Bioethics Discussion Blog: Responsibilities of a Radiologist: Acknowledging Interpretation Errors to the Patient?

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Thursday, November 01, 2007

Responsibilities of a Radiologist: Acknowledging Interpretation Errors to the Patient?

The doctor-patient relationship and the trust which is expected by the patient has been discussed on this blog and others. But the question can be asked as to where the doctor-patient relationship begins and ends. One example of a professional activity where the relationships might be unclear and perhaps ambiguous is that of the radiologist who inspects and interprets (?diagnoses?) the radiologic results. The patient may have never seen the radiologist and may be even unaware of the radiologist's name or experience. When the radiologist has performed his or her duties by interpreting the film, to whom is the radiologist professionally related? The patient? Or the physician who ordered the X-ray or other exam? And what if later it is found that the radiologist has made a mistake or missed a critical diagnosis..has, for example, made an interpretation which is regarded as a false negative. If, as is currently emphasized in the medical, ethical and legal literature the importance of acknowledging medical error and offering the patient an apology at a minimum, if not also an offer of compensation as indicated, which professional should assume that responsibility? The current treating physician who may or may not have been involved in the previous diagnosis or the radiologist who may have never seen the patient but had read the film?

Here is the scenario that was presented in this month's Virtual Mentor on this subject which was then commented upon by Thomas H. Gallagher, MD, and R. James Brenner, MD in the article entitled "Disclosure and the Retrospectoscope." Please go to the link, read the commentary and then return to express your views of this case and what you think would be the right and ethical approach toward resolution. ..Maurice.


Mrs. Lee is a busy, working mother. She has raised three children, all of whom are successful attorneys, and was looking forward to retirement when she was diagnosed with breast cancer in her left breast. Her tests following surgery showed no cancer, and six months later Mrs. Lee went to a breast imaging center for a follow-up visit.

Dr. Harris reviewed old imaging studies in preparation for her meeting with Mrs. Lee. She looked at the mammogram that had been interpreted as normal by another radiologist, 18 months before Mrs. Lee was diagnosed with breast cancer. After careful examination, Dr. Harris noted a small, ill-defined density in the left breast. It was in the location where the cancer was diagnosed on the subsequent mammogram and, in retrospect, it most likely represented the cancer in an earlier stage. In her own mind, Dr. Harris believed that many radiologists, possibly even she herself, would have interpreted the mammogram as normal. She wondered whether to tell Mrs. Lee what she had seen.

17 Comments:

At Saturday, November 03, 2007 10:40:00 AM, Blogger MJ_KC said...

In my opinion, this is far from being a situation with a clear answer. Once a growth gets to a large enough size, it is easy to make the diagnosis. At that point, knowing the exact location can allow a doctor to review earlier scans and pinpoint when it first became possible to see the problem.

That doesn't mean that an error was made in the early imaging interpretation, but just that hindsight is 20/20.

I speak from personal experience on this issue. I had Hodgkin's Lymphoma diagnosed in late 1975 and my doctors said that the mass in my chest could actually be seen in its early stages in an x-ray taken early in the year. When you already know exactly what to look for and where to look, it is easy to go back and see something that nobody would have been likely to see at the earliest possible time.

To expect this to be possible is not realistic in my opinion. We might wish it was possible, but that doesn't mean that we have the right to expect it.

 
At Saturday, November 03, 2007 10:58:00 AM, Blogger Maurice Bernstein, M.D. said...

MJ KC, was it the attending physician or the radiologist or some other doctor who told you about the previous X-ray results? How did he or she actually break the "news"? Or was that original spot known to you when it was first discovered? ..Maurice.

 
At Saturday, November 03, 2007 5:51:00 PM, Blogger MJ_KC said...

It was my family doctor. He was the one who had taken the original x-ray about 7 months before the diagnosis was made. It was taken because of a bad lung infection.

He indicated that there was a very tiny dot on the x-ray that he could only see because he knew exactly where to look. I think he used a hand magnifier to look at the area of the x-ray.

I think that he was the one who sent me to an oncologist when he took another x-ray later in the year because of another lung infection. I used to have a lot of these. It was clearly visible at that point.

This was a long time ago and the scanning technology was nowhere close to what is available now. Even the oncologists had to rely mainly on plain old x-rays to see what was going on.

 
At Sunday, November 04, 2007 6:29:00 PM, Blogger Maurice Bernstein, M.D. said...

MJ KC, it sounds like there was avery trusting and good doctor-patient relationship in your case. On the other hand, what would be your opinion as to whether a radiologist who had no direct relationship or communication with a patient should be responsible for speaking directly now to the patient and informing about his or her error and as appropriate apologize? ..Maurice.

 
At Sunday, November 04, 2007 7:03:00 PM, Blogger MJ_KC said...

I would say yes to this only if it was clearly a mistake. Not if it was something that would have been very difficult to detect without already knowing the location of the problem.

Medical personnel should strive to do their best, but to expect perfection is not reasonable of anybody in any profession.

 
At Monday, November 05, 2007 1:33:00 PM, Anonymous Anonymous said...

The reason for informing the patient is also important. What is the point of telling him that the dr could have known he had deadly cancer three years ago when the outcome would have been the same? If the only reason we see the 'mass' is because we know where to look, then there is no reason to inform the patient especially since the outcome might be a lawsuit. Obviously, things change when it is clear to all and sundry that there could be something there.
I think the problem is worse the drs says there is something, and treatment is started and it turns out there is nothing. Eg, Discovering there was no breast cancer after a masectomy.

 
At Tuesday, November 06, 2007 5:59:00 PM, Anonymous Buttercup said...

Another tale from the patient's perspective: had a missed finding from years ago that was discovered recently, not something that would have impacted my clinical course but could have. I tried to contact the radiologist to discuss what had happened and wasn't permitted to speak with him. I just wanted to understand what had happened, and it felt very disrespectful that this physician who held the responsibility of reading my films wouldn't talk to me directly. As physicians don't radiologists have a duty of care that extends beyond that dark room?

 
At Tuesday, November 06, 2007 6:43:00 PM, Blogger Maurice Bernstein, M.D. said...

Buttercup, your question "As physicians don't radiologists have a duty of care that extends beyond that dark room?" exactly defines the reason I put this thread up for review. I would think that most people and physicians themselves would answer "yes". But to what extent does the "care" go? To the referring general physician? Or beyond, to the patient where no direct relationship has been established?
That is the question. ..Maurice.

 
At Tuesday, November 06, 2007 9:15:00 PM, Anonymous Buttercup said...

Right -- well, putting the referring physician in the middle can pose disadvantages as well. I would've rather heard directly so as not to put my internist in the awkward position of mediating. Professional collegiality can be a hindrance to complete candor when talking to patients about another physician's error. Since I would have rather established that "direct relationship" with the radiologist, my suggestion is that the patient's wishes be respected whenever possible.

 
At Tuesday, November 06, 2007 10:22:00 PM, Blogger Maurice Bernstein, M.D. said...

Buttercup, I wish we had a lawyer here to help with an answer to the question from a legal point of view. Could it be that by assuming the responsibility of performing a consultation for a case, even if the radiologist and patient have never met face to face, the assuming by the radiologist constitutes that a doctor-patient relationship has been established with all of the legal requirements associated with it?

From an ethical point of view, I find no reason not to conclude that the radiologist has a direct ethical duty to the patient and should make errors known to both the referring physician and the patient. ..Maurice.

 
At Thursday, November 08, 2007 12:23:00 PM, Anonymous js md said...

Ethical dilemmas. Unfortunately I rarely come across a clear cut answer unless the law is clear, in which case the law takes precedence even if the ethics are debatable (which they usually are).
I cannot say if the radiologist should report the oversight to anyone. It really depends on whether the lesion was clear enough that it should have been routinely at least questioned in the report and follow up recommended. If it was clearly an oversight or gross error, the ordering physician should be notified first. One cannot call a patient out of the blue and say 'You don't know me, I'm Dr X and I missed your cancer.' Most malpractice carriers would entertain such a question from a doctor and give advice. I'd like to know what advice they would have given the radiologist though that's a step removed from the ethics involved. But a physician who didn’t notify his carrier and talked to a patient, with whom he had no legal relationship, might be in trouble with his carrier.

 
At Thursday, November 08, 2007 8:37:00 PM, Blogger MJ_KC said...

Radiologists can't hide their heads in the sand any more. Their names will be attached to the medical findings based on what they see when they interpret a scan.

Some hospitals are to the point where various types of scans are stored on a central server and can be called up for review by the prescribing physician, often while they are in the examining room with the patient. It will be very easy for a doctor to call up a previous scan and see what was visible in the same area where a problem is indicated on newer scans.

It isn't the old days where it would be difficult and time consuming for a doctor to access old scans. I have already seen this done with CT scans and echo cardiograms.

 
At Friday, November 16, 2007 3:59:00 PM, Anonymous kvs said...

My husband and I both had mri's done on our backs. Both of our mri's showed something wrong on our right kidney. I thought there was a mix up, but they said we each had a different problem. My husbands radiologist called our pain clinic doctor , who then called our family doctor. They wanted him to come in for testing right away- it happened so fast I decided to wait to see what the deal was with mine.
My doctor has a copy of my report but has never contacted me about it. Does this mean there is nothing to worry about? My pain doctor never said anything either - he saw the report before I did and I didn't read it until I came home with a copy from them.
So it must be nothing since 3 professionals saw it and never said anything?

 
At Friday, November 16, 2007 5:55:00 PM, Blogger Maurice Bernstein, M.D. said...

kvs, I can't defend the inaction of your family doctor or pain doctor's inaction in communicating the result of you MRI to you. You must call them and ask both of them specifically regarding their understanding of the MRI reading.

I have never said to the patient "Go get this test and if I don't call you with the results you can know that the test was normal." I think this is unprofessional and represents unconcern for the patient's concern. It is also a source of potential error. If the patient doesn't get a call back from the doctor with the results, who can say that the doctor even received the results or the doctor received the results and it was filed away by staff without even the doctor reading the results?

I'm sorry that your husband needs further evaluation and possible treatment. However, I am also sorry that you are not getting the best care since since you still remain ignorant of the results of your test. Call them! ..Maurice.

 
At Saturday, November 17, 2007 1:09:00 PM, Anonymous kvs said...

I keep trying to get back to you and once I send it , it fails and I have to type all over again. So it's keep getting shorter... But my husband had his kidney out Wed., they said it was enlarged and nonfunctioning. He's doing well, but it'll be a long few weeks I guess.
We would have to wait regardless of what my results are as our medical bills are way out of our budget with all the tests they ran for him. I guess mine said it was only a 2cm mass, so maybe it is no big deal and it normal.
Thanks again, it really means alot to me that there is someone I can talk to.
kvs

 
At Saturday, November 17, 2007 5:57:00 PM, Blogger Maurice Bernstein, M.D. said...

kvs, obviously I can't diagnose your study but didn't your doctors discuss with you not only the findings on the MRI but also it's possible significance. If they discribed a cyst, then maybe 2cm cyst might be normal. If they described a mass, you should talk to your doctors about it.

With regard to the cost of medical care including the issue of patients avoiding or delaying necessary surgery because of their financial status is a topic about which I should start another thread! ..Maurice.

 
At Friday, September 24, 2010 11:02:00 AM, Anonymous Anonymous said...

As a practising radiologist, I have different view to your blog. In some hospitals like us where Radiologists has to report cases in shortest time to cover all patients report. It becomes sometime difficult to maintain the quality for all cases despite of keeping all precautions.

Moreever these errors can happened at any level from registration of the patient, typing mistake, spelling mistake or machines related artifacts.

I would like to invite all of you to discuss this issue at following blog where we Radiologists are currently discussing the topic ERRORS in radiology -

http://www.iradix.in/543-errors-in-radiology-practice.html

Hope with the help of your inputs we may come to common consensus.

Regards
Dr. Mark Mathew, MD

 

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