A Closer Look at Lies of Omission in Radiology

Do we settle for oblique truths more often than not to mitigate potential repercussions?

A lot of lies get told in our field. We are not special in that regard. Most folks who want to function in a society learn to lie on a near instinctive level. “The truth shall set you free” might play well in the Bible, but strict truth telling will set you free of your job and most of your friends.

There are, of course, different flavors of lies, some more benign than others. You might forgive me for telling a lady friend that her hairdo looks better than I really think it does, or for playing along with the notion of Santa Claus when dealing with little kids whose parents have chosen to maintain that particular illusion. You might not even find it particularly slimy when a politician plays games with the truth, especially if you are in favor of his or her policies.

Nevertheless, the phrase “lying radiologist” probably sparks your imagination in very few flattering ways. You might think of fraud, like the case of a rad falsely claiming a bunch of computed tomography (CT) scans had 3D recons when they did not. (This would not have even occurred to me as a possibility if a local rad group hadn’t gotten itself into the crosshairs of the Centers for Medicare and Medicaid Services (CMS) for systematically doing that a few years ago). Another potential fraud situation may be “splitting” abdominal and pelvic CTs for separate reporting back when the powers that be first decided the combination should be reimbursed for less.

You might also think of lying out of laziness or carelessness. One example might be reporting that there were no prior studies available for comparison when they were available. Another example might be claiming to have done a comparison without really looking at the previous images. In this scenario, the radiologist might think “The current study is normal enough. What could the prior imaging show me to change my mind? I will just say I looked at it and nobody will be the wiser.”

However, we also tell lies that our colleagues would allow, if not laud us for doing so. These are often lies of omission. For instance, maybe a rad sees a probable primary malignancy that was, retrospectively, present but subtle and thus missed on the previous scan, and its rate of growth isn’t going to impact care in any way.

Pure truth telling would be to report that it was there and has grown, maybe even offering one’s appraisal of the severity of the previous rad’s “miss.” But would that really help anybody aside from lawyers? It sure wouldn’t do much for the rad group’s reputation or, indeed, that of the clinicians who referred to the rad group. This could also compromise the sense of teamwork in the rad group, perhaps even starting a tit-for-tat vendetta that opens cans of worms in other cases.

The alternative might be a bending of the truth. For example, the statement “A mass lesion has developed since the previous study” doesn’t say it is new, but it might be interpreted that way. It’s certainly better and more professional than “This mass was present before, and I’m frankly appalled at the work of the rad who read the previous case.”

Not all that long ago, a scan crossed my path with a note on the record: A demented patient was not, under any circumstances, to be told about the cancer she was being imaged for. I guessed that she had been told about her condition before, repeatedly forgotten it on account of her dementia, and every time she “learned” of her malignancy anew, it sent her into a tizzy.

Still, if I happened to run into that patient and she asked about her imaging, my realistic choices would have been to lie (“Everything’s okay”) or sort of lie (“No bad news for you today!” or “I haven’t gotten a chance to sit down with it yet. This should be taken care of in the next hour or two.”). There would be no room for the unvarnished truth.

The lies of omission are usually the ones that preserve our professional relationships, if not our jobs. Just imagine, for instance, if you sounded off in your reports about every time a referrer ordered something incorrectly, a tech did a less-than job, or a patient didn’t cooperate.

“This chest CT was ordered as a follow-up for a lung nodule that has been stable for 10 years, and previous reports specifically stated no further surveillance was needed. If there was some other, valid reason for this scan, it has not been included in the provided clinical history.”

“This non-contrast abdominal CT was a waste of everybody’s time and unnecessarily radiated the patient; I advised MRI and referrer X insisted on doing things his or her way.”

Even without psychological issues to blame for such failures of self-editing, all but the most saintly of rads is occasionally going to be tempted to excessively truth tell. We care about doing a good job, which includes making sure the best possible care is being rendered. It can annoy and even infuriate us when we see that our best efforts are flouted. There are limits to how much a person can suppress, especially if one is in an emotionally charged setting (short turnaround times, high case volumes, etc.). Stuff can get blurted out.

Some of the potential damage can be mitigated if the ugly truth is oblique, rather than being blunt and in your face. I think of it as the “snide butler” approach, sort of like when Alfred Pennyworth sasses Bruce Wayne (Batman for you non-geeks) without directly mouthing off. Then there is Basil’s more confrontational style from the Fawlty Towers TV series. It is worth remembering that while his quips earned him some self-satisfaction and laughs from the audience, the remarks often got him in trouble, sooner or later.