CME article 12

How and why Radiologists get sued: your turn next?

This article is written with a view for opening our eyes, and reducing the errors that we inadvertently make while sending reports, or by not talking to patients and their referring physicians. The value of seeking a basic history prior to reporting even a simple chest radiograph cannot be repeated. The involvement of non-radiologists in diagnostic arenas and what we as Radiologists practicing in India should do is briefly discussed. A discussion board section has been kept aside for messages pertaining to this topic.

The ACR Standard for Communication1 indicates that direct communication can be accomplished in person or by telephone. This is an oral report, which should be documented, because the final written report does not substitute for direct communication. The radiologist who insists that the written report provided all the information that the referring physician needed will be perceived as uncaring and callous if a simple telephone call could have averted a bad outcome! 2

Does this make sense? Read on….

Case 1

A 39-year-old man was involved in a brawl and was taken to the emergency room complaining of neck pain. Cervical spine radiographs were read as normal and he was sent home. The next day, he saw a chiropractor because of persistent neck pain. After 3 weeks of treatment and persistent neck pain that was not improving, the chiropractor sent him for a nonenhanced MRI scan of the cervical spine. The impression of the interpretive report was, "There is no evidence of disc herniation or spinal stenosis. There is a mass expanding the upper cord. There are several smaller masses in the mid-and lower cord. This finding is compatible with a large syrinx." Upon receiving the written report, the chiropractor telephoned the radiologist. The radiologist testified that he told the chiropractor that the patient needed to see a neurologist.

This conversation was not documented by the radiologist.

The neurologist looked at the films and concluded, as did the radiologist, that this was a syrinx. Just to be sure, the neurologist called in a neuro-surgeon who also concurred that this was a syrinx and probably congenital. Does this satisfy the requirement to communicate the findings? The patient was told that this was a benign condition and probably congenital and that he didn't need any further workup.
Approximately a year later, after persistent neck pain and increasing weakness in the upper extremities, an MRI scan with gadolinium was performed, which showed multiple areas of enhancement with tumoral cysts. Biopsy revealed an ependymoma. There was testimony against the radiologist that the findings on the nonenhanced MRI scan were highly suspicious for a spinal cord tumor and not consistent with a "congenital syrinx." The American College of Radiology (ACR) Standard for Communication was used against the radiologist for failure to diagnose and failure to properly communicate the abnormal results. The jury verdict was against the radiologist for $565,000.

Case 2

A 60-year-old man was admitted from the emergency room with a fever, constant abdominal pain, and draining from a suprapubic incision. The patient had undergone a right inguinal herniorrhaphy at a different hospital 1 month previously. A KUB was performed on the night of admission but was interpreted 2 days later. The radiologist reported "a ribbon-like radiopaque opacity overlying the mid-abdomen presumably a surgical drain. Correlation with clinical history would be helpful. The patient responded to antibiotics and was discharged 2 days after admission.

The patient was readmitted approximately 3 months later from the emergency room with a high fever and severe abdominal pain. The interpretive report indicated that there was a "ribbon-like opacity overlying the mid-abdomen which may represent a surgical drain."
However, the radiologist suggested a CT scan, which showed a retained surgical sponge. The initial radiologist fell below the standard of care by not recognizing that the "ribbon-like opacity" represented a surgical sponge. There was testimony that the very reason the "ribbon-like opacity" is placed on a surgical sponge is so that it will be identified and recognized on an x-ray. While the radiologist is not obligated to obtain clinical information, sometimes it might be a good idea to do so, such as in this case. He also fell below the standard of care by not suggesting the next appropriate procedure, a CT scan, which would have localized the opacity within the pelvis 3 months earlier. Furthermore, he failed to appropriately communicate unexpected findings. The attending physician claims he never saw the film nor the interpretive report from the first admission because the report did not reach the patient's chart until after the patient was discharged.

The initial radiologist was unaware of the recent herniorrhaphy at a different hospital. The surgeon, as well as the hospital where the herniorrhaphy was performed, settled out of court, as did the radiologist, the emergency room physician, the attending physician, and the hospital for the second admission.



All is not lost. In general, there are four main reasons why radiologists get sued: errors in perception (finding is missed but is there in retrospect, and was just not seen at the time of reporting), error in interpretation (misdiagnosis), failure to suggest the next appropriate procedure (is this self-referral?), and failure to communicate in a timely and clinically appropriate manner (should communicate findings directly to the physician).

In India, the situation seems so different!! Many centers are run by non-Radiologists, especially those run by obstetricians who feel that performing a sonography of their own patient would obviate the need of a sonologist; this trend has been increasing. Can this trend be reversed by IRIA? Of late, various Radiologists have taken up this issue with the Government with limited success. Should there be a standard code of reporting, and communication? What is the legal position of the Radiologist when many patients in our country are lost to follow up or doctor shopping?

While we don't know most of the answers, we can keep the problems down to a minimum, by fostering a community bonding amongst us (crazy! We're competing!). This means taking into consideration the first Radiologist's report while it comes to you for a second opinion: for example: ectopic pregnancy, acute appendicitis, acute pancreatitis: changes can take place in days, so don't run the first report down: it could be your turn next!
Ask for correlating tests be it lab tests or further Radiology investigations or even a follow up. Many a time, surgeons want everything diagnosed on an ultrasound, when it is not always possible. In India, USG is the choice of investigation for acute appendicitis, while in the west it is a CT abdomen always. Do not hesitate to ask for further higher-end studies in your report.
Be well-read, and treat the patient as your own. Instigation of patients by fellow colleagues/ Radiologists is the main cause getting sued. Avoid this!!

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American College of Radiology. ACR standard for communication: Diagnostic radiology. In: Standards. Reston, VA: American College of Radiology, 2001:1-3.
Berlin L, Hendrix RW. Perceptual errors and negligence. AJR Am J Roentgenol 1998; 170: 863-867.
Berlin L. Missed radiographic diagnoses do not constitute negligence: Wisconsin Court of Appeals rules. ACR Bull. 1998; 554 (3):20-23, 30.
1. Berlin L. Malpractice issues in radiology: Defending the "missed" radiographic diagnosis. AJR Am J Roentgenol. 2001;176: 317-332.

Dr. Jashanjot Singh Bhangu, Jallandar