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New York Methodist Hospital Brooklyn, NY 11215
Defensive medicine. That is what most of us are forced to practice in the new millennium. As pointed out by Drs. Smith and Berlin [1], this extends to radiology and, specifically, the radiology report. The Holy Grail is an accurate, intelligent, detailed-yet-terse report that is reliably delivered to the requesting physician (and sometimes the patient as well) as soon as possible. The reality is that all these laudable goals are not often achieved.
When an error is made, who is responsible? Clearly the radiologist reporting the case must meet that nebulous thing called "the standard of care" in the accuracy of his or her report.
Many problems are avoided if the report is generated immediately, possibly with the use of voice-recognition reporting, while the case being dictated is in front of the radiologist. Clearly, this makes it easy to compare the transcribed report with the actual images. This will not totally remove transcription problems, such as writing, "There is evidence of liver metastases," when the radiologist actually said, "There is no evidence of liver metastases," but at least there will be the option of immediately comparing the report with the study. Having the study and the report next to each other should significantly reduce occurrence of the all too common right-versus-left error, as well.
Virtually all working radiologists will agree that they almost never rereview studies when signing reports. Admittedly, this would benefit some patients, but the time and cost of this rereview would be immense and it is simply not done. Therefore, when the interpreting radiologist signs reports—no matter how carefully they are read—he or she will seldom be aware of, let alone correct, these kinds of transcribing errors. To expect the proxy signer to do better is absurd in the extreme.
How should the problem of left-to-right mis-speak be handled? Certainly, the interpreting radiologist should not make this error—but there is no doubt that it will sometimes be made and will seldom be picked up when the report is signed. The referring physician has an absolute responsibility to see the imaging examination before performing the surgery. In the example given in the article [1], any "urgency" in the arthoscopic surgery was far less important than getting the side right. Furthermore, didn't the surgeon have clinical signs and symptoms that indicated the side of concern?
Reviewing reports to correct syntax, spelling, or outlandishly stupid errors is important because these errors may make the radiologist look foolish, careless, or disinterested. An incomprehensible report is wrong (and, if it is common in your practice, referring doctors may decide to refer to a competitor), but such a report should rarely, if ever, result in malpractice. Who is responsible for the lack of successful communication between the radiologist and the clinician? If the report is generated and sent to the requesting doctor or service in a timely and standard manner but never received or never read, who should be responsible? It is facile to demand that the radiologist call the requesting physician or clinic with all significant findings. Who should define "significant"? Certainly, a call or calls should be made if the finding is urgent (e.g., pneumothorax), but what if the request says, "r/o [rule out] lung cancer" and the study shows a probable cancer? Are you obligated to call and make sure the requesting MD knows you found the important, but not urgent, finding he was suspecting? Must you call if the study is negative? Should the referring doctor be called if one sees a suspicious nodule? What about an area that might be a nodule? Should the referring physician be called for all requests for repeated chest films with nipple markers? Some of them? Which ones? Should the radiologist or staff spend hours every day in a vain attempt to contact the referring doctor? Have you ever tried to contact a physician in a hospital clinic, or a responsible party for a patient who has been discharged from an emergency department? Good luck.
The requesting physician has an absolute responsibility to obtain the result of each and every lab test, study, and consultation that he or she requests. This certainly includes imaging examinations and procedures. If the physician is in a clinic or an emergency department and does not have an ongoing relationship with the patient, then the clinic or hospital must shoulder this responsibility.
The radiologist must call with urgent findings, especially if they are unexpected. He or she must call with definite serendipitous findings that are clearly significant. The radiologist does not have to call about every "could be" and "might be." Nor does the radiologist have to call for every examination with negative findings, although this, too, is sometimes demanded. To call when required is laudable; to have to always call is hell.
In the example given by Drs. Smith and Berlin of the 18-month delay in diagnosing a benign neurofibroma on the chest film, who cares? Yes, it should have been seen. Yes, it may indicate a problem with the ability or diligence of the interpreting physician (or it may not). But what harm was done? What was the claim of damages?
The radiologist's responsibility is first and foremost patient care. The report is part of that care. It should be accurate and timely. However, the radiologist cannot make up for systemic problems in the rest of the medical community. Careless generation and review of the radiology report will reflect poorly on the radiologist and may result in a loss of referrals, but it will seldom equate with malpractice. The American College of Radiology and the Radiological Society of North America should devote some of their efforts to making a clear understanding of this difference part of the standard of care acknowledged by the medical—legal community. Case law must be established, and laws enacted to establish this. There are more than a million hungry lawyers out there looking to make work where none exists. The need to clearly define the radiologist's and the requesting physician's respective responsibilities in communicating with each other is not a quixotic quest. It is an essential duty.
References
Rush North Shore Medical Center Skokie, IL 60076
Dr. Lautin has written a poignant letter in response to our article [1]. I believe that he accurately reflects the befuddlement, the frustation—indeed, the exasperation—that most, if not all, radiologists feel about medical malpractice. Dr. Lautin's letter is in essence a lamentation on the great extent to which malpractice litigation has adversely affected every facet of our day-to-day professional lives, a lamentation that I suspect is shared by every reader of the AJR, including myself. Although there may be sound bases for this lamentation, certain realities must be faced.
It is of course true, as Dr. Lautin writes, that few, if any, radiologists rereview studies while signing reports. It is also true that our radiology reports sometimes contain mistakes attributable to our misspeaking into dictation equipment or to typographical errors made by a transcriptionist. Dr. Lautin correctly states that such "outlandishly stupid" errors make the radiologist look "foolish, careless, or disinterested," even though that is far from the truth. Therein lies the rub, however. In a malpractice trial, the actions of a radiologist are judged by a jury of laypersons. If a defendant radiologist looks foolish, careless, or disinterested to his or her colleagues, he or she most surely looks that way to the jurors. The truth notwithstanding, if jurors perceive that a defendant radiologist has been careless or disinterested, the jurors may well render a verdict against the radiologist, even if the objective medical facts do not support such a verdict.
Dr. Lautin expresses puzzlement about the ambiguity of the term "significant findings." He wonders whether every "could be" or "might be" diagnosis should be telephoned to the referring physician. Who should define the word "significant," Dr. Lautin rhetorically asks. The answer is, of course, the radiologist who renders the interpretation. It is the radiologist who must use his or her best judgment to determine whether a particular finding is significant. It follows that if a medical malpractice lawsuit is subsequently filed and eventually tried in court, it will be the jury's job to second-guess the defendant radiologist by determining after the fact whether the radiologist's original judgment about the significance of a particular finding did or did not amount to malpractice.
Although perhaps many radiologists would prefer that their duty end once a radiographic interpretation is dictated, such is not the case. Courts have extended the radiologist's duty to communicate far beyond rendering the written report. The courts have ruled that the communication of radiologic results to the patient is just as important as identifying the abnormal findings [2,3,4].
Dr. Lautin also questions with understandable anguish why a radiologist should be found negligent for failing to communicate a radiologic abnormality when it ought to be the responsibility of the physician who ordered the study to seek the radiology report in the first place. Although Dr. Lautin's logic appears reasonable to most radiologists, it does not appear so to the courts, which have ruled that a radiologist is responsible for his or her own negligence, even if another physician involved in the case has committed an act of equal or greater negligence [5]. A proposed revision of the current American College of Radiology (ACR) Standard for Communication: Diagnostic Radiology [6] will be considered by the council of the ACR at its annual meeting in September 2001. The revision includes a statement that the referring physician has an equal responsibility to follow up in a timely manner on results of radiographic studies he or she has ordered (Bjork SS, personal communication). Even if this revision is adopted, I do not believe it will substantively influence the opinions of the courts.
Dr. Lautin is correct in pointing out, toward the end of his letter, that the radiologist's responsibility is first and foremost patient care, and that careless generation and review of the radiology report will reflect poorly on the radiologist. Alas, Dr. Lautin is incorrect, however, in concluding that such conduct seldom equates with malpractice. In his book, Damages, Barry Werth wrote, "Almost all malpractice cases were decided not on the basis of fact but on the perception of what a jury was likely to think was fact" [7]. I suspect that with or without the assistance of the "million hungry lawyers looking for work," jurors and judges will likely continue to believe that as far as communication of radiologic findings is concerned, the ACR Standard for Communication: Diagnostic Radiology [6] accurately reflects the standard of care demanded of radiologists throughout our nation, and that failure to adhere to the standard will more likely than not constitute malpractice.
References
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  L. Berlin Using an Automated Coding and Review Process to Communicate Critical Radiologic Findings: One Way to Skin a Cat Am. J. Roentgenol., October 1, 2005; 185(4): 840 - 843. [Full Text] [PDF]
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