The Best Medical Legal Exhibits: Medical Legal Illustration, Personal Injury Illustration & Medical Malpractice Illustration

"I have become a believer in using medical illustrations as part of presenting my case to a jury." -Jack H. Simmons, Personal Injury and Medical Malpractice Attorney

Leg Injuries Personal Injury Medical Legal Illustration

The Purpose of a Medical Legal Illustration

While a blackboard or a whiteboard may be used in the courtroom to draw specific details of a medical case, whenever size, shape, location, placement, distance, or other medical or anatomical details must be precisely reflected, a prepared medical legal illustration will be necessary.

A medical legal illustration is demonstrative evidence designed to help a layperson or anyone unfamiliar with a case to understand complicated medical and scientific information. Unlike generic or stock illustrations, which are often complex and designed for medical audiences, medical legal illustrations are

Specific and customized to a particular case
Reduce into one or a few exhibits the specific information from many interrelated X-rays, hospital records, scans, surgical notes, photographs, models, or mortality tables
to a few selected key points
Serve as guides to support medical experts in expressing complex information in a straightforward explanation
Focused to inform the jury as well as the judge to give understanding, to a greater extent, the pain and suffering of a client, loss of income, shortened life expectancy, or body injury.

"In the majority of personal injury trials demonstrative evidence represents an essential part of the case. Such evidence, when used effectively, is an invaluable aid to clarify the issues during the course of the trial." -Paul N. Luvera Jr. "DEMONSTRATIVE EVIDENCE PROBLEMS IN A PERSONAL INJURY CASE"

Chest Injuries Personal Injury Medical Legal Illustration

Background Medical Legal Illustration

Medical Illustration students are introduced to the strategy of medical legal illustration for medical legal, personal injury, and medical malpractice cases fairly early in their medical visual coursework. Instruction includes expert guidance from experienced instructors, as well as visits with attorneys with experience in using demonstrative trial exhibits and with hiring medical legal illustrators.

Medical Illustrators are trained for several years, usually enrolled along side the medical students. Their artistic training is derived from prior exposure to their graduate degree in medical visualization, and it is during the period of learning incorporated with the highly detailed approach required for medical illustration and animation. Professionally, medical terminology and medical visualization are their daily purpose.

The same is not true for attorneys. Anatomy courses are not a typical component of legal training, and the skill is acquired on the job for those specializing in medical legal, medical malpractice, or personal injury law.

Medical Legal Illustration: Arm Injuries

"Most trial lawyers believe that illustrations explaining oral testimony are essential for a complete understanding of the facts of a personal injury case." -Paul N. Luvera Jr. "DEMONSTRATIVE EVIDENCE PROBLEMS IN A PERSONAL INJURY CASE"

Brief History of Demonstrative Evidence in Court

Medical illustrations in the courtroom are defined as “demonstrative evidence”. Demonstrative evidence are objects, pictures, models, or other devices intended to clarify facts for a judge and a jury. This includes for example, depictions medical conditions, damages, how an alleged crime was carried out, how an accident occurred, and surgical approaches. Typically medical evidence is presented in the form of photographs, x-rays, medical CT or MRI scans, videos, audio recordings, simulations, animations, drawings, and maps.

According to Wikipedia, widespread use of medical and demonstrative evidence in U.S. courts did not begin until the 1960s. Before this time in history, medical evidence was submitted as “substantial evidence”. This was a time when scientific evidence was accumulating a greater level of understanding by and respect from the general public. The history of scientific evidence in court as a respectable source of information has a fascinating history, covered by Debra Blum in “The Poisoner’s Handbook.” Before this time, attorneys had only the use of testimonial and substantive evidence.

Admissibility of demonstrative models and illustrations rests at the discretion of the trial court. To be admissible, demonstrative exhibits must “fairly and accurately represent the real object at the relevant time” (Federal Rules of Evidence 901, 902, and 1001-1004).

While the use of medical illustrations is widespread and historically a standard practice, precedents have been set to guide the decision making. Determination of their admissibility rests within the discretion of the trial court. A particular court case is often referred to as a way of setting the standard for admitting demonstrative evidence:

“Courts should approach the admission of models, samples and things offered exclusively for illustrative purposes with wariness and circumspection, to the end that fact be not confused with fancy and artistic interpretations push aside and take over the role of truth unadorned. A ruling designed to allow the admission of a model house in evidence should guardedly preclude an air castle, even though the two may have cogent similarities. Thus, models, samples and objects offered in evidence for purely illustrative purposes must not only be relevant and material in character to the ultimate fact sought to be demonstrated by their use, but, additionally, must be supported by proof showing such evidence to be substantially like the real thing and substantially similar in operation and function to the object or contrivance in issue. If the proffered evidence does not meet this test it should be rejected.” – State v. Gray. 64 Wn.2d 979 (1964). 395 P.2d 490. The Supreme Court of the State of Washington, Respondent, v. HENRY LEROY GRAY, Appellant. No. 37137. September 24, 1964. (See the actual case document here for more information.)

In reviewing this precedent, Paul N. Luvera suggests that this strict requirement would be more relaxed in civil cases than suggested above for a federal case.

A commentary in McCormick on Evidence states that, while a trial judge holds ultimate discretionary power as a way of preventing abuse, “So useful in giving clarity and interest to the spoken statement that no special control over their admission is needed beyond the requirement for all testimony that it be relevant. (from Richard Touby, MCCORMICK ON EVIDENCE. By Professor Charles T. McCormick. Indianapolis: Bobbs-Merrill Co., 1954., 9 U. Miami L. Rev. 500. 1955)

Leg Injuries Personal Injury Medical Legal Illustration

Demonstrative Evidence Versus Substantial Evidence

A practical and simplified guide for submitting demonstrative evidence, such as a medical legal illustration, would be these simple 3 questions, as offered in the Gonzaga Law Review, March 1967:

Does the illustration assist the jury in understanding the case?
Does the illustration assist the witness in explaining the testimony?
Is the illustration “substantially like” the thing sought to be illustrated?

After a medical illustration has been created with these intents, it must be formally presented as demonstrative evidence by its proponent. With this approach, the evidence admitted into the official record of the case. The proponent will first ask for the evidence to be marked by the court for identification purposes. If it is not presented in this way, the evidence can only be used as a prop, as “substantial evidence”. Substantial evidence is defined as “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion“, and it is not taken as seriously in court.

Personal Injury Illustration Panel

After the evidence is marked for identification, the proponent of the demonstrative evidence must “lay a foundation”. To lay a foundation, the proponent will ask the judge or court commissioner to move the exhibit into the court record, where it is designated as a “full exhibit”. The proponent of the demonstrative evidence is not obliged to, but will typically show any demonstrative evidence to the opposing party before marking it for identification purposes. If it is a criminal case, the proponent is obliged, by law, to disclose all demonstrative evidence under the rules governing discovery (Brady v. Maryland).

If the evidence is admitted as a full exhibit, this allows the jury and court members to examine and refer to the evidence throughout the deliberation process. Demonstrative evidence like medical illustrations may be challenged for its relevance. Luvera suggested that a test of validity in a courtroom situation can be expressed very simply when demonstrative evidence is produced. I provide here a typical example of a test in-court:

Proponent: Doctor, I have produced what has been marked as defendant’s “Exhibit No. 1”. Please tell me what this figure represents.

Medical Expert: This is a drawing of the surgical procedure used to remove obstructed bowel.

Proponent: Is this figure reasonably accurate from an anatomical perspective?

Medical Expert: Yes.

Proponent: Does it specifically reflect the surgery performed on the plaintiff?

Medical Expert: Yes.

Proponent: Will this drawing aid you in explaining your testimony?

Medical Expert: Yes.

Proponent: Your honor, plaintiff offers into evidence plaintiff’s “Exhibit No. 1” for illustrative purposes only.

If the evidence is not marked as a full exhibit, the jury cannot refer to the exhibit during deliberation and the evidence is seen as only substantial evidence. It cannot be referred to during the deliberative process.

Overview Injuries Personal Injury Medical Legal Illustration

Why use Visual Information instead of Verbal or Written Information to Educate a Jury?

There is a growing body of evidence over the past 60 years, revealing the importance of visually presented information as a powerful learning tool. Briefly stated, a few major points:

Research has revealed that attorneys are inclined to be auditory or verbal learners. However, 2/3rds of their juror pool, the general public, are visual learners. For an extensive list of studies to support the importance of visual evidence in revealing information to jurors, read this.
Visual aids assist in the storytelling of a case, which forms the primary thread in a juror’s comprehension of case details.
Visual aids hold the jury’s interest, which increases comprehension.

Planning Ahead

Set goals for what the legal illustration is to accomplish
Use the illustration as a part of the story you will tell, and also a road map for the case.
Explain to the jury what the illustration is intended to show. And then, after presenting the illustration, summarize what the illustration has shown.
While illustrators are taught to prepare illustrations in a neutral way, anticipate, if relevant, any negative reactions to the medical details from jurors, and address them during the verbal presentation.
Again, while the illustrator is trained to prepare the illustration as simply as possible, plan for the illustration to be simple and direct to the point.
Practice the presentation and prepare the technology so there are no glitches which keep the jury and judge waiting

Overview Injuries Personal Injury Medical Legal Illustration

Steps Involved in Preparing a Medical Legal Illustrations

Preparing medical legal illustrations, whether to be used in a courtroom situation or in outside negotiations, is a fairly complex process. But the steps are fairly similar in each case, and follow this general arrangement:

The illustration process begins once a tentative deadline is established. If the illustrator is expected to review evidence, allow sufficient time for preparation of first sketches.
Together the illustrator and attorney agree how many illustration panels might be expected.
The attorney sends the medical illustrator relevant medical records to the medical illustrator, either digitally or by mail. These include emergency room reports, clinical notes, radiological reports, surgical reports, x-rays, and follow-up records.
The medical illustrator makes suggestions for exhibits: how many panels and what content each will hold. Suggestions will be offered so that each panel entirely reveals one injury or one aspect of the case. If there are several injuries in different regions of the body, an overview illustration may be recommended.
The attorney reviews these suggestions, offers personal perspective, and a discussion of the details will finalize the concepts to be demonstrated in each panel.
The finalized proposal is sent to the attorney including the suggested illustrations and cost.

Fetal Circulation Medical Legal Illustration

The attorney signs the proposal, including an agreed-upon portion of payment so that the illustration process may begin.
Medimagery prepares preliminary sketches for the attorney. The medical illustrator consults with the treating physician or other experts, as necessary. Within the timeframe allowed, physicians and other experts may be requested to offer approval of sketch materials.
The medical illustrator forwards sketches to the attorney for initial approval. After receiving the preliminary sketches, the attorney and any consultants will review the sketches and make any necessary corrections.
The experts return the sketches signed with an approval or with any corrections indicated. A sketch revision may be necessary and will be sent for approval. If signed and approved the sketches from both the attorney and the experts have not been returned by the deadline, the attorney will be notified. The attorney will decide whether Medimagery completes the medical legal exhibit/s. Approval is necessary before proceeding.
Once authorization is received for the sketches, the final medical exhibit/s are completed, labeled with any pertinent medical terminology and delivered by print in the form agreed-upon. All changes must be made during the sketch phase. Any changes made after the sketches are approved will be charged at an additional rate.
After delivery of the medical-legal exhibits, a bill is sent for the final costs and shipping. The process is complete.

Infant Medical Legal Illustration

Medical legal illustrations or models, used as demonstrative evidence in the courtroom, are now a mainstay in medical malpractice cases, personal injury cases, and certain criminal cases. If you have any questions or anything to add to this material, please write to me. I would be grateful for the feedback.