Excerpt
from What You Don't Know Can Kill You: A Physician's Radical Guide to Conquering the Obstacles to Excellent Medical Care
by Laura Nathanson
Red Flags in Radiology Reports:
An Added Crucial Step
The only radiologist who double-checks a radiology report is the radiologist who wrote it. There is nobody in charge of reviewing reports for completeness, much less for accuracy and clarity of expression. One exception: there are institutions that have installed special software with templates that require the radiologist to fill in every item recommended by the guidelines of the American College of Radiology. If one stays blank, the report can't be signed out or billed for.
But, you might say, the clinical physician who ordered the report and receives the interpretation must review it for clarity and completeness. Right? Isn't there a double-check on the report?
Alas, nobody checks that the clinical physician actually does read the report. Every time there is a communication between doctor and doctor, about anything, there is a new opportunity for error. So you, Vigilant One, need to keep a special eye on data reports of all kinds, including radiology reports. Here's how:
First, once again, you preshrink the report:
- Substitute every medical jargon word with "thing," "thingy," etc.
- Search for scary words and uncertain terms.
- See if there is a scary diagnosis that has not been excluded.
- Look for any signs of fuzzy logic.
Then -- and this is new -- you go on to an additional set of red flags reserved for data reports.
First, the clinical physician has ordered a study to answer a specific question: What's that metallic thing up the kid's nose? Is this wrist fractured? Does this woman have pneumonia? A red flag is indicated by a report's failure to include any of the following:
- The data doctor must make clear that he understands the question -- the reason for the test.
- The data doctor must describe his findings clearly enough so that the clinical physician can judge the reasonableness of the data doctor's diagnosis.
- The data doctor also ought to give either a specific diagnosis ("Mason lapel pin high in left nostril") or a differential diagnosis ("Foreign body, metallic, high in left nostril? Barbie slipper charm? earring? part of dog collar?")
- Finally, if the data doctor feels it is appropriate, he should suggest further study or action. ("Recommend prompt removal of foreign body in nose due to danger of aspiration during sniffing.")
The clinical physician and data doctor should be engaged in an active written dialogue where each listens to and queries the other with attention and respect. This means that the clinical physician should review each data report critically to make sure that the most important question has been understood and answered.
The second step in checking a data report is to make sure that its import actually got through to the clinical physician. If a serious error or omission in such a report goes unnoticed by the clinical physician, there can be dire results.
You may recall seeing the following news story about the world-famous paleontologist, Stephen Jay Gould, from an Associated Press release, May 20, 2005. Professor Gould had survived one cancer twenty years earlier, which put him at risk for developing other cancers. So he had frequent check-ups, including chest X rays.
The family of the late paleontologist and evolutionary scientist Stephen Jay Gould sued two Boston hospitals and three doctors Friday, alleging the famed author would still be alive if they had properly diagnosed his cancer four years ago.
The doctors all failed to recognize a 1-centimeter (size of a marble) lung lesion on a chest X ray taken of the Harvard University professor in February 2001, according to Alex MacDonald, the lawyer for Gould's survivors.
Thirteen months later, after another chest X ray was taken, the lesion had grown to 3 centimeters and the cancer had spread to Gould's brain, liver and spleen, MacDonald said.
"All of a sudden, it was like out of the head of Zeus, he's got fourth-stage cancer," Gould's wife, Rhonda Roland Shearer, said in television interviews on Friday.
Gould, 60, died 10 weeks later, in May 2002.
How could such a thing happen, when the patient was a celebrity, his physicians alert for exactly such a finding, and the institutions so august? Note that there are three possible explanations for such a disaster:
1. The radiologist did not notice the tumor on the first chest X ray.
2. The report was ambiguous or incomplete, and the clinical physician did not clarify it.
3. The radiologist identified the tumor and wrote a full report, but the clinical physician either didn't read the report or misread it.
The New Red Flag for Data Reports
The last two explanations for error are ones that you, and only you, can find and correct before it's too late. Once an incorrect data report is ratified as "not worrisome" by a clinical care physician, it is very unlikely to be corrected by anyone else.
Here, then, is the new red flag that should arouse your utmost vigilance:
- Make sure the radiologist's report clearly states what he is supposed to look for.
- Make sure the report clearly states whether or not he found it.
- Make sure that the evaluation clearly states whether the finding is definite and unambiguous.
If any of these three steps is missing, that red flag can spell big trouble.
Copyright © 2007 Laura Nathanson