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Commentary |
Department of Radiology, Rush North Shore Medical Center, 9600 Gross Point Rd., Skokie, IL 60076, and Rush Medical College, Chicago, IL 60612.
Received April 15, 2005; accepted after revision April 19, 2005.
Address correspondence to L. Berlin
(lberlin{at}rsh.net).
There's more than one way to skin a cat.—English idiom meaning a task can be accomplished in several ways [1]
Breakdown in communication is a causative factor in up to 80% of all malpractice lawsuits [2]. Malpractice lawsuits that involve failure of communication of radiologic results occur with less frequency but are nonetheless commonplace. Indeed, a report issued jointly by the Physician Insurers Association of America (PIAA) and the American College of Radiology (ACR) revealed that the fourth most common primary malpractice allegation lodged against radiologists is failure of communication [3]. The same report also disclosed that in nearly 60% of malpractice lawsuits involving radiologists, the referring physician had never been directly contacted with urgent or significant unexpected findings. Members of an ACR task force appointed to explore liability issues related to radiologic communication reviewed medical malpractice lawsuits resulting in indemnification payment to plaintiffs filed in the United States between 1999 and 2003. The task force found that the number of lawsuits related to communication failures averaged nine per year [4]. The task force also reported that 25% of all ACR members responding to a questionnaire acknowledged being involved in at least one malpractice claim involving allegations of failure to communicate.
In 1991, the ACR issued its first Standard for Communication: Diagnostic Radiology [5]. Contained within the standard were the following statements:
Radiologists should attempt to coordinate their efforts with those of the referring physician to best serve the patient's well being. In some circumstances such coordination may require "direct communication of unusual, unexpected, or urgent findings to the referring physician."
Subsequent revisions of this standard in 1995 [6], 1999 [7], and 2001 [8] contained similar language. All mandated essentially that radiologists who discover "urgent or significant unexpected findings" should communicate those findings directly to the referring physician.
The portion of the standard (name changed to ACR Practice Guideline in 2003) that deals with direct communication of significant radiologic findings has become one of the most contentious—if not the most contentious—issues among the radiologic community [9], because it is the alleged violation of this portion that serves as the basis for much malpractice litigation. Attempting to comply with the direct communication of significant unexpected radiologic findings clause has engendered widespread frustration among radiologists who feel they are being compelled to "spend hours every day in a vain attempt to contact the referring doctor" [10].
Radiologist Murray Dalinka has summed up the anguish felt by many radiologists [11]:
It is sometimes extremely difficult, if not impossible, to notify our clinical colleagues when abnormalities are found on studies they order. It is not rare to spend 20 to 30 minutes trying to reach a "body" only to find that the one who answers is unaware of anything about the patient, even if the patient is truly theirs.
The Michigan Experience
In an article appearing in a future issue of the American Journal of Roentgenology [12], Vaishali Choksi and associates at the University of Michigan Department of Radiology describe a process that seems to have greatly minimized, if not altogether eliminated, the difficulty radiologists encounter in trying to adhere to the ACR practice guideline that calls for direct communication of critical findings. The Michigan group has developed a system that requires radiologists to code all radiologic reports in three possible ways: no unexpected findings requiring follow-up, detection of an unexpected acute finding (not cancer) requiring follow-up, or detection of an unexpected finding indicating malignancy. An equivocal finding for which the radiologist recommends further evaluation because of a concern for malignancy, no matter how equivocal the finding, is assigned to the third code.
The Michigan radiologists still attempt to contact the referring physician or an appropriate member of the clinical team caring for the patient to report findings coded in the second or third categories. Such contact, if successful, is documented in the radiologic report. However, in addition to (or sometimes in lieu of) this contact, a cancer registrar who is a nurse practitioner retrieves all reports that are coded as possible malignancy and monitors the medical center's electronic clinical records to determine whether appropriate follow-up has been performed. If the registrar cannot confirm that follow-up testing or appropriate medical care has occurred within 2 weeks after radiologic interpretation, the registrar contacts the ordering physician and also notifies the members of the hospital's tumor board of this potential deficiency.
In the 1-year period extending from early 2003 to early 2004, approximately 38,000 reports of radiologic examinations were rendered at the University of Michigan. Of these, 1% were coded as possible malignancy and thus were followed up by the cancer registrar. Malignancy was ultimately diagnosed in 45% of these cases.
Of great importance from both patient care and financial perspectives is that during this 1-year period, eight patients would have been completely lost to follow-up if the coding and review process had not been instituted. These eight patients represented 0.02% of all imaging tests performed within the department during the 12-month study period and 2% of all radiologic examinations coded for possible malignancy. Of the eight patients, five were ultimately diagnosed with a malignancy.
The ACR's task force review of indemnification paid to plaintiffs in malpractice cases alleging failure of radiologic communication found that the payment averaged $1.9 million per case [4]. If all of the five patients who were ultimately diagnosed with malignancy and who would have been lost to follow-up if the coding and review process had not been instituted had filed medical malpractice lawsuits against the University of Michigan because their diagnosis had been delayed, potentially $9.5 million would have been paid to the injured patients. This figure does not include legal defense costs. If this nearly $10 million indemnification and legal expense figure were extrapolated to radiologic facilities that perform many more times the number of examinations done at the University of Michigan, the potential annual indemnification figure would be enormous.
The concept of coding radiologic reports in a manner that guides referring physicians in determining a course of follow-up action of their patients' radiographic findings is, of course, not novel. The Breast Imaging Reporting and Data System (BI-RADS) [13] instituted by the ACR requires radiologists to categorize mammography reports according to whether significant abnormal findings are present and, if so, the degree of likelihood of malignancy. A formal standardized reporting system such as BI-RADS would be difficult to adapt to general radiologic imaging with its myriad methods and complex techniques. Nonetheless, the process devised by Choksi et al. [12] that promptly and aggressively alerts referring physicians when a radiologic study on their patient discloses a finding suspicious for malignancy appears to be quite effective and practical.
In April 2005, a Georgia radiology group [14] reported its experience using a software process in which radiologic reports that contain significant unexpected abnormalities are flagged by the interpreting radiologist. These flagged reports are then downloaded from the radiology information system and relayed to a clerical employee who then telephones the flagged report to the physician who ordered the radiologic study. This system, too, appears to work efficiently and well.
The Radiologist's Legal Duty to Communicate
The nature of the duty that American courts have imposed on radiologists to ensure that referring physicians receive radiologic reports of findings that may adversely affect the health of their patients has been discussed in detail previously [15–18]. Nevertheless, a recent decision rendered by the Arizona Supreme Court contains considerable commentary on this duty and is thus worthy of mention here. A radiologist was hired by a business company to interpret preemployment chest radiographs and send reports of those examinations to the company. The radiologist noted a small lung lesion on the radiographs of a woman who was a potential employee and appropriately reported the finding to the company. Although company policy required it to notify the woman of the results of the chest radiograph, the company failed to do so.
Ten months later, the woman was diagnosed with lung cancer. She subsequently filed a medical malpractice lawsuit against the company and the radiologist, claiming negligence for failing to inform her of the abnormal finding, thus causing a delay in diagnosis. The company declared bankruptcy, leaving the radiologist as the sole defendant. An Arizona trial court dismissed the lawsuit against the radiologist, ruling that a legal doctor–patient relationship between the patient and the radiologist had not been established. An Arizona appellate court reversed the dismissal and reinstated the lawsuit against the radiologist, stating [19]:
The issue presented is whether a radiologist, to whom a person is referred...who detects a medical condition for which further inquiry or treatment is appropriate, has a duty to inform that person. We conclude that the radiologist does have such a duty....This is the approach we are persuaded to follow: it is reasonable to expect that the patient's primary physician would obtain the results of the various diagnostic studies ordered...and evaluate to what degree the patient needed to be advised of the results. However, the [radiologist] to whom the referral was made, and who performed the diagnostic tests, bears no such duty with regard to advising the patient of the results unless there is no referring physician or the referring physician is unavailable, in which case the duty shifts to the [radiologist].
The radiologist then appealed to the Arizona Supreme Court that, just this past year, affirmed the reinstatement of the lawsuit. However, the court added commentary regarding radiologists' duty to communicate that may well exert considerable influence on courts in many other states and thus commands the attention of all radiologists [20]:
All courts have recognized that in placing oneself in the hands of a medical professional, even at the request of one's employer or insurer, one may have a reasonable expectation that the expert will warn of any incidental dangers of which he is cognizant due to his peculiar knowledge of his specialization.... [The radiologist] recognized the existence of abnormalities on the X-ray that may have evidenced an unreasonable risk of harm to [the patient] of which she was unaware. [The radiologist] should have anticipated that [the patient] would want to know of the potentially life-threatening condition and that not knowing about it could cause her to forego timely treatment, and he should have acted with reasonable care in light of that knowledge.... [The radiologist] placed himself in a unique position to prevent future harm to [the patient].... We can envision no public benefit in encouraging a doctor who has specific individualized knowledge of an examinee's serious abnormalities to not disclose such information. We conclude that public policy is better served by imposing a duty in such circumstances to help prevent future harm, even in the absence of a traditional doctor–patient relationship....The appellate court held that a radiologist had a duty to report abnormalities directly to the patient if "there is no referring physician or the referring physician is unavailable." We decline to find a duty to report directly to the patient...[but] we do agree that the duty imposed is to act as a reasonably prudent health care provider in the circumstances. But whether this duty requires direct communication with the subject of the X-ray regarding any abnormalities discovered may depend on factors such as whether there is a treating or referring physician involved in the transaction, whether the radiologist has means to identify and locate the patient, the scope of—including any contractual limitations on—the radiologist's undertaking, and other factors that may be present in a particular case.... Whether [the radiologist] acted reasonably in his interpretation of the X-ray is a matter of the standard of care to be resolved by the trier of fact.
In short, the Arizona Supreme Court declined to hold that as a matter of law radiologists automatically have the duty to communicate significant unexpected findings to the patient if the referring physician is unknown or unavailable, but instead ruled that a jury must decide whether such a duty exists on a case-by-case basis, depending on the specific circumstances of that individual case.
ACR Practice Guideline for Communication
This editorial cannot be concluded without mention of the most recent revision of the ACR Practice Guideline for Communication of Diagnostic Imaging Findings that was approved during the April 2005 meeting of the ACR effective October 1, 2005. The preamble of the guideline emphasizes that the guidelines are [21]
...educational tools designed to assist practitioners in providing appropriate radiologic care for patients. They are not inflexible rules or requirements of practice and are not intended, nor should they be used, to establish a legal standard of care.... The ACR cautions against the use of these Guidelines in litigation in which the clinical decisions of a practitioner are called into question.... An approach that differs from the Guidelines, standing alone, does not necessarily imply that the approach was below the standard of care.
No longer does the practice guideline itself refer to "direct communication," but, rather the guideline delineates two categories of radiologic communications, "routine" and "nonroutine." Routine reporting is communicated "through the usual channels established by the hospital or diagnostic imaging facility." The guideline then focuses on nonroutine reports [21]:
In emergent or other nonroutine clinical situations, the delivery of a diagnostic imaging report should be expedited by the diagnostic imager in a manner that reasonably ensures timely receipt of the findings. Situations that may require nonroutine communication include (i) Findings that suggest a need for immediate or urgent intervention;...(ii) Findings that are discrepant with a preceding interpretation and where failure to act may adversely affect patient health;...and (iii) Findings that may be seriously adverse to the patient's health and that the diagnostic imager reasonably believes are unexpected by the treating or referring physician.
Communicating Critical Findings: More Than One Way to Skin the Cat
Whereas previous versions of the communication practice guideline indicated that direct communication could be accomplished only in person or by telephone, the revised guideline simply provides that [21]
...nonroutine communications be handled in a manner most likely to reach the attention of the treating or referring physician in time to provide the most benefit to the patient. Communication by telephone or in person...is appropriate and confirms receipt of the findings.... There are other forms of communication that provide documentation of receipt, which may also suffice to demonstrate that the communication has been delivered and acknowledged.
The guideline then concludes:
While other methods of communication may be considered, including text pager, facsimile, voice messaging, and other nontraditional approaches, these methods do not ensure receipt of the communication. Therefore, in these instances, the diagnostic imager may consider initiating a system (italics added) that explicitly requests confirmation of receipt of the report by the clinician. When confirmation or other response is not received within a time appropriate to the diagnosis after the initial communication, a staff person then notifies the clinician to document follow-up.
Recently published studies disclosed that the typical primary care physician reviews 800 chemistry reports, 40 radiology reports, and 12 pathology reports per week [22] and that communication problems related to diagnostic testing account for 47% of all errors made in their medical practices [23]. Let us emphasize these key words of this latest revision of the ACR's Practice Guideline on Communication: "The diagnostic imager may consider initiating a system that explicitly requests confirmation of receipt of the report by the clinician." The guideline calls for development of a system, not the system; in other words, there is more than one way to skin a cat. Choksi et al. [12] have given us one way to ensure that referring physicians are notified of critical findings on radiologic studies performed on their patients. As mentioned earlier, a Georgia radiology group has given us another [14]. To be sure, these are certainly not the only ways to achieve this level of effective communication. The challenge for all radiologists, however, is to either adopt one of these ways or develop another.
References
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  H. Singh, H. S. Arora, M. S. Vij, R. Rao, M. M. Khan, and L. A. Petersen Communication Outcomes of Critical Imaging Results in a Computerized Notification System J. Am. Med. Inform. Assoc., July 1, 2007; 14(4): 459 - 466. [Abstract] [Full Text] [PDF]
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 L. Berlin Replacing traditional text radiology reports with image-centric reports: a shift from epiphany to enigma? Am. J. Roentgenol., November 1, 2006; 187(5): 1156 - 1159. [Full Text] [PDF]
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R. J. Stanley Primum Non Nocere (First Do No Harm) Am. J. Roentgenol., October 1, 2005; 185(4): 831 - 831. [Full Text] [PDF]
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