Variations in practice may harm care and create liability issues

In this issue of Diagnostic Imaging, a column by our medical malpractice expert, Dr. Richard Chesbrough, cites a case in which confusion over mammographic markers resulted in a delayed cancer diagnosis. You can read more about the case in the column ("Mammographic markers may spark confusion," page 27). As you do, you should recognize that this is an issue that extends beyond mammography to the rest of radiology, because variations in procedure are far more extensive than they should be. Even if you don't read mammography images, Dr. Chesbrough's column should be taken as a reminder that variations in approach can compromise the quality of care and can lead to legal liability.

It is true that much of radiology is bound up in procedures that usually deliver good quality care. The American College of Radiology has codified good radiology practice in a weighty tome (now available on CD) that has been published for a number of years. But the recommendations aren't as widely followed as they should be. Talk to experts like Dr. Chesbrough (who is a defense consultant in medical malpractice cases) and others, and you'll hear of many cases where procedures vary widely between practices and sometimes even within them.

Resistance to conforming to a defined set of procedures is very strong within all of medicine. Consider that in 2003 the ACR's good practice guide was referred to as "Standards." That changed to "Practice Guidelines and Technical Standards" in 2004. Behind the name change was some radiologists' fear that the ACR's "Standards" would become legal standards that could be used against them in medical malpractice proceedings.

Although the ACR made the name change, the shift provides a fig leaf rather than body armor. Whether they are published by the ACR as practice guidelines or reflected in research published in peer-reviewed journals, best practices are constantly being developed and updated and are readily available to any competent malpractice lawyer. And where good practices may once have been locally determined, they are increasingly nationally based, so the fact that your colleagues across town are doing it that way won't necessarily help you if you come up with a bad result.

Further fueling this trend and focusing attention on variability in practice is the fact that in today's world of digital imaging, radiology images increasingly are part of a large network. Inconsistencies in approaches may no longer be confined to just one practice. Some breast images, for example, are now part of large databases. There may come a time when a mammographer calls up a prior from another practice or a database. Inconsistently used markers can introduce variations in interpretation. Alternatively, an awareness that these inconsistencies exist can require time-consuming searches to pin down precise approaches.

Smart practice and good patient care require that you keep up with these developments and make sure that you have a standard operating routine reflecting the best care available. That can be a constant challenge. How often have you been asked to read an image without a patient history or even a specific reason for the imaging exam? How often have you been asked to read an image for which contrast was indicated but not used, for no apparent reason?

Many will argue that what's best is always a shifting target, and that is true. It's the nature of science to always seek something better. New equipment, new research, and greater understanding will result in changes to our notion of what's best. But even given that change is a constant, simply having defined procedures in place can prevent slipups of the type that resulted in the delayed breast cancer diagnosis Dr. Chesbrough describes.