Personal Injury Radiology: How Images Can Prove Your Case Despite Contrary Reports

Transcription

1 Personal Injury Radiology: How Images Can Prove Your Case Despite Contrary Reports LAJ Last Chance Meeting NOLA December 14, 2012 Mark D. Herbst, M.D., Ph.D.

2 Mark D. Herbst, M.D., Ph.D. How to use a radiology expert to increase damage awards (for plaintiffs) or decrease damage awards (for defendants)

3 Dr. Mark Herbst B.S., M.S., and Ph.D. in Chemistry Ph.D. in Physical Chemistry, focused on NMR, the basis of Magnetic Resonance Imaging M.D. Internship: One Year Internal Medicine Residency: Four Years Diagnostic Radiology, including one year as Chief Resident Fellowship: One Year MRI, Bill Bradley, Jr., MD, PhD Radiology Practice since 1991 National Lecturer Thousands of Medicolegal Reviews (70-80% plaintiff), > 270 Depositions, > 70 Trials (98% plaintiff)

4 Personal injury attorneys are often presented with radiology reports that may or may not support their side of the case.

5 Not every normal radiology report is accurate. Findings may be missed. An accurate normal report does not always mean that the patient is normal. Radiologists don t always agree on imaging findings. Attorneys need to know more about the causes of radiology errors and discrepancies between radiology reports.

6 Report A: Report B: Normal. Two herniations. One fracture. Possible tumor. Which report is correct?

7 One way to deal with discrepancies is to find an unbiased third party to review all images and reports.

8 Meaning of Agreement or Disagreement Agreement on a finding? Possible Causes Yes Both right Both wrong No Both right, but used different terms Both wrong One right, the other wrong

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14 Unbiased Radiology Review Protocol 1. Images on CD arrive. Assistant imports them onto PACS and prepares file with HIPAA or NNP, cover letter, prepayment, original reports, etc. 2. Radiologist reviews images in chronological order and makes notes on each study. 3. After the notes are made, Radiologist phones the consulting attorney and reads his findings. He may also show the images over the internet via screen sharing. He can also read the previous reports at this time. 4. Finally, Radiologist finds out what side the images came from.

15 Why should your Radiology Expert review original images? 1. Digital images should be reviewed digitally. 2. Digital copies of digital images are exact copies. 3. Digital copies of analog films are usually excellent, and sometimes better than the originals, unless the originals are of extremely poor quality. 4. Analog copies of analog films lose information that may be critical to the visibility of findings. 5. Digital images printed on analog film or on paper lose information that may be critical to the visibility of findings.

16 St. Petersburg Independent Diagnostic Radiology, Inc. Mark D. Herbst, M.D., Ph.D cell

17 Radiologists are not infallible Radiologists can make mistakes False positive = images interpreted as abnormal, but on review, they are normal False negative = images are interpreted as normal, but on review, they are abnormal Interobserver variability = about 10-30% Intraobserver variability = about 2-25%

18 What could cause a Radiologist to miss an important finding on an image? Distraction Fatigue Lack of knowledge/expertise Spent too little time examining image Misdirection by inaccurate or absent history Satisfaction of search error Poor viewing conditions

19 Detection errors occur often False positives = 30% False negatives = 25%

20 What does normal mean? Textbook normal No positive findings No positive findings visible No positive findings visible, but invisible abnormalities may exist No positive findings visible, but invisible findings are likely, given the patient s clinical history No positive findings visible, but given the history, positive findings may show up after weeks, months, or a year, or by using a different imaging technique. Subtle positive findings were missed Obvious positive findings were missed

21 What does degenerative changes mean? Degenerative changes seen are common in older people or years after trauma Degenerative changes seen are not from recent trauma (less than 6 months to a year old) Changes seen can be painless, but if traumatized, they can become painful Degenerative changes are seen, and this makes it difficult to see possible new evidence of trauma, like superimposed herniations or fractures Degenerative changes are seen, but this does not mean the patient does not have new injuries that were difficult to see when the scan was first read

22 Why might an imaging study not show abnormalities, and be correctly read as normal, but the patient actually has an injury? Slices too thick, or pixels too big Slices placed above and below, or right and left, but not through the abnormality The imaging modality is not sensitive to the pathology in question (like CT for disc herniation MR is better) The study was not of good quality (motion artifact, low field strength magnet, insensitive sequences used)

23 What factors would help you sway a radiologist from an initial opinion of normal? 1. Assure the radiologist this inquiry is not intended to prove malpractice. 2. Appeal to their scientific integrity. Opinions change with new data. 3. Get them to agree that new clinical information can change one s interpretation of images, and that referring physicians commonly ask for addenda on reports for this reason. 4. Provide them with new or very specific clinical information about the circumstances of the injury and the severity of the symptoms, and ask for a second look, as if the treating physician were asking. 5. If they still do not see the abnormality, ask specifically about certain slice numbers or views. 6. Make sure they are using the correct terminology. Offer definitions or grading systems, and ask them to categorize the findings accordingly. 7. If they see the abnormality, but call it something else, ask for a differential diagnosis list, and make sure your desired diagnosis is on that list.

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27 Summary: How can images not show abnormalities? Angle of the x-ray beam does not go through the fracture. Poor positioning. Radiograph was not properly exposed. Images viewed under suboptimal lighting conditions. CT or MR slices were too thick to see the abnormality. Images were of low resolution. Images were noisy. Images were not windowed in a way that the abnormality would be visible. Modality used was not one that would show the abnormality well, and the proper modality was not used. The radiology test resulted in one of the few, but expected, instances of a false negative study.

28 Radiology is not infallible Even the best imaging tests have some false results False positives = the images are interpreted correctly as abnormal or possibly abnormal, but the patient is normal False negatives = the images are interpreted correctly as normal, but the patient does have an abnormality

29 Errors have consequences Overcall normal as abnormal: leads to unnecessary further tests, anguish, complications Missed findings: delayed diagnoses, patient harm, death Erroneous diagnoses: unnecessary confirmatory tests, delay of true diagnosis But, this should be correlated with clinical picture and any incongruity should be followed by a re-read of the images with additional history

30 Three reasons things are missed by radiologists Finding not evident Finding below threshold for worry Finding missed

31 Some radiographs are harder to read than others Fracture film: good contrast easy to see abnormality most normal bones look alike Not all breast cancers are this obvious

32 Some radiographs are harder to read than others Mammogram: often poor contrast cancer looks similar to normal tissue breast tissue varies in the same patient and between patients, some dense, some not hard to see cancer in dense breasts

33 Discrepancies in Radiology Reports May Come From Mistakes or from Misrepresentations

34 Hired guns will say what you want to hear, for a price.

35 Hired guns have become advocates instead of unbiased experts.

36 Experts can make mistakes, or lie Plaintiffs expert: May call a bulging disc a herniation. May exaggerate the effect of upright position or flexion and extension. May ignore chronic degenerative changes like osteophytes and facet joint arthritis. May assume symptoms that are not present. Defense s expert: May call a herniated disc a bulge. May report a disc-osteophyte complex or report osteophytes when osteophytes are not there. May report calcified discs that are not able to be detected on MR. May ignore the possibility of herniation occurring at a previously degenerated level that had prior osteophytes and dehydration. May assert that a herniation is not acute or from trauma unless there is hemorrhage, edema, and swelling.

37 Considering the Negative or Normal Radiology Report Three scenarios: 1. The report is correct and the patient is normal. 2. The report is correct, but the patient is not normal. The images do not show the abnormality. 3. The report is not correct. The radiologist missed the abnormality on the images.

38 False Positive test: Not a tumor, a blood vessel

39 Several film factors influence errors Exposure Orientation Inspiration/expiration Digital images or filmed Resolution of digital images Lossy compression of stored digital images

40 The appearance of the patient may cause errors Coexisting lesions One finding may distract the radiologist from another Unusual patient anatomy kyphosis, scoliosis prosthesis, metal artifacts obesity

41 Reporting environment factors can influence error rate Ambient lighting and masking Increased ambient light decreases conspicuity of lesions

42 Reporting environment factors can influence error rate Noise and other distractions in the reading room

43 Reporting environment factors can influence error rate Light box or monitor luminescence

44 This slide simulates reading a film in an Emergency Room with all the lights ON.

45 This slide simulates reading a film in an Emergency Room with some lights ON.

46 This slide simulates reading a film in an Emergency Room with all lights OFF.

47 Types of error Visual error Cognition error Satisfaction of search Camouflage

48 Image quality impacts error Image processing Image display Ambient lighting

49 Ergonomic factors impact error Fatigue Computer interface Window/level, brightness/contrast Color tint of images

50 Computer Assisted Detection and Computer Aided Diagnosis (CAD) impacts error Accuracy Reader psychology Interobserver variability

51 Cognitive illusions Ambiguous images Paradoxes Distortions

52 Cognitive illusions Ambiguous images Paradoxes Distortions

53 Where does Radiology fit in?

54 Medical imaging is only one piece of the puzzle. Imaging tests are complementary with each other and with other tests.

55 RG Radiography X-Ray

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59 Clavicle Fracture?

60 Clavicle Fracture? No? False Negative

61 Clavicle Fracture

62 Clavicle Fracture

63 Talus Fracture?

64 Talus Fracture? No? False Negative

65 Talus Fracture

66 Softball Injury

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68 Subtle Fracture

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71 Obvious Fracture

72 Left hip fracture

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74 More than one view is important Fractures may not show up on one view or on the same view done at a different time. One abnormality may look like another if only shown in one view

75 Healing Fracture

76 Correct Exposure Helps

77 Thoracic spine fracture missed

78 Pleural Effusion related to spine fracture

79 Missed fracture leads to spinal cord injury

80 Wrist fracture in a child (Salter-Harris II)

81 Was the test done correctly? Cervical spine for fracture Two views Three views Five views Seven views Swimmer s view if C7- T1 is not seen well.

82 Cervical Spine after MVA

83 Cervical Spine after MVA

84 CT to see C7-T1

85 Signal-to-Noise

86 Signal-to-Noise

87 Signal-to-Noise

88 Signal-to-Noise

89 Traumatic spinal cord cyst seen on 3T, not on 0.7T MR machine

90 Volume Averaging

91 Volume Averaging

92 Effect of slice thickness on visibility of a small herniation

93 Missed herniation

94 Missed Hepatic Artery Aneurysm

95 Normal MRI, injured patient with persistent pain for 3 months who failed conservative therapy and had symptoms of disc injury

96 Normal Lumbar MRI, abnormal discogram

97 Disc Nomenclature Normal Bulge Protrusion Extrusion Sequestration or Free Fragment Intravertebral Herniation (Acute Schmorl s node) Annular tear

98 Spine, 26(5):E93-E113 find the link at

99 Endorsements

100 Endorsements 2003

101 Normal Discs

102 Symmetrical Bulging

103 Asymmetrical Bulging

104 Intravertebral Herniations

105 Herniation

106 Normal Disc

107 Focal Herniation

108 Broad-based Herniation

109 Protrusion and Extrusion New Definitions

110 Sequestration

111 Protrusion and Extrusions New Definition

112 Annular Tear

113 Intra-annular displacement

114 Degenerative Changes

115 Disc Desiccation and LB Strain

116 Zones

117 Phrases that should raise a RED FLAG: Disc-osteophyte complex Paracentral bulge Focal bulge Broad-based bulge Spondylitic protrusion

118 Normal Discs

119 Free Fragment

120 Cervical Herniations

121 Chronic Disc Changes

122 Extrusion of a Desiccated Disc

123 Radiology Modalities RG CT MR US NM PET All of these produce images (pictures) of the body.

124 Pictures of a thing are not the same as the real thing.

125 Imaging tests are complementary with each other and with other tests

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127 Frequently Missed Trauma Findings The subject of missed findings is common in articles, resident conferences, and presentations at national meetings. Often the same findings are missed by several radiologists and non-radiologists. Misses are often made when radiologists forget their training.

128 Brain CT missed findings Residents and general radiologists miss about 2% of the significant findings compared to neuroradiologists.

129 Radiology results are influenced by knowledge of the history and physical and other lab tests

130 Imaging tests are complementary

131 Tactics of Hired Gun Radiologists

132 Opposition Expert Tactics Claim no abnormality on a study that uses an insensitive technique or incorrect study Misuse definitions to the advantage of their client Claim no abnormality on a study that has a possibility of being a false negative test or reading Claim no abnormality because it was missed by the first radiologist radiology error Claim no abnormality on suboptimal images volume averaging, poor resolution, noisy images hide lesions

133 Opposition Expert Tactics Claim abnormality on a study that is subject to artifacts Misuse definitions to the advantage of their client Claim abnormality on a study that has a possibility of being a false positive test or reading Claim abnormality because it was called by the first radiologist radiology error Claim abnormality on suboptimal images volume averaging, poor resolution, noisy images simulate lesions

134 Using different angles in radiographs makes changes the way things look.

135 Using different angles in radiographs makes changes the way things look.

136 Ignoring that you are comparing different slices makes it look like a change has occurred.

137 Ignoring that you are comparing different slices makes it look like a change has occurred.

138 Using an insensitive MR protocol can hide abnormalities that are visible otherwise.

139 In-Plane Resolution This is a photo that has been taken at 165x256 resolution

140 In-Plane Resolution This is a photo that has been taken with 329x512 resolution

141 In-Plane Resolution Original Resolution 720x1150

142 Know your enemy.

143 To deal with hired guns, understand the underlying causes of radiology errors and conflicting report findings.

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