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Oshkosh, WI 54902
As vice-chairman of guidelines and standards for the American College of Radiology (ACR), I read Dr. Berlin's article [1] with particular interest.
Since the article was accepted for publication, there have been significant changes to the ACR Standards that Dr. Berlin mentioned were under consideration at that time. Specifically, the Standards were renamed ACR Practice Guidelines and Technical Standards at the annual meeting of the ACR Council in May 2003. Most of the documents, including the Standard for Communication: Diagnostic Radiology that was discussed in this article, are now classified as Practice Guidelines. Perhaps more important, a new preamble that accompanies each practice guideline and technical standard will replace the old disclaimer referenced by Berlin. As discussed by Berlin, guidelines and standards may act as a "sword" or a "shield" in a malpractice case. The intent of these changes to the former ACR standards is to clarify their purpose and use and therefore to blunt the sword without excessively weakening the shield.
In addition, a new ACR Task Force on Reporting in Diagnostic Radiology is now at work specifically to review the Practice Guideline for Communication: Diagnostic Radiology. Berlin's article [1] shows some of the significant issues with this practice guideline and will be helpful to this task force in its deliberations. The sections of the guideline that discuss direct communication are a small part of the entire document but are also the most important to litigation and by far the most contentious. A major on-going question is whether this portion of the guideline should reflect purely legal precedent or whether the ACR can or should put forth a possibly contradictory opinion that might be more desirable to radiologists. Indeed, as Berlin notes, "Long before the ACR adopted the Standard for Communication, the courts had taken the position that radiologists have a duty to directly communicate significant radiologic abnormalities to referring physicians." Perhaps the primary internal purpose of this practice guideline is to inform radiologists of what the courts expect of them. However, does restatement by the ACR of the principles defined by the courts lend them additional credence in legal proceedings, perhaps to the detriment of radiologists? Hopefully, the Task Force on Reporting can answer some of these questions.
From a personal standpoint, I find the cases discussed by Berlin disturbing. It is easy to blame an organization such as the ACR and a program such as its practice guidelines and technical standards for some of the malpractice issues that face radiologists. Leaders and members of the ACR must strive to act in the best interest of all radiologists, but programs such as the practice guidelines and technical standards must primarily benefit patients and society as a whole. The ACR cannot produce self-serving documents that will not be respected by others. In the three cases discussed by Berlin, he states, "it appears that the actual wording of the standard did not substantially favor one side over the other." Despite this, "the respective attorneys and insurance claims managers obviously placed more credence in the spin of the plaintiff's experts," and all three cases were settled. Of course, we are not told the full details of the cases, and there could be other reasons to settle in any individual case. However, I am concerned that the greatest expansion of the expectation that the radiologist will directly communicate findings comes not from the ACR Practice Guideline on Communication but from individual radiologists, their attorneys, and their insurers who settle questionable cases even when, as in one of the cases cited, "the defendant radiologist was advised by his attorney that he could offer a reasonable defense at trial." Although such settlements do not set a legal precedent in the manner of an appeals court decision, they certainly send a message to plaintiff's attorneys that the issue of communication may be fertile grounds for a lawsuit even when there is no error in interpretation. It is certainly stressful and time-consuming to endure a malpractice suit. However, as individual radiologists, perhaps the greatest contribution we could make to push the pendulum back to a central position is to stand up and fight these allegations when they are questionable or unfounded.
References
Rush North Shore Medical Center Skokie, IL 60076
As Dr. Larson has correctly observed, my article [1], although published in the AJR 3 months after the 2003 annual meeting of the American College of Radiology (ACR), had been submitted to and accepted for publication by the AJR editor 2 months before the meeting. After Dr. Larson wrote his letter but before its publication and this response, a subsequent article dealing with the subject of ACR guidelines and standards [2] was published in the AJR.
That the ACR leadership has addressed and continues to address concerns raised by ACR members regarding ACR standards, particularly as they relate to medical malpractice litigation, is laudable. Indeed, the ACR Council's overwhelming endorsement of the leadership's recommendation that ACR Standards be renamed ACR Practice Guidelines and Technical Standards was so enthusiastic that the speaker delivering of the recommendation was met with a standing ovation by ACR councillors attending the 2003 annual meeting.
ACR members should welcome with equal enthusiasm the appointment by the ACR leadership of the new Task Force on Reporting in Diagnostic Radiology.
As pointed out by Larson, the ACR standard— or, as it is now called, Practice Guideline: Communication in Diagnostic Radiology—particularly as it relates to direct communication of significant abnormalities by radiologists to referring physicians, is quite important in malpractice litigation and therefore extremely contentious. Larson has clearly identified the issues: should the ACR practice guideline heartily endorse or attempt to curb previously published appeals court pronouncements regarding duties of radiologists to communicate radiologic abnormalities? An even more basic issue that must be addressed is the question of whether a legal standard of radiologic care should have its genesis in the courts— or in careful deliberations by the radiology profession itself. The task force will have to wrestle with these very complex issues; to be sure, resolution acceptable to all will not be easily achieved.
I agree with Larson that the apparent recent expansion of the expectation that the radiologist will directly communicate findings comes not from the ACR Practice Guidelines themselves but rather from individual radiologists who act as expert witnesses. In other words, it is not so much the use of ACR Practice Guidelines that in many cases has been detrimental to radiologists involved in questionable or unfounded medical malpractice lawsuits but rather its misuse.
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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