Medical Malpractice Bulletin – September, 2015

Charles A. Pilcher MD FACEP

September, 2015

[Editor’s Note: As a member of the Society to Improve Diagnosis in Medicine, I will be attending their international conference in Washington, DC, this month. The theme this year is “Diagnostic Error in Medicine: After the IOM Report, What’s Next?” I hope to return with new research and insights to share with you in future issues of this Bulletin./CP]

Perspective: Are radiologists blind? They should be!
By Charles A. Pilcher MD FACEP

Last year in the Journal of the American College of Radiology, Durand et al. published a thorough review of the biases inherent in experts’ review of radiologic images during the course of med mal litigation. They then discussed strategies that might be helpful in mitigating those biases. Any time an x-ray becomes the subject of litigation, there will be experts to support both sides. In order to parse out what is truth and what is opinion, Durand et al. illustrate several approaches that would result in cases being better litigated for all concerned. Read more here, especially if you have an interest in mis-interpreted radiologic findings, the biases that lead to them and ways the problem can be remedied. Much of the information in the review applies to biases likely to be present in testimony of expert witnesses in all areas of medicine, as I have written about in a previous  “Perspective.”

Even radiologists must communicate
Following up on the “Perspective” above, an article in Diagnostic Imaging by Whitney Howell illustrates why radiologists must develop their own communications skills – with referring physicians, their own techs, other radiologists, and patients. According to Dr. Graham Billingham of insurer Medical Protective Company, 75% of lawsuits are due to failure to diagnose or communicate. Radiologist Dr. Jonathan Berlin of NorthShore Medical Group says that providers must be proactive, and seek out additional available information, even in a different modality such as CT or US. Techs often have more info on the case. Radiologists must also ensure that referring physicians read their reports. According to a 2011 Radiology study, 37% of referring physicians believe their interpretations are better than a radiologist’s, and 15% admit they don’t read radiology reports at all. A recent ACR member survey showed that while 97% of radiologists will call a referring physician with emergency findings, only 24% will call about unexpected, significant findings. These are often the ones that lead to “misses” – and lawsuits.

Shaken baby syndrome gets a second look
Last week’s medical news was all about the final installment of the very thorough report in the Washington Post called “Shaken Science.” The report indicates that we have probably been overly aggressive in diagnosing “shaken baby syndrome.” In 200 0f the 1800 cases reviewed, charges against an alleged perpetrator were dropped, and at least one woman who was imprisoned for such a crime has been exonerated. The report indicates that science has yet to prove that shaking can produce the bleeding and swelling that have been attributed to the diagnosis, and other conditions can trigger identical conditions in babies. One law professor advocates a second look at ALL shaken baby convictions. 

Should warfarin be stopped if a patient is having surgery?
Both bleeding and clotting risks are increased during surgery, so what is one to do for the patient needing surgery who is on the anti-coagulant warfarin to prevent clotting? UpToDate Online (subscription publication) recently changed its recommendation. Until now, warfarin is stopped and heparin or a similar drug given during the peri-operative period (because it is easy to reverse if bleeding occurs.). The new recommendation is based on a study by Dockets et al. in NEJM who found that most patients, typically those with atrial fibrillation, are low risk. Both bleeding and clotting outcomes are the same in both the treated group and the placebo group if the warfarin is simply stopped and no “bridging” anticoagulant is used. In fact, patients treated with heparin (dalteparin) had a higher risk of bleeding. Bridging is still recommended for high-risk patients such as those with artificial heart valves, and doctors must continue to weigh the risks and benefits of “bridging.”

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