Cases do not normally end like this.
A cardiologist implanted a pacemaker. He ordered a follow-up check X-ray to check the leads and make sure there were no complications. A second cardiologist checked the films and discharged the patient from the hospital. The radiologist’s report noted the placement of the pacemaker leads. It also noted a potential lung nodule and recommended follow-up X-rays.
Four months later, the patient returned to the original cardiologist’s office. The cardiologist never shared any information about the lung nodule. No follow-up chest X-ray was ordered.
One year later, the patient was diagnosed with lung cancer. He died 23 months after the pacemaker was placed.
The man’s wife sued the cardiologists for medical negligence. It argued that failure to relay the radiologist’s message resulted in a “loss of chance” of survival for her husband. The wife identified an oncologist as the sole medical expert.
The cardiologists filed for summary judgment. They argued that Alaska law mandates an expert must be board certified in the same specialty as the defendant. Here, the defendants were cardiologists. The expert was an oncologist. The cardiologists also submitted an affidavit certifying they met the standard of care for cardiologists.
The affidavit stated the cardiologist who reviewed of the x-ray was not required to perform a thorough radiological evaluation of the man’s overall health. The cardiologist who performed the surgery explained that he did not have a duty to go back through the entire chart and check all other care providers’ medical records.
The chest x-ray review by the other cardiologist had already confirmed the pacemaker implantation did not have complications. The purpose of the follow-up visit was to check the pacemaker, discuss chest pain, and discuss the results of a nuclear stress test.
The Supreme Court of Alaska ruled in favor of the cardiologists.
Here, the radiologist should have picked up the phone and alerted the ordering physician of the unusual finding and need for follow-up. I do not know if the radiologist was also sued; but typically, every person whose name was on such a chart would be sued and someone would be writing a check for delay in diagnosis.
Cases do not normally end like this.
Hagen v. Strobel, 2015 WL 4167381 (Alaska, Jul 10, 2015)
One of the problems is Radiologist Chicken Little Syndrome. I’ve never seen an “Official” x-ray report that didn’t mention some CYA potential abnormality and suggest radiologic follow up.
I think it is worth referring to the National Lung Screening Trial (reported by the National Cancer Institute.) It is one of the largest sampling studies done on this subject, involving 155,000 participants between the ages of 55 to 74. *
An absolutely resounding feature of the study is that: “Annual Screening with Chest X-Ray Does Not Reduce Lung Cancer Deaths.”
This suggests the possibility that even with follow-up x-rays the cancer would have remained undiscovered, possibly until metastatic lesions were found elsewhere.
The author of the study, Christine Berg MD summarized it as follows:
“Results from the trial “are as definitive as most studies get,” Dr. Berg continued. “They really indicate that lung cancer screening with chest x-ray is of no benefit for reducing lung cancer mortality, regardless of an individual’s risk profile.”
Research groups are still analyzing the NLST results, Dr. Berg added, including the implications of the high false-positive rate associated with CT screening in that trial.”
As a DPM who never treated cancer, I am not qualified to make any judgments on this issue. But this study is very interesting and worth reporting.
Michael M. Rosenblatt, DPM
*http://www.cancer.gov/types/lung/research/screening-x-ray
(Posted: December 2, 2011
This text may be reproduced or reused freely. Please credit the National Cancer Institute as the source. Any graphics may be owned by the artist or publisher who created them, and permission may be needed for their reuse.)
Really, guys?
A new lung nodule is a must call item. Radiologists–at least at universities where I’ve worked as a neuroradiologist for a little over 40 years–didn’t get the Chicken Little memo to which Mr. “Brandeis” refers.
As for Dr. Rosenblatt’s comments, while routine chest x-ray screening doesn’t reduce the overall death rate from lung cancer, it is not true that all lung cancers are incurable, especially if caught early before the disease has had a chance to metastasize. Excusing flagrant neglect with the argument that screenings–which this was not–fail to prolong life statistically is a non-sequitur.
Take a parallel situation: you break your arm falling from a roof where you were cleaning a gutter. You go to an ER where the fracture is radiographed and, by the way, since you were in the ER and you’re over 60 (it’s a hypothet), you’re on an EKG monitor. It shows mild ST elevation, so they do a 12-lead which shows ischemia. The fracture is repaired and you go home. No one tells you about the EKG abnormality. A few months later you have your MI and become a cardiac cripple, even though you could have had an angioplasty and no MI.
Who here is going to say that there was no negligence or malpractice in this situation? Who is going to say that the situations aren’t parallel? I’d testify against whoever failed to inform the patient here, and I’d do the same in Alaska. As for Alaskan medicine, if their supremes affirmed the defense verdict, I’d take out an ad in the newspapers and make sure the media got their noses into it. It is inexcusable to practice that way. It is even more inexcusable to stonewall it.
I think the cardiologists would not have prevailed in another state. If a physician orders an exam, he or she is responsible for reviewing the results of that study. There have been cases where a pre-op chest x-ray showed a potential tumor and the surgeon never bothered to read the report. It was cancer and the surgeon lost the case. I think the radiologist also got hung on this as well. There is no doubt the radiologist should have called and documented the abnormality, but I would not absolve the cardiologists of culpability either. Don’t order studies if you are not going to review the results and then take appropriate action. I had an endocrinologist order a chest x-ray that had an abnormality. I told him he needed to order a chest CT. He told me he didn’t really feel like it was his problem to deal with. I am sure that would go over well with a jury if it had turned out to be something serious. Again, don’t order the tests if you are not going to review and act on the results. And there is a large amount of CYA medicine practiced by cardiologists, orthopedists, ob/gyns, etc, so I do not think radiologists are alone to blame for that particular problem.
Dr. Horton brought up the very important subject of so-called “incidental findings.” The courts are replete with judgments against even limited licensed practitioners for “ignoring” important incidental findings and failure to make the appropriate referral.
In the case of DPM’s, since DPM’s are generally not licensed to treat “systemic conditions” beyond the ankle, we are severely indoctrinated in our residencies and DPM colleges on the issue of referring “incidental findings. ”
For DPM’s the most common cause of referral is elevated blood sugar and Hemoglobin A1C. Another is hypertension, the result of taking a patient’s blood pressure for a routine procedure or examination.
The very presence of our limited licensure makes us an entry-place for incidental and unexpected findings. Somewhat unexpectedly, in the process, we end up practicing diagnostic medicine. Rather than looking at this as a licensure disadvantage, DPM’s have widely welcomed this responsibility as a doorway to additional physician referrals and high level patient care.
I once saw a long-standing patient in the office who was diaphoretic and complaining of “arthritis” pain in her left shoulder. After taking her blood pressure and asking her a few questions I realized she was having an active MI. I called 911 and they got her to the ER. At the ER, her husband was told that “I was the podiatrist who caught his wife’s MI in time for a CABG surgery.”
Michael M. Rosenblatt, DPM
This scenario if as presented, is blatant sweeping things under the rug. Inexcusable, inhumane and without compassion, empathy and consciousness. Shame on the cardiologist and shame on the judicial circuit involved
Funny how when we all did our rotations no one asked what you were going to specialize in, and then excused you from certain knowledge re. ‘incidental’ or other findings. The chest Xray was read the way the radiologists training us taught us: a systematic rigorous review of everything that the image told us re. heart size, position, vasculature, lung parameters etc., etc., in a very regimented way. Once you laid eyes on it you made your reading. If u had questions after the radiologists reviewed that same film and especially if they had additional information to share, this was the teaching moment. And along with the information came the responsibility that the oath we took applied to: Do no harm! It’s amazing to me to see ‘specialists’ especially herein cardiologists whose area of study is quite simply without argument the chest cavity where the heart resides, and all the neighboring structures act as if it was not their job to note abnormal findings and make recommendations and referrals. Although many states have adopted similar restrictions with regard to ‘equivalent’ specialties only being allowed to testify vs. the same specialty, it is in my view a step backwards as multiple specialties all of which ‘specialize’ in chest disease, and are all proficient in reading the various studies performed with appropriate and adequate radiological backup should ALL be responsible for informing the patient of ANY abnormality picked up. How the patient then utilizes this new information then becomes the patient’s own responsibility
All comments, reviews, and critiques are respectfully appreciated. I might observe that even if a malignancy might be found on a chest imaging study and proven to have no reasonable chance of a “cure;” nevertheless after my having been through my own Cancer Surgeries (papillary/follicular carcinoma of my thyroid gland) and my own Cancer Survivor Support Group – all of whom are deceased; i.e. all except me…I still feel and endorse that a Cancer Survivor may well choose to live differently if and when a Malignancy is Discovered. The problem might be somewhat further compounded if the Identified Patient has no telephone number or simply endorses, “I do not know my telephone number as I do not call myself!” and/or may well have no permanent address either or both may well obtain here in (rural–appalachia). Respectfully submitted…Doctor Josh {editors, colleagues, students know me as Doctor Josh}
I imagine the look on the plaintiffs’ faces resembling the countenance of OJ when “not guilty” was read.
I can appreciate the cardiologists viewpoint. On Long Island, NY we call it NIMBY (not in my backyard) Fortunately for them, they practice in Alaska where specialists are judged by other specialists. In New York, as a general dentist, if I perform a specialist procedure, ie root canal, difficult extraction, etc, and something goes wrong, I am judged against how the specialist would have performed. And for a cardiologist to note that there is a suspicious nodule on a chest xray, and to say nothing to anyone, is malpractice. If he didn’t want to take responsibility, he should have given that patient a referral. It’s called “sharing responsibility” and is done all the time.
In the case cited:
1) The ordering cardiologist didn’t check the xray himself because?
2) The second cardiologist who has training in xray interpretation couldn’t identify the lung nodule, why?
3) The radiologist did not pick up the phone and notify of an unexpected abnormal finding because?
4) No one actually read the radiologist’s report, and noted it in the progress notes in the patient’s chart why?
So this is malpractice x 4.
I have been victimized by poor or lack of communication by radiologists. I agree with the ordering physician taking responsibility for the test but I also agree with the focus by the cardiologist for proper implant placement. I think the radiologist knowing the cardiologists narrow focus should have made a special effort to directly contact the cardiologist as well as the PCP. All too often radiology becomes a “9 to 5” job without enough attention to the patient’s well being. As a surgical sub specialist I run into this lack of communication all the time.
In the operation of my Medicare Certified Surgical Center, I used check lists to deal with the minutiae of detail management. For DPM’s missing an incidental finding that requires referral is a “life-death” issue for patient management. Since we are not licensed to treat general medical conditions (for the most part), this requirement is a shining beacon for managing patients.
The so-called “plenary” medical license can be as much a burden as an advantage. Nobody can be an expert at managing everything, and it is exceedingly easy to lose details, even important ones. When you add the increased requirements for electronic record keeping and Obamacare requiring that you see 30% more patients than you can reasonably handle, I would predict that “ignored” incidental findings will get worse…not better.
When we write hospital discharge notes, we look through the chart to create a good summary. When I did my hospital internal medicine rotations at the VA and Army hospital, I was instructed on creating “summary notes” every third hospital stay-day, which required looking through lab, x-ray, scans and nursing notes to create the summary.
They required this of all residents, not just DPM residents. The business of modern medicine and the multiplicity of scans, x-rays and consults enormously complicates patient management. DPM’s would request co-management for class II and III patients (numbers of major organ abnormalities) with internists. They would take over that responsibility during hospitalization.
Co-management is no longer uncommon. When I was working, orthopedists, ENT and other surgeons would routinely request co-management. it made sense then and it makes sense now. But you still have to deal with the minutiae of patient management. Somebody has to.
An “incidental findings” check list in the chart would prevent some tragedies, and likely would have prevented this one.
Michael M. Rosenblatt, DPM