratory studies, diagnostic considerations, differential diagnoses, and treatment recommendations. Links to additional medical references are cited for ease of reference and further research. Additionally, the App or website versions offers authoritative drug information, as well as drug contraindications and interactions between medications. 


From a medical research standpoint, UpToDate.com is usually my first point of reference when analyzing the medico-legal aspects of a case. Regardless of the type of case you’re evaluating, it is essential to understand how a client’s pre-existing co-morbidities (by 50 most of us have one or more), medication use, family history, social history, occupational or environmental exposure may impact one or more issues in your case. If, for example, a patient comes into your office with Stage IV non-small cell lung carcinoma, alleging a misdiagnosis by five years, all the above information becomes critical to the issues in her case. 


Suppose you have a premises liability case, and the defense expert claims your client fell due to orthostatic hypotension, rather than a ½ inch defect in a walkway (yes, the defense made the claim). With UpToDate, you can type in “orthostatic hypotension”, and the following will appear, along with 65 peer-reviewed references.:



At the time of this paper, I have yet to find any truthful medical expert disagree that UpToDate is not a “reasonably-reliable” source of information, within the meaning of N.J.R.E. 803©(18). To the contrary, in a recent trial in Monmouth County, an adverse internal medicine expert testified that he does not use the PDR, but instead refers to UpToDate on pharmacological information.


Other notable subscriptions worth mentioning are the New England Journal of Medicine, at nejm.org and JAMA, at jamanetwork.com. Both are available as online and print subscriptions and offers current peer-reviewed and archived articles. Finally, LexisAdvance offers thousands of Elsevier full-text medical journals available by subscription. All of these options are worth the price of admission and the coffee analogy allows me to justify the expense.


Finally, although many now view textbooks as antiquated, I am still fond of paper. I much prefer reading a textbook to staring at the cold glare of a computer screen, iphone, or ipad. Major publishers, such as Elsevier, have continued to publish high-quality medical textbooks, with “value-added” features. Inside the cover of the book, an access code is provided that allows you to obtain full-access online features, as well as videos of surgical procedures and enhanced images. 


I’ve found that the best way to determine whether a text is “reasonably reliable” on a subject is to ask a doctor friend, my own expert, or, preferably, ask an opposing expert what books he may refer to, or that he has in his own library at the office or home. I’ll then go on Amazon and buy the text for use in that case or for later use.


So, yes, “a little knowledge [can be] a dangerous thing”, especially when the source of the publication is untrustworthy. The only way to improve our understanding of medicine is to do a deep-dive into reliable medical resources and to learn the fundamentals.

FUNDAMENTALS OF MEDICAL RESEARCH FOR LAWYERS

When I first began trying injury cases back in 1991, my father gave me an eight-hundred page medical-legal textbook, entitled “Trauma and Disease”, by Moritz and Helberg. “Read this book—in order to try cases involving medical testimony, you need to know the medicine cold,” he emphasized. True statement, no doubt. 


“Trauma and Disease” is beautifully bound in leather, well-written, and contains many of the medical-legal analyses that are still relevant today. The problem is that that book was used by my grandfather in workers’ compensation court and was published in 1959. Yes, 1959 -- an era well before the advent of CT and MRI imaging, before minimally-invasive surgical interventions, before the development of thousands of medication therapies for various diseases, and the like.


Imagine trying to cross-examine an expert in 1991 with a book published back in 1959. Not happening… My father was right -- I needed to learn medicine, thoroughly and quickly, with current medical information. From that point forward, I sought to build an extensive medical library with textbooks in every conceivable area of medicine. I subscribed to JAMA, the New England Journal of Medicine, the Journal of the AAOS…


And then came the internet and Google. Suddenly, hundreds of thousands of medical articles, abstracts, peer-reviewed and open-source articles became available to the public. Every day, new medical studies, theories, treatment options, and medications are published on the internet. Are textbooks outdated before publication? How reliable are the sources of medical information contained on the internet? How can we, as lawyers, use medical resources that are ever-evolving in our daily lives and in our practices? 


I.    A GOOD STARTING POINT


The proverb “a little knowledge is a dangerous thing”, ascribed to Bacon or Pope -- for our purposes, should be reframed to state “a little [medical] knowledge is better than no knowledge at all.” For our own health, as patients, and to adequately represent our clients, we need to learn the fundamentals of medicine. Harrison’s Principles of Internal Medicine, now in its 20th edition, is an excellent two-volume textbook that addresses core principles of medicine. Although written for physicians, I recommend that every lawyer and judge own a copy for his or her own reference. The preface to the 20th edition of Harrison’s, referencing the first edition, succinctly states the ever-developing expansion of medical and scientific thought as “an explosion of scientific information”, which is “[o]ngoing and accelerating.”



Will select portions of Harrison’s be admissible as “reasonably reliable” on direct or cross-examination of a medical expert, under N.J.R.E. 803©(18) and Jacober v. St. Peter’s Medical Center, 128 N.J. 475 (1992)? Although most experts will agree that Harrison’s is a good foundational resource on basic internal medicine, some will disagree that the text is “reasonably reliable” on a specific topic, usually on the topic at issue in the case. 


In my experience, the current consensus is that the electronic app and internet-based resource Up To Date is used by most physicians on a daily basis, and few will challenge the “reasonable reliability” of that source. I will discuss Uptodate.com in greater detail below.


There are countless free internet medical resources available. Wikipedia is, not surprisingly, the most commonly-used site by patients who are researching medical issues. Shockingly, Wikipedia is also the most commonly-used wiki in the medical community. According to a 2014 article by CL Ventola, “Social Media and Healthcare Professionals: Benefits, Risks, and Best Practices ”, Wikipedia “is often used as a reference by clinicians, despite its known shortcomings, such as errors and narrow breadth of information. One study found that 35% of 1,056 pharmacists used Wikipedia, although only 19% trusted it. In another survey of more than 1,000 pharmacists, one in five respondents said they trusted Wikipedia, but only one in four knew that anyone could edit the site (emphasis added).”

The author also cited a study that found that “70% of 35 junior physicians used Wikipedia to find medical information during a week-long period, with 93% citing ease of use as their primary motivation”.

In my view, use Wikipedia at your own risk. Alternatively, I recommend six free, reasonably-reliable sources that are available that contain current and archived medical research. First, Google Scholar is a good resource for general and specific full-text and abstracts of peer-reviewed source materials. Many of the articles will refer you to other websites, such as nejm.org or researchgate.net. Google Scholar is a good, free starting point. Merck Manual Professional Version, found at merckmanuals.com/professional, is another solid, free source to learn about current drug information and medical research. 


Perhaps the best, free source for current and archived medical literature is available at www.ncbi.nlm.nih.gov/pubmed. PubMed and PubMed Central is the largest medical and scientific database from the Central National Library of Medicine at the U.S. National Institutes of Health. A large majority of the publications may be downloaded in PDF format or are available as an abstract (which you can later access from other sources). PubMed is an invaluable resource, particularly when researching the accuracy and legitimacy of medical expert witness citations contained on CVs.


Next, the Centers for Disease Control and Prevention provide excellent resources and medical guidelines for physicians that are reliable and current, at www.cdc.gov/DiseasesConditions/. The U.S. Food and Drug Administration offers free, fully searchable resources concerning drug safety, approvals, warning letters, adverse event reporting, and drug research, at www.accessdata.fda.gov/. Finally, The Wiley Online Library is a great resource for peer-reviewed journals in medicine, as well as other fields, at onlinelibrary.wiley.com. Although the site contains a great many free, full-text medical articles, some publishers require charges to download a PDF. 


II.    SOMETIMES MEDICAL RESOURCES ARE WORTH THE COST 


I am a huge coffee drinker. Six to ten cups a day. If you go Rook or Starbucks, you’re spending $3.00 to $4.00 for a “venti” or “bigger” cup. Multiply that number times, say six cups a day, times 365 days…you can see where I’m going with this time-unit argument. You can make the same argument for a bottle of water, beer, wine, or other beverage of choice.


For $1.77 per day, less than one cup of coffee, you can obtain full access to UpToDate. UpToDate is a web and/or application-based subscription service, available for Iphone, Ipad, Android, or computer. Over 90% of the academic medical centers in the United States and over 1.7 million physicians are currently using UpToDate as a medical reference and to make clinical, evidence-based decisions. 


The App offers current, peer-reviewed discussions of most all medical conditions, providing summary and recommendations for treatment, clinical manifestations, laboratory studies, diagnostic considerations, differential diagnoses, and treatment recommendations. Links to additional medical references are cited for ease of reference and further research. Additionally, the App or website versions offers authoritative drug information, as well as drug contraindications and interactions between medications. 


From a medical research standpoint, UpToDate.com is usually my first point of reference when analyzing the medico-legal aspects of a case. Regardless of the type of case you’re evaluating, it is essential to understand how a client’s pre-existing co-morbidities (by 50 most of us have one or more), medication use, family history, social history, occupational or environmental exposure may impact one or more issues in your case. If, for example, a patient comes into your office with Stage IV non-small cell lung carcinoma, alleging a misdiagnosis by five years, all the above information becomes critical to the issues in her case. 


Suppose you have a premises liability case, and the defense expert claims your client fell due to orthostatic hypotension, rather than a ½ inch defect in a walkway (yes, the defense made the claim). With UpToDate, you can type in “orthostatic hypotension”, and the following will appear, along with 65 peer-reviewed references.:



At the time of this paper, I have yet to find any truthful medical expert disagree that UpToDate is not a “reasonably-reliable” source of information, within the meaning of N.J.R.E. 803©(18). To the contrary, in a recent trial in Monmouth County, an adverse internal medicine expert testified that he does not use the PDR, but instead refers to UpToDate on pharmacological information.


Other notable subscriptions worth mentioning are the New England Journal of Medicine, at nejm.org and JAMA, at jamanetwork.com. Both are available as online and print subscriptions and offers current peer-reviewed and archived articles. Finally, LexisAdvance offers thousands of Elsevier full-text medical journals available by subscription. All of these options are worth the price of admission and the coffee analogy allows me to justify the expense.


Finally, although many now view textbooks as antiquated, I am still fond of paper. I much prefer reading a textbook to staring at the cold glare of a computer screen, iphone, or ipad. Major publishers, such as Elsevier, have continued to publish high-quality medical textbooks, with “value-added” features. Inside the cover of the book, an access code is provided that allows you to obtain full-access online features, as well as videos of surgical procedures and enhanced images. 


I’ve found that the best way to determine whether a text is “reasonably reliable” on a subject is to ask a doctor friend, my own expert, or, preferably, ask an opposing expert what books he may refer to, or that he has in his own library at the office or home. I’ll then go on Amazon and buy the text for use in that case or for later use.


So, yes, “a little knowledge [can be] a dangerous thing”, especially when the source of the publication is untrustworthy. The only way to improve our understanding of medicine is to do a deep-dive into reliable medical resources and to learn the fundamentals.

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Shrewsbury, NJ - Main office

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Shrewsbury, NJ 07702

Monday to Friday - 8:30am -5:30pm

Evening and weekend appointments available upon request




Freehold, NJ

25 Monument St

Freehold, NJ 07728

Monday to Friday - 9:00am -5:00pm





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