A few weeks ago, I cited a case where a urologist failed to follow-up on a deadly cancer found on a pre-operative chest x-ray.
Jeffrey Parks takes exception to my opinion, and instead, wonders why the radiologist shouldn’t shoulder some of the follow-up responsibility.
“For some reason radiologists are immune to the usual expectations of physician responsibility,” writes Dr. Parks. “It must be nice to just have to dictate an addendum in your report about ‘follow up’ and ‘clinical correlation’ in order to exonerate you from all future culpability. A subtle liver or lung lesion gets passed off to the ‘ordering physician.’ Because you can’t expect a radiologist to care about what happens to patients whom they have been consulted to provide radiologic expertise on, right?”
Not sure about the radiologists in Ohio, where Dr. Parks practices, but those that I work with always speak to me by telephone to alert me of a dangerous finding. Those who simply dictate “follow up” without alerting anyone else really are practicing below an acceptable standard of care.
That said, I’m also not sure I would want radiologists, who often are unfamiliar with the patient, coordinating care after a suspicious finding. Realistically, the best we can expect is promptly communicating dangerous findings to the doctor who ordered the test.
Related posts:
- How many radiologists cheat or take short-cuts in their interpretations?
- Radiologists and communicating mammogram results to patients and their doctors
- "Radiologists are sabotaging the practice of medicine"
- Should radiologists apologize to patients?
- A cancer missed, who’s responsible for telling the patient?
- Are radiologists overstepping their bounds?
- Teleradiology
{ 14 comments }
Asking a radiologist to coordinate care or provide follow-up is akin to expecting a cardiologist to recommend angiography or valve replacement based upon an abnormal echocardiogram ordered by a referring doctor.
While studies do suggest that providing clinical cues in radiology/echocardiography reports may improve certain aspects of follow up (Heidenreich et al. have a nice paper on this), some primary care physicians may take exception to being told what to do by a physician who has never actually met the patient.
Communication is appropriate, but its absence should not exempt the ordering physician from taking responsibility. If you order the test, you should be responsible for the results.
@jamesbeckerman
Yeah, I do get a little tired of seeing the phrase, “Cannot rule-out, yada yada yada” even in a clear cut case. Radiological assessments should be clearly and simply stated when the situation calls for it instead of being a case of CYA. I can’t speak for Ohio radiologist reporting habits either but I can definitely relate to the sentiments expressed.
Dr. Parks is spewing personal opinion or anecdote or worse(? invective).
The truth is clear-cut and the courts have made this point consistently and with major damage awards: the radiologist is responsible for assuring adequate, documented oral communication of important findings to the physician ordering the test. Period. Some courts have even held radiologists responsible for assuring adequate follow-up of abnormal findings. If that communication is not done, and documented, and the case goes to court for malpractice litigation, the radiologist loses. End of story. This case has been lost numerous times by many radiologists, especially in mammography where communication is the number two reason for losing a malpractice case, next to delay in diagnosis.
This isn’t even in question.
No one is talking about a radiologist “running” a case or commanding the therapeutic chain of events. That’s too absurd to even discuss.
And insofar as “hedging” goes (please), there is a differential diagnosis for almost every finding on a radiological examination; some of the elements in that differential are rare, even exceedingly rare; however, if you are a high volume radiologist you will see rare things every month.
No doubt, the radiologist should express those items in a list of descending probability and even indicate which item he/she favors; however, the charge of “CYA” is so overblown– especially in this day and age– that the really tiring thing is hearing your own medical colleagues repeat something so wrong-headed.
Here’s what I’m “spewing”:
The radiologist needs to be more proactive in cases where incidental but suspicious findings are noted on imaging. That doesn’t imply “coordinating care”. It simply means being held accountable for the reading given. Call the primary or ordering doctor directly. Recall that the KevinMD post that prompted my own blog post on the subject attributed the majority of the scorn on the urologist whose name was on the report as “ordering physician”. I didn’t think that was right. It was a pre-op CXR that was probably automatically ordered by the pre-op testing center of the hospital. The radiologist ought to be aware of that fact and be more pro-active in making sure the right person gets the information….That’s all.
If a patient of yours asks you to explain the report/scan to you, whoose should do the explaining? Should you call the radiologist to come and do the explaining.
1)After all they are billing for the scan.
2)The ordering doctor has limited experience/ training reading the scans.
3)The patients decision for surgery might depend on how well the scan is explained to him or her.
What do you all think?
Why can’t the radiologist call the patient?
A common scenario:
A CT is read at night by a contracted on-line radiology group. The hospital group over reads it and discovers a missed brain bleed, missed appendicitis, missed tumor, etc…. Decisions and dispositions are made based on the real time reading. The over reading radiolgist expects an ER doctor the next day who was never involved in the case to reconcile the difference.
Why can’t a radiologist look up the patient information, pick up a phone and notify the proper people?????
Sometimes I notice that the radiologist dictates “Paged Dr. Me at the time of interpretation.” As a hospitalist, my pager is not always on – it is forwarded to the on call person though. This has happened several times where I KNOW I didn’t get the results of that scan over the phone at 2 in the morning, but I did see them the next day when I came back to work. Maybe they spoke to my colleague, but not me. And the statement says “Paged Dr. Me.” Not “discussed results with Dr. Me”. Who’s responsible if something bad is missed?
Michael Riesberg MD from Pensacola Florida responds. I am a surgeon and here is my experience with PRE-OP testing. If I do surgery at an OUTPATIENT PHYSICIAN-OWNED center, there is DEFINED criteria between anesthesiology and surgeons. I am aware of the pre-op labs required—-I order them and review them in pre-op. If the ANESTHESIOLOGIST needs additional testing, the ANESTHESIOLOGIST notifies ME and I order the testing and review it. If I do surgery at the HOSPITAL, I order labs pre-op for what I as the SURGEON deem medically necessary. If I do not see an indication for a CHEST X-RAY as the SURGEON, I very well may not order one. However, if the ANESTHESIOLOGIST decides that a chest X-ray is indicated, it is ordered under the ANESThssiologist NAME, NOT THE SURGEON. WHere this situation gets ugly is the incidental find of a lung mass. The RADIOLOGIST may call the abnormal result to the anesthesiologist—-but if the SURGEON is not notified about an abnormal result on HIS private patient, he/she can be stuck behind the 8-ball. We are ALL doctors whether we are surgeons, radiologists, pathologists, or anesthesiologists. I am fortunate to say that MOST of our radiologists or pathologists will give me a personal phone call for abnormal results. I, in turn, try to do the same thing when I am in consultation or when I see critical things that affect a patient’s well-being. I realize that radiologists can be very busy—–but the 2 minutes of time for a personal phone call to alert me on a critical problam on a patient really says a lot!! I will refer LOTS of patients to that radiologist because he cares about my patients.
The Happy Hospitalist,
A radiologist could call your patient and inform them of the results. What happens when the patient asks what should be done next? A radiologist could start recommending things to the patient even though he/she might not know anything else about the patient’s medical history. Is that what we all want to happen? What if the radiologist recommends to the patient something different than what the PCP would have done? At most the radiologist could inform the patient of the abnormality and that the patient should consult with their PCP regarding follow-up.
Anonymous post#7,
A radiologist could call the patient and inform them of the new results. The problem is that the radiolgist would not know what precations or treatment have already been done to the patient while in the ER. The ER doc would have access to the ER records of what happened to that patient.
Anonymous post#5,
It seems to me that you patient wants you to explain to them the results of the radiology report; they’re not asking you to read the exam. Would expect the pathologist to call your patient and explain biopsy results and lab results or do you do that yourself?
Buckeye surgeon,
If I’m hearing you correctly you don’t neccesarily read the pre-op chest x-ray reports on your patient because sometimes they are ordered automatically by the surgical center?
Yes, radiologists are responsible for conveying results of suspicious or critical or immediately life-threatening results by calling the ordering physician and documenting it. On the flip side shouldn’t you as a surgeon be responsible for finding out the results of tests ordered on your patient?
Should these automatic pre-op chest x-rays be done or should they only be done when ordered by a physician who thinks that it is indicated?
I agree with Dr. T. It is not unusual for benign and maligant pathologies to have the same or similar presentation on a radiology exam. Typically a radiologist would not know much if anything about a patient’s medical condition and history. The radiologist doesn’t know that the patient has microhematuria or has melanoma or has other signs and symptoms. Knowledge of that information can be key in narrowing down the radiological differential diagnosis.
Many PCP colleagues complain about how the radiologist doesn’t communicate enough with them regarding pertinent findings. Communication is a two way street. Not enough physicians communicate pertinent signs and symptoms to the radiologist. When the order for a chest x-ray or CT says “cough” or “pain” what is a radiologist supposed to say when he finds a lesion? Knowledge of pertinent info can make one diagnosis more likely than another.
It would be nice if the radiologist could call up the physician and have a discussion about each case but do we really want to be called on the phone multiple times a day to answer questions about patients? It’s not practical givent he sheer volume of exams done each day, 24/7/365.
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