Direct exam of a treating physician


Outlines serve a purpose.  They just shouldn't be relied upon to the exclusion of the rest of what is going on in a courtroom.

This general outline has been in my repertoire for 20 years.  My former boss, Tom Chambers, developed it.  I have barely changed it.  I use it as a reminder.  As a guide.  Not as a script.

Sample.  Outline direct examination treating health care provider (mix and match order)


  • Name
  • Address
  • Occupation
  • CV

First visit

  • Date
  • What is your understanding of treatment  plaintiff received following the incident and before s/he saw you
    • Did you perform an exam
    • What were significant findings
    • Initial diagnosis
    • Definition injury
    • History of incident
    • Developme nt of pain/disability

Course of care

  • Reasonable
  • Necessary
  • Improve with care
  • When was last appointment

Mechanics of injury and causation

  • How did the incident cause injury
  • After trauma can injury cause:
    • Physical limitations
    • Degenerative changes
    • Susceptibility to future problems in area
    • After last appointment what was prognosis in terms of reasonable medical probability
    • Reasonable to expect plaintiff would suffer continuing symptoms requiring continuing treatment to this day on a more probable than not basis from acc.

Pre-existing condition

  • If plaintiff had previously injured ____, but had not had medical care or symptoms for almost __ yrs before the incident, would it be fair to say that the injuries were caused by the incident

Medical expenses

  • Are you familiar with the costs of health care in this community
  • Show bills:  Have you had a previous opportunity to review the medical expenses.
  • Were the health care services provided to plaintiff reasonable
  • Were they necessary
  • Were the health care bills charged for those services reasonable and customary in the medical community
  • In terms of reasonable medical probably, do you have an opinion as to whether or not the medical conditions and symptoms of plaintiff which you have testified about today were caused by the incident?
  • Wage loss
    • I’d like you to assume that immediately following this incident, plaintiff missed work for ____ (or was unable to return to work).
    • Would you have an opinion as to whether or not the time off work (or inability to return to work) that I just described is a reasonable period of convalescence for plaintiff as a result of the incident.
  • Future losses
    • Can you detail the future medical care that plaintiff will require?
    • What is the cost of that care?
    • Can you describe future limitations of plaintiff
      • Daily life activities
      • Need for care or assistance
      • Recreational
      • Work
      • Emotional and interpersonal
    • Have you met with NAME, vocational counselor/life care planner
    • Did you provide information to that individual to assist in creation of a life care plan
    • Did you review the completed report – do you agree with the medical portions of that report
    • Future medical risk factors or complications
    • Loss of life expectancy

Final opinion re causation

In terms of reasonable medical probability, do you have an opinion as to whether or not the plaintiff's medical conditions and symptoms were caused by the incident of DATE?