Two dangerous risks of CT, MRI, and other diagnostic radiology exams
Better communication between ordering doctors and radiologists is needed to ensure accurate results
Diagnostic imaging is an amazing tool that has rapidly advanced in medicine over the past few decades. In addition to old-school x-rays, radiologists have tools like MRI scans, CT scans, MR angiograms, CT angiograms, and other tests that can help provide insight on what is going on inside a patient’s body.
Radiological information can be extremely valuable to doctors caring for a patient because it allows them to link clinical findings, signs, and symptoms, with findings from the scans.
One significant challenge with diagnostic imaging, though, is that many factors can influence how a radiologist interpets an image.
With the advent of high-speed internet connections, radiologists are often no longer at a hospital when they read diagnostic images. Instead, they are in a dark room somewhere, logged onto a computer that provides a queue of images that need interpretation. The computer system places stat (emergency or urgent) images at the top of the list, and provides limited information about the indication (reason) that a doctor ordered the x-ray, MRI, or CT.
When radiologists are looking at images off-site, they are unable to review a scan with the ordering physician in the room to talk with them about the patient and what to look for.
As a Texas medical malpractice, I have handled numerous cases where a patient was seriously injured—or worse—because of bungled radiology practices. There are typically two reasons for this type of problem: (1) not enough clinical information is provided to the radiologist to give context for the purpose of the imaging; and (2) there is a significant delay in getting the results interpretation of the scan to the ordering doctor, which causes a dangerous delay in starting appropriate treatment started.
Lack of clinical information
How radiologists interpret a scan is often dependent on what information that they are provided about the patient. This is called the clinical indication.
This concept is illustrated by a psychological principle known as selective attention bias, or inattentional blindness. It means that we tend to interpet things through a lens that is shaped by the information available to us.
A Harvard researcher looked into this and found that 83% of radiologists did not see a picture of a man in a gorilla suit shaking his fist that was superimposed onto a series of slides that they were reviewing to look for lung cancer. (Photo credit to Trafton Drew and Jeremy Wolfe).
Please do not get me wrong—radiologists are bright people. They just are not looking for gorillas on lung slides. But when it comes to radiology orders from emergency room and other doctors, sometimes the clinical information is so barebone, radiologists really do not know what they are looking for. And this omission can lead to faulty interpretations that lead to poor patient care.
In 2014, the American College of Radiology (ACR) published its revised Practice Parameter for Communication of Diagnostic Imaging Findings. The ACR recommends that, “A request for imaging should include relevant clinical information, a working diagnosis, and/or pertinent clinical signs and symptoms.”
In my experience as a Houston medical malpractice lawyer, I have rarely seen physician orders for a radiology test that come anywhere near this level of deatail. Instead, the order leaves the radiologist in the dark as to why the person needs an MRI or CT. This presents an unnecessary risk to patient safety.
This brings to mind a case that I am working on right now for a client who suddenly started having the worst headache of his life. He went to a freestanding emergency room, where they did a head CT. The radiologist thought it looked okay, so the man was discharged.
The next day, the man went to a nearby hospital emergency room, with the same problem. The emergency physician and nursing staff requested a HIPAA release to get the head CT and medical records from the prior facility. The patient signed it, but the hospital ended up discharging him and never actually got the freestanding ER’s records.
For the third day in a row, the man returned to the emergency department, this time once again to the hospital ER. He still had the worst headache of his life. This time the emergency room doctor ordered another head CT. But the CT order only provided this clinical information: “Headache with dizziness and giddiness.”
That information was generated from computer billing codes and provides virtually nothing useful to the radiologist. There was no report that this patient had been to the ER three days in a row with the worst headache of his life, or any mention that a head CT from two days earlier.
Speaking of the earlier CT, even though the HIPAA authorization was in his medical records, no one bothered to go down the street to the freestanding emergency room to get a copy of the CT scan and the medical records. The ACR realizes the importance of this information, though, in that its parameter says, “Whenever possible, previous reports and images should be available for review and comparison with the current study.”
As you might have guessed, the radiologist who interpreted the head CT at the hospital botched the interpretation. My client ended up with lifelong damages because of a severe stroke that could have been avoided. I think she may have interpreted the CT correctly if she had the comparison imaging and more context about what was going on with the patient clinically. This would have guided the radiologist in what to look for and closed the gap caused by selective attention bias, or inattentional blindness.
Poor communication between radiologists and clinicians
The other area where I have seen significant errors in the medical negligence cases that I have handled is someone drops the ball when it comes to communicating clinical radiology findings back to the doctors and nurses taking care of patients.
The ACR’s parameter splits these communications into routine communications and nonroutine communications.
Routine interpretations are not emergent or urgent, and typically pass through the usual channels established by the hospital or facility. These results typically will not change the course of treatment of a patient.
On the other hand, nonroutine communications require special handling because they provide critical values or information that will likely lead to an emergency or urgent response by the doctors taking care of the patient clinically.
In a surgical or ER context, the ACR references examples like pneumothorax (free air in the thoracic cavity), pneumoperitoneum (free air in the peritoneum), or a misplaced line or tube. In cases that I handled, there have been issues with a CT or MRI showing an early or active stroke, or brain swelling so severe that the brain was nearing herniation. All of these are life-threatening critical values that require emergency intervention.
On other occasions, a nonroutine communication may become necessary when the current interpretation differs from prior radiology studies, in a way that could compromise the patient’s health; or when the radiologist believes that the patient’s condition will worsen over time without clinical intervention.
Yet, sometimes radiologist drop the ball and use routine channels to communicate emergency findings. To combat this problem, the American College of Radiologists recommends that both radiologists, as well as the ordering physician and nursing staff, take responsibility for obtaining diagnostic radiology interpretations an results.
The radiology report
In my observation, few patients actually see the radiology report. Instead, they rely on their doctor to explain it to them orally. I recommend that you ask to see the report before or while your doctor visits with you about it.
The “Impression” section of the report lists the radiologist’s office conclusions and diagnosis of the scan. Although some of the terminology may be unfamiliar to you, when you have a copy of the report in-hand you can easily ask your doctors to explain it to you.
In addition to this information, the ACR specifies that radiology reports should contain thorough information, including where the study was performed; the name, gender, and age or birthdate of the patient; the name of the doctor who ordered the report; the type, date, and time, of the examination; relevant clinical information that was provided; a description of the procedures done and whether contrast media was used; findings; potential limitations, including any factors that may have compromised the sensitivity and specificity of the scan; reference any clinical issues or questions; and comparison with any prior radiology studies.
Improving the process
Physicians can help improve the process by talking with each other, rather than relying solely on computers and billing codes. When ordering a radiology study, the doctor should provide adequate information so that the radiologist gets a good feel for what is going on with the patient clinically. If there is a significant finding, the radiologist should pick up the phone and talk to the ordering physician.
When it comes to the patient side of things, when the doctor mentions ordering an MRI or CT, ask him or her to be sure and tell the radiologist that, for example, you have had the worst headache of your life for three days in a row. That could make a big difference.
We are here to help
The medical malpractice lawyers at Painter Law Firm are experienced in handling cases where there was an error in interpreting a diagnostic radiology image, or in timely communication findings to the clinical team of doctors and nurses. In fact, we have represented clients in countless kinds of medical negligence lawsuits, including malpractice and medical mistakes by hospitals, doctors, surgeons, radiologists, pharmacists, and others.
For a free consultation, call Painter Law Firm’s Houston office at 281-580-8800.
Robert Painter is a medical malpractice lawyer at Painter Law Firm, in Houston, Texas. He is a trial attorney who represents victims of medical negligence. Robert Painter has unique know-how from his background as a hospital administrator and early-career representation of doctors and hospitals. A former officer in the U.S. Army, he is not afraid to tackle complex cases against any hospital, doctor, or institution.
Robert Painter is a medical malpractice lawyer at Painter Law Firm PLLC.
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On 4/1/2018, the new law will end the current practice where doctors can secretly enter a DNR order against patient and family wishes
This article was originally published in the September/October 2017 edition of "The Houston Lawyer" magazine
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