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Digital mammography brings benefits but may increase radiologists' malpractice risk

Radiology Administrator's Compliance and Reimbursement Insider, May 1, 2005

By Cam Teems, CPC, CPHIMS

A shift toward digital mammography is often seen as step forward, a means of improving image quality, but its benefits may also work against radiologists by making them more vulnerable to lawsuits.

Digital mammography is capable of producing more accurate images than traditional film-screen mammography. It allows radiologists to manipulate images and magnify areas to gain clarity. It also, in some cases, allows for more portability of the image. Radiologists can review images at home or in other areas of the facility that have computers, so they don't necessarily have to be in the mammography area at a light box.

Digital mammography also creates more involvement for technologists in the acquisition of images. The technologist may see the initial image and choose to create a "spot" image of an area for the radiologist.

All of digital mammography's advantages-notably the newfound accuracy and efficiency-are exactly what contributes to its risk. Although radiologists have more tools at their disposal to help review images, so do the radiologists hired by defense attorneys to review images for problems.

Consider the following scenario: A plaintiff's attorney subpoenas films from a radiologist or defendant and asks another radiologist to review them. The plaintiff's attorney hopes the radiologist he or she chose as a potential expert witness will review the images and say, "I certainly would have reviewed this area further or ordered additional views." Or even better: "This is clearly a spiculated mass that is suspicious of malignancy."

The pieces of film used in this example must stand alone and speak for themselves. Technically, the film captures abnormality; the problem lies in the interpretation of what one may or may not see.

Digital images add a further dimension to this process. The issue becomes not only what someone did or didn't see, but also how they saw it. Reviewing radiologists now have additional tools at their disposal to conduct more thorough reviews of the images for potential problems with the initial radiology interpretation. Viewing consoles allow radiologists to manipulate images. Different vendors offer machines with different resolution. For example, pixel size can vary from 27 to 70 microns, but most have high-resolution views. Improved pixel size and other factors can produce exceptionally sharp images, enabling reviewers to see early microcalcifications and determine an abnormality's morphology.

Additionally, digital technology allows reviewing radiologists to manipulate and magnify images. The image can also be reviewed a second time with another set of variables (e.g., ambient light, magnification, different display screen, etc).

Although digital mammography provides a host of advantages for everyone using the technology-including both sides in a legal affair-there are also disadvantages that both sides must overcome. For example, most first-generation digital mammography users are comparing a digital image to a previous plain film image. This could raise the risk of errors.

Also, all of these enhanced features can be challenging to explain to a jury-and can create bias. For example, although digital mammography's portability is a great benefit to many radiologists, imagine the reasonable doubt that could be created just because a mammogram was read on a personal digital assistant or in a home office at 2 a.m.

Most trials that involve "failure to diagnose" claims include the testimony of a radiology expert witness explaining the finer points of mammography interpretation to a jury. The modality certainly plays a significant role in the education process. Digital images are more complex and therefore the nuances of the images may be more difficult for a jury to understand. For example, how do you recreate a digital image for a jury in the courtroom (e.g., the image may have originally been viewed using ambient lighting, etc.)?

The real question is whether using digital v. analog may hurt a radiologist's defense in practice. If using digital images is a step toward better interpretation, we must make sure that such strides are not negated by greater vulnerability.

According to the 2002 Breast Cancer Study conducted by the Physician Insurers Association of America, internists were named in 7% of the surveyed failure-to-diagnose breast cancer suits brought during the 1990s. Family physicians were named in 11% of cases and gynecologists were named in 29%. However, radiologists topped the list, being named in 40% of all failure-to-diagnose breast cancer claims. Let's hope that the next study shows that advances in technology have helped-rather than hurt-these numbers.

Cam Teems, CPC, CPHIMS, principal consultant, Practice Advantage, LLC, Atlanta. cam.teems@practiceadvantage.com.

Women receive fewer referrals for imaging procedures designed to diagnose coronary artery disease than their male counterparts, according to a consensus statement from the American Heart Association, Cardiovascular Device Liability Week reported.

Procedures such as single photon emission, computed tomography, and stress echocardiography are as effective in women as they are in men, according to the report. But diagnostic testing may need to be varied when used on female patients because of hormonal differences that may have an effect on the vascular system and test results, said Cardiovascular Device Liability Week.

"Women should not be assessed with a 'what's good for the goose is good for the gander' approach to noninvasive testing," said Jennifer H. Mieres, MD, chair of the committee that wrote the statement, according to Cardiovascular Device Liability Week.

A new study shows that it may not benefit healthy individuals to undergo full-body CT scans because the procedure's benefit does not justify the cost, the study's authors said, Aging and Elder Health Week reports. "Our findings show that the average person should think twice before having a whole-body CT examination," said study author Scott Gazelle, MD, PhD, according to Aging and Elder Health Week. "When money is wasted on ineffective interventions, it drives up the cost and decreases the availability of other necessary healthcare interventions."

The cost of a full-body scan was about $900 in 2001. The increase in life expectancy in healthy individuals was approximately six days, which is considered a minimal benefit. The study also found that 908 of every 1,000 patients have false-positive test results, which prompts further testing. "At this time, whole-body CT screening just doesn't appear to be a good use of healthcare funding," said Gazelle.

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