Failure to properly interpret a screening mammogram

Presentation and physician action

A 42-year-old patient was referred by her gynecologist to a mammography center for a screening mammogram. The patient did not report any problems with her breasts. She provided the screening center with her medical history, including a family history of breast cancer. Her mother, two aunts, and grandmother all had breast cancer.

At the time of this mammogram, the patient’s two previous mammo­gram films were available. The radiologist, the defendant in this case, interpreted the mammogram as negative for evidence of malignancy.

Seven months later, the patient returned to her gynecologist com­plaining of a knot in her left breast. She detected this lump a week before the visit. The gynecologist attempted to aspirate the lump, but no fluid was obtained. He referred the patient back to the mammography center for a diagnostic mammogram and sonogram.

The defendant radiologist reviewed the diagnostic mammogram and sonogram. He believed the mass, visible on the mammogram, was suspicious for malignancy. He measured it at approximately 1. 5 cm in diameter and recommended a surgical consultation.

During this visit to the mammogram center, the patient reported that a staff member “in a white coat” informed her that the radiologist would have found the lump in her breast on the earlier mammogram if he had looked for it. This state­ment was made as the staff member reviewed her films. The patient was unaware of the staff person’s name.

The patient next came to a general surgeon, who performed a needle biopsy. The biopsy showed malignant cells consistent with mammary duct cell carcinoma. The surgeon told the patient that he did not want to offer an opinion as to why the radiolo­gist did not detect the lump on the earlier mammogram. The patient was quite curi­ous and concerned that the condition had gone undetected.

The patient was admitted to the hospital where the surgeon performed a left exci­sional breast biopsy, a left breast lumpectomy, and axillary lymph node dissection. Clear margins were established around the tumor during surgery. The pathologist staged the patient’s cancer at stage II A. Over the next two years, the patient com­pleted chemotherapy, radiation therapy, and was started on hormonal therapy. She has remained free of cancer.

Allegations

In her suit against the radiologist, the patient alleged that he negligently interpreted the screening mammogram films. As a result of this alleged seven-month delay, the plaintiffs claimed the cancer progressed to a more advanced stage, required more ex­tensive treatment than would otherwise have been necessary, and that the patient’s prognosis worsened.

Legal implications

The plaintiffs obtained experts supportive of their allegations, mainly that the mass was visible on the patient’s earlier mammogram and was missed by the radiologist.

Defense experts supported the defendant radiologist’s interpretation of the mammogram. These reviewers, including one for the plaintiff, also stated that the patient would have received the same treatment — surgery, chemo­therapy, radiation, hormone therapy — if the cancer had been detected in the earlier mam­mogram. The experts also hotly debated whether or not the cancer progressed to a more advanced stage during the seven-month period between mammograms.

Disposition

This case was settled on behalf of the radiologist.

Risk management considerations

As this case illustrates, health care professionals can and do incite patients to file lawsuits.

The following risk management recommendations may help minimize the risk of trigger­ing lawsuits against other physicians due to critical comments.

• • Stick to the facts without blame. If the patient asks you directly whether a previous physician was negligent, you might say “I can tell you what I’ve found and what I rec­ommend. But I did not see for myself what happened, and it’s not my role to determine fault.”
  • If the patient is coming to you for a second opinion and you disagree with the first physician’s opinion, be honest with the patient and state your opinion factually. Do not state the other physician is wrong. Simply acknowledge that your recommended course of treatment is different.
  • If an error has occurred, you must be open about the situation. Do not lie or cover up for a colleague. Be factual and honest, but do not disparage the previous physician. If the patient asks you why the error occurred, you might say “There are a number of factors that could have caused this to happen. But, I was not there and I cannot answer that for you.”
  • Avoid coming to a conclusion without having all the facts. Sometimes the history provided by a patient or family member contains erroneous information. Collect all relevant information before assuming that a patient or family account of the care deliv­ered is accurate.
  • Express empathy for the patient’s situation. Showing sincere interest and commit­ment to solving the problem is important.
  • Be aware that seemingly innocent remarks, tone of voice, facial expressions, and body language may lead the patient to believe there was something wrong with their previ­ous treatment. Comments such as “I would hardly expect that kind of complication from such a simple procedure,” or “This surgery will be much more complicated now because someone else has been here before,” may signal a problem to the patient.
  • Make sure your employees understand this applies equally to them. A casual com­ment made by a staff member preparing a patient for examination may be all it takes to provoke a lawsuit. Instruct staff to tell patients to refer questions about previous treatment to you.
  • Beware if a patient presents with less than optimal results from a procedure, ex­presses anger at the previous physician, and solicits your opinion about the treatment. Encourage the patient to speak directly to the physician about the problem. State that since you were not present at the initial treatment, you do not know how or why the result occurred.
  • Just as you would not want to openly criticize a colleague in front of the patient, do not do so in the medical record. When describing the situation, it is appropriate to quote the patient. You might document as follows: “Patient states that Dr. Jones felt a biopsy was unnecessary.”
  • If you suspect there may be a problem with the physician, go through the appropriate channels to address it. Appropriate channels include a hospital peer review committee, the state medical board, a specialty society disciplinary committee, etc.
  • The medical record is not the place to air grievances or discuss differing opinions with other physicians, nurses, therapists, etc. This, too, should be handled through the appropriate channels.
  • Extreme caution is warranted if you are contacted by a plaintiff’s attorney asking about a patient’s previous physician.
  • As always, whether you have talked to the patient or communicated with the previ­ous physician yourself, document your conversations and recommendations in the medical record.