A teaching moment from breast imaging malpractice

Best clinical practice to reduce the chance of litigation in breast imaging has been identified in an article published online June 2 by the Journal of the American College of Radiology.

According to lead author Elizabeth Kagan Arleo, MD, of the New York-Presbyterian/Weill Cornell Medical Center in New York City, and colleagues, radiologists have a 50 percent chance of facing a lawsuit by the age of 60. Breast imaging is particularly prone to malpractice litigation due to claims of diagnosis failure or delay of diagnosis.

“In breast imaging, the gap between the public perception that breast cancer is detectable, when present, 100 percent of the time and the reality of the limitations of the modalities and inherent human imperfections has additionally fueled litigation claims,” wrote Arleo and colleagues. In order to determine the best clinical practice to lessen litigation in breast imaging, the authors reviewed malpractice cases and compiled the following list of lessons learned:

• Follow the guidelines- Physicians should follow guidelines distributed by the American College of Radiology to standardize breast imaging and assist in the application and interpretation of screening and diagnostic mammography.
• Properly deal with recalls- Patients recalled from screening mammography should undergo a full diagnostic workup of the area to completely define the finding. At least two views should be acquired due to the deceivingly soft nature of certain kinds of tumors.
• Properly deal with palpable masses- Definitive diagnosis of a palpable mass is highly recommended. Initial workup should include a triangular marker on the skin, spot compression on mammography in two views and a manual ultrasound. Negative findings warrant surgical consultation for fine-needle aspiration or core biopsy under palpable guidance. A palpable mass should not be declared a cyst until ultrasound is performed and the finding meets all criteria for a cystic lesion on ultrasound.
• Use computerized system flares- Computer-aided detection or R2 signal for calcification on digital mammographic equipment should not be ignored. If detected, an additional look should be taken and further workup of the finding should be considered.
• Avoid accepting suboptimal patient positioning, recommending follow-up based on a screening exam and ignoring the subareolar region- Straying from the basic requirements for patient positioning can lead to major pitfalls if a lesion is not included on the film. Acceptable positioning is especially crucial for the posterior tissues immediately in front of the pectoralis and the inflammatory fold. Additionally, an initial workup must be documented before recommending nonannual follow-up. Lastly, the subareolar region shouldn’t be ignored because seemingly innocuous masses here are more significant in the breast than elsewhere.
• Maintain a strong administrative infrastructure-An administrative structure should lead to effective communication, which is vital in avoiding litigation. A system needs to be in place to catch unreported mammographic examinations. If findings are classified as a BI-RADS four or five, outcomes need to be documented. If findings are classified as a BI-RADS zero, administrative supports needs to make sure diagnostic workup happens at the facility or a referral site. Patient notification must also be reported.
• Practice consistent, logical reporting-Radiology reports must make sense as they are legal documents; a congruence between findings and recommendations needs to be evident. Descriptions of lesions should be clear and recommendations about masses need to include “biopsy” unless categorized as a BI-RADS two finding.
• Directly address concordance between imaging and pathology-A nonspecific pathologic report should not be accepted in the presence of a lesion on imaging. Consistency must be found between the clinical setting, imaging findings and pathology reporting to avoid pitfalls or problems.
• Optimize the work environment-The environment for screening mammography should have minimal visual and audio distractions, feasible volume goals and an efficient and reliable reporting system. If possible, a state-of-the-art digital platform should be used to help detect any changes over time.
• Talk with patients-Opportunities to speak with patients should be capitalized upon to minimize misunderstanding.

“These lessons were learned over many years of everyday practice, punctuated with expert participation in malpractice cases,” wrote the authors. “We hope that this valuable case study in clinical practice management will optimize breast imaging for patients and radiologists alike,” they concluded.