| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Review |
1 Department of Radiology, Rush North Shore Medical Center and Rush Medical College, 9600 Gross Point Rd., Skokie, IL 60076.
Received June 21, 2007;
accepted after revision June 21, 2007.
Address correspondence to L. Berlin
(lberlin{at}rsh.net).
Keywords: communication • medical–legal issues • practice of radiology
 Top Introduction The Radiologist's Duty to...Courts Extend the Radiologist's...Courts Extend the Radiologist's...The Arizona Court Decision...The Mammography Quality...The Medical Community:...The Public's PerceptionThe Prevalence of Communication...Communicating Radiologic Results...SummaryReferences |
|---|
Is it not really the patient we are obligated to serve above all others?—Robert S. Sherman [1]
Writing in Radiology 41 years ago, New York radiologist Robert Sherman [1] prophetically observed that radiologists "can do an injustice to the patient by withholding our superior knowledge." Asking rhetorically "Is it not really the patient we are obligated to serve above all others?" Sherman pointed out that it is the "radiologist who is legally and ethically responsible to [patients]...for their diagnosis." Five months later, North Carolina radiologist William Sprunt [2] retorted that a "personal relationship between a patient and his doctor...cannot be satisfactorily developed in diagnostic radiology," and that radiologists "are not required to listen to prolonged descriptions of vague symptoms and systems reviews nor to make complete physical examinations. Anyone who wants to do these things should be something other than a radiologist."
A decade later, Berlin [3] described two unrelated medical malpractice lawsuits filed against Chicago-area radiologists, each alleging negligence because the radiologist had failed to directly inform a patient of the results of his or her radiologic examination. "Because the responsibilities of radiologists have expanded," suggested Berlin, "it seems possible that radiologists may eventually be charged with directly informing patients of the results of procedures as well."
Exactly 13 years later, writing in the April 1990 issue of the ACR [American College of Radiology] Bulletin, Wyoming radiologist and member of the ACR Professional Liability Data Collection Committee Steven Liston [4] called the radiology community's attention to a type of litigation that until that time had received little notice:
A new kind of legal action against radiologists seems to be emerging. It has been claimed that radiologists who find a cancer are at fault for failing to assure proper communication of their diagnoses.... Damage awards were made because the radiologist did not effectively communicate a finding...or because effective communication was not documented in a permanent record.... In the cases we have seen, the radiologist was held responsible for assuring the report of possible cancer was received and understood, not just that it was sent.
Indeed, malpractice litigation alleging failure of radiologic communication had quietly and almost imperceptibly begun. In the Chicago area, lawsuits alleging failed radiologic communication, although still accounting for fewer than 2% of all medical malpractice cases filed against radiologists, nevertheless rose from four during 1975–1979 to 11 in the next 5-year period, and increased to 15 in the period from 1985 to 1990 [5–7]. In New York, however, radiologist Harold Schwinger reported that during the same general period, communication cases constituted more than 15% of radiology malpractice lawsuits [8].
The Radiologist's Duty to Communicate Begins to Evolve
|
TopIntroductionThe Radiologist's Duty to...Courts Extend the Radiologist's...Courts Extend the Radiologist's...The Arizona Court Decision...The Mammography Quality...The Medical Community:...The Public's PerceptionThe Prevalence of Communication...Communicating Radiologic Results...SummaryReferences |
|---|
It seems to have been the advent of screening mammography that began bringing about a change in this practice pattern. Previously the referring physician would suspect an abnormality because of a patient's symptoms or clinical findings, order a radiologic examination, actively await its results, and likely contact the radiologist if a written interpretation was not received in timely fashion. With screening mammography, however, because patients were asymptomatic and both the referring physician and patient expected the results to be normal, physicians were not likely to seek out the report if it went astray. The fact was, however, radiologists' reports not only of mammograms, but of other radiologic examinations as well, were indeed going astray—and the ACR leadership took notice.
In 1985, the ACR published a leaflet, "Policy Statement: Breast Cancer Screening Centers" [10], that contained the following admonition:
A positive finding should be reported promptly in writing to a physician.... The radiologist must be certain that the result of a positive mammogram is acknowledged by the primary care physician.... In all cases, appropriate acknowledgment of the notification should be sought.
Shortly thereafter, radiologists Bird and McLelland [11] spelled out radiologists' duties in more specific terms: If a mammogram is suggestive of malignancy, the referring physician should receive a telephone report in addition to the written report. Schwinger [8] later added that because "first class mail is not always reliable" and "radiologists frequently cannot depend on the clinician reading a written report," radiologists should "directly contact referring physicians by telephone."
In 1990, the ACR issued its first Standards focusing on communication of radiologic results, although the Standards dealt specifically with screening mammography [12]:
All reports in the high probability category should be communicated to the referring physician or his designated representative by telephone, by certified mail, or communicated in such a manner that receipt of the report is assured and documented.
One year later, the ACR published its first Standards dealing exclusively with communication in all aspects of diagnostic radiology [13]: "Some circumstances...may require direct communication of unusual, unexpected, or urgent findings to the referring physician in advance of a formal written report." The communication standard (changed to "practice guideline" in 2003) underwent revision in 1995, 1999, 2001, and 2005.
Other articles calling for direct communication between radiologist and referring physician began appearing in the radiology literature. Potchen et al. [14], in 1991, wrote that "Radiologists should attempt to establish a standard practice of verbal communication whenever a surgical consultation is recommended," and that a notation of the verbal communication should be included in the written report. Brenner [15, 16] stated that direct communication between radiologist and referring physician is "most likely required" whenever there is a suspicious finding on a mammogram, adding that "a suspicious mammographic finding imposes on the radiologist a higher duty for directly communicating the results to the referring physician."
Against the backdrop of this increasingly recognized expansion of the radiologist's duty to directly communicate to the referring physician significant radiologic findings, there began to emerge a second trend, one that began with little notice by most of the radiology community: extension of the radiologist's duty to include communication of findings directly to patients. Direct patient communication was fueled by four sources: the judiciary, the radiology community itself, the federal government, and the consumer movement. Let us examine each in greater detail, beginning with the courts.
Courts Extend the Radiologist's Duty to Communicate to the Referring Physician
|
TopIntroductionThe Radiologist's Duty to...Courts Extend the Radiologist's...Courts Extend the Radiologist's...The Arizona Court Decision...The Mammography Quality...The Medical Community:...The Public's PerceptionThe Prevalence of Communication...Communicating Radiologic Results...SummaryReferences |
|---|
Two years later, a State of Washington appellate court ruled similarly. A 16-year-old boy who had sustained an injury to his neck in an automobile accident underwent radiographic examination at the request of the examining emergency department physician. The emergency physician interpreted the study as normal and the patient was discharged. Later that day a radiologist interpreted the radiographs as showing compression fractures of two cervical vertebrae. The report was mailed, but was not received by the patient's attending physician until 4 days later. Because of the resulting delay in treatment, the patient suffered permanent neurologic damage. He later filed a lawsuit against the radiologist for failure to communicate the radiographic findings directly to the emergency department physician. In ruling against the defendant radiologist, the court stated [18]:
The community medical standards of that area would require telephone communication to [the emergency physician] by [the radiologist] of the X-ray diagnosis.... Because of the serious implications of the report, a personal contact was required to insure prompt action.
Two other state appellate or supreme court decisions dealt with the same issue and are worthy of mention. First, in Ohio, a 4-year-old girl who had injured her arm underwent radiographic examination, which was interpreted as normal by the emergency department physician. On the following day, the hospital-based radiologist interpreted the study as disclosing a fracture of the distal humerus. The radiologist dictated the report and sent it through usual hospital channels, but the patient's family physician claimed that he never received it. As a result the child sustained permanent deformity. In an oft-quoted decision, an Ohio appeals court stated [19]:
The communication of a diagnosis...may be altogether as important as the diagnosis itself.... The particular form of communication must depend on the fact and the circumstances of the case.... In certain situations, direct contact with the treating physician is necessary beyond communication through administrative personnel. Certain medical emergencies may require the most direct and immediate response involving personal consultation and exchange.
In the second case, a North Carolina appeals court also upheld a radiologist's duty to communicate significant findings directly to a referring physician. Cervical and thoracic spine radiographs ordered by an emergency department physician on a patient who had fallen from a truck were interpreted by the radiologist as essentially normal, but included in the radiology report was a statement that the C7–T1 level was not well visualized. No additional studies were done, the diagnosis of a C7 fracture was delayed, and a lawsuit followed. The radiologist later claimed that he had verbally communicated that information to the emergency department physician, but the physician testified that he had not been so informed by the radiologist. In the subsequent court proceeding, the radiologist acknowledged in his testimony that he had a duty to inform the emergency physician directly that the C7–T1 area was not well shown. The court ruled that the radiologist's "own testimony established the standard of care by which his actions are to be judged" [20].
Courts Extend the Radiologist's Duty to Communicate to the Patient
|
TopIntroductionThe Radiologist's Duty to...Courts Extend the Radiologist's...Courts Extend the Radiologist's...The Arizona Court Decision...The Mammography Quality...The Medical Community:...The Public's PerceptionThe Prevalence of Communication...Communicating Radiologic Results...SummaryReferences |
|---|
In the New Jersey case, a routine chest radiograph obtained on a woman who had been admitted to a hospital for treatment of a fractured wrist was interpreted correctly by the radiologist as disclosing a probable carcinoma of the lung. However, the radiologist's written report never reached the ordering physician or the patient's hospital chart before her discharge. Diagnosis of the tumor was thus delayed, the patient ultimately died of carcinoma, and her family sued the radiologist and her physician because of the delay in diagnosis. The radiologist denied liability but the court disagreed, stating [21]:
...In some situations, indirect service may provide justification for the absence of direct communication with the patient [underlining added], but that does not in any way justify failure of communication with the primary care physician.
The Supreme Court of Arkansas went a bit further. A breathing tube had been placed in the trachea of a 20-year-old man who had suffered a fracture of the cervical spine in a diving accident. A subsequent radiograph of the neck was interpreted by the defendant radiologist as disclosing displacement of the tube. The radiologist dictated and later signed a written report to that effect, but there was no direct communication with the treating physicians. Receipt of the report by the treating physicians was thus delayed, aggravating the injury to the patient. Although the court found the defendant radiologist not liable because of the technical reason that no expert witness had testified against him, nevertheless the court did state [22]:
[The patient] was in a life-threatening situation and indeed almost died. He deserved more than routine care under these circumstances.... When a patient is in peril of his life, it does him very little good if the examining doctor has discovered his condition, unless the physician takes measures and informs the patient [underlining added], or those responsible for his care, of that fact.
Other state appeals courts were far more direct in declaring that at times radiologists indeed have a duty to communicate abnormalities directly to patients. A District of Columbia federal appeals court turned its attention to a 20-year-old potential armed forces inductee who had undergone chest radiography. A radiologist under contract with the Selective Service System interpreted the radiographs as suggestive of lymphoma. The potential recruit was rejected for service without explanation and was never informed of the radiographic finding. He later was diagnosed as having Hodgkin's disease and eventually died. The patient's family sued the federal government, claiming that the radiologist who had been retained to interpret the radiographs was negligent for failing to inform the recruit of the abnormal radiographic findings. The court held that the radiologist had the duty to inform the patient of radiologic results [23]:
The government physician was under a duty to act carefully, not merely in the conduct of the examination but also in subsequent communications to the examinee.... It was the doctor's silence that misled the examinee.... [The plaintiff] assumed that the silence of the examining physicians meant that the results of tests they had performed were negative.... A physician undertaking a physical examination has a duty to disclose what he has found and to warn the examinee of any finding that would indicate that the patient is in danger and should seek further medical evaluation and treatment... [The radiologist] owed a duty of care to [the plaintiff and] breached this duty when he failed to notify him of his abnormal X-ray.
A Louisiana court ruled similarly. Although the case involved a primary care physician who had been contracted by an employer to conduct a preemployment physical examination on a potential employee, the ruling could equally apply to a radiologist. The plaintiff filed a lawsuit against the physician, alleging injury due to the physician's failure to inform the patient that he had an early carcinoma. In ruling that the physician could be held liable for this failure of communication, the court stated [24]:
In placing oneself in the hands of a person held out to the world as skilled in a medical profession, albeit at the request of one's employer, one justifiably has the reasonable expectation that the expert will warn of any incidental dangers of which he is cognizant due to his peculiar knowledge of his specialization.... This imposes on the examining physician a duty to conduct the requested tests and diagnose the results thereof...and to take reasonable steps to make information available timely to the examinee of any findings that pose an imminent danger to the examinee's physical or mental well-being.
A Washington State federal appeals court in 1991 dealt with a similar issue, this time specifically involving a radiologist. The radiologist had been employed by a Veterans Administration hospital to interpret a chest radiograph obtained on a man undergoing a preemployment physical examination. The radiologist noted an abnormality that later proved to be sarcoidosis. However, the patient was never informed of the findings until 4 years later, when the diagnosis was established. Alleging that the delay in diagnosis caused permanent injury to his health, the patient sued the radiologist for malpractice. The patient was awarded damages at the trial court level, but the case was appealed by the defense. The federal appeals court, after pointing out that "most courts that have considered this question (e.g., Louisiana, Maryland, Ohio, New York, New Jersey, and Mississippi) had reached similar results," affirmed the jury award, ruling that the radiologist had breached a duty to communicate with the patient [25]:
We have a little trouble holding that the VA radiologist owed [the plaintiff] a duty.... At a minimum, the radiologist should have notified [the plaintiff] of the abnormality. This duty is hardly burdensome.
The Arizona Court Decision and Its Far-Reaching Implications
|
TopIntroductionThe Radiologist's Duty to...Courts Extend the Radiologist's...Courts Extend the Radiologist's...The Arizona Court Decision...The Mammography Quality...The Medical Community:...The Public's PerceptionThe Prevalence of Communication...Communicating Radiologic Results...SummaryReferences |
|---|
The defendant radiologist then brought an appeal to the Arizona Supreme Court, which affirmed the appellate decision in language that may well exert considerable influence on courts in many other states and therefore warrants the careful attention of all radiologists [27]:
[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.... By virtue of his undertaking to review [the patient's] X-ray [the radiologist] placed himself in a unique position to prevent future harm to [the patient].... In such a circumstance, an examinee reasonably expects the physician to sound the alarm if any serious abnormality is discovered.... The trend [among] courts in many jurisdictions now favors imposing a duty, and 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.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 would 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 abnormality 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...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 facts presented at trial. Given that juries are often sympathetic to patients who have been injured while under medical care and may have difficulty understanding why a radiologist would not directly inform patients of significant abnormalities, it is reasonable to believe that juries may be disposed to more likely than not find radiologists negligent under such circumstances.
The degree to which the Arizona Supreme Court decision will affect courts in other states remains to be determined. However, the Arizona court's written decision is far from superficial or flippant; on the contrary, it is one that goes into minute detail and uses numerous authoritative sources to justify its outright rejection of previous court decisions that had exempted radiologists from the duty of directly communicating radiologic abnormalities to patients. Because of its depth and analytic perspective, the Arizona court decision may become a watershed that once and for all opens widely the judicial door to the radiologist's duty to communicate to patients. It will be interesting to see whether appeals courts in other states adopt a similar stance in future decisions.
Let us now turn to the U.S. government's involvement with radiologic communication.
The Mammography Quality Standards Act (MQSA) and Its Impact on Malpractice Litigation and Referring Physicians
|
TopIntroductionThe Radiologist's Duty to...Courts Extend the Radiologist's...Courts Extend the Radiologist's...The Arizona Court Decision...The Mammography Quality...The Medical Community:...The Public's PerceptionThe Prevalence of Communication...Communicating Radiologic Results...SummaryReferences |
|---|
Each facility shall send each patient a summary of the mammography report written in lay terms within 30 days of the mammographic examination. If assessments are "suspicious" or "highly suggestive of malignancy," the facility shall make reasonable attempts to ensure that the results are communicated to the patient as soon as possible.
A Physician Insurer's Association of America–ACR survey published in 1997 disclosed that a substantial percentage of malpractice lawsuits filed against radiologists had been brought by women who alleged that they had not been informed that their mammograms had been interpreted as suspicious for carcinoma [29]. Implementation of the MQSA, with its mandate that mammographic results be transmitted directly to patients, has virtually eliminated failure-of-radiologic-communication medical malpractice lawsuits involving mammography.
Many referring physicians who had historically held the paternalistic belief that it is only they who should give radiologic results to their patients reacted with displeasure when the MQSA mandated that radiologists communicate mammographic results directly to patients. However, inasmuch as this communication had been instigated and imposed by the government rather than by any voluntary effort on the part of the radiology community, referring physicians had no choice but to accept this new standard, and any displeasure they voiced seems to have quietly and quickly disappeared.
Let us now consider the medical community's influence in shaping the radiologist's duty to communicate findings directly to patients.
The Medical Community: Nonradiology and Radiology
|
TopIntroductionThe Radiologist's Duty to...Courts Extend the Radiologist's...Courts Extend the Radiologist's...The Arizona Court Decision...The Mammography Quality...The Medical Community:...The Public's PerceptionThe Prevalence of Communication...Communicating Radiologic Results...SummaryReferences |
|---|
The patient has the right to receive information from physicians and to discuss the benefits, risks, and costs of appropriate treatment.... Patients are also entitled to obtain copies or summaries of their medical records [and] to have their questions answered.... It is a fundamental ethical requirement that a physician should at all times deal honestly and openly with patients. Patients have a right to know their past and present medical status."Independent medical examiners," who are independent contractors providing medical examinations within the realm of their specialty, [have] the same obligations as [other] physicians.... The physician has a responsibility to inform the patient about important health information or abnormalities that he or she discovers during the course of the examination. In addition, the physician should ensure to the extent possible that the patient understands the problem or diagnosis.
The ACR bylaws [31] do not specifically address radiologist–patient communication. Nonetheless, they do state that "The principal objective of the medical profession is to render service to people with full respect for human dignity and in the best interest of the patient.... Members should...deal honestly and fairly with patients."
The ACR Standard for Communication has been mentioned previously in this article. In its 1999 revision, the standard for the first time introduced the concept of direct communication to the patient [32]:
In those situations in which the interpreting physician feels that immediate patient treatment is indicated...the interpreting physician should communicate directly with the referring physician.... If that individual cannot be reached, the interpreting physician should directly communicate the need for emergent care to the patient [underlining added] or responsible guardian, if possible.
The latest revision of the ACR Practice Guideline for Communication, which became effective October 1, 2005, contains several provisions pertaining to communication with patients [33]:
Diagnostic imagers should recognize that performing imaging studies on self-referred patients establishes a...responsibility for communicating the results of imaging studies directly to the patient....Regardless of the source of the referral, the diagnostic imager has an ethical responsibility to ensure communication of unexpected or serious findings to the patient. Therefore, in certain situations the radiologist may feel it is appropriate to communicate the findings directly to the patient.
Various members of the radiology community have overtly espoused direct communication of radiologic findings to patients. Radiologist Heather Ohrt, writing on behalf of the ACR Committee on Ethics [34], has pointed out that a radiologist's disclosure of examination results directly to patients is both ethically and legally appropriate. Indiana radiologist Richard Gunderman, discussing how radiology residents can improve communication skills, observed [35]:
Keeping the patient "in the dark" merely breeds uncertainty and anxiety, and a sense of impotence that is antiethical to a strong patient–physician alliance.... Keeping patients informed and involved bespeaks a high level of physician respect that helps to preserve and promote patients' sense of their own vigor and dignity.... Communication deserves every bit as much one-on-one attention as differential diagnosis and catheter technique.
Arl Van Moore, Jr., chair of the ACR Board of Chancellors, recently offered the following advice to radiologists [36]:
In today's health care culture, we cannot simply envelop ourselves with our high-resolution monitors and our vividly detailed images and tell ourselves that we are focusing on what is important. Today's uncompromising health care culture places a tremendous emphasis on communication. It is now a critical key not only to what we do, but also to who we are.... [Undertake] one-on-one communication with your patients...[and] make that extra effort to interact with patients and their families and not be a detached member of the health care team.
One well-known academic institution has already taken steps to make direct communication to patients a reality. The University of Pennsylvania's radiology department has undertaken a research project to determine the feasibility and efficacy of sending results of radiologic studies directly to patients (Bryan RN, written communication, June 17, 2007). A randomized set of patients who have undergone chest radiography, chest CT, or brain MRI at the university receive a letter signed by the department chair informing them of the name of the radiologist who interpreted their study and that the results of the examination will be forwarded to the referring physician. The letter recommends that patients call their physician to discuss the results and informs them that they can request a copy of their radiology report by calling a telephone number or logging on to a Website, both of which are plainly identified in the letter. In addition to the letter, patients receive a consumer satisfaction survey. Patients are also tracked to determine if receiving a letter improves compliance with the follow-up examination. It is the intention of the department radiologists to begin sending these letters to all outpatients and eventually sending them their radiology reports as well. Depending on the responses from patients and the reactions of the attending physicians, the radiology staff will decide whether to continue this practice.
Finally, the Joint Commission on Accreditation of Healthcare Organizations, although not directly focusing on radiologists specifically, also emphasized direct communication with patients when the new standards it issued in 2001 required hospital personnel to inform patients and their families of the outcomes of medical care [37].
Let us now turn our attention to the public at large and gauge its wishes regarding radiologic communication.
|
TopIntroductionThe Radiologist's Duty to...Courts Extend the Radiologist's...Courts Extend the Radiologist's...The Arizona Court Decision...The Mammography Quality...The Medical Community:...The Public's PerceptionThe Prevalence of Communication...Communicating Radiologic Results...SummaryReferences |
|---|
A New York Times article [39] describes the anxiety experienced by a woman who spent "two terrible days waiting by the telephone" for her doctor to tell her about results of a CT examination she had undergone to investigate a suspicious mass in her chest: "All those clichés when someone is facing a terminal diagnosis are true; racing pulse, dry mouth, total self-preoccupations with what-ifs to the point that real life doesn't exist—willing the telephone to ring."
Would this anxiety be alleviated if patients received reports of their radiologic studies from the radiologist? A 1993 survey disclosed that 75% of referring physicians and 90% of radiologists favored a radiologist's directly informing patients of results of their radiologic examinations [40]. A 1995 survey conducted by Texas radiologist Melvyn Schreiber et al. [41] found that 94% of patients believe that they are entitled to an explanation of the test results by the radiologist. A subsequent survey by Schreiber [42] reiterated support by both radiologists and nonradiology physicians for such direct communication by the radiologist.
A 1994 survey of women's attitudes regarding mammographic results, conducted 5 years before the MQSA policy on communication was instituted, disclosed that more than 90% of respondents agreed that the radiologist should send a report of the mammographic findings directly to them [43].
It seems quite clear that the public is receptive to, if not desirous of, direct communication from radiologists regarding results of their radiologic examinations.
The Prevalence of Communication Problems
|
TopIntroductionThe Radiologist's Duty to...Courts Extend the Radiologist's...Courts Extend the Radiologist's...The Arizona Court Decision...The Mammography Quality...The Medical Community:...The Public's PerceptionThe Prevalence of Communication...Communicating Radiologic Results...SummaryReferences |
|---|
The current environment in both hospitals and physicians' offices is rife for failure of communication between radiologists and nonradiology physicians, between nonradiology physicians and patients, and between radiologists and patients. The typical primary care physician in the nation receives 800 chemistry reports, 40 radiology reports, and 12 pathology reports a week [46]. Eighty-three percent of these physicians report delays in receipt of test results, and only 41% indicated they are satisfied with how test results are managed. Communication problems related to diagnostic testing account for 47% of all errors made by typical primary care physicians in their medical practices [47]. A recent study of deficiencies in communication and information transfer at hospitals found that direct communication between hospital-based physicians and primary care physicians occurs only infrequently—3–20% of the time [48]. Discharge summaries lacked important diagnostic test results in up to 63% of patient charts reviewed. Outpatient physicians estimated that their follow-up management was adversely affected in 24% of cases due to delayed or incomplete discharge communications. Communication of diagnostic test results presented substantial patient safety concerns, with radiologic studies posing the greatest problem.
Failure of communication involving radiologic findings is associated with substantial malpractice litigation. An ACR task force charged with reviewing medical malpractice settlements and verdicts occurring during 1999–2003 [49] found that radiologist defendants were held responsible in 25% of the cases, and the average payment to the plaintiff in each case was $1.9 million. According to the Physician Insurers Association of America, communication errors in radiology are commonplace, and in fact are among the top five reasons radiologists are sued for medical malpractice [50].
With the number of radiologic examinations increasing every year in all of the 50 states, there is no reason to doubt that under the current radiologist–patient communication paradigm, there will be a corresponding increase of medical malpractice litigation generated by the failure of patients to receive reports of their radiologic examinations. Although some of these lawsuits will be directed at the family physician, many others will in addition, or instead, certainly involve radiologists [51].
Communicating Radiologic Results Directly to Patients: The Pros and the Cons
|
TopIntroductionThe Radiologist's Duty to...Courts Extend the Radiologist's...Courts Extend the Radiologist's...The Arizona Court Decision...The Mammography Quality...The Medical Community:...The Public's PerceptionThe Prevalence of Communication...Communicating Radiologic Results...SummaryReferences |
|---|
In what format would the results be transmitted? A letter describing the findings written in lay language, similar to MQSA requirements, or simply copies of the final radiology report? Should all communication be sent by U.S. mail? Could fax, e-mail, or telephone be used? Should both outpatients and inpatients receive reports? What about patients whose addresses are unknown, or who are so seriously ill that they are unable to comprehend the report? These, and many other questions, would have to be resolved.
Adopting direct patient communication could possibly generate myriad problems affecting relationships with referring physicians. In addition, the possibility exists that radiologists could find themselves in the uncomfortable position of having to advise patients on treatment options or other aspects of clinical management in which radiologists have not previously been involved and for which they are inadequately prepared, thus subjecting radiologists to potential malpractice litigation. This leads us to another important question: If there is to be communication of reports from radiologist to patient, how much information should a radiologist provide? Can the radiologist give too much information to the patient? Can the radiologist give too little information? These questions could pose a dilemma.
It is possible that giving too much information to a patient can generate problems or even a malpractice lawsuit. A decade ago, a New York Times reporter publicly lamented that a sonographic study performed during her pregnancy revealed that her fetus had a clubfoot deformity. At the end of gestation, however, the reporter mother delivered a healthy baby without the deformity. Although relieved, the mother became angry and asserted that communication between the physician and patient must be taken "far more seriously," that women who undergo sonography should be told in detail about the limitations of screening and should be informed that some studies show that there may be "no benefit to scanning in a normal pregnancy" [52]. A follow-up article pointed out that obstetric sonography has a false-negative rate of 39% and a false-positive rate of 18% relative to fetal abnormalities and that women should be told that "there are no guarantees of the results" [53].
San Francisco radiologist Roy Filly [54] addressed grave concerns about giving too much information to patients. Filly pointed out that in 10% of normal pregnancies, sonograms contain apparent "abnormalities" that can be interpreted as markers of Down syndrome but that turn out to be clinically unimportant findings. He then asked rhetorically what the radiologist performing a routine sonogram who finds one of these markers should tell the mother-to-be, answering [54]:
[Once the parents are informed of this "abnormality,"] enjoyment of the anticipation of the birth of their son or daughter is now replaced by anxiety. From my vantage point, the identification of these "abnormalities" in low-risk women has crossed the line of "more harm than good".... Think about it! For the tiny residual number of Down Syndrome fetuses that may potentially come to light by chasing down every last "marker," we intend to put at least 10% of all pregnant women with perfectly normal fetuses through a great deal of worry.So then what should I do tomorrow? Should I have the courage of my conviction to simply ignore these features? I wish I had that courage, but I don't. Even with my considerable clout in the world of obstetrical sonography, I cannot unilaterally ignore the sonographic medical literature. That is not how American medicine works.
In the event that radiologic studies show even a remote possibility of malignancy, telling a patient too much—that is, about a finding that later turns out to be a false-positive—may also cause problems by instilling into the patient a fear of cancer. Fear in an otherwise healthy person is a recognized patient injury for which juries and courts have awarded compensation. Indeed, in a medical malpractice lawsuit in which a patient claimed mental anguish, the New Jersey Supreme Court stated [55]:
The patient claimed...both physical and emotional injury...manifested in "insomnia, weight gain, and fatigue".... Courts have come to recognize that mental and emotional distress is just as "real" as physical pain and that its evaluation is no more difficult.... [The plaintiff] was entitled to be compensated for the pain and suffering endured.
The Colorado Supreme Court has ruled similarly [56]:
It has been argued that emotional damages are too speculative to permit claims of emotional distress. However, in recent years the medical profession has made advances in diagnosing and evaluating mental injuries. Psychiatry and psychology provide sufficiently reliable information concerning psychic injuries. When defendant's conduct is negligent because it may cause bodily harm, and if plaintiff escapes threatened harm but is so frightened or shocked as to be made ill, defendant is liable.
On the other hand, radiologists should be aware that patients may not be told enough. The courts of the nation have been and continue to be adjudicators of many medical malpractice lawsuits generated by a radiology report in which the interpreting now-defendant radiologist mentioned a very questionable abnormality in the patient's breast, lung, or other organ, but then concluded that the finding was a normal variant, only to find out months later that the finding did indeed represent a malignancy. "If only I had been told I had a possible cancer, I would have told my doctor to perform more tests," is the common-denominator patient complaint in these cases. Emphasized another state supreme court [57]:
The duty of disclosure...is grounded in the right of self-determination. The doctor's duty is to communicate to the patient enough material information to allow her to make an informed choice.
|
TopIntroductionThe Radiologist's Duty to...Courts Extend the Radiologist's...Courts Extend the Radiologist's...The Arizona Court Decision...The Mammography Quality...The Medical Community:...The Public's PerceptionThe Prevalence of Communication...Communicating Radiologic Results...SummaryReferences |
|---|
At present, neither the courts nor the ACR consider radiologists' communication of findings of all radiologic examinations directly to patients to be the standard of care. Whether such a duty may eventually be imposed on radiologists is yet to be determined; nevertheless, as this article points out, there does seem to be a clear trend in that direction.
In the meantime, radiologists, with an eye on the goal of potentially eliminating failure-to-communicate litigation, may wish to ponder the question of whether they want to hasten the practice. Has the time come for radiologists to embrace Sherman's 41-year-old reminder that it is indeed the patient whom they are obligated to serve and to whom they are ethically responsible for their diagnoses? Therefore, has not the time come to communicate results of all radiologic examinations directly to patients?
|
TopIntroductionThe Radiologist's Duty to...Courts Extend the Radiologist's...Courts Extend the Radiologist's...The Arizona Court Decision...The Mammography Quality...The Medical Community:...The Public's PerceptionThe Prevalence of Communication...Communicating Radiologic Results...SummaryReferences |
|---|
1. In: Digest of council actions, 2007.
Reston, VA: American College of Radiology, 2007:21
–24
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
 |
|
  L. Berlin Tuberculosis: Resurgent Disease, Renewed Liability Am. J. Roentgenol., June 1, 2008; 190(6): 1438 - 1444. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||
