The Sword of Radiolocles

January 8, 2014

With the burden of communicating the results of the imaging study resting squarely on our shoulders alone, the prospect of disaster hangs by a thread above all our heads like the sword of Damocles.

I’m sure you have heard the story of the ER doc who had a chest X-ray done on himself, after hours, off the record and never seen by the radiologist. Time passes, the ER doc is discovered to have lung cancer and the phantom chest X-ray is produced and found to demonstrate an early stage lesion, retrospectively. Because the radiologist’s contract specified that he would report on all studies done at the hospital, he is found liable for the missed diagnosis on a study he never had the opportunity to interpret.

I don’t know if this is a radiological urban myth or it actually happened. It is frightening enough to be true and, I suspect, at least some variations on this theme have actually occurred. This is but one of the cautionary tales used to emphasize the critical importance of communicating results.

We have all been taught that this responsibility goes well beyond just dictating and signing a report. We are held responsible for ensuring the referring physician has received and understood the report. Reports of a critical nature are to be called directly to the physician. In circumstances where the referring physician cannot be reached, it may even be appropriate for the radiologist to contact the patient directly. Lay language reports of mammograms for patients are already a requirement of mammography certification. We all know that this is theoretically prudent if not always realistically practical.

Reporting findings to ER physicians has always been a particular challenge - partially due to the volume of studies and partially due the sequence of events. Many of the studies are viewed by the ER physician and the patient treated before the radiologist ever gets involved. In theory, the ER physician records their findings so that, if the radiologist discovers a discrepancy, the ER can be promptly notified. In the pre-digital age, this was usually accomplished by a scrawled note on a flash card or log sheet. In the best system I ever experienced, a copy of the ER patient disposition sheet actually accompanied the films submitted for interpretation.

Nowadays, the ER staff is supposed to enter a preliminary report in the radiology information system. In my experience, the results of this have been highly variable. One ER physician I know refuses to ever record his preliminary findings. In another case in a busy ER, a missed discrepancy resulted in a lawsuit and a meeting of the ER physician director, hospital administration, and hospital attorney. When asked how such a significant discrepancy between the ER preliminary report and the radiologist’s report could pass unnoticed, the ER director stated matter-of-factly, “Oh we never read the radiology reports. There are too many of them.”

Currently, I estimate that only about 20 percent to 30 percent of ER studies in our hospitals have preliminary reports by ER staff. This leads me to wonder which discrepancies are going unrecognized. With the burden of communicating the results of the imaging study resting squarely on our shoulders alone, the prospect of disaster hangs by a thread above all our heads like the sword of Damocles.

On an average day, even at three minutes a call, it would take more than seven hours to call every report to every referring physician, so that isn’t the answer. Our dilemma is that we are held liable for a system over which we have only minimal control.

So, I try to interpret the studies in the queue as accurately and quickly as I can, hope that all the dominoes fall along the correct path, and I try not to look up, too often. How about you?