In the days of active consumerism , reducing credibility of medical profession and informed decision making , it is vital to understand the scenario, and act accordingly (instead of the usual , I am very good and do not make mistakes, while others less knowledgeable than me, make all the mistakes !). An excellent write up submitted by Dr MGK Murthy, Sr Consultant Radiologist
A mistake is a mistake.( neither it is mine (make me guilty!) nor yours (makes me arrogant!), and it need not be owned.
"I would give great praise to the physician whose mistakes are small, for perfect accuracy is seldom to be seen. "Hippocrates
"Errors in judgement must occur in the practice of an art which consists largely in balancing the probabilities " Sir William Osler ( considered Father of modern medicine , 1849-1919)
From a practical point of view once an abnormality has been pointed out and a lay person can see it , it is not easy to convince that a Radiologist who is trained for the job and paid for seeing it , should be exonerated for missing it.
- In all branches of medicine , there is an inevitable element of patient exposure to problems arising from human error ,and this is increasingly subject of bad publicity , often skewed towards an assumption that perfection is achievable , and any error or discrepancy represents wrong and must be punished!
Unfortunately the public (and hence the executive &judiciary) frequently expects a medical investigation will produce "the correct answer" all the time .
- Radiology involves decision making under conditions of uncertainty , and therefore can not always produce infallible interpretations of reports . Interpretation of human picture (radiology in essence) is not a binary process ; the answer is not always normal or abnormal , cancer or not etc
Final report is often influenced by many variables , not least among them , available clinical/ other information at the time of reporting .
- With respect to radiology investigations , the use of the word "error" is often unsuitable .It is more appropriate to concentrate on "discrepancies " between a report and a retrospective review of a film or outcome .
- "Opinion" may be defined as " a conclusion arrived at, after some weighing of evidence , but open to debate or suggestion" and hence radiology reports are not expected to be incontrovertible
Somewhere between clear cut errors and the inevitable difference of opinion in interpretation of a picture , is an arbitrary division defining the limit of professional acceptability .
- Approximately about 1 billion radiological investigations are carried out across the globe annually, and literature quoted ,average error rate of 4% (across all modalities , though range is 2-20% in a large 20 year review study)is considered as acceptable , making an appx 40 million radiological investigations suspect for their utility.
A large study at MGH, Boston ( 2010 ) suggested after a double blinded study (of abdominal CT scans) an inter observer difference of appx 26%(between two different similarly trained Radiologists ) and(ironically! )intra observer (same person reading the same pictures at different times ) rate higher at 30%. We can safely say hence "we differ more with ourselves than with others!
Another recent global study has revised the figure of "real time" error rate in day to day radiological practice averaging at 3-5%.
- The factors for the discrepancies are many including the time of viewing the film (4 secs is considered as optimal for Chest x ray viewing and any prolongation (visual dwell ) would lead to higher false +ve or -ves/ system related parameters including acquisition parameters / Technique used OR available data at the time / work load of the day / mental frame of the Radiologist / Viewing conditions etc etc
- Common experience in radiology suggests that many errors are of little or no significance to the patient and some significant errors remain undiscovered
- Perfection = An imaginary state or quality distinguished from the actual by an element of known as excellence , an attribute of the critic .
Legal basis for negligence involves a breach of standard of care , which is usually defined as "care exercised by an average physician of similar knowledge , skill and ability under similar conditions"
- In conclusion, there is an absolutely unavoidable human factor at work in review of films/ images ; some abnormalities ( even obvious ones ) would be missed ; the mere fact that a Radiologist misses an abnormality, does not constitute malpractice ; and also not all radiographic misses are excusable ;
Therefore the focus of attention should be on issues such as Proof of competence , habits of practice, and use of proper techniques. A few simple steps would mostly reduce , if not eliminate the so called errors or discrepancies.
- Train technician to obtain adequate history / clinical data , and make him /her the preliminary reader of the images with ref to the clinical question(you may or may not agree with the opinion, at least it can facilitate your second look at his region of interest ). I have immensely benefitted from such interactions (if one is blessed to have PGs , they suit the role brilliantly)
- Start your report with the clinical question and why is the investigation ordered
- Answer the findings in relation to the question ,+vely or -vely in the very first paragraph itself
- Do not use diagnostic terms in the findings (for eg : glioblastoma/ cancer etc). Instead use only anatomical descriptions .
- Impression/ conclusion should bring abbreviated highlights of +ve findings in relation to the clinical question and a suitable confirmatory or exclusive investigation (preferably radiological) should be offered (with the words as would help to give legal leverage to the clinician/ patient to act appropriately)
- Rest of the study shows …. Should be next conclusion (brief … and not copy paste the Findings ) , with a similar suitable advice of other investigations if necessary. Conclusion should use diagnostic terms / reflect one opinion about disease and not an echogenic …. Etc . one can take the help of , could rep…. in view of …… etc
- Comparison with old images should follow , expressing various components including the effect of therapy/ progression of the disease findings etc
- Always proof read your report with the help of your data entry operators( who would even confirm that you have reported the correct patient , i.e. images and report belong to the same individual/ investigation done is what the clinician ordered etc)
- Do not try to make report as if one has studied the tissue and not a picture ! Murphys law states "if something can go wrong , it WILL go wrong)
- Spend a few minutes summarizing your days work before departure, rather than feeling sorry at a later stage ( a bit of unpaid time at work can keep our dopamine/ serotonin/ oxytocin levels(happy guys) high enough to feel contended)
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