When doctors, physician’s assistants, or nurse practitioners order a diagnostic radiology study, such as an MRI or CT scan, it’s based on a clinical indication.
The clinical indication on a radiology order is important
The clinical indication refers to the clinical situation that’s the reason for the study and is typically the only clinical information that’s provided to the radiologist.
For example, if a patient arrived at the emergency room (ER) with symptoms that make the physician suspect stroke, the clinical indication may be “stroke.” On the other hand, if the patient’s main complaint when arriving at the ER is a terrible headache (which can be caused by lots of different things), then the clinical indication would probably be “headache.”
By the way, on the topic of CT scans and strokes, physicians don’t order them for the reason that many people think. When there’s a suspicion of an ischemic stroke, a CT scan is ordered to make sure there’s no bleeding or intracranial problem that would make the patient ineligible to receive the clot-busting drug tPA. Thus, a negative CT scan doesn’t mean that a person isn’t having a stroke.
In my experience in handling numerous radiology medical malpractice cases, the odds of getting a complete and accurate interpretation of a CT or MRI scan are better when the clinical indication of the order is more detailed, as compared to minimally-detailed clinical indications. There’s really no need to hide the ball when it comes to ordering a radiology study!
I believe that the reason for this is that there are lots of things on a scan that can occupy or distract a radiologist’s attention. Having the added information is what the clinical providers use to help focus the radiologist’s attention, particularly in a day and age when clinical physicians often don’t ever speak to radiologists in conjunction with the scan that’s ordered. More information helps focus attention where it needs to be.
An opposite concept of focused findings related to clinical indication is the incidental finding.
When a radiologist identifies a potential abnormality on a diagnostic scan that’s unrelated to the clinical indication, it’s called an incidental finding. Incidental findings are often completely unrelated to what brought the patient to the doctor or hospital. The way that they’re handled, though, can sometimes ultimately mean the difference between life and death.
Take for example what happened to a woman in her mid-50s who went to a pain management doctor in July of one year for help with her back pain. The next month, the pain management physician ordered an MRI of the patient’s thoracic spine.
When the radiologist interpreted the MRI, his report included findings that dealt with the thoracic spine, as well as an incidental finding of “possible 9 mm right lung nodule.” As radiologists almost invariably do when there is an incidental finding, he recommended an additional study—in this case a CT scan—if the pain management doctor thought it was clinically indicated.
At the next appointment, the pain management physician and staff didn’t say a word about the pulmonary nodule. The patient had two more office visits that year and 14 office visits with the pain management clinic the next year. During all those visits, though, neither the pain management doctor or his nurse practitioner ever mentioned the pulmonary nodule.
In July, almost 2 years after the MRI, the nurse practitioner at the pain management clinic finally reviewed the chart and noticed the MRI report. She informed the patient of the results and encouraged her to discuss them with her primary care doctor.
The primary care physician received the two-year-old MRI report from the pain management clinic and then ordered a CT scan. The CT confirmed the worst news—a mass that a biopsy identified as small cell carcinoma.
This woman faced treatment with chemotherapy and radiation and within several months the cancer went into remission. She continued to face several hospitalizations, though, to deal with breathing difficulties and overall weakness. Around a year later, this woman’s family found her dead at home. The death certificate recorded a cause of death as multi-system organ failure, with lung cancer is a contributing factor.
The wrongful death beneficiaries of this patient pursued a successful lawsuit against the pain management physician based on his failure to communicate the MRI incidental finding and, therefore, failing to diagnose her lung cancer. In the lawsuit, an oncology expert for the plaintiffs testified that the delay in diagnosis and treatment caused by the ignored incidental finding from the MRI reduced the patient’s survival odds and caused her death.
The standard of care requires a physician who receives a radiology report that includes incidental findings to:
• Discuss them with the patient
• Refer the patient to a primary care physician (if the doctor who received the report is a specialist), and send the report to that physician
• As an alternative, the physician who receives the radiology report may order the additional imaging studies that the radiologist recommended
As a patient, you can improve your safety by always requesting a copy of the test results for any radiology study. Always read them carefully and ask your doctor about any language you don’t understand. I can’t imagine any patient who read a radiology report about a suspicious lung nodule leaving the doctor’s office without insisting on the CT scan recommended by the radiologist.
If you or someone you care for has been seriously injured because of bungled radiology or follow-up care, then contact a top-rated experienced Houston, Texas medical malpractice lawyer for help in evaluating your potential case.