In an imaging landscape where 64 percent of recommendations for supplemental screening are ignored by referring physicians, radiologists face a legal question: To what extent are they responsible for making sure colleagues follow through on their advice?
According to medico-legal and ethics expert Leonard Berlin, MD, who wrote a related column in the American Journal of Roentgenology, radiologists are required by law to disclose any recommendations for additional imaging in their written reports, but beyond that, they’re “not expected to be policemen.”
“Radiologists have neither a legal duty nor a moral duty to track their recommendations for follow-up or additional studies,” Berlin wrote in AJR, answering a clinician’s question about the possible legal consequences of failing to follow up. “However, the communication gap between the radiologist and the referring physician—and perhaps even the patient—must be closed.”
The write-in question concerned a tricky situation within the asker’s own radiology group, where an internist failed to follow-up on additional abdominal imaging recommended by a radiologist after a chest CT. The internist later claimed he “forgot” to order the extra CT, which in turn meant the patient in question was diagnosed later than necessary with an early malignancy.
“This incident precipitated quite a serious discussion within our group,” the radiologist wrote. “Should radiologists check to determine whether every recommendation we make is followed by the ordering physician?”
The short answer, Berlin said, is “no,” because radiologists wouldn’t have enough time in the day. But the stats speak for themselves: In a western Massachusetts teaching hospital where radiologists recommended additional imaging in 15.6 percent of chest, abdomen and pelvic CT reports, just 36 percent of those suggestions were followed through. A 2017 study out of Boston mirrored those results, suggesting at least one-third of recommendations were ignored.
“There is no doubt that there is no follow-through of most radiologists’ recommendations for additional imaging,” Berlin wrote. But from a legal standpoint, he said, radiologists have zero obligations barring their duty to comply with the standard of care, which requires recording the suggestion in a written report.
The Massachusetts study found verbally communicating those recommendations to referring physicians meant physicians were twice as likely to order follow-up imaging—a practice that’s mentioned in the American College of Radiology Practice Parameter for Communication of Diagnostic Imaging Findings but isn’t necessarily considered law.
Several studies have delineated other options for closing the communication gap, Berlin wrote, including giving patients access to their electronic health record, emailing study reports to patients or offering online portals with access to radiology reports.
“I cannot conceive that a radiologist would be sued for malpractice by failing to track whether the referring physician carried out his or her recommendation,” he said. “However, it is always a possibility that a radiologist could be sued for failing to directly communicate to the referring physician a significant unexpected finding seen during interpretation of a radiologic examination.”