Chapter 11: Radiology

INTRODUCTION

In 1999, the Institute of Medicine (IOM) reported that medical care was responsible for up to 98,000 deaths per year in the United States.^{* 1} In 2016, Johns Hopkins University researchers estimated that medical errors account for more than 250,000 deaths per year in the United States, resulting in medical error representing the third most common cause of death in the United States.² The practice of defensive medicine to minimize failure to diagnose disease in a patient has led to increasing volumes of diagnostic tests ordered by physicians across a range of medical specialties.³

Radiology is an integral part of all oncology practices. Imaging of oncology patients constitutes a major portion of the studies performed at most hospital radiology departments.⁴ Advanced imaging using high-resolution sonography, multidetector computed tomography (CT), 3-T magnetic resonance imaging (MRI), positron emission tomography (PET)–CT, and PET-MRI has increased the sensitivity and specificity of diagnosing, staging, restaging, and treatment monitoring of cancer patients. At the same time, the exponential growth in the number of images submitted for interpretation of each study contributes to a greater workload for the radiologists, only to be compounded by complexity of cases and greater demand for more detailed measurements required for patients enrolled in clinical trials evaluating the efficacy of novel systemic therapies. Screening examinations (e.g., mammography, low-dose CT scanning for lung cancer, coronary artery calcium scoring) have created new challenges for radiologists, and one can speculate that diagnostic errors on screening examinations will comprise an increasing liability for radiologists.⁵

Radiologists compose approximately 4% of physicians in the United States, but they rank sixth in the number of malpractice lawsuits naming physicians as defendants.⁶ The likelihood of a radiologist being named as a defendant in at least one malpractice lawsuit by 60 years of age is 50%.⁷ Diagnostic errors are an unfortunate, but inevitable, part of any radiology practice, and the most common reason for malpractice lawsuits against radiologists.⁸ Another major contributor to malpractice litigation against radiologists is communication errors.⁹ The technical advancements that have led to improved image quality combined with a greater volume of imaging over the past few decades also have resulted in detection of more incidental abnormalities (“incidentalomas”) on routine or follow-up imaging of nononcology and oncology patients. Reporting incidentalomas and assessing their clinical significance is challenging and has been a subject of a large volume of research and publications on the topic. Fortunately, incidentalomas have a less than 1% chance of representing a lethal cancer.¹⁰

The individual topics pertaining to medical malpractice liability against radiologists in general, and oncology imagers in particular, will be examined and discussed in more detail in the following sections of this chapter.