Can you be sued for not spending enough time interpreting an imaging study? A recent South Florida case has raised concerns that a patient may allege this claim in future lawsuits.
A 64-year-old man taking blood thinning medications hit his head on a filing cabinet while tying his shoe. Paramedics transported him to the hospital, where he was evaluated in the ED and non-contrast CT scans of the head and cervical spine were ordered and performed. The radiologist found a scalp hematoma but allegedly failed to diagnose an acute subdural hematoma. The patient was discharged and sent home. His condition deteriorated and he was eventually admitted to a different hospital, where he was diagnosed with massive intracranial bleeding. The patient passed away the next day. The initial parties settled out of court for $2 million.1
The initial head CT scan showed a scalp hematoma with a contrecoup subdural hematoma, but the radiologist only mentioned the scalp hematoma. The radiologist was trying to reach a settlement when the plaintiff’s attorney subpoenaed the director of radiology to produce a printout of the record of each keystroke the radiologist made on his PACS computer the day he reviewed the CT images of the plaintiff. The subpoena showed that a total of 6 minutes and 27 seconds was spent looking at 691 images of the CT scans of the head and cervical spine. The plaintiff’s attorney alleged that this amounted to one-half a second per image — claiming that the radiologist was lax in his reading of the CT scan. Painting the radiologist as lax in his duty to the patient enabled the plaintiff’s attorney to leverage the CT scan to negotiate a
Since this case never reached a jury, there is no way to tell if the case could have been successfully defended on its merits. Errors in perception can occur in the absence of negligence.3 Mistakes are inevitable in the practice of medicine and will occur even with the best-trained radiologist. There is a recognized 4% error rate in radiology for daily work, which has been relatively stable for five decades.4
Realistically, the “speed per image” allegation would probably not be raised if there was not an error in interpretation. There is no standard of care for what constitutes a reasonable amount of time to spend interpreting a particular imaging study. Furthermore, no articles in the peer-reviewed literature address time spent per image. There has been considerable anecdotal data concerning the relationship between reading speed and accuracy, but there is no valid evidence to suggest that a “fast-reading” radiologist is reckless or that a “slow-reading” radiologist is more careful.5 However, a limited study of five radiologists tried to assess how radiologists perform when they read outside of their normal reading speed. The researchers initially concluded that there was a positive correlation between faster reading speed and the number of major misses and interpretation errors.6 The authors further noted that radiologists did not do well when reading faster than their baseline rate.7
Since there is no established standard for the viewing time of an image or a series of images, this leaves the field wide open for attorneys to allege — based upon expert witness testimony — that the radiologist did not spend enough time in reading the imaging study. While looking at an image for less than a second might seem reckless, the radiologist actually scans through the images in cine fashion looking for abnormalities, rather than stopping and looking at each individual image. CT and MRI images are usually reviewed by scrolling through the various series, most often in two or more planes simultaneously — similar to how one would view a movie. In addition, some of the many images may be oblique reformatted images, additional thin cuts, and/or 3D reconstructions.
When looking for stroke on diffusion weighted imaging or blood on gradient echo, we look for a focal signal abnormality or change in signal, rather than looking at every structure on each image. This is often done quite rapidly as we scan through all the images. Alleging that the radiologist was lax because they did not spend enough time per image ignores the way that most radiologists actually read the scans. Nevertheless, this will not stop a plaintiff’s attorney from using this against us in a court of law.
A South Carolina radiologist reported that he was asked in deposition about keystroke monitoring on PACS to determine the amount of time he spent reviewing a particular MRI scan and the total number of images reviewed.8 You do not even have to be aware of keystroke monitoring since you will probably be asked in deposition how much time you spent reading the imaging study. This can occur whether you are a defendant or an expert witness. Be careful how you answer, as it is then quite easy to calculate the average time in seconds spent on each image. Most radiologists scroll through the images, in two or more planes, and don’t spend an equal amount of time on every image. If this is how you read scans, make sure you are able to explain this in a concise and understandable manner that jurors can comprehend. Be prepared to actually demonstrate this to the jury if you go to court or are deposed. While the “lax radiologist” is a novel allegation, it is one that could receive recognition and approval from jurors.
The ACR does not currently have a Practice Parameter (PP) that addresses the minimum interpretation speed per image. Even if the issue is later addressed by a PP, these documents are educational tools and not intended to establish a legal standard of care.9 However, the trial courts have mostly allowed “guidelines,” such as the ACR PP, into testimony as relevant to the decision-making process in a case, but not as a document that defines the legal standard of care.10