Q&A with Leonard Berlin, MD: Errors, quality and malpractice

When ACR’s Radiology Leadership Institute honored Leonard Berlin, MD, with a 2015 Leadership Luminary Award this past August, some may have assumed Berlin was getting ready to take a bow and move on toward retirement. Yet, 56 years into his eventful radiology career, Berlin still works with the energy and focus of an up-and-comer.

The professor of radiology at Rush Medical College and the University of Illinois College of Medicine—contributor to more than 430 medical journal articles, presenter of 385 lectures and author of the much-consulted book Malpractice Issues in Radiology, now in its third printing—took questions from Medical Imaging Review (MIR) on his areas of ongoing interest.

MIR: What is the acceptable range of error for a radiology practice in the U.S., and how does this compare to other medical specialties?

Berlin: The fact is that we have two figures. We have the retrospective research figure, which shows a 25% to 30% error rate. Then there’s what the average radiologist misses during a usual workday’s work, and the data on that show an error rate of just 3% to 4%. So the 25% to 30% is a research figure. The 3% to 4% is a realistic figure. As for where this fits with the rest of medicine, a number of studies have been published showing, again, error rates approaching 30%. So that figure is not isolated within radiology. It shows up across the board in medicine.

It’s important to point out that, of the actual errors that get made, most are minor. Many errors get corrected before patients sustain any injury. Or it might be a minor error in diagnosis that doesn’t harm the patient. Or it might be that a radiologist made an error today on the x-ray, the patient comes in tomorrow for follow-up, and then the radiologist notices that he or she made an error. The error is corrected and the patient has not been harmed.

MIR: What impact have teleradiology companies such as vRad had on quality benchmarks for the industry?

Berlin: Initially, when teleradiology and telemedicine began in the late 1980s, maybe the equipment wasn’t so good and there were errors. In the last two decades or so, since we are all on electronic transmission and computers now, the error rates are no different with teleradiology than when we read them sitting in the hospital. What’s the difference if I’m reading images on my computer in my office or reading them on a computer in Switzerland? It’s the same image.

When you talk about companies like vRad, you do bring up the issue of quantity. And that is an interesting issue. Generally speaking, radiologists of course read at different speeds. Does a teleradiologist read more cases than I do sitting in my office in the x-ray department? We don’t know. Some do, some don’t. We have slow readers and fast readers. It’s intuitive to believe that the faster we read, the more errors we will make. But there are no hard data out there one way or the other. It has never been studied.

It also is intuitive to believe that the more cases we read, the more fatigued we will get, and the more errors we will make. Again, there are no hard data out there to support or refute that intuition. In fact there was an x-ray reading study done way back in the 1970s at the University of Missouri. The error rate actually increased with the time spent looking at the image. Just like with any test you and I took as students, if you spend too much time on any one question, the problem becomes overthinking the answer.   

So what’s the bottom line? Whether it’s 20 seconds or 20 minutes, the fact is, we have to do what we have been trained to do as radiologists: spend adequate time to properly interpret the study. And don’t spend too much time.

MIR: Are there areas in radiology that are more error-prone than others?

Berlin: There have been recent articles looking at scrolling errors, where we tend not to look very closely at the beginning or ending slices in a CT series. As a result, some incidental or peripheral findings get missed. That’s an interesting thing that we have to be aware of. We’re going to scroll through a bunch of images, but we have to look at the first image and the last image. They can be just as important as are the middle images.

MIR: Are you seeing any trends in malpractice litigation of late?

Berlin: Interestingly enough, the number of malpractice cases in the U.S., not just in radiology but across the board, has decreased annually for the last three years. They are down about 10% or 15% from last year and down another 10% or 12% from the previous year. The reason is probably economic. In the United States, we work on a contingency basis. The plaintiff’s attorney has to lay out the money and the patient pays nothing. The economics are such today that court costs are high and expert witnesses are expensive, so lawyers are very careful. Unless they see a chance for a reasonable return on their investment, they are not going to take a case.

So, although the number of cases is down, one of the concerns there is electronic medical records. EMRs are increasing errors, as is widely known, and the concern is that we will see more malpractice suits because of EMRs. They are supposed to diminish errors, and they are increasing errors. There’s a lot of duplication. Once something is in a medical record, it’s there forever—and if it’s not in there, it doesn’t become part of the patient history. We cut and paste, so that error keeps getting repeated.

In radiology, mammography is still the most common modality for which radiologists are sued for missing diagnoses.

MIR: How can radiology practices minimize their error rates?

Berlin: We have to compare with previous diagnostic studies. We have to take adequate time to interpret an individual study. We should try to obtain as much patient history as possible. The other issue is not only making the diagnosis but also communicating the diagnosis.

We have seen an increase in malpractice suits because a significant unexpected finding has not been properly communicated to the referring physician. Radiologists have to communicate directly to referring physicians when we see a significant unexpected finding. Too often, it’s the case that the abnormality was in the report, but it wasn’t sufficiently well communicated.

MIR: It’s interesting that, despite all the focus we’ve seen on improving quality—all the financial incentive and penalty systems, all the reporting requirements—combined with the tremendous advances in technology, we aren’t seeing error rates nosediving.  

Berlin: We’re all human. We’re always going to make errors, and technology only goes so far. We still have the human brain to deal with here. I would love to say errors are way down. Well, thanks to the EMR, they’re not way down. But we have to keep errors in perspective. Medical care is better than ever. And most of the errors that are labeled errors do not injure patients. Every so often a patient does get harmed, and then we have to compensate the patient and take care of it. But not every error is bad. We make errors, and we should learn from our errors—which we all continue to do.