Misdiagnoses, lack of supervision, and poor communication land radiologists in court

Radiologists have the dubious distinction of being the most frequent defendants in malpractice lawsuits, particularly for the misdiagnosis of breast cancer, with the payout to a plaintiff averaging more than $200,000.

A group from the Henry Ford Hospital in Detroit reviewed published studies and medico-legal case summaries and uncovered a common thread in these lawsuits, ranging from the incomplete work-up of mammographic abnormalities to the failure to communicate results.

According to data compiled by the Physicians Insurers Association of America, errors in the diagnosis of breast cancer made up 20% of all claims against radiologists, explained Dr. Varalaxmi Samudrala at the American Roentgen Ray Society meeting in May. Lung cancer came in second at 7%.

"In two-thirds of the cases, the patient found a palpable mass herself, which was initially overlooked by the primary care physician or the radiologist," Samudrala said.

Not listening to the patient was one of the problems that resulted in incomplete care, the group found in their review. In 25% of the cases, patients complained of focal pain and tenderness, but a complete follow-up was not done. In many cases, patients found masses on their own, but because mammograms were read as negative, a pathological evaluation was not ordered.

"Mammography should not be the only tool for evaluation of a palpable mass," Samudrala said. "A complete work-up, including needle aspiration, is recommended for a patient with a palpable cyst, according to the American College of Radiology standards."

Screenings conducted without the direction of a radiologist was another recurring pattern that emerged in the lawsuits. A full one-third of claims alleged that the diagnostic study was not performed under a radiologist's supervision, Samudrala said.

Another issue was false assumptions made by the clinicians. In one instance, a palpable mass was labeled as a skin lesion by the radiologic technologist. The radiologist did not double-check the lesion and the result was a delayed diagnosis of cancer.

Improper technique served as the smoking gun in many cases. In one instance, the patient came in for a diagnostic screening and only right and left cranio-caudal views were taken.

"She came back a year later with a palpable mass that ended up being invasive lobular carcinoma. The problem here was that additional views should have been obtained in the first study in order to detect occult lesions," Samudrala said.

Finally, a lack of communication between the radiologist, the primary care physician, and the patient was cited in many lawsuits alleging malpractice. In 82% of cases, there was a lack of direct communication about suspicious or unexpected findings, Samudrala said.

Although U.S. law requires that patients be notified of screening results in writing, clinicians would be wise to go the extra mile and call the patient as well as the referring doctor. In a separate presentation at the National Conference on Breast Cancer in April, Dr. Carl D'Orsi of the University of Massachusetts Medical Center in North Worcester suggested that mammographers use "good horse sense" when discussing results.

"There's no legal requirement that you need to speak with the referring physician on the phone, but it's important to have that human element. Don't assume that the primary care physician is going to pass the information on to their patient, either. If you can talk to the patient for even five minutes, you can create that bond," he said.

Clear communication may be especially important when dealing with patients who are under age 50. Based on the PIAA survey of 117,000 cases over a five-year period, 60% of plaintiffs were less than 50 years old, Samudrala said. The younger the patient, the higher the payment, she added.

"It sort of takes you aback when you realize that over 50% of the medico-legal cases (involve women) under 50," commented Dr. Alfred Watson Jr., the ARRS session moderator. "Those are the ones that we really need to watch for. You have a young mother or wife involved and there's a lot of emotion that goes into the trial. It's harder to defend these cases."

By Shalmali Pal
AuntMinnie.com staff writer
May 17, 2000

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