Due to the potential for delayed treatment and diagnosis, the criticality of radiology results may require direct communication between the radiologist and ED physician.
Another aspect of communication between radiology and the ED is the radiology report itself. ED physicians may rely on radiology reports — in addition to or as an alternative to the information the radiologist communicates directly to the ED — to make treatment decisions.1
In the following case, the radiologist’s passive attitude and ambiguous report contributed to the delay in treating the patient’s critical condition. Consider the different ways this adverse outcome could have been avoided by better communication between the radiologist and ED physician.
Allegation
The radiologist’s failure to appreciate and communicate spinal infection to the ED physician resulted in delayed diagnosis and treatment culminating in below-the-waist paralysis.
Case File
A 52-year-old female patient with a history of spinal osteoarthritis presented to the ED complaining of 9/10 back pain. The pain was so severe she was unable to stand or walk. She also reported hip pain and a burning and tingling sensation in her legs. Her temperature was normal and she reported no trauma. She was given pain medication, which reduced her pain to 8/10. This information was documented in the triage and nursing notes. The ED physician documented a relatively normal though incomplete neurological assessment — she did not assess whether the patient was able to walk — and ordered a CT scan of the lumbar spine.
The CT scan was completed and the radiologist entered a preliminary report in the EHR within an hour. The report findings focused on severe degenerative changes to the patient’s vertebrae. In addition to degenerative disc and facet disease, he concluded “a pathologic process cannot be excluded,” but also concluded there was no obvious acute abnormality.
The ED physician reviewed the preliminary report and concluded the arthritis was causing the patient’s pain. She noted the patient’s pain had improved with medication (though she did not notice that the pain had only improved from a 9/10 to an 8/10). She also didn’t realize the patient was unable to walk because of the pain. Therefore, she discharged the patient with instructions to follow up with her primary care physician and return if the pain worsened.
The following day, the patient was transported by ambulance to a different hospital where studies indicated a spinal abscess was impinging on her spinal cord. Despite undergoing immediate surgery, she never regained use of her lower body. She filed a lawsuit against the first hospital, ED physician, and radiologist.
Discussion
In many claims involving critical results reporting between the radiology and emergency departments, it is difficult for defendants to avoid blaming each other for the patient’s injury. In this case, the hospital, ED physician, and radiologist blamed each other for the delay in diagnosing the spinal infection with each claiming they had met the standard of care.
For example, the radiologist argued that the ED physician should have obtained a full history of the patient’s symptoms and should have ordered a different study than a CT scan, which was not the optimal modality for diagnosing a spinal infection. The radiologist further believed that the ED physician, after accessing the preliminary findings in the EHR, should have initiated discussions with him about whether the patient needed further work-up. Finally, the radiologist believed the order for the CT scan was incomplete and his findings and impressions were reasonable explanations for lower back pain. In other words, if the order had included the patient’s pain level and her inability to walk the radiologist would have been more likely to suspect infection and would have specifically included it in his impressions. However, expert support of the terminology in the radiologist’s report and whether he had a duty to contact the ED physician was mixed.
A primary point of contention was the defendant radiologist’s use of the phrase “a pathologic process cannot be excluded” instead of using “infection” or “an inflammatory change” and “destruction” of the bone. Experts also faulted the radiologist for failing to identify the location of “the pathological process.” There was also conflicting expert testimony regarding whether the standard of care required the radiologist to recommend an MRI, which would have been the appropriate method for diagnosing the spinal infection. Short of a recommendation, a number of the radiology experts believed the defendant radiologist could have prompted the ED physician to order an MRI by using less ambiguous language in his impressions.
Medical Liability Risk Management Recommendations — Radiology Report Writing
Consider the following recommendations when writing a radiology report:2,3,4,5
- Be concise.
- List the most important findings first.
- Create reports with separate “Findings” and “Impression” sections.
- List critical findings in both the “Impression” and “Findings” sections of the report.
- Choose unambiguous words and terms.
- Interpret your findings.
- Comment on the quality of the image if it affects your interpretation.
- Comment on the limitations of the examination.
- If limitations can be solved by reviewing the patient’s medical record or discussing the patient with the referring physician, do so.
- Make recommendations for further investigations.
- Be careful when editing your transcriptions.
Before saving a report to the system, stand in the shoes of the referring physician who will rely on the report. Assess whether the report at least has clearly answered the following four questions:
- What did you see?
- What do you think the findings mean?
- What do you want the referring physician to conclude from your report?
- What do you think the referring physician should do next?
References
1. Huamao Ye, et al. “A Minimally Invasive Method in Diagnosing Testicular Torsion: The Initial Experience of Scrotoscope.” Journal of Endourology. 2016;30(6):704-708. DOI: 10.1089/end.2015.0724
2. Giles W. Boland, et al. “Communication of Actionable Information.” Journal of the American College of Radiology. 2014;11(11):1019-1021.
3. J. Jones. “The Perfect Radiology Report.” ACR Bulletin. 2016. (not available online at the time of publication)
4. “How to Compose a Radiology Report.” Chest X-Ray. 2014.
5. Ferris M. Hall. “Language of the Radiology Report: Primer for Residents and Wayward Radiologists.” AJR. 2000;175:1239-1242. DOI: 10.2214/ajr.175.5.1751239
6. Esteban F. Gershanik, et al. “Critical Finding Capture in the Impression Section of Radiology Reports.” AMIA Annual Symposium Proceedings. 2011; 465–469.
7. American College of Radiology. ACR Practice Parameter for Communication of Diagnostic Imaging Findings. (Resolution 11) 2014.
8. Mitzi Baker. “Radiology Research Tackles Squishiness of Wordiness: When Radiologists Share Their Findings with Clinicians, the Meaning May Be Fuzzy.” Stanford Report. 2003.