Malpractice and Radiology: A Hapless Relationship

England, 1765

British legal scholar Sir William Blackstone published Commentaries on the Laws of England, in which “neglect or unskillful management of a physician or surgeon” was referred to as “mala praxis.” It is from this term that the modern word “malpractice” is derived.

Connecticut, 1832

A state supreme court establishes the Standard of Care (SOC) for a physician: “A physician and surgeon is liable for injuries resulting from the want of ordinary diligence, care, and skill.… Ordinary means usual, common. If you were to draw a line of distinction just halfway between the eminently learned physicians and those grossly ignorant, you would hit exactly on those who are ordinary.”

Pennsylvania, 1853

A state supreme court added the following: “The law requires physicians to possess reasonable skill and diligence… not extraordinary skill such as belongs only to few men of rare genius and endowments.”

Colorado, 1896

One year after Roentgen’s discovery of the x-ray, an x-ray image showing a bone fracture was offered as legal evidence for the first time in an American court. Disagreeing with a lawyer’s arguing against admitting the x-ray, the judge stated: “We have been presented with a photograph showing a femur bone which is surrounded with tissues and therefore is hidden…. Modern science has made it possible to look beneath the tissues of the human body and has aided in telling hidden mysteries. The photograph will be admitted in evidence.”

United States: First Half of the 20th Century

In the decades prior to the end of World War I, most malpractice cases focusing on radiology involved alleged x-ray and radium burns. For the entire first half of the 20th century, most malpractice lawsuits filed against all physicians focused on errors of commission : that is, the doctor did something wrong.

United States: Second Half of the 20th Century

Beginning in the early 1950s, allegations of malpractice evolved from errors of commission to errors of omission; that is, the doctor failed to do something right: they failed to make a timely diagnosis. In the last 3 decades of the 20th century, allegations of malpractice against radiologists focused mainly on failure to diagnose; that is, the radiologist missed an abnormality on the radiographic images. By the mid-1980s, missed lung and breast cancers became the most frequent reason radiologists were sued for malpractice.

United States: The Present

Of all radiology medical malpractice lawsuits, 57% to 67% are diagnosis related. Failure to diagnose accounts for most of these. Only 2% of all patients sustaining adverse events file malpractice lawsuits.

Radiologic Errors

Causes of error in radiology are multifactorial: poor technique, failure of perception, lack of knowledge, poor judgment. Numerous research studies reported over the past 60 years have disclosed an average 30% “miss rate” in the retrospective evaluation of general radiographic, computed tomography (CT), magnetic resonance, and ultrasound examinations. This means that if 100 radiologic examinations containing abnormal findings are given blindly to radiologists, an average of 30% of the abnormalities will be missed. Such studies, however, do not reflect the everyday practice of radiology, where the number of normal examinations far exceeds those that are abnormal. Various studies and performance improvement data derived from radiologists’ interpretations under ordinary working conditions of both normal and abnormal radiologic studies disclose an average error rate of 3% to 4%. Fortunately, most of these errors are not injurious to the patient or are corrected by review of radiologic studies before they become injurious.

Seventy percent of missed radiologic diagnoses are perceptual in nature; that is, the radiologist fails to “see” the abnormality. The remaining 30% are cognitive errors; that is, the radiologist “sees” an abnormality but attaches the wrong significance to what is seen, either through lack of knowledge or lack of judgment. Diagnostic errors are also caused by the phenomenon known as “satisfaction of search”; that is, an imaging study may contain several abnormalities. The radiologist notes one or perhaps two abnormalities but then tends to “stop looking” for additional abnormalities; his or her “search” has been “satisfied” prematurely. Another cause of errors is the “alliterative” error, also termed “diagnosis momentum.” Here, the radiologist looks at a previous study and previous report rendered by the same or another radiologist before interpreting the new follow-up study, and if the previous diagnosis was erroneous, the radiologist interpreting the new study has a tendency to repeat the same error.