Authors' reply

Drs Kwan and Friel make familiar general points about the interpretation of prospective research. However, they underestimate the practical, methodological and ethical difficulties of obtaining and using medical records and of qualifying information about life events. It is also worth noting that in medico-legal practice it is very common for medical experts and lawyers to disagree about the significance of medical histories and of life events following the identified trauma.

Dr Ferrari's first paragraph over-interprets multivariate analysis dependent on statistical significance in concluding that initial anger or anger cognitions are early predictors of pain in claimants. Although there are some differences between claimants and non-claimants, our overall experience in this study, and in a previous paper which followed up claimants for 6 years, is that the two groups are very similar (Bryant et al, 1997). The research findings, together with clinical experience, indicate that litigation is one of a number of reminders of the accident which do result in subjects focusing on their aches and pains. Further accidents, continuing medical complications and persistent financial difficulties are probably other important factors acting in a similar manner.

Fourteen per cent of accident victims with no recorded injury in the emergency department had pain at 3 months which was attributed to the accident. Perhaps the most likely explanation is that these people suffered minor musculo-skeletal injuries but that the symptoms did not become significant for hours or days after the accident. This is well described in relation to whiplash neck injury. It is therefore incorrect for Dr Ferrari to use our evidence to draw conclusions about the extent to which pain reported by whiplash patients may be independent of physical injury.

I also strongly disagree with Dr Ferrari's final conclusion that patients who are not to blame but angry should be advised not to enter a claim. The financial and other losses may be considerable and compensation desirable and even necessary. The more appropriate conclusion is that medical and legal procedures should take account of the patient's reactions and beliefs, avoid increasing distress and attempt to provide a sympathetic and rapid resolution of both the medical and the legal issues.