Book Review

Whiplash and Other Useful Illnesses

N Engl J Med 2003; 348:1413-1414April 3, 2003

Article

Whiplash and Other Useful Illnesses
By Andrew Malleson. 527 pp. Montreal, McGill–Queen's University Press, 2002. $49.95. ISBN: 0-7735-2333-2

The term “whiplash” conjures up images of a violent encounter between two automobiles, spider-webbed windshields, broken bones, and twisted metal. In fact, whiplash claims are just as likely to result from low-energy “bumper thumps” as they are from more destructive collisions. Ten percent of persons who make whiplash claims report a substantial permanent disability. So how can whiplash be considered a “useful” illness? In Whiplash and Other Useful Illnesses, Andrew Malleson details the evolution of whiplash, from its innocuous beginnings in 1928, when Harold Crowe first used the term at a meeting of orthopedic surgeons to describe eight cases of neck injury, to its present medicolegal standing, which results in costs of $13 billion to $18 billion annually in the United States. Spine specialists have long known that patients with secondary gains — workers' compensation claims or lawsuits — have significantly worse outcomes than those who do not. In fact, in scientific studies designed to judge the efficacy of interventions, investigators must exclude such patients or report their results separately. Of course, such considerations are not limited to spine-related injuries. In a broad sense, Whiplash and Other Useful Illnesses is about the way in which illnesses for which patients may receive compensation are created and sustained for the benefit of a few at the expense of many.

Malleson chooses to write about whiplash, the condition he has spent the most time researching and with which he is most familiar. But his observations are applicable to a broad spectrum of manufactured medicolegal illnesses. Malleson writes with a self-admitted bias from years of working as a defense expert in legal cases involving whiplash and other illnesses for which patients may be compensated. He meticulously conveys his thesis in this thoroughly referenced and documented book. The book includes 59 pages of chapter-by-chapter notations and 56 pages of references. In a somewhat tedious manner, Malleson initially details the “junk science” that has given whiplash the status of a legitimate (and thereby compensable) illness. A psychiatrist by training, he particularly faults physicians for publishing poor scientific work in an effort to advertise themselves as experts in the field. This advertising allows them to secure an additional lucrative source of income in the face of a contracting health care market. He points out the insidious effort to legitimize the condition and discusses the interactions of medicine, lawyers, and the media that create “epidemics” by taking advantage of people's suggestible nature.

Malleson draws parallels with other illnesses that were “fashionable” in other periods, such as “railway spine” and “repetitive strain injury,” which reached nearly epidemic proportions in other countries until laws allowing compensation were rescinded. After the revocation of these laws, the ailments virtually disappeared. Whiplash claims, however, continue to multiply relentlessly, shifting vital resources and money away from where they are truly needed within the health care system to the benefit of a select few “victims,” doctors, and lawyers. Malleson faults this conspiracy for its role in perpetuating the concept of whiplash as a form of prolonged disability. He scathingly criticizes many subspecialties within medicine for jumping on the “whiplash bandwagon” and perpetuating the pretense of lasting harm in the face of what should be an innocuous event. His portrayal of physicians as driven primarily by greed and self-interest under the guise of their patients' best interests, however, appears to be unwarranted and unsubstantiated. Lawyers are singled out for attempting to enrich themselves by means of the “whiplash lottery” and simultaneously allowing their clients to become professional patients who will not ultimately be cured by the verdict. Furthermore, lawyers continually fight to maintain the current adversarial system, which wastes valuable legal and health care resources. Malleson believes that many patients use whiplash as a convenient diagnosis to mask preexisting depression. It is socially more acceptable to be the victim of another person than to admit to being depressed, since depression comes from within. In this manner, an accident can be viewed as a reputable and rewarding escape from a difficult situation. Finally, Malleson faults insurance companies for not doing enough to combat fraudulent claims, instead using the losses incurred to justify further rate increases for all customers.

Malleson's writing style is somewhat dry, and the individual chapters do not seem to flow into one another, making the reading slow and the book difficult to pick up at times. Nonetheless, his thesis is credible and well substantiated. He provides the perspective of someone who has spent many years of practice inside a medicolegal system that he feels is fundamentally flawed and in need of immediate reform. With the health care system in crisis, we can no longer afford expensive, ineffective therapies that are often used only to meet an arbitrary minimal monetary threshold for bringing suit or demonstrating long-term disability. Malleson's repeated call for randomized clinical trials to substantiate the efficacy of medical interventions is shared by most in the field of medicine. Whiplash and Other Useful Illnesses isfor anyone involved with persons seeking care or compensation for illness.

Brian Grottkau, M.D.
Massachusetts General Hospital, Boston, MA 02114
bgrottkau@partners.org