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Relying on the Radiologist

¹ Department of Radiology, Rush North Shore Medical Center, 9600 Gross Point Rd., Skokie, IL 60076, and Rush Medical College, Chicago, IL 60612.

Received December 10, 2001; accepted after revision December 10, 2001.

 
Case summaries are based on actual events and lawsuits, although certain facts have been omitted or modified by the author, who has supplied and obtained authorization for the reproduction of the radiologic images. All opinions expressed herein are those of the author and do not necessarily reflect those of the American Journal of Roentgenology or the American Roentgen Ray Society.

Address correspondence to L. Berlin.

The Case

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A 58-year-old woman was admitted to a hospital because of abdominal pain and a palpable tender mass in the lower abdomen. Sonographic examination was interpreted by the radiologist as disclosing a pelvic mass, suggestive of either an abscess or ovarian tumor, and CT was recommended for further evaluation. A CT scan obtained the next day was interpreted by another member of the hospital's radiology group as disclosing a large, complex fluid collection in the pelvis, probably representing a large multiloculated abscess. The radiologist also noted a cyst in the lateral aspect of the right kidney as well as a "rounded low-density area in the anterior aspect of the right kidney" (Figs. 1A and 1B). The radiologist concluded that the latter finding "may be a hemorrhagic cyst which should be further followed up with a sonogram of the kidneys" and added that "a solid lesion in the kidneys is not seen."

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —58-year-old woman with abdominal pain and palpable mass in lower abdomen. In addition to pelvic CT, which disclosed abscess, abdominal CT was performed. Radiologist noted cyst on lateral aspect of right kidney (A) and "rounded low-density area on anterior aspect of right kidney [B] that may be a hemorrhagic cyst and should be further followed up with sonogram."

View larger version (127K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —58-year-old woman with abdominal pain and palpable mass in lower abdomen. In addition to pelvic CT, which disclosed abscess, abdominal CT was performed. Radiologist noted cyst on lateral aspect of right kidney (A) and "rounded low-density area on anterior aspect of right kidney [B] that may be a hemorrhagic cyst and should be further followed up with sonogram."

Soon thereafter, the patient was taken to the operating room, where she was found to have a perforated appendix with a multiloculated abscess. After a short postoperative stay in the hospital during which she received antibiotic therapy, the patient was discharged in excellent condition.

Approximately 3 years 6 months later, the patient visited her family physician because of complaints of "fullness" in the abdomen, hematuria, and weight loss. CT now revealed a large tumor involving the right kidney consistent with renal cell carcinoma (Fig. 1C). Despite undergoing surgery for removal of the tumor and receiving postoperative chemotherapy, the patient died 7 months later.

View larger version (127K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C. —58-year-old woman with abdominal pain and palpable mass in lower abdomen. In addition to pelvic CT, which disclosed abscess, abdominal CT was performed. CT scan obtained 42 months after A and B shows large renal cell carcinoma.

The family of the deceased patient filed a medical malpractice lawsuit against the patient's family physician and surgeon, as well as the radiologist who had interpreted the initial CT scans, claiming that the negligence of these clinicians led to a delay in the diagnosis of the renal cell carcinoma, thus depriving the patient of the opportunity for early treatment and cure.

Medical—Legal Aspects

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Legal discovery proceedings unfolded with the deposition of an expert radiologist retained by the attorney for the plaintiff. The expert was highly critical of the defendant radiologist's interpretation of the CT findings pertaining to the patient's right kidney. Although the expert agreed that the lateral kidney lesion likely represented a cyst, he contended that the more ventral lesion was heterogeneous with an apparent solid rim of tissue and central necrosis, findings that were "almost surely indicative of neoplasm." The expert also took issue with the defendant radiologist's characterization of the lesion as a "hemorrhagic cyst," which he believed would be highly unlikely.

The expert further asserted that the defendant radiologist's statement in his dictation that "a solid lesion in the kidneys is not seen" misled the referring physician into believing that the CT findings excluded the possibility of a renal neoplasm. Finally, the plaintiff's expert charged that recommending clinical follow-up for a solid renal mass is "meaningless," because "once a solid renal mass is discovered by CT, the next step is almost always surgical excision."

In their depositions, both the patient's attending physician and surgeon testified that they focused their attention mainly on treating the patient's appendiceal abscess and "getting her on the road to recovery as quickly as possible." They acknowledged that they read the radiologist's report about the CT examination, but they claimed that they were lulled into believing that the findings relative to the kidney were not particularly significant. When asked specifically if they would have quickly followed up on the kidney abnormalities if the radiologist had stated in his report that the kidney lesion was suspicious for renal cell carcinoma, the two physicians gave strongly affirmative answers. Both physicians were adamant in their respective depositions that they "totally relied" on the radiologist's report because they did not consider themselves "experts in radiographic interpretation."

A radiology expert retained by the defense attorney supported the defendant radiologist's report. The expert pointed out that even though the report "was not totally accurate," the defendant radiologist did call attention to a lesion of the kidney, emphasizing that the report stated that the lesion may be a cyst but "should be clinically evaluated and further followed up with a sonogram of the kidneys." The expert also said that he did not find anything incorrect or misleading in the defendant radiologist's statement that "a solid lesion in the kidneys is not seen" because the lesion did contain mixed components. "Looking at the essence of the report as a whole," contended the defense expert, "the defendant radiologist met the standard of care."

It was the consensus of the attorneys representing the three physicians and the claims manager of the insurance company that insured them that the likelihood of prevailing in a malpractice trial was extremely poor. After considerable negotiation, the lawsuit was settled. The exact amount of the settlement was not disclosed publicly, but the figure was understood to be approximately $2 million, with 70% of the legal liability and payment allocated to the radiologist.

Discussion

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Previous articles have emphasized to radiologists the importance of constructing radiology reports in a manner that conveys meaningful information to ordering physicians [1, 2]. Various commentators have urged radiologists to avoid reports that "describe in detail all that the roentgenologist sees in the film but does not tell what he thinks about it, what conclusions he draws from it, and what it means to him" [3]; reports that contain "a rambling description of findings without a reasonable conclusion" [4]; and reports that are written in "soporific language that lulls referring physicians into inaction and lethargy" [5]. Without question, both the radiology and nonradiology medical communities overwhelmingly agree that radiologists must communicate radiologic findings in an accurate, precise, succinct, and unambiguous fashion.

In the case presented in this article, a radiology report dealing with abdominal CT became the issue around which a malpractice lawsuit of substance was filed. In this particular case, attention was focused not so much on the accuracy of the report, but rather on the ordering physician's reliance on the report. Let us examine more closely how the nature and degree of an ordering physician's reliance on the radiologist impact medical malpractice litigation.

A recent survey of clinicians conducted by a group of Canadian radiologists found that 95% of clinicians wanted radiology reports to include the radiologist's recommendations for further studies [6]. In another Canadian survey of referring physicians [7], researchers reported somewhat different results. More than half of general practitioners wanted radiology reports to include radiologists' recommendations for additional studies, but this ratio decreased to one third for internists and surgeons. General practitioners also liked reading long differential diagnoses in radiology reports, in contrast to surgeons who "appreciated brevity with telegraphic style."

The findings of a survey of referring physicians conducted in the United States by Gunderman et al. [8] also indicated less-than-enthusiastic support for radiologists' recommendations:

Many referring physicians value the radiologist as a lesion detector more than as a lesion interpreter. They want radiologists to tell them what they see and trust in their own abilities to determine what it means. Another explanation for the relatively low rating of the radiologist's recommendations would be that some referring physicians actively dislike them, because they feel that radiologists recommend too many additional imaging studies that are not really indicated, yet must be performed for medicolegal reasons, once mentioned in the radiology report.

Gunderman et al. [8] also observed differences in attitudes toward radiology reports among generalists and specialists. According to these researchers, specialists, notably orthopedic surgeons and neurosurgeons, "are more likely than generalists both to view diagnostic images themselves and to feel comfortable interpreting the images themselves."

Although some radiologists believe that radiologists should virtually never include in their reports recommendations regarding additional imaging studies [9], others disagree. Kessler [10], for example, stated that to

...withhold recommendations for additional studies raises the question of whether we are avoiding our responsibility to the referring physician and the patient.... Recommendations for further examination should be included in the report.

The revision of the American College of Radiology's Standard for Communication: Diagnostic Radiology, which became effective January 1, 2002, states that "Follow-up or additional diagnostic studies to clarify or confirm the impression should be suggested when appropriate" [11]. Because the words "when appropriate" are not specifically defined, individual radiologists must use their best judgment to evaluate what these words mean.

Notwithstanding the responses given in surveys by certain physicians, particularly specialists, who express little desire to have radiologists include in their reports recommendations for additional studies, the opinions of these same physicians often change suddenly when they are named as defendants in a medical malpractice lawsuit. Attitudes of referring physicians regarding the desirability of having radiologists include recommendations in their reports may be quite different in the legal arena than in isolated clinical situations. In the legal environment, the defendant nonradiologist physician may claim that he or she relied heavily on the radiology report and the radiologist's interpretations because the degree of reliance on the radiologist may be a major determinant when the courts assess the comparative liability of various medical codefendants.

As has been explained previously [12], including as many codefendants as possible in a malpractice lawsuit is a common strategy among plaintiff's attorneys, because this strategy maximizes funds available in the event the lawsuit succeeds for the plaintiff. At the same time, individual malpractice insurance companies do not want their physician insureds to be determined the only culpable parties because the company would then be responsible for the full amount of a plaintiff's damage award. The companies and their respective defense attorneys therefore sometimes encourage their defendants to point fingers at each other at trial. Under this strategy, the defendant radiologist who under different circumstances might be found not guilty of wrongdoing may instead find blame shifted to him- or herself, thus causing the radiologist to be the "deep pocket" who provides the bulk of the indemnification to the patient. It is thus easy to understand why clinicians who in a clinical setting rely on their own radiologic expertise, rather than that of the radiologist, may in the medical—legal setting claim that they relied solely on the radiologist's opinion.

The degree of apparent reliance of the clinician on the radiologist may be carefully evaluated by the courts. An example of a court's reasoning about this issue can be seen in an Illinois case in which the family of a male patient who died during a coronary angioplasty sued the family cardiologist; the interventional cardiologist, who had recommended the angioplasty after reviewing the cardiac angiograms that had been obtained elsewhere; and the interventional cardiologist, who had performed the angioplasty [13].

The defendant interventional cardiologist who had recommended the treatment asked to be dismissed from the lawsuit, claiming that he had never participated in administering medical care to the deceased patient and had only given an "informal opinion" to the patient's other two cardiologists who, in his opinion, should bear all the liability. The Illinois court refused to dismiss the "recommending" interventional cardiologist, however, and ruled that the cardiologist knew or should have known that the family cardiologist would rely on his opinion because he possessed the expertise in cardiology to determine the need for angioplasty. The Illinois court explained that the family cardiologist could not be held responsible for determining whether angioplasty was indicated because he did not possess the superior and unique knowledge possessed by the recommending interventional cardiologist.

In the eyes of the Illinois court, the degree of reliance that the family cardiologist placed on the recommending interventional cardiologist determined against whom the liability would be assessed. This kind of reasoning may have been operating with regard to the radiologist and nonradiologist physicians in the case presented in this article. Juries and judges may delve into the nature of the radiographic findings and the degree to which the referring physician relied on the radiologist's superior knowledge. The key question in such cases is likely to be whether the radiographic findings are easily discernible to the requesting physician or can be detected and interpreted only by a highly skilled radiologist. If the radiologist is judged to be the person who possesses the required radiologic expertise, then the radiologist will bear all or most of any indemnification awarded to the injured patient.

Radiologists should again be reminded that if delays in diagnosis and treatment result from lackadaisical, if not substandard, conduct on the part of the referring physicians, the law nevertheless will hold the radiologists responsible for lapses in their conduct, irrespective of any liability that may be imposed on nonradiologist physicians [14]. Some radiologists may feel comforted by the current revision of the ACR Standard for Communication: Diagnostic Radiology, which became effective January 1, 2002, that includes for the first time the following statement [11]:

It should be noted that the referring physician or health care provider also shares in the responsibility of obtaining results of imaging studies they have ordered.

Any expectations that this new phraseology in the ACR Standard for Communication: Diagnostic Radiology [11] will relieve radiologists of the legal responsibility of communicating to referring physicians accurate and meaningful written—and, at times, oral—reports of radiologic findings may not be realistic, however. The fact remains that in any medical malpractice lawsuit that includes an allegation of negligence on the part of the radiologist, it would be extremely difficult to dispute claims by referring physicians that they relied on the radiologist to give them prompt and correct reports and that any faulty management decision they committed was caused by the radiologist's faulty reporting. It seems highly unlikely that a court would absolve a radiologist's negligent conduct, even though other physicians may have committed intervening acts of negligence.

Summary and Risk Management

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Despite occasional protestations or claims in surveys to the contrary, there seems to be little doubt that referring physicians rely heavily on the opinions of and reports rendered by radiologists. There is even less doubt that the courts will consider the degree of this reliance as a major determinant in apportioning comparative liability among multiple physician codefendants that include a radiologist. As a result, the need for radiologists to communicate their radiologic interpretations in a meaningful and effective manner is even greater today than ever. As Gunderman et al. [8] have pointed out, radiologists may be the world's greatest lesion detectors or possess the most encyclopedic knowledge base of differential diagnoses, but if they are poor or tardy in communicating their thoughts to referring physicians, the value of their input may be minimal and their inadequacy may precipitate a malpractice lawsuit.

Risk management in radiology can lessen the likelihood of incurring a medical malpractice lawsuit involving the rendering of a radiology report; maximize the chance for a successful defense if such a suit is filed; and, at the same time, enhance patient care.

The following risk management pointers will help radiologists meet all three of these objectives:

• Radiologists should attempt to convey interpretations of radiologic studies in a clear, unambiguous, meaningful, and concise manner.
  
• Radiologists should strive to initiate processes that improve the capabilities of referring physicians to receive reports and access images in a timely manner from radiologic studies that they have ordered. In this new digital era, paperless electronic reporting may provide the means by which more efficient communication can be effected [6, 15].
  
• Radiologists should avoid using phrases such as "if clinically indicated" when assessing an abnormal finding, especially if the finding is incidental or the patient is asymptomatic. Because of their training and experience, radiologists are expected to possess greater skill and knowledge than physicians who are not radiologists in the observation and interpretation of radiologic studies. Thus, the radiologists are better positioned than nonradiologists to evaluate the potential importance of an abnormality shown on imaging.
  
• Even though certain referring physicians, typically specialists, frequently believe that they can interpret radiographic studies independently and may pay little heed to radiology reports, radiologists should not delude themselves into believing that reports directed to these physicians should be any less cogent or meaningful than those prepared for other physicians.
  
• Radiologists should carefully adhere to the ACR Standard for Communication: Diagnostic Radiology [11] that calls for the inclusion in radiology reports of a "precise diagnosis...whenever possible," "a differential diagnosis...when appropriate," and suggestions for "follow-up or additional diagnostic studies...when appropriate."
  

References

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1. Berlin L. Radiology reports. AJR 1997;169:943 -946[Free Full Text]
2. Berlin L. Pitfalls of the vague radiology report. AJR 2000;174:1511 -1518[Free Full Text]
3. Enfield CD. The scope of the roentgenologist's report. JAMA 1923;80:999 -1001
4. Spira R. Clinician, reveal thyself. Appl Radiol 1996;25(11):5 -8, 13
5. Goldsmith SJ. If clinically indicated. J Nucl Med 1996;37:3A
6. Naik SS, Hanbidge A, Wilson SR. Radiology reports: examining radiologist and clinician preferences regarding style and content. AJR 2001;176:591 -598[Abstract/Free Full Text]
7. Lafortune M, Breton G, Baudouin JL. The radiological report: what is useful for the referring physician? Can Assoc Radiol J 1998;39:140 -143
8. Gunderman R, Ambrosius WT, Cohen M. Radiology reporting in an academic children's hospital: what referring physicians think. Pediatr Radiol 2000;30:307 -314[Medline]
9. Lawson DE, Siegel SC. A recommendation on recommendations. AJR 1997;169:351 -352[Free Full Text]
10. Kessler HB. The contemporary radiologist: consultant or film reader? AJR 1997;169:353 -354[Free Full Text]
11. American College of Radiology. ACR standard for communication: diagnostic radiology. In: Standards, 2000-2001. Reston, VA: American College of Radiology, 2001:3 -5
12. Berlin L. The deep pocket. AJR 2000;175:1243 -1247[Free Full Text]
13. Bovara v St. Francis Hospital, 700 NE2d 143 (Ill App 1998)
14. Reed v Weber, 615 NE2d 253 (Ohio App 1992)
15. Rogers LF. Information transfer: radiology reports. (editorial) AJR 2001;176:573[Free Full Text]

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This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Berlin, L. Search for Related Content PubMed PubMed Citation Articles by Berlin, L. Social Bookmarking                      What's this?