A 55-year-old woman came to her family physician with complaints of chest congestion, wheezing, and shortness of breath. Diagnoses included asthmatic bronchitis, rhinitis, otitis media, and hypertension.
A chest x-ray was completed and read two days later by a radiologist, the defendant in this case. The film was compared with a study done five months earlier that demonstrated an area of atelectatic change or infiltrate. This was no longer present and the current study revealed no active lung disease. The radiology report was faxed to the family physician.
Six weeks later, the patient returned to the family physician. She reported continuing symptoms, and was assessed as having asthma, rhinitis, hypertension, and obesity. Three months later, the patient again reported breathing problems and “not getting enough air.” The assessment at this visit included asthma, rhinitis, hypertension, dyspepsia, and right arm numbness. The patient was given prescriptions and instructed to return the next week.
That evening the patient came to the emergency department (ED) of a local hospital reporting shortness of breath and difficulty breathing. The ED physician ordered a chest x-ray and discharged the patient with instructions to follow up with her family physician.
Three days later, the defendant radiologist interpreted the study and noted an area of slightly hazy density in the left lung with nearby fibrotic changes. Differential diagnoses included a developing small nodule or mass and a CT scan was recommended. This radiology report was sent to the ED, but there was no indication that the ED forwarded the report to the family physician.
A note in the patient’s ED medical record dated the day after the ED visit indicated awareness of the evaluation. The entry stated the pulmonary function, oxygen saturation, and chest x-ray were “OK.” The entry also included comments about patient anxiety, a prescription for alprazolam, and that the patient was advised to see her physician in two days.
The patient was seen by the family physician six days later. She reported better breathing and decreased anxiety. Physician assessment indicated that the patient’s asthma had improved, and again listed hypertension, rhinitis, RUE numbness, dyspepsia, and anxiety.
Eight weeks later, the patient came to the ED reporing breathing problems and chest pain. A different ED physician saw her. He ordered a chest x-ray, which he interpreted as showing increased pulmonary markings. The ED physician prescribed medication, told the patient to continue using an inhaler, and instructed her to follow up with her family physician.
Again, the defendant radiologist over-read the chest x-ray, and compared it with the patient’s first x-ray, but not the x-ray completed during the previous ED visit. The radiologist reported no acute lung disease and no significant change from the earlier study. No mention was made of the suspicious density in the left lung with nearby fibrotic changes that prompted the recommendation for a CT scan. There was no indication in the medical record that this report was forwarded to the ED or the family physician.
Two days later, the patient was seen by her family physician reporting midsternal tightness that increased with exertion, wheezing, dyspnea and a “thick” tongue. Over the next seven months, this patient was seen seven times with continuing report of difficulty breathing. The record for these visits reflected the same assessment of asthma, rhinitis, and hypertension.
Another four months passed. During an appointment, the family physician noted for the first time the existence of a left upper lobe nodule. The patient was sent to a specialist who performed a lung biopsy. The patient was diagnosed with inoperable lung cancer. She was subsequently evaluated by an oncologist and underwent chemotherapy. The patient died one year later.
Lawsuits were filed against the family physician, the radiologist, the two ED physicians, and the hospital. The allegations against the defendant radiologist included:
- failure to diagnose lung disease or cancer;
- negligence in the failure to inform the patient or her physician of the recommendation for a CT scan; and
- failure to compare all chest x-rays available.
Determining exposure when multiple defendants are involved can be difficult. Three TMLT consultants reviewed this case. Two were generally supportive of the interpretations made by the radiologist. One was critical and felt the developing mass could be seen on the early film.
The case was also reviewed by the Claim Review Committee with a conclusion that was reasonably supportive of the interpretations, but critical of the radiologist’s failure to communicate the recommendation for a CT scan to the ordering physician. The plaintiff’s attorney also retained a well-credentialed expert who was highly critical of the communication issue.
This case was settled on behalf of the radiologist. The hospital and family physician also settled their cases. The outcome of the case against the ED physicians is unknown.
Risk management considerations
An emergency medicine physician who reviewed this claim criticized the hospital for lacking a system to ensure follow up for abnormal x-ray findings and notification of physician and patient. It is imperative for radiologists to communicate with referring physicians. Even though there is often no direct encounter between the radiologist and the patient, a physician-patient relationship does exist. Prudent risk management calls for a radiologist to notify the referring physician when a study is abnormal and to carefully document this action.
In this case, there were three opportunities to act on the recommended CT. The defendant radiologist had the opportunity to communicate with the ED physician, ED staff, or the family physician to ensure the scan would be ordered. ED staff had the opportunity to confirm the over-read was done, and to act on the radiologist’s recommendation. The abnormal x-ray was part of the family physician’s medical record, and one may surmise, not reviewed for more than a year.