At The Radiologist’s Mercy 2
Posted by WhiteCoat on January 8, 2008
For all those who mock the ED physicians as nothing more than those licensed to order CT scans on everything that walks through the door, here’s something for you to chew on:
A patient was at one of the local drinking establishments when he got into an argument with two less intoxicated gentlemen and had the smackdown put upon him. He came in complaining of pain in his jaw and pain in his neck.
He got sent for x-rays of his jaw and neck. No fractures were seen, but the following are snippets of the reports that were returned from the radiologist:
Legally, what are the ED physicians now supposed to do?
If we don’t perform the CT scans and there is a fracture present, the radiology reports can be thrown in our faces as “proof” that we were negligent for not doing the scans. After all, if we ordered an x-ray to rule out a fracture, our suspicion for a fracture must have been “high,” right?
If we perform the CT scans and they are negative for fracture, non-clinicians publish studies that ED physicians are “unnecessarily” running up the cost of medical care and are causing cancer with all of the excess radiation.
Oh, and if we perform the CT scans and they are positive for a fracture, everyone asks the ED physician why he didn’t just order the CT scan in the first place.
Exactly what are we are supposed to do in this scenario?
January 8, 2008 at 2:49 pm
When this happens to me (usually involving breast implants–old double lumen in particular, and mammograms) I document my physical and clinical exam and ignore the radiologist. I know that isn’t as critical as a fractured neck, but the key for me is the “clinical suspicion”. Document, document, document.
January 8, 2008 at 4:03 pm
Don’t you know that ER docs are supposed to have X-ray vision?
January 8, 2008 at 5:08 pm
Personally, I call the Radiologist and twist his nut-sack a little, ask him if he’s always been an equivocating coward, tell him I’m not afraid to keep “running the line” until he says “uncle.” Afterall, you’ve got little to lose when your at the bottom (outpatient Internist). I’ve even once sent a letter to the doc (a euphemism in the case of Radiology) with a demand for a written response; refusal will result in a letter sent detailing the inappropriate cost and risk dumping, to the following:
Office of the Inspector General
HHS TIPS Hotline
P.O. Box 23489
Washington, DC 20026
I know I sound like an asshole, but if you start at square one, the patient comes first, it is inappropriate (in most cases) to allow your colleagues to treat patients this way. Furthermore, when it is quite obvious I am daily giving myself my own bifid scrotum, it is inappropriate to let colleagues treat YOU this way
The equivocating part gets on my nerves sometimes, but when I put myself in a radiologist’s shoes, sometimes the films may not be of the best quality or may be at the wrong angle, or a million other things that would impact upon the ability to see an abnormality. I can see where they’re coming from. When I look at the films, I have the advantage of knowing where the pain or knowing what problem I am performing the test to rule out. I try to convey that info to the radiologist in my preliminary interpretations as much as possible so we both win.
I was intending the post to be more of a reflection on how the legal atmosphere can increase the costs of medical care through additional testing as Happy Hospitalist says “just to be sure.”
January 8, 2008 at 6:51 pm
And one more reason why failure to diagnose lawsuits add uncountable billions (I’m sure) to the bottom financial line of our country.
We always have to be sure. Right?
Is that 100% sure acceptable?
Is that 95% sure acceptable?
What is acceptable short of perfection?
I absolutely agree with you. Fear the bad outcome.
January 8, 2008 at 9:42 pm
Ask the nurse what to do. <<—***Always the best option***
OR
Write for follow-up, and let the primary figure out if the CT for mandible fx is necessary if you’re not suspicious enough to do it on your own. A mandible fx is not life-threatening. Cerv spine is a little more tricky, of course because, ya know, the guy could be a quad….Overall, the chances of a cerv spine fx in a young fellow who simply had the crap kicked out of him is quite low, no? You’d have to consider the mechanism of injury
Remember, the thing say “if clinical suspicion is high”. You could always argue that the clinical suspicion was low based on exam.
January 8, 2008 at 11:08 pm
If my clinical suspicion is high, I order the CT scan. If it isn’t, I don’t.
My point is that if the patient ends up having a fracture, then you’re going to get whacked either way. If you didn’t have a high suspicion and there was a fracture, you look like an idiot. If you had a high suspicion and there was a fracture, you didn’t follow the recommendations.
January 9, 2008 at 12:12 am
Funny thing is that CT scan reports sometime say “if clinical suspicion is high, consider MRI”! WTF!
I usually document that prior to d/c, the patient has minimal or zero pain and thus, I now have “low suspicion”. In the few cases where there is still a lot of pain, I do the CT. In many cases the films were likely ordered because the guy was drunk anyway.
January 9, 2008 at 2:50 am
I think I may have had too much radiation.
I don’t blame anyone. What’s a girl to do? What had to be had to be. It was what it was. It is what it is. Three different docs with the CTs at different times in my life, same with the X-rays.
Is there anything I can read that might tell me how to help protect myself from all the exposures…past or future? Does EVERYONE succumb to cancer because of frequent exposure to these tests?
I refuse to accept the studies if that’s what they say. I mean is God not God? I think he created each of us for a purpose and as long as there is a purpose…people will overcome the odds/predictions etc.
* Not my intention to offend anyone who is either agnostic or an atheist…just expressing from my perspective.
January 9, 2008 at 10:15 am
“And one more reason why failure to diagnose lawsuits add uncountable billions (I’m sure) to the bottom financial line of our country.
We always have to be sure. Right?”
If they’re uncountable how can you be sure how much they are?
What lawsuit requires a radiologist to be sure?
Personally, Matt, I suggest you call these guys and ask them:
http://www.youhavealawyer.com/misdiagnosis/
You can get a “free misdiagnosis consultation” while you’re at it.
-WC
January 9, 2008 at 10:17 am
feminizedwesternmale, you are a jealous asshole. you are at the bottom of the food chain, because you chose to be there. i doubt that any radiologists are intimidated by the rantings of a triage nurse (oops, “outpatient internist”}. roll over and die. it is inevitable. you will be happier. “thank you for this referral.”
January 9, 2008 at 3:09 pm
I personally am good friends with several radiologists at our hospital and there are certain ones I really trust - I find that if I call them, they will usually tell me more directly what they really think vs the report. I am sure most of this crap is all paranoia about lawsuits just like the majority of the documentation we do on our ER charts. Too bad there are some who really will never make a definite call.
January 9, 2008 at 11:22 pm
I am a radiologist and our practice covers level 1 and level 2 trauma centers. We work with a lot of ER doctors, and I definitely understand and sympathize with your concerns.
So my question to you is as follows: What would be your preferred way for the radiologist to report this sort of finding?
As a similar real-life scenario, now that it’s wintertime we see a lot of hip x-rays from the ER for “fell on icy sidewalk; r/o fracture” in osteopenic old ladies. And of course if the film is positive, then it’s straightforward. But as we all know, a negative hip film does not exclude a fracture in this scenario. So several of my partners will say something very much like: “No fracture is seen, but if there is a continued strong suspicion for an occult fracture, then an MRI would be the best next imaging test.”
Is there something else we could say that protects both the ER doctor and the radiologist from a medicolegal point, but doesn’t handcuff the ER doctor?
Thanks for your thoughts.
Are you aware of any legal cases in which a radiologist has been held liable for just interpreting a film instead of delving into what options to take based on levels of clinical suspicion? If so, I’m not being snide when I tell you that I’d sincerely like to look at them. Please e-mail them to me.
If a mandible x-ray shows no fracture, why can’t the reading just say “no fracture”? C-spine shows straightening? Why can’t the reading say “Loss of lordosis with no evidence of bony abnormality”?
With your hip fracture scenario - do you also recommend x-rays of the wrist and ankle because everyone knows that people who fall with enough force to break their hip may also have bony abnormalities elsewhere? Do your reports state that many falls in elderly patients are due to poor balance and recommend an MRI of the brain to exclude NPH or space occupying lesions? Do you recommend carotid dopplers if the clinical suspicion of a syncopal event causing the fall is high enough? See what I’m getting at? Where do the clinical recommendations end? Let me practice medicine and I’ll let you practice radiology. We work together as a team.
Personally, you’d help me most by sticking to a strict interpretation of the test. If I have questions, I’ll call you. -WC
January 10, 2008 at 4:06 pm
Part of the problem is that our (i.e., the American College of Radiology) reporting guidelines include the following element as part of a “proper report”: “Follow-up or additional diagnostic studies to clarify or confirm the impression should be suggested when appropriate.” And multiple malpractice lawyers have told me that they definitely look at the official “Practice Guidelines” for relevant subspecialties, even if the doctors themselves may not.
With respect to specific legal cases, here is an article that aroused a fair amount of discussion in the radiology community. The author is Dr. Leonard Berlin, who is both a radiologist in academia and a JD with expertise in medical malpractice. I’ve excerpted a couple of relevant passages below:
“Malpractice Issues in Radiology: Errors of Omission”
American Journal of Roentgenology 2005; 185:1416-1421
“…Defensive Medicine by Radiologists
“Although this article has focused primarily on failure-to-order-radiologic-studies malpractice lawsuits lodged against referring physicians, by no means are radiologists exempt from such litigation. The American College of Radiology “Practice Guideline for Communication of Diagnostic Imaging Findings” [49] states that, “Follow-up or additional diagnostic studies to clarify or confirm the impression should be suggested when appropriate.” The words “when appropriate” are not defined, and thus the circumstances under which radiologists should suggest additional radiologic studies are left to the radiologist’s own judgment.
“***A radiologist’s failure to recommend additional radiologic studies may well subject that radiologist to a medical malpractice lawsuit.***
“Such was the case of a 37-year-old man involved in an automobile accident who was taken by paramedics to a nearby hospital emergency department. Conventional cervical spine radiographs were interpreted accurately—as normal—by the radiologist. After the patient developed neurologic abnormalities the next day, a CT scan revealed a C5-C6 fracture-dislocation. The patient later filed a malpractice lawsuit, naming as a codefendant the radiologist, alleging that the radiologist was negligent because he “should have known that spine fractures can be missed on plain films” and had failed to order a CT scan at the time he interpreted the initial cervical spine radiographs [50]. Radiologists whose practices include mammography have found themselves defendants in malpractice litigation for failing to recommend spot compression or magnification views [51] or breast biopsies [52]. Many other examples of lawsuits filed against radiologists alleging their failure to order additional radiologic studies have been reported previously [53, 54].
“Outlook for the Future”
“Clearly, allegations of errors of omission have ignited the spark and become the dominant theme of malpractice litigation in American courtrooms in the 21st century. The total number of imaging procedures in the nation grew by 40% over the past 5 years alone and is projected to grow by another 26% by 2008 [61]. As this number and the sophistication of radiologic and nonradiologic procedures and tests continue to grow, so surely will errors caused by physicians’ omission of ordering or using this medical technology. Nonradiology physicians will continue to be increasingly sued for failure to order sonographic, radionuclide, CT, MRI, and PET studies on their patients.
“***Radiologists will continue to be increasingly sued not only for failure to recommend radiologic tests, but for failure to recommend other diagnostic procedures as well.***”
===
Now I *don’t* like having to practice “cover-your-*ss” radiology. But when the education officer of malpractice insurance carrier (himself an MD) tells us every year in our annual risk management review that we better make sure that we issue “appropriate followup recommendations” as part of our reports, it’s hard to say no.
It is true, that I don’t go overboard as in the various scenarios you stated (e.g., extra wrist/ankle films for hip trauma, brain MRI for possible syncope, etc.) You are right, that is the ridiculous logical extreme of these over-inflated concerns.
But for certain conditions where a failure to diagnose could lead to a big problem (such as missed hip fracture in an elderly woman), the orthopedic radiologists in our group have said that we should throw in the “recommend MRI if still have high clinical suspicion”. Most of the ER docs we work already know this; however a lot of the family practitioners and other primary care docs who might see a patient in their office might not know about this particular high-yield recommendation.
It’s similar to what our mammographers do with women who feel a lump in their breast, and the family practitioner (correctly) orders a mammogram which then turns out to be negative. Since the next step in the workup in such cases is an ultrasound, but this might not be always known to an average family practitioner, they always say something in their report like, “In the setting of a palpable lump with a negative mammogram, we recommend an ultrasound as the next test, since a malignancy is still not yet excluded”. That way, we avoid the problem of the family practitioner erroneously concluding that the negative mammogram was good enough, and that he could safely stop the workup. Lawyers and mammography experts have told us that failure to recommend an ultrasound in such cases would definitely expose us to a lawsuit, and that we *can’t* just stop at describing what we see.
It may be that the way the medicolegal system has evolved, we’re basically in a Catch-22. I don’t particularly like it. I don’t want to make life harder for my friends who are ER docs, but I also don’t want to get burned by a bogus lawsuit any more than you (or any other physician) does.
I hope this makes sense.
January 10, 2008 at 4:07 pm
The URL for the Berlin article is:
http://www.ajronline.org/cgi/content/full/185/6/1416
January 10, 2008 at 11:33 pm
Just as some additional background, here is a related article by Dr. Berlin in which he discusses whether radiologists should or should not give recommendations for follow-up exams in their reports. In short, he recognizes that many referring doctors *don’t* like those recommendations for precisely the reason you mention. But if there’s a lawsuit, the same doctors who normally say, “I don’t want you radiologists to recommend further tests; just tell me what you see and let me decide what to do with the findings”, may then later say in court, “Hey, I counted on the radiologist to tell me whether to order something else; if he didn’t, then he should also share some of the blame, since I would have done so if only he had recommended it”.
Again here are a couple of excerpts:
“Malpractice Issues in Radiology: Relying on the Radiologist”
Leonard Berlin
American Journal of Roentgenology 2002; 179:43-46
http://www.ajronline.org/cgi/content/full/179/1/43
“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.
“…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.”
=====
I went to a radiology CME course a few years ago where Dr. Berlin was one of the lecturers. He reiterated those points and basically said that if we issued recommendation for follow-up studies in our reports, it could help protect us legally and that if we didn’t then it could come back to haunt us in the courtroom.
Again, I don’t necessarily like it, but I acknowledge it as part of the medicolegal reality I have to deal with.
Of course, the radiologists I work with also understand that it’s not helpful to issue a report that includes something like, “We recommend that you must order a CT next”. We recognize that this sort of unqualified blanket statement handcuffs ER doctors by giving them zero latitude. So most radiologists I know try to use some sort of qualifier like, “If there is a high clinical suspicion for disease X, then…”. I was taught in my training that this phrasing would help keep you ER doctors off of the medicolegal hook by allowing you to either order the CT or not order it based on information that you had but that I didn’t. So I’ve always thought I was doing you a service by including some sort of qualifier in my reports to give you some needed “wiggle room”.
But if real-life ER medical practice is such that my qualifier doesn’t really give you any genuine latitude to not order the CT, then we’re probably stuck.
In summary: Our literature, lecturers, and lawyers tell us that it’s often prudent (and sometimes obligatory) to protect ourselves by making follow-up imaging recommendations in our reports, especially when we feel that the current test won’t show a relevant abnormality but another test will. If your lawyers tell you that once we do so, you won’t have the latitude to not order the CT scan even when we deliberately try to phrase things in way to give you that latitude, then you have no choice but to protect yourself as well. And I understand that.
In that case, it sorta sucks all around…
(I’m not trying to be snide. It’s just that with the radiologists I know, we’re not trying to be wishy-washy or difficult when we issue follow-up imaging recommendations as part of our interpretations. I don’t enjoy reading a half-dozen extra CT scans at 3am any more than you enjoy ordering them — it can be frustrating for us too.)
January 11, 2008 at 8:38 pm
I am a radiologist who reads a lot of ER cases. I have a great deal of sympathy for your complaint. I try as much as possible to be as definitive as I can.
Having said that, this is a complex problem with fault on both sides. I can’t tell you how many times I get films with terrible history or no history at all. I also can’t tell you how many cases I read that are clearly “shotgunned”, sometimes by the admitting nurse before even being seen by the ER doc. For example, a patient that has a wrist fx in which; hand, wrist, forearm, elbow and humerus are ordered. You protect your ass (and you need to), I need to protect my ass as well.
The example of the osteoporotic lady with the hip X-Ray is a good one. In the first place, in most cases I have no idea whether the patient “examines like a fx” or not. If I am dealing with an experienced ER doc I may not feel obliged to add the disclaimer about CT or MR. But in many cases I don’t know whether I am dealing with a PA or if the ER doc has even examined the patient yet.
In the second place, X-Rays of old osteoporotic patients frequently aren’t of very good quality. I can pretty much guarantee you that if I miss a subtle or questionable fx, the plaintiff can find an expert who will see it clear as day.
This situation is an excellent example of how malpractice adds to the cost of medicine. Unfortunately, the situation is getting worse not better. Based on my personal (and unscientific) observations, older ER docs order far fewer “unnecessary” exams. Similarly, younger Radiologists tend to suggest more extra “unnecessary” studies than older ones.
Maybe Hillary or John Edwards will solve this problem when they are elected President (sarcastic remark)
January 12, 2008 at 3:48 pm
First of all, ER-Rad, thank you for adding meaningfully to this discussion. It really helps to see where both sides are coming from.
The articles you cite are distressing. Unfortunately a few successful outlier lawsuits seem to have created their own “standard of care.” One of my mentors once told me that the quickest way to change a medical standard is to win a lawsuit against a physician for doing it. Pundits in the specialty who perpetuate what seems to be an unachievable standard don’t help.
This is where the ACR has to pick up the ball and run with it. If there are a bunch of “experts” testifying about untrue standards of care, then the ACR needs to sanction them. Review their testimony and kick them out of the college. That is a reportable event to the National Practitioner Databank. A few of these cases and those who testify to untrue or unachievable standards may have reason to rethink their testimony. The American Academy of Neurological Surgeons (www.aans.org)is quite active in this regard.
It is a bunch of BS that radiologists are (or should be) expected to pick up every possible abnormality on every single exam. I haven’t visited the ACR web site, but perhaps the ACR should have a policy stating that radiologists can miss subtle findings and still have practiced within the standard of care (if they don’t such a policy already).
You both seem like team players and I’m sure the staff and ED docs appreciate you.
January 13, 2008 at 5:31 pm
The ACR does sanction “expert” witnesses once in a while. But it’s impossible to sanction someone who is not a member.
Another good point. What to do about rogue “experts.” Perhaps fodder for a future post …
January 14, 2008 at 4:58 am
“legally, what are the ED physicians supposed to do”
Really, these dictations, while not being what you might ultimately desire, are valid. This is purely an exercise in Bayesian analysis. I KNOW that not all the cases you order exams on are high pre-test probability of disease. When I see an exam that may not be ideal in quality, I want to tell you what I can, which is that I don’t see anything of import. Now, if (in the case of the C-spine) the patient has no tenderness, no neurological findings, etc, then the pre test probability is low (say ~ 2%)and the negative xray lowers this even further. On the other hand, say you had a patient with transient paraplegia, and the x-ray looked OK. This person has a very high chance of a significant injury (say >90%) and the the fact the xray does not reveal any abnormality lowers this, but only to maybe 85%, not enough to stop looking, certainly.
What I would hope you would do is think: he is minimally tender, no neurologic deficits, I really didn’t think there was a fracture, I was just being careful, so home he goes. OR: This guy really feels like a fracture. The xray is negative, but because his pre-test probability is so high, I have to look further.
As another example: cardiac imaging. A 50 y.o. male with typical angina who has a negative EKG and a negative MIBI has had his likelihood of significant CAD lowered from 95% to about 60-70%. Still a level that he really needs to be cathed, but some referring physicians don’t get it. You bet on these cases, I say that the negative tests in someone with very suspicious clinical findings should be disregarded and the patient needs to be cathed.
I have seen a situation in which a physician felt that a negative mammogram was enough to clear a patient who had an obvious breast mass. One year later, a fatal cancer was finally diagnosed. There were suits all around, enough for all, on that one. So you need to understand that this qualifying language, while not comforting, is necessary.
Some are jumping on radiologists for “equivocating”. Really, this is simply trying to paint as accurately as possible the degree of confidence we have in the findings. This is of course subjective, and of course varies with the radiologist, just like every other subjective judgment in medicine. Simplistically considering an imaging study “positive” or “negative” just doesn’t get it. And by the way, we aren’t the only ones: “non-specific ST changes”
We all participate in CYA activities, and you in the ER must do this all the time. The number of head CT’s that I see that are unexpectedly positive (excluding the guy who just had his head nearly knocked off, or has fixed, dilated pupils –) are under 1%. Our ER docs get a head CT for every head bump, it seems. It probably costs $500,000 to find anything significant. I approached one of my ER buddies once and asked him if there were a way to protocol the patients so that we could develop a local standard of care to NOT do so many head CT’s. His answer was revealing. He said: if an unexpected epidural is a 1 in 10,000 chance, I will see one or two in my career. If I don’t scan them, it could kill the patient and be a career ending event. I will continue to order them.
So there you have it. All of us are affected by this. It is manifested in different ways.
Feminizedwesternmale:
You say “I know I sound like an asshole” I congratulate you on your insight. Does “running the line” mean allowing the radiologist to help you determine which test would be the most effective in ruling out the process you are considering? If so, that is a very effective way of getting the most definitive result in the quickest time. I wish more of your colleagues would consult with us in that manner.
Your language is so confrontational, I am sure you get the same in return simply as a defense, and that increase your sense of us against them. Why not take a radiologist to lunch today and start a constructive dialog?
January 14, 2008 at 10:02 pm
[...] Pretty amazing analysis of what the horns of the dilemma are on which an emergency room physician is impaled: If we don’t perform the CT scans and there is a fracture present, the radiology reports can be thrown in our faces as “proof” that we were negligent for not doing the scans. After all, if we ordered an x-ray to rule out a fracture, our suspicion for a fracture must have been “high,” right? [...]
January 15, 2008 at 9:36 am
Hey since I spend considerable time covering ER’s I get to know the doc’s well. I usually actually talk to them. I’ve seen so many C-spine fractures that are simply not seen on plain films, but I don’t recommend CT on every neg C-spine.
One odd thing that happens is that when the clinical suspicion is high, a CT is always ordered, when it’s low plain films get ordered. This clearly has a logical fault…ordering the less sensitive test when pre-test prob is the lowest… On the other hand I’m not aware of any outcome data saying anyone with neck pain who doesn’t get a CT has a worse outcome.
So I think part of this phenomenon is that referring doc’s don’t understand what the sensitivity of the tests they order is, and don’t have a good idea of how to combine their pre-test probability with test sensitivity to come up with predictive value. If so simply document the facts and I think you’d be all set (except for having to explain the statistics behind your decision to the jury)
January 18, 2008 at 6:47 pm
Agree with Scalpel.
Stop ordering plain films for cervical spines. Palpate the spinous process, watch the patient, and make a clinical diagnosis. My most occult C spine fx. diagnoses were made on clinical grounds.
I agree that clinical exams work well with young healthy alert patients. What about intoxicated patients, little old ladies with brittle bones who wince everywhere you touch them, and nonverbal nursing home patients who fall out of bed and whack their heads? Low threshold CYA x-ray or just CT everyone?
May 18, 2008 at 5:12 pm
[...] CT and MRI scans has been getting a fair bit of discussion at the medical blogs lately, e.g. White Coat Rants, GruntDoc, and [...]