Standard of Care and Neurologic Causation

An adverse outcome does not by itself establish that the care was below the standard of care. In the same way, identifying a potential deviation does not automatically establish that the deviation caused the patient’s injury.

Those questions have to be analyzed separately.

A standard-of-care review looks at the circumstances that existed when the clinical decision was made. What symptoms were documented? What did the examination show? What information was available? What diagnoses were reasonably being considered? What treatment options were available at that point in time?

Causation begins after that. If a different decision should have been made, the next question is whether that different course would likely have changed what happened to the patient.

In neurologic cases, these two questions are equally important.

Clinical decisions are made prospectively. Medical-legal review happens retrospectively.

That difference matters.

By the time a case reaches review, the diagnosis is often known, the imaging has been completed, the hospital course is documented, and the neurologic outcome is clear. The treating physician did not have all of that information when the original decision was made.

Dr. Cheung reviews the case from the standpoint of what was reasonably known at each stage of care.

That may include the history available at presentation, the neurologic examination, vital signs, laboratory data, imaging, consultant recommendations, changes in the patient’s condition, available hospital resources, and the clinical response to treatment.

The question is not whether a different decision looks obvious after the fact. The question is whether that decision was reasonably apparent under the circumstances that existed at the time.

Neurologic disease can be difficult to diagnose early because the presentation may be incomplete, evolving, or nonspecific. The differential diagnosis in neurologic disease can start very broadly.

A patient who is eventually diagnosed with stroke, seizure, encephalitis, spinal cord disease, or another neurologic emergency may not have presented with the complete picture that became apparent later.

This is one of the reasons hindsight can distort medical-legal review.

Once the final diagnosis is known, earlier symptoms may seem more specific than they actually were. An imaging abnormality identified later may change how an earlier examination is interpreted. Subsequent deterioration can make the seriousness of the initial presentation appear more obvious.

A fair review has to separate what became known later from what could reasonably have been recognized earlier.

That does not mean earlier decisions are beyond criticism. It means they should be evaluated in the clinical context in which they were made.

One of the most important causation questions is whether the patient actually had an alternative treatment opportunity.

It is not enough to identify something that theoretically could have been done. The patient must also have been an appropriate candidate for that treatment at the relevant time.

Depending on the case, that analysis may involve timing, clinical severity, neuroimaging, contraindications, comorbid conditions, available resources, need for transfer, or whether the proposed treatment was actually capable of addressing the underlying neurologic problem.

Stroke cases are a common example. An earlier diagnosis may matter if it would have changed eligibility for thrombolysis or mechanical thrombectomy. But an earlier diagnosis alone does not establish that either treatment was indicated, available, or likely to improve the eventual outcome.

The same reasoning applies more broadly in acute neurology. The existence of an alternative does not automatically establish that it was medically appropriate or, more importantly, that it would have changed the eventual course of the disease.

Neurologic outcomes are often driven by the severity of the underlying disease itself, together with the patient’s baseline health and functional status.

A large stroke, intracerebral hemorrhage, hypoxic-ischemic injury, prolonged seizure, severe infection, or spinal cord injury may result in significant neurologic disability despite appropriate medical care.

For causation analysis, Dr. Cheung considers the severity of the initial injury, the expected course of the disease, subsequent progression, available treatment opportunities, and whether the alleged deviation materially changed the eventual outcome.

In some cases, the record supports a meaningful effect from a delay or deviation in care. In others, the underlying neurologic disease and the patient’s baseline condition better explain the outcome. The medical record has to support whichever conclusion is reached.

A delay can be clinically important, but it can also exist without being causative.

The first step is usually to define the delay: when the relevant condition should reasonably have been recognized, what should have happened next, and when that action actually occurred.

The next step is more difficult: would earlier action have changed anything meaningful?

This often requires determining whether earlier treatment would have been available, whether the patient was eligible, whether disease progression had already occurred, and ultimately whether the proposed earlier treatment would likely have changed the degree of neurologic injury.

This is particularly important in time-sensitive neurologic emergencies, where a delay may affect treatment opportunities. But the presence of a delay itself does not answer the causation question.

The analysis has to link the delay to a medically substantiated change in the patient’s outcome.

Causation analysis often depends on reconstructing the sequence of neurologic events and injury.

The medical record may include preliminary pre-hospital paramedic reports, emergency documentation, serial examinations, consultant notes, nursing observations, procedure records, transfer documentation, and multiple imaging studies obtained over time.

Dr. Cheung reviews these records within their context rather than treating each piece of information separately.

Neuroimaging can be particularly useful when the question involves identification and progression of stroke, hemorrhage, edema, vascular occlusion, spinal cord injury, or another structural neurologic process.

A CT or MRI obtained later in the course may show the final extent of injury, but it does not necessarily establish exactly when that injury occurred. Serial imaging, changes in the examination, treatment timing, and the eventual clinical course may help narrow that question, but piecing together the entire record is imperative.

The strongest causation opinions are derived from agreement between the clinical timeline, examination findings, and imaging rather than from any one source by itself.

First and foremost, not every medical-legal question has a definitive medical answer.

Documentation may be incomplete. Different clinicians may describe the same presentation differently. Symptom timing may be uncertain. Imaging may establish that an injury occurred without establishing the exact moment it may have become irreversible. A proposed alternative treatment may have uncertain benefit in the specific circumstances of the patient.

Dr. Cheung distinguishes between what is documented, what can reasonably be inferred, and what cannot be established from the available record.

Where the evidence supports more than one plausible interpretation, that uncertainty should be identified rather than removed by assumption.

The goal of the review is to determine what reasonable conclusions can be supported by the medical record, not to force a particular theory onto the case.

Depending on the facts of the matter, standard-of-care and causation review may address questions such as:

• Was the patient’s neurologic condition reasonably recognizable at the time?
• Was the differential diagnosis appropriate for the presentation?
• Were additional testing, imaging, consultations, or treatments reasonably indicated?
• Was an alternative treatment available and beneficial to the patient?
• Would earlier recognition have changed treatment eligibility?
• Did any alleged delay allow neurologic injury to progress?
• Was the injury already established before the alleged deviation?
• Is the outcome better explained by the severity or natural history of the underlying disease?
• Does the neuroimaging support the proposed timeline of injury?
• Would different care likely have changed the degree of neurologic injury or disability?
• What conclusions can reasonably be supported by the medical record, and where does uncertainty remain?

The relevant questions depend on each case. Standard of care and causation cannot be assumed from the outcome alone.

Through Crux Neurology, Dr. Cheung provides:

• Early case screening and consultation
• Medical record review
• Clinical timeline reconstruction
• Neuroimaging review
• Standard-of-care review
• Neurologic causation analysis
• Review of opposing expert opinions
• Written expert opinions and reports
• Deposition testimony
• Trial testimony

Dr. Cheung accepts matters that fall within his current clinical practice and areas of expertise. Reviews are performed independently for both defense and plaintiff counsel.

Dr. Cheung is board-certified in Neurology and Vascular Neurology and practices as a neurohospitalist caring for patients with acute stroke and other hospital-based neurologic emergencies.

He serves as Stroke Medical Director at a Comprehensive Stroke Center and has more than six years of independent clinical practice.

His current work routinely involves time-sensitive neurologic decision-making, interpretation of neuroimaging, treatment eligibility, neurologic deterioration, and assessment of how acute disease progresses over time.

That clinical perspective is central to how he approaches both standard of care and neurologic causation.

Learn more about Ryan Cheung, DO →

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