Thoracic and GI anatomy present challenges to malpractice suit avoidance

Cancer of the lung is overwhelmingly the most common cause of suits involving thoracic disease, outdistancing by far any other condition within the confines of the thoracic cavity. Conversely, failure to diagnose gastrointestinal conditions is an uncommon cause of suits against radiologists, but perforated viscus awards are much higher than for other gastrointestinal conditions.

Researchers at the University of Medicine and Dentistry of New Jersey, under the tutelage of Dr. Stephen Baker, say that malpractice issues in radiology are an enduring concern and that the specifics of their frequency and particular causes need to be brought to general attention.

For the studies, researchers examined the malpractice history of 3937 radiologists, associated with One-Call Medical, a specialty preferred provider organization, from 40 states over a three-year period. Every filing resulting in no adverse action, settlement, or jury verdict was listed in information provided by the National Practitioner's Databank, including the primary allegation for each claim.

The thoracic study, led by Dr. Kriti Gwal, considered 310 of 3231 total claims (9.6%). A total of 217 of those were categorized as failure to diagnose a pathological condition. Approximately 50% were related to lung cancer cases, the remainder included a wide range of conditions, the most common being aortic dissection, tube and line placement, and pulmonary embolus. Nearly half of lung cancer cases were settled, with an average award of $262,371.

"Lung cancer represents the second most frequent diagnosis allegedly missed by radiologists," said Gwal, who presented the study on Monday morning. "However, the suits involving lung cancer remain a distant second to those claims involving alleged breast disease malpractice."

The second study, led by Dr. Michael McGuire, examined the same database for malpractice claims against radiologists in gastrointestinal imaging.

Researchers found that 6% of all malpractice claims were related to gastrointestinal imaging. Failure to diagnose was the issue in 124 of those 197 cases (63%). The two most common pathologic conditions were cancer (23%), of which colon cancer made up the majority, and perforated viscus (10%).

For cases resulting in decisions against the radiologist, the average colon carcinoma award was $289,156, whereas the average perforated viscus award was $858,333.

"Why was there a discrepancy in the size of the two awards?" McGuire asked rhetorically.

The researchers theorized that it's because radiologists are the only physicians to make the diagnosis of perforation, whereas the radiologist may be removed from the case in colon cancer suits, as other physicians are involved.

To help avoid lawsuits, radiologists must image the entire abdomen, from the top of the hemidiaphragm to the obturator foramen, McGuire said. He also suggested that radiologists get two films if necessary, or a CT scan, because free air in the upper abdomen may not be seen on KUB (kidney, ureter, and bladder) alone.

Pneumoperitoneum cases typically involve middle-aged or even younger patients who have acute onset. If the diagnosis is not made by the radiologist in the first 24 hours, the patients get very sick or die, Baker told Diagnostic Imaging.

"You don't have to use CT to make the diagnosis, but you cannot image the entire abdomen with one film," Baker said. "You need to get two views, which is our standard, and we've found very small pneumoperitoneum, as small as you can find with CT, over the liver shadow."

The team of researchers concluded that because imaging may be the only means to make this diagnosis, the responsibility to detect perforation and the consequences for the radiologist of failure to recognize it are particularly high.