Reflective Assignment

Clinical Case in Radiography

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Table of Contents
Introduction.................................................................................................................................................3
Summary of Scenario...................................................................................................................................4
Initial Outcome and Considerations............................................................................................................4
Peer Consultation with XXX.........................................................................................................................5
Clinical Staff Consultation with YYY.............................................................................................................8
Academic Staff Consultation with ZZZ.........................................................................................................8
Conclusion...................................................................................................................................................8
Reference List..............................................................................................................................................8
Introduction
The assignment is to understand an ethico-legal case which I have experience during my clinical
experience in radiography, using the theory learnt at the university and applying them to practical
experiences. To understand the scenario at hand I would be following a standard problem solving
framework to reach a reasonable solution. The problem solving framework is as follows.

1. Identify the problem

2. Understand the key areas of the problem
a. Clarify the concepts and language
b. Identify the question to be answered
c. Restate the problem in your own words
3. Data collection about the problem
a. Gather and write down any important data or information
b. Understand restrictions and conditions
4. Application of researched data
5. Determination of solution for the problem

The problem solving process is highly dynamic and it follows the passage from identification and
understanding of a problem to its proper conclusion. Also as the process is dynamic there may be some
times when there may be digression from the flow to follow up a particular key component of the
problem or a researched application. But broadly using this flow as the base I will try and reflect on the
issues raised by the ethico-legal clinical case.
Summary of Scenario
A 66 year old man had a routine investigation in a hospital at Perth. As a part of this examination he
underwent chest radiography. The radiologist on duty at the time interpreted the posteroanterior and
lateral radiographs as showing normal findings. The examination did not yield any adverse result and the
patient did not come back to the hospital.

After 3.5 years, the person in question came to his physician with extreme cough, chest discomfort and
weight loss. The physician got a chest radiography done again and this time the radiograph revealed a
large anterior mediastinal mass. He ordered a needle biopsy to confirm the diagnosis of malignant
thymoma.

The person was treated with surgery, chemotherapy and radiation, though this made little effect on the
patient’s condition which steadily deteriorated. He died 16 months after the diagnosis had been
established.

Shortly before his death, the patient and his family filed a medical malpractice lawsuit against the
radiologist who had interpreted the initial chest radiographs. The plaintiff alleged that the defendant
radiologist had been negligent by failing to diagnose the malignant tumor revealed on the radiographs,
and that the 3.5 year delay in diagnosis had precluded curative treatment. The radiologist immediately
notified his professional liability insurance company of the lawsuit, and a defense attorney was
appointed.
Initial Outcome and Considerations
This issue has cropped up before me in previous clinical experience also. A patient comes for a routine
checkup and does so regularly. During the routine checkup the doctors fail to detect any problem, but
after some time the patient has some symptoms and he/she is then diagnosed with some problem,
although this later diagnosis comes a little late to save the patient.

I became interested in the medical and ethical issues of these types of cases and upon reflection saw the
following issues which are relevant to this problem

1. Negligence of the doctor on duty during the routine checkup

2. Inadequacy of the routine tests for early detection of the malignant tumors and level of
radiation required for better x-rays
3. How delay in diagnosis affect the patient. Was he late in reporting his systems to his physician
due to the non detection of any issue during the initial checkup.

To research the issues which have arisen in this case I have divided the problem into the following key
components to be investigated further.

1. What is the potential danger for the patient due to the delay in diagnosis?
2. Is X-ray as a checkup methodology in the routine checkup tests actually enough for an early
diagnosis or other imaging techniques such as MRI should be introduced in these tests?
3. Are doctors negligent during routine checkups?

To investigate this problem and to follow the problem solving approach that I have stated in the
introduction, I would conduct the following to understand the problem and gather data about the key
components of the problems.

1. Conduct academic research on each of the identified key components.

2. Peer interaction with XXX, Law student at _____ university for Negligence and duty of care law
3. Clinical staff member interaction with YYY, MIT at _____ clinic for X-Ray technology
4. Academic staff interaction with ZZZ, Professor at _________University for diagnosis techniques
for malignant tumors
Peer Consultation with XXX

The defense attorney showed the original chest radiographs to several radiology experts and sought
their opinions about whether the defendant radiologist’s interpretation of them conformed to the
standard of care. The experts responded that once they had seen subsequent radiographs that showed
the large tumor mass, they knew exactly where to look and, therefore, could retrospectively find a
density on the original radiographs that probably represented the tumor. However, the experts believed
that because of the subtlety of the findings and the fact that the defendant radiologist had no
knowledge of subsequent radiographs at the time of initial interpretation, his reporting of normal
findings on chest radiographs had conformed to the standard of care. In the meantime, the defense
attorney was informed that the attorney for the plaintiff had retained radiology experts who believed
that the tumor was obvious on the original radiographs and that the defendant radiologist’s failure to
see and report the abnormal finding constituted negligence.

As initial discovery proceedings began, the defense attorney decided to focus on two major issues:
frequency of perceptual errors among radiologists and the influence of hindsight bias. With regard to
errors, the radiology experts who had been consulted by the defense attorney called attention to the
many articles published in the radiology literature that indicated that perceptual error rates of
radiologists hovered in the 30% range [1–4]. One study the defense attorney found particularly
appropriate under the circumstances was a study conducted by researchers at the Mayo Clinic, which
found that up to 90% of lung carcinomas that were eventually diagnosed on radiographs could be seen
on retrospective review of chest radiographs initially interpreted as showing normal findings [5]. If
perceptual errors were that common among radiologists, wondered the defense attorney, could the
alleged interpretive error made by the defendant radiologist in this case truly be considered negligence?

The second issue dealt with the opinions of the radiology experts retained by the plaintiff that the
defendant radiologist had been negligent by missing the tumor on the initial chest radiographs. Was it
likely, as had been suggested by the radiology experts consulted by the defense attorney, that the tumor
on the original radiographs became obvious only after the subsequent radiographs had been reviewed?
What perplexed the defense attorney was the fact that on one hand the law required a radiologist to
exercise the degree of skill and care expected of a reasonably prudent radiologist acting in the same or
similar circumstances at the time the care in question was rendered, while on the other hand radiology
experts for the plaintiff were basing their opinions solely on their review of the initial radiographs after
they had full knowledge that the radiographs obtained 3.5 years later showed an obvious tumor. The
defendant radiologist was being accused of negligence because of an alleged misinterpretation of chest
radiographs that had been rendered prospectively and without any knowledge of what future
radiographs would disclose, and yet he was being judged by radiology experts who had full knowledge
of what the future radiographs actually did disclose. Thus, concluded the defense attorney, because the
same or similar circumstances at the time the care in question was given could never be reproduced,
evaluation by retrospective review could never be accurate. With these concepts in mind, the attorney
for the defense commenced discovery proceedings determined to have all the radiology experts,
whether retained by the attorney for the plaintiff or the attorney for the defense, concentrate on the
issues of error rates and hindsight bias. However, at deposition the radiology experts retained by the
plaintiff held firmly to the opinion that the tumor on the initial chest radiographs was so large and
obvious that the defendant radiologist’s failure to see and report the lesion was a clear breach of the
standard of care. Radiology experts retained by the defense held firmly to the opposite view, stating
that the mass, even if discernible on the initial chest radiographs, was so subtle and inconspicuous that
failing to observe and report it did not constitute negligent conduct. With neither side retreating from its
position, resolution by settlement was never seriously entertained by either party. The lawsuit thus
proceeded to a jury trial [6].

Discussion

The subject of radiologic errors has been studied extensively for more than 50 years. The generally
accepted error rate for radiologic detection of lung cancer is between 20% and 50% [7], but articles
published in the radiology literature that have evaluated previous “normal” chest radiographs of
patients who subsequently developed lung carcinoma reveal that the carcinoma could be seen in
retrospect in as many as 90% of cases [5]. The lesions that were missed varied widely in size, density,
and location [1–4]. As to the relationship between viewing time and probability of error raised during
the trial by one of the plaintiff’s radiology experts, the data are conflicting. Researchers at the University
of Missouri in 1976 found that in cases in which radiologists missed findings, the average viewing time
was 147 sec, whereas in cases in which radiologists reached a correct diagnosis, the average viewing
time was 113 sec [8]. The findings of the Missouri researchers supported the observation that
radiologists’ confidence in the accuracy of their opinions vary inversely with the length of their reports.
More than a dozen years later, however, Oestmann et al. [9] described contradictory results: accuracy of
interpretation diminished as viewing time decreased. In their study, radiologists found 30% of “subtle”
lesions in 0.25 sec of viewing time, but the number of lesions identified increased to 74% with unlimited
viewing time. Radiologists found 70% of obvious carcinomas in 0.25 sec of viewing time, and this
number increased to 98% with unlimited viewing time. The detectability of lesions decreased
considerably as viewing time became less than 4 sec. To what extent the missing of a lung lesion
constitutes negligence remains as unclear today as it was 105 years ago when Roentgen discovered X
rays. A recent decision rendered by an appellate court in Wisconsin sheds some light on this somewhat
blurry distinction [10]:

The radiologist’s having failed to perceive defects that could have been perceived in radiographs does
not establish that he failed to conform to acceptable standards of practice in the manner in which he
read them… In determining whether a physician was negligent, the question is not whether a reasonable
physician, or an average physician, should have detected the abnormalities, but whether the physician
used the degree of skill and care that a reasonable physician, or an average physician, would use in the
same or similar circumstances… A radiologist may review an x-ray using the degree of care of a
reasonable radiologist, but fail to detect an abnormality that, on average, would have been found…
Radiologists simply cannot detect all abnormalities on all x-rays… The phenomena of “errors in
perception” occur when a radiologist diligently reviews an x-ray, follow[s] all the proper procedures, and
use[s] all the proper techniques, and fails to perceive an abnormality, which, in retrospect is apparent…
Errors in perception by radiologists viewing x-rays occur in the absence of negligence.
Clinical Staff Consultation with YYY

Academic Staff Consultation with ZZZ

Conclusion

Reference List