Diagnostic Imaging
October 2003

BACKSCATTER

As insurers begin to fail, breast imagers quail

Mammographers become sitting ducks when malpractice pond dries up

I read my first mammogram in 1978. My mentor at the time, Dr. David Witten, had coauthored one of the early texts on film mammography, and he let me go through the teaching file on which the book was based. Reports then went something like, "The huge ulcerating mass you feel has x-ray characteristics suggesting it may be malignant." Those studies didn't produce a lot of detail. You could get more information from a Burma Shave sign. We have come a long way, although I still probably use the word "suggesting" too much.

Having done mammography for so long, I am a believer in it. And we have convinced a majority of women to believe in it. I really hate that mammography is about to die.

In his excellent commentary in the August Diagnostic Imaging ("Say no to peers who weaken mammography," page 25), Dr. Mark Klein of Washington, DC, calls mammography "lawyer candy." I agree. I have always complained about lawyers and the cost of malpractice insurance, which I saw as a ridiculous expense built into our system to reward lawyers, not to fairly compensate patients. My perspective has changed.

Earlier this year, the major malpractice insurer in Virginia went under. With one stroke, we lost our insurance and our tail coverage for any events in the past. We also lost a lot of premium dollars. When shopping for a new carrier, we learned that no top-rated company will now insure radiologists in Virginia. It was hard to find any company that would take us on, and our record is perfect. Groups that had actually lost a suit found they could not get coverage.

This changed my whole perspective on mammography. We have a test that is 80% in the best of hands, but it is held to a standard of 100% in court. Mammography is the number-one cause of suits, primarily because the deck is stacked in the plantiff's favor. In Virginia and a lot of other states, if you lose a suit, you will probably lose your coverage. With no coverage, it is difficult to practice. We did this for a few months when our insurer went under. If you think reading mammograms is stressful with coverage . . .

I predict that in the very near future my group, and private groups all over the country, will stop doing mammograms. Only practices that are part of large self-insured organizations and government institutions will be able to take the risk.

No doubt, some people will think this is about money. For us it isn't. Being hospital-based, our practice makes money on every test we read. The problem isn't the reimbursement level. It is the idea of risking one's entire practice on a test that, more than anything else we do, takes us to court, where the odds are stacked against us.

Our hospital loses money on every mammogram it does, but sees it as a loss leader. Because women decide where the family gets its healthcare, women's imaging is a must. For us, it isn't a loss leader, it is a suicide mission.

As mammography lines up at the firing squad, the only good I see is the turmoil this conflict might create when women can no longer get a mammogram. Large institutions will still do them, but they'll never keep up with demand. The problem is magnified by the fact that no one in their right mind wants to do a mammography fellowship now. Perhaps this will be the straw that breaks the camel's back and forces Congress to act on tort reform.

It seems a shame that because of our ridiculous legal system, a good but imperfect test, which saves thousands of lives every year, is going the way of Burma Shave signs.

Dr. Tipler is a private-practice radiologist in Staunton, VA. He can be reached by fax at 540/332-4491 or by e-mail at btipler@medicaltees.com.