Litigation in breast imaging in both the U.K. and the U.S. is increasing, and it's crucial to focus on risk management to avoid malpractice suits, wrote Dr. H. N. Purushothaman of St. Bartholomew's Hospital and colleagues.
"Problems with image interpretation and decision-making in the diagnostic workup have resulted in breast radiology being the most common cause of litigation in radiology in the U.K.," they wrote (Clinical Radiology, July 2012, Vol. 67:7, pp. 638-642).
Although in the U.K. only 2% of malpractice litigation cases actually go to court, in the U.S., malpractice litigation involving patients diagnosed with breast cancer is now the second most common reason for payout by insurers, beaten only by claims resulting from neurologically impaired newborns, according to Purushothaman and colleagues.
The group examined records of 120 medicolegal investigations over a 10-year period. Mean age of the patients was 48 years, and the main complaint was a delay in diagnosis (92%), followed by inappropriate or inadequate treatment (8%). Of the cases included in the study, 81% were patients who had presented to the clinic with symptoms; the majority (65%) had a palpable lump.
Substandard care was cited in 41% (49 of 120) of the cases, with the most common reason for substandard care being delayed diagnosis (46 of 49 cases, or 94%), the researchers found.
Of the 49 substandard care cases, 61% were considered the fault of the radiologist and 14% were considered the fault of the breast surgeon. Of the cases in which the radiologist was considered at fault, microcalcification was the most common mammographic sign to be missed or misinterpreted (46%). (The authors noted that the study only included cases that required a radiological opinion; thus, there was a bias toward radiologists.)
Purushothaman and colleagues also found that a disproportionate number of younger women had malignancies. In one case, a 22-year-old woman was dismissed after an ultrasound of a palpable lesion was pronounced benign; however, upon review of the images, features that suggested cancer were present, and a needle biopsy should have been performed.
"There is often a perception that the younger the patient, the more likely the breast symptom is to be due to benign change," the team wrote. "However, every case should be thoroughly evaluated and not be dismissed purely on the basis of age."
Open discussion is key
How can radiologists reduce the chance of being named in a malpractice suit? Patients are less likely to sue if they have been part of clear communication with their treatment team, Purushothaman and colleagues wrote.
"Errors [in diagnosis] should be openly discussed with empathy and apologies issued particularly with a view to 'learn from the mistake' in future cases," they wrote. "Failure to disclose the error can double the chance of litigation."
And it's not only patients who need clear communication: referring colleagues do as well, the group noted, citing a study that found that a normal mammogram -- or one misinterpreted as normal -- was common among patients with delayed diagnosis.
Purushothaman and colleagues listed risk management actions radiologists can take, including the following:
- Ensure that the mammogram is of adequate quality with appropriate follow-up and additional views.
- Always compare the current study with previous studies.
- Ensure that the "triple test" -- clinical assessment, imaging, and, when appropriate, needle biopsy -- is complete and there is adequate follow-up, if necessary.
- Formally document all aspects of radiological care and outcomes at multidisciplinary meetings.
"By keeping to these recommendations, the chances of medicolegal investigation will be greatly reduced and, more importantly, patients will receive a high standard of care," the group concluded.