To Avoid Malpractice, Radiologists Must Communicate

CHICAGO - With the roll-out of the Affordable Care Act (ACA) still ongoing and the move toward some type of accountable care organization model still underway, it’s unclear how radiology will fare in any medical malpractice lawsuits.

But, industry experts at this year’s Radiological Society of North America meeting all point to one key component of financial survival – communication. Communication with referring physicians, the patient, and each other.

“You have to remember there are three factors to communication – the referring physician, the radiologist, and the patient,” said Leonard Berlin, MD, a radiologist with NorthShore University Health System. “Communication is the link between all three. It’s obviously a real problem when there’s a failure to communicate emergency or acute findings, but it’s significant that there’s a large amount of significant and unexpected findings that don’t get communicated either.”

The State of Medical Malpractice in Health Care
The impetus behind medical malpractice cases remains the same, according to Graham Billingham, MD, chief medical officer for Medical Protective Company, the largest U.S. professional liability medical malpractice insurance company.

“You don’t get sued for a bad outcome – you get sued for a bad outcome and an upset family,” he said. “A big part of the problem is that people don’t understand the coverage they have, so they’re hit with big deductibles. And, if they have a bad outcome and are also sent to hospital collections, there’s a lot of pressure that comes with that.”

And, with 40% to 50% of patients still unable to afford healthcare premiums under the ACA, this is a problem that will grow. It’s possible to defuse patient tension and reduce the risk of lawsuits, he said, by keeping them updated about any clinical findings

“Patients want to be in the game and be told what’s going on, and for years, we’ve put up walls,” he said. “A number of people think that’s wrong and patients get more upset when they get stonewalled. We should probably have these conversations.”

He also cautioned providers that patients’ attorneys can now subpoena personal, hand-held devices, such as iPads and smartphones, to show whether providers were distracted at a time when the patient experienced a bad outcome. Everything within and outside the electronic health record (EHR) is time-stamped.

Medical Malpractice in Radiology
In radiology, 75% of lawsuits center around a failure to diagnose or communicate, Billingham said. Most diagnostic misses happen with breast cancer, abdominal and pelvic scans, and fractures, and 56% of errors are subtle. Mammography is mentioned in 43% of cases, and X-rays and CT in 19% and 15%, respectively.[[{"type":"media","view_mode":"media_crop","fid":"30600","attributes":{"alt":"medical malpractice","class":"media-image media-image-right","id":"media_crop_9810336756127","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3212","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 123px; width: 160px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":" ","typeof":"foaf:Image"}}]]

Poor supervision of nurse practitioners, physician assistants, and radiology assistants, as well as medication complications in the radiology suites, are also cited in lawsuits.

In 2014, radiology ranked 6^th out of 28 specialties in the frequency of medical malpractice suits filed and 5^th in the number of dollars paid out to plaintiffs. Radiologists were named in 13% of law suits against academic medical centers and in 20% of cases filed against community hospitals. In recent years, he said, the average payout has risen from $350,000 to $409,000.

Radiology also faces a new set of trends that could result in more lawsuits, Billingham said. New procedures; patients with larger body mass indexes; pediatric exposure regulations; radiation burns; dose creep; proper training for associated radiology assistants, physician assistants, and nurse practitioners; and the need for sufficient records of communication all present additional risks.

Survival Strategies
In some cases, radiologists can shield themselves somewhat by joining large, consolidated health systems or multi-specialty practices. This type of move is an effective way to share the financial burden of medical malpractice insurance, but it can’t protect individual providers from being sued, said Jonathan Berlin, MD, a diagnostic radiologist with NorthShore Medical Group. It’s no longer easy to simply shift responsibility to another provider.

“It’s a misconception that if you blame someone else, that you won’t be affected, so responses like ‘Who’s the idiot who missed this?’ aren’t really appropriate,” he said. “You must be cognizant that responses like that aren’t helpful if you ever end up facing a medical malpractice suit.”

To truly protect themselves, providers must proactively seek out all information available to them, he said. Compare current tests to previous ones, and remember to search for any previous exams that might have been conducted with a different modality.

Reduce cognitive errors by seeking the opinions of others, he said. Don’t hesitate to seek out the input of the technologist who performed an exam.

In addition, said Leonard Berlin, radiologists must be more proactive about ensuring referring physicians read the radiology reports. Just sending the report isn’t enough. According to a 2011 Radiology study, 37% of referring physicians believe their interpretations are better than a radiologist’s, and 15% admit they don’t read radiology reports at all.

Rather than leaving the onus on the referring physician, he said, radiologists must become more comfortable with reaching out. A recent American College of Radiology member survey revealed that while 97% of providers will make a phone call to a referring physician with emergency findings, only 24% will call about the unexpected, significant findings. It’s those often-overlooked findings that can lead to malpractice law suits – and the radiologist could be held liable for ineffective communication.

Ultimately, he said, radiologist must take more responsibility going forward in educating patients about their health findings. The advent of web-based patient portals is a step forward, but they aren’t a guarantee that patients will be kept up-to-date. Direct patient contact is preferable.

“If the patient doesn’t want to read the report, they won’t go find it,” Leonard Berlin said. “So, if there’s an accusation of a delay to diagnose, you can’t sit there and blame the patient. The jury won’t buy it. We have to be aggressive and take the active stance. We can’t be passive.”