0:02

Hello, and welcome to today's Noon Conference co-presented

0:05

by MRI online and A A WR.

0:08

The A A WR was founded in 1981 to provide a forum

0:12

for issues unique to women in radiology, radiation oncology,

0:16

and related professions.

0:18

The association sponsors programs that promote opportunities

0:21

for women and facilitates networking among members

0:24

and other professionals as well.

0:26

The A A WR strives to meet the diverse

0:28

and changing needs of its members

0:30

through mentorship opportunities for the next generation

0:33

of women Radiologists A A WR has membership opportunities

0:37

for those who have completed their training.

0:39

Members in training

0:40

and internat international radiologists learn more about

0:44

their mission and membership@a.org.

0:47

We're thrilled to partner with A A WR on these lectures

0:50

as part of our shared commitment to advancing

0:52

and supporting women in radiology

0:54

and transforming the way radiologists learn and thrive.

0:58

Today, we are honored to welcome Dr.

1:00

Gretchen Green for a lecture entitled, maximize Performance

1:03

and Minimize Malpractice Risk, how I Teach Clarity

1:06

and Confidence in Mammography.

1:08

Dr. Gretchen Green is a radiologist turned expert educator

1:12

explorer, who has taught hundreds of physicians

1:14

and other clinicians how

1:15

to launch expert witness businesses.

1:18

She also teaches radiologists, radiologists

1:21

to reduce their mammography malpractice risk

1:23

and improve clarity and confidence using lessons she has

1:27

learned serving as an expert in over 100 breast

1:29

medical malpractice cases.

1:32

She serves on the US space

1:33

and Rocket Center Foundation Board

1:35

and is a chair emerita of the Space Camp alumni board.

1:39

Dr. Green loves taking inspiration from space travel

1:42

and translating it into lessons

1:43

that help her students achieve new heights of success.

1:46

In the summer of 2022,

1:48

Dr. Green reached the North Pole on a polar class

1:50

to icebreaker and teaches her students about the personal

1:54

lessons she has learned throughout her personal

1:56

and professional life that continue

1:57

to keep her shooting for the stars.

2:00

At the end of the lecture, please join Dr. Green in a q

2:03

and a session where she will address questions you may

2:05

have on today's topic.

2:06

Please remember to use the q

2:08

and a feature to submit your questions so we can get to

2:10

as many as we can before our time is up.

2:13

With that, we are ready to begin today's lecture.

2:16

Dr. Green, please take it from here.

2:19

Hello, it's such a pleasure to be here.

2:21

Thank you so much for having me,

2:23

and I'm looking forward to this noon learning opportunity

2:26

and the opportunity to talk with you about how we can reduce

2:32

your medical practice risk and learn more about mammography.

2:37

So I've shared my slides

2:39

and again, the, the focus will be on

2:41

how you can reduce your malpractice risk,

2:44

but hopefully your takeaway message will be

2:46

how you can ultimately improve your own practice

2:49

and your enjoyment in doing what can be a very challenging

2:52

but very rewarding job as a radiologist and breast imager.

2:58

So, as a disclosure, I do teach students, physicians

3:02

and clinicians how to launch

3:03

and build expert witness businesses.

3:05

That began a number of years ago,

3:08

and since then I've expanded my courses

3:10

to also include the business aspects

3:13

of being an expert witness

3:14

to consult in medical malpractice cases

3:16

and also how to review medical board cases

3:19

for your state medical board,

3:21

and most recently also a class on

3:25

reducing malpractice risk in mammography.

3:29

So just a little bit about me.

3:31

I'm originally from Illinois

3:33

and I knew I always wanted to be a doctor growing up as much

3:37

as you know, I could tell my family as soon as I can talk

3:40

and walk, basically, I told them that I was going

3:43

to become a physician.

3:44

So this was a lifelong passion and goal of mine.

3:47

You can see one of my early presence was a doctor kit,

3:50

and so this was my grandfather teaching me all the physical

3:53

exam skills that he knew so that I could learn

3:56

to use all the equipment.

3:59

So I grew up actually in Waynes world, Aurora, Illinois,

4:03

if you remember from the movie.

4:05

And there were a lot of days surrounded by cornfields

4:08

and some pretty gray skies out in the flat Midwest.

4:11

Later, my journey then took me to New England where I went

4:15

to Brown for the eight year medical program I stayed on

4:19

and earned also a master's degree in the history of medicine

4:23

and pharmacology, and my thesis centered on the patient's

4:27

medical movement for twilight sleep,

4:30

early obstetric anesthetics,

4:32

and also how women physicians organized around

4:35

that topic in the progressive era of America.

4:39

I then got my MD

4:41

and did my internal medicine re um, internship at Brown.

4:45

I then moved just a little bit west of Rhode Island

4:48

to Connecticut where I completed my diagnostic radiology

4:52

residency at Yale, followed

4:54

by a one year women's imaging fellowship,

4:56

including breast imaging at Brigham

4:58

and Women's Hospital in Boston.

5:01

While I was in Boston, I had the wonderful opportunity

5:05

to work with my physician attending mentors in co-authoring

5:09

two diagnostic imaging breast textbooks.

5:12

These were the initial additions that I worked on

5:15

and was a cover author

5:16

for the Breast Diagnostic Imaging textbook

5:19

and its follow-up companion on breast MRI.

5:25

So life went on

5:26

after fellowship, I joined a private practice in

5:28

North Carolina, a growing large group in the

5:32

center of the state.

5:34

I was a partner and had two kids and went on a cruise

5:38

and made the mistake of checking my email.

5:41

So instead of unplugging as I probably shouldn't have done,

5:44

I checked my email and I found out that I had been sued.

5:48

This was a lawsuit for medical malpractice that, uh,

5:52

in which there was a very young defendant in her early

5:56

twenties whom I had seen at our breast center,

5:59

and I recommended that she have a biopsy, but she refused

6:03

because she said she was afraid of needles.

6:06

I did not document

6:07

that fear at the time in the medical record out of concern

6:10

that it might look like I was blaming the

6:12

patient or being judgmental.

6:14

I stated the facts in my report,

6:17

however, it's potentially possible that omitting that piece

6:21

of information maybe could have influenced ultimately if a

6:24

lawsuit had been filed, but multiple people involved in her

6:28

care were all, uh, named in the lawsuit.

6:30

And this went on for several years.

6:34

This time was, as you can imagine, early in my practice,

6:38

re you know, just a couple years out of fellowship

6:40

with two young kids and my entire career ahead of me.

6:43

This was a really challenging time,

6:46

and fortunately I had a wonderful defense attorney

6:49

who really walked me through the process

6:52

and helped me see ways

6:53

to be very proactive in my own defense.

6:56

I made PowerPoint presentations.

6:58

I knew everything that I could regarding the literature

7:02

and the background of the information in this case.

7:05

And in the meantime, however, the, uh, plaintiff was

7:09

involved in a lot of media coverage.

7:11

She was on television interviews

7:14

and was very well known in our community.

7:16

Therefore, ultimately, despite the fact

7:18

that we thought we had a very strong case,

7:20

we ended up settling the case out of concern

7:23

that we wouldn't be able to get an impartial jury.

7:25

So a lot of factors went into this medical malpractice case,

7:30

and I learned about as much about the system

7:33

and about myself as I did about the medicine.

7:36

And when it was all said

7:37

and done, my defense attorney recommended

7:40

that it later I serve as an expert witness.

7:43

I had never had any details about what that meant

7:46

before my own case.

7:48

I never knew what an expert witness was or what they did,

7:51

and this was a really eye-opening, uh, opportunity for me

7:54

to learn how expert testimony was important,

7:58

both in how cases get filed

8:01

or sometimes how they don't if, uh,

8:03

review finds nothing was wrong,

8:04

and also how they're involved in,

8:06

in the evolution and support of a case.

8:09

So years later, I did get a call out of the blue to serve

8:13

as an expert, and that was the beginning of my next chapter

8:17

in that professional sphere as well.

8:20

So in, uh, 2020

8:22

after I'd been reviewing cases for lawyers for a few years,

8:26

I got calls from lawyers who were looking for physicians

8:30

to review malpractice cases.

8:32

As we remember at the beginning of the pandemic, you know,

8:34

many of us went on lockdown.

8:36

If you had a a, a large exposure to outpatient centers,

8:40

you may have found that your volumes

8:41

dropped or even stopped.

8:43

And so with up to two thirds

8:45

of physicians having their pay cut

8:47

and also, uh, getting furloughed during that time,

8:50

even losing their jobs, that there was a mutual need

8:54

for physicians who wanted to do work with their own skills

8:57

and expertise as physicians to review expert witness cases

9:00

and for lawyers who needed physicians to do those reviews.

9:04

And so I put my skills

9:06

to work in an online course called Expert Witness Startup

9:09

School, and this was the first time that I was able

9:12

to tell my story

9:13

and help mentor other physicians like me to learn the ropes,

9:17

but without having to learn the hard way through trial

9:20

and error to be able to quickly use their skills

9:23

to become expert witnesses, to review cases.

9:28

Then over time, due to demand,

9:30

and as about 50%

9:33

of my reviews involve breast imaging cases, I began

9:36

to see patterns emerge.

9:38

I've always been an educator in breast radiology, both

9:42

to the public in late talk,

9:43

and also, again, through textbooks

9:45

and through other lectures to my colleagues

9:48

and to other medical professionals.

9:50

And this was again, just that next facet

9:52

that if you asked me at the beginning of my career,

9:55

I could never have predicted,

9:56

but was a real opportunity for me

9:58

to help others learn from patterns that I began

10:01

to see repeated over

10:03

and over again in breast radiology, uh,

10:06

involved medical malpractice cases.

10:08

And so the Mammography Malpractice Masterclass is my

10:13

online course that helps teach the lessons that I've learned

10:16

so that other people can be more confident

10:18

and clear in how you interpret mammography

10:21

and also to get some more enjoyment from this job,

10:24

which again, has such good value

10:27

for the population at large,

10:29

but can be very challenging to do on a day-to-day basis.

10:33

So combining all of these perspectives

10:37

and going again back to my background and Ben Brown, and

10:41

before that, in the history of medicine,

10:43

I have really consolidated a number of these concepts

10:46

to help think a little bit more at the 40,000 foot level

10:50

about how things happen in malpractice cases in breast

10:54

imaging, and how we can learn to put our knowledge to use,

10:58

but also think about some of the softer skills

11:00

of communication and other ways that patients interface

11:03

with our technology and information.

11:06

So you may have remembered there's an acronym PEEP that is

11:10

usually associated with ventilators,

11:13

but where I think

11:14

that's really useful is in the patient expectation versus

11:19

exam performance mismatch.

11:21

And so when we just remember those letters, the PEEP, I love

11:26

how it's a mirror image

11:27

because it reminds us that communication is two ways

11:30

with patients and with physicians and other clinicians.

11:34

And we really need

11:35

to take into account the perspective from both sides in

11:38

order to understand how we can mitigate risk

11:41

and improve patient's compliance

11:43

and their trust in how we offer technology

11:46

and our knowledge to help reduce breast cancer

11:49

overall and help with treatment.

11:52

So I've come up with a haiku again

11:55

to help you take away some quick lessons from this.

11:58

There are 17 syllables that help lead to success.

12:02

Density is key.

12:04

You are looking for cancer and use the Birads card.

12:09

So I'll keep coming back to these,

12:11

but these are going to be some of the information framework

12:14

that these concepts will fit into as we go along.

12:17

So first talking about breast density.

12:20

This is a very hot topic, has been for a number of years,

12:24

but it's important in breast imaging

12:26

and how to reduce your risk of being sued

12:29

and improve your skills, interpreting it in a way

12:32

that you may not have thought of quite the same way before.

12:36

So breast density, as we think about it for mammography,

12:39

is primarily a risk for missing cancer in

12:43

that the whiteness of breast tissue may mask

12:46

or cover up the appearance of cancer.

12:50

However, it has been associated

12:52

with a minimally increased risk of breast cancer, probably

12:56

because as we know, breast cancer occurs in breast tissue.

13:00

So there is simply a volumetric effect that

13:02

where there is breast tissue, there may be an increased risk

13:05

of cancer in that breast tissue just because it's there.

13:10

Remember, however, that 50%

13:12

of the population can be categorized

13:14

as dense if you combine the heterogeneously dense

13:18

and extremely dense categories, category C and D,

13:22

and that the relative risk

13:24

for the heterogeneously dense breast category C

13:28

is less than 1.2 above the baseline.

13:32

And actually the risk factor of obesity for development

13:35

of breast cancer is a greater risk than is just having

13:39

heterogeneously dense breasts.

13:41

So when we put this into context, we as breast imagers

13:44

and physicians know

13:46

that density is a very small component in terms

13:49

of the overall risk of cancer,

13:52

even though public perception is very different.

13:55

Finally, for density D

13:57

or the extremely dense breast category, that uh,

14:00

risk factor is less than 2.1, again, about twice the risk.

14:05

However, that's about the same

14:07

as having a first degree relative with breast cancer.

14:11

So again, the outlying risk is not substantially greater

14:15

than that involved in much more common factors.

14:19

You may have had your state, uh,

14:22

impose breast density legislation on the wording language

14:25

that you use and reporting

14:27

and how you communicate to patients.

14:29

There is variability state to state in that language.

14:32

Some legislation also covers the performance of ultrasound

14:36

and MRI as adjunct screening mental modalities.

14:39

How, however, the insurance component is highly variable.

14:43

So a lot of patients may receive a recommendation

14:47

to consider or speak

14:48

with their physician about using adjunct screening

14:51

modalities, but most states do not offer insurance

14:54

compensation or support for that recommendation,

14:57

which contributes to some of the confusion

15:01

and some of the difficulty in communication when patients

15:04

are trying to weigh the risks

15:06

and benefits of obtaining additional screening,

15:09

but possibly at their own expense.

15:13

So most patients, as we know from doing risk calculations,

15:16

will not need additional testing,

15:18

and that goes back to the American College of Radiology

15:22

criteria and others for the advocation

15:25

of high risk screening in patients with a greater than

15:28

or equal to 20% lifetime risk over, uh, the course

15:32

of their medical care.

15:34

And a lot of this additional testing,

15:36

unless you have very specific qualifications

15:38

as a high risk individual, will not be covered by insurance.

15:43

There was of course, the Akron 6, 6, 6, 6 trial

15:47

that looked in a multidisciplinary multi-state national

15:50

fashion at the role of screening ultrasound, which found

15:53

that it was of no increased utility on a population basis

15:58

for those without an increased risk of cancer.

16:02

So I love the far side,

16:05

and I always think back to this, um, cartoon,

16:09

which I think really describes what happens a lot

16:11

between doctors and patients where we are talking at people

16:15

and we think we're communicating,

16:16

but in fact, patients may not hear everything that we say,

16:20

especially if our conversation involves the use

16:22

of the word cancer, which is very

16:24

common with breast imaging.

16:26

As soon as the patient hears the word cancer,

16:28

everything else can blur

16:30

or can just not be audible, just as in this case,

16:33

the owner is talking to the dog

16:35

and all the dog hears is the dog's own name.

16:38

And that's the same thing again with the word cancer

16:40

or something else that the patient is

16:42

concerned about with their health.

16:46

You may be familiar with the breast density movement,

16:49

which began as a patient led movement

16:53

by a PhD, Dr.

16:55

Nancy Capello. And, uh, Dr.

16:58

Capello was in Connecticut

17:00

and she was diagnosed with breast cancer.

17:04

She attributed her delay in diagnosis to the presence

17:08

of dense breast tissue

17:09

and the fact that she had not been told about having had

17:13

breast uh, density as a potential contributor

17:16

to her delay in diagnosis.

17:18

And this is a great example

17:21

of patient advocacy in the very beginning

17:25

of the social media

17:26

and internet presence of lay, uh, medical movements.

17:31

So this is just easier, I think, for this movement

17:35

to have begun because technology enabled this dissemination

17:39

of this information nation nationwide.

17:42

But as I'll show you in a little bit, patient

17:44

activism is nothing new, especially in women's healthcare.

17:48

So, uh, I highlighted some

17:50

of the text from the rense.org website just

17:55

to help again, with a patient expectation

17:57

and that mismatch of language

18:00

that is really important in communication,

18:02

especially with breast imaging.

18:04

So as Nancy Capello stated, I did

18:07

what the medical field told me.

18:09

So there's a high degree of trust between patients

18:12

and physicians and the medical field.

18:14

However, as I've said, things can erode that

18:17

or have patients increase their questions about

18:20

that recommendation, especially when they find conflicting

18:23

or contradictory language.

18:27

So one thing again that

18:29

that is a consistent theme in the breast density movement is

18:33

that breast density is important for the detection

18:36

of breast cancer and the risk.

18:38

And that until it was mandated by law,

18:41

physicians intentionally failed to disclose to patients

18:47

and possibly physicians

18:48

that ordered studies the breast density.

18:52

So a lot

18:53

of this terminology repeats itself when you see the

18:57

literature from are you dense.org and Dr.

18:59

Capello's, uh, talks

19:01

and her information on social media

19:04

that this was the best kept secret.

19:07

Again, the secret in that directly states that patients, uh,

19:11

needed the information that doctors intentionally withheld

19:15

and she would, uh, refer to reports as the happy gram,

19:18

that being what a normal mammography result report would

19:23

indicate, sending that there was no risk of

19:25

or no presence of cancer.

19:28

So in her case, she had a normal mammogram,

19:32

and then several weeks later, by her report,

19:35

her doctor felt a palpable abnormality,

19:37

which then was evaluated with mammography and ultrasound.

19:41

In that case, she states the mammogram was normal,

19:44

but the ultrasound found an abnormality

19:46

that later was detected as cancer, which had metastasized.

19:50

And unfortunately, Nancy Capello did ultimately die

19:54

of breast cancer, uh, despite treatment

19:57

and the website.

19:59

Again, I think when you, when you look at this, it's,

20:02

it's a window into the mindset

20:05

and the patient concerns that they're hoping

20:08

to have alleviated

20:09

or improved by, um, alteration of

20:12

what we do in our practice.

20:14

So the map of breast density legislation over time

20:19

mirrors the legislation that was passed, uh, from state

20:23

to state with, again, a lot

20:24

of variability over several years.

20:27

So this is the copy of the map from

20:30

of the US in which breast density notification legislation

20:34

had been passed as of February 2nd, 2018.

20:39

And then fast forward over time, uh, one branch

20:43

of the are ru dense.org organization is their advocacy arm,

20:47

uh, kind of a pact

20:48

or you know, political action committee where

20:50

they would raise money to do awareness, uh, options

20:53

and things like that to try to advocate

20:56

for legislation from state to state.

20:58

This is the North Carolina law, which was passed in 2013,

21:04

um, effective on January 1st, 2014,

21:07

in which it was mandated that reporting to patients

21:11

and clinicians have certain language.

21:14

And this was done with some coordination with physicians,

21:19

but was not written solely by physicians.

21:22

This was, uh, the product of legislation.

21:24

And therefore, I think

21:26

whenever we have the government that's telling doctors

21:29

directly what to say to patients, there is a potential for

21:33

miscommunication or suboptimal communication that we have

21:36

otherwise relied on

21:38

that direct physician patient relationship.

21:41

And so to be aware of some of the process that

21:44

by which this legislation came about in various states is

21:47

important so that we can communicate effectively when we

21:50

have the opportunity to talk one-on-one with patients

21:53

and our referring physicians.

21:55

Of course, Facebook and social media got involved.

21:59

There were many breast density groups on Facebook,

22:02

and again, a lot of opportunity to propagate this in a way

22:05

that's different over time than,

22:07

uh, what we've had in the past.

22:10

The media, of course,

22:12

is another way in which public information about breast

22:15

density legislation has really taken hold.

22:18

And, uh, the Chicago Tribune from 2018

22:22

documented how the laws were appearing

22:27

to move faster than physician knowledge or action on it.

22:31

And this is, this is not where we want to be.

22:34

We want physicians to be the leaders in

22:37

giving medical information to the public

22:40

and advocating for science and based action.

22:44

But, uh, this was something that again,

22:47

because it was a patient-led movement,

22:48

it it had a life of its own.

22:51

So finally, as of, uh, later the, uh,

22:55

breast density organizations stated

22:57

that the map was all pink

22:59

because in 2019, the FDA mandated

23:02

that breast density would be included in all reports.

23:06

So again, for a means of the compliance, which is something

23:10

that I teach physicians about, making sure

23:12

that your practice is compliant

23:14

with the MQSA legislation administered by the FDA, um,

23:18

it's required that you list your breast density

23:22

in a patient report.

23:24

So this is now, um, consistent over time, even though the,

23:28

again, that legislation for what you are required

23:30

to include in reports varies from state to state.

23:33

So if you go to the airport or the grocery store

23:37

and you take a look at some of the magazines

23:40

that are there at the checkout, you can find very

23:43

interesting publications like this

23:44

that are titled What Doctors Don't Tell You.

23:47

And you have to just step back

23:49

and think, what is the situation we find ourselves in,

23:53

in terms of trust and that communication

23:55

that we've always enjoyed with patients,

23:57

if this is the thesis that's prompting publications of,

24:00

of entire magazines.

24:02

And so it, it is important that we communicate clearly

24:06

and effectively with patients,

24:07

but just understand that from some perspectives this may be

24:10

an uphill battle because of that difference in perception.

24:15

In the New York Times, around the same time here, 2018,

24:18

there was an article of about, again,

24:21

a heart risk factor even doctors don't know about.

24:24

So it's not just exclusive to breast imaging,

24:28

this possession of knowledge, um, a secret identity.

24:32

It it's not just related to medicine as well.

24:35

There are other professions who face this, and it's

24:38

because we do specialized work

24:40

that does have specialized knowledge

24:42

that is hard to come by.

24:43

And so we just have to keep in mind that the core emotions

24:48

that usually come into play with,

24:50

with topics like this are fear that patients are afraid

24:53

of being unhealthy or having complications

24:56

or even dying, that there's a universal desire to be healthy

25:00

and well, and to live as long as possible.

25:02

That's a human desire that I think we all share.

25:06

And so bringing as much empathy and sympathy

25:09

and connection as we can to these types

25:11

of communication is one first step

25:14

to just acknowledging the factors

25:16

that go into perceived miscommunication.

25:20

Of course, COVID had probably, uh,

25:23

never more than then more opportunities for miscommunication

25:26

as information rapidly evolved.

25:29

And we saw the need

25:31

for internal policing within the medical community

25:34

that people who propagated incorrect

25:36

or misleading information really needed an outward facing

25:40

message from medical authorities to indicate

25:43

that they were out of line with our professional standards,

25:46

because patients really look to us to be authorities.

25:49

And the fact that organized medicine, um, needed

25:53

to get involved and some

25:54

of these cases is a very beneficial thing for patients

25:57

to see that we can regulate our own,

26:00

that we can make informed, uh,

26:02

and unified policy decisions together.

26:07

So again, um, all, all old is new again.

26:10

We, we love to think that these kinds of issues are unique

26:13

to social media's development

26:15

or the web propagating information quickly or email.

26:19

But when we look back to topics from a hundred years ago,

26:24

we can find some really fascinating parallels in history

26:27

between different patient led medical movements.

26:31

And again, the reason I know about this topic, and it's near

26:34

and dear to my heart, was this was the subject

26:36

of my research that I began in high school, actually.

26:39

And that kind of, it took two different turns.

26:43

I studied the patient led advocacy movement

26:46

for twilight sleep, which was anesthesia

26:48

during childbirth just at the beginning

26:51

of World War I time era, just for perspective.

26:54

And also that a group

26:56

of women physicians specifically led a lot

26:59

of this movement in concert with their women patients

27:03

to help advance the research on the technique,

27:06

to provide relief from childbirth pain

27:08

and also as a way to help organize women physicians.

27:11

So there are some really fascinating social

27:14

and scientific parallels that happened.

27:16

And we can see these echoes,

27:18

I think from over a hundred years between the statements,

27:21

again, these words that we're listening to,

27:24

to understand the factors

27:25

of communication even a hundred years ago.

27:28

So just as there was,

27:31

or dense.org begun by Nancy Capello in 2012

27:34

and Connecticut a hundred years previously,

27:37

there was the Twilight Sleep Association,

27:40

and this was a group of women in New York

27:42

who founded an organization during a time,

27:45

the progressive era, when this is very common to do.

27:48

There were a lot of organizations that were founded

27:50

to advance various principles

27:52

and for people to come together for strength in numbers.

27:56

And, um, it's just, it's again, very interesting to

28:00

to see their, their mission statement.

28:02

Just as arden.org sought to have all patients aware

28:07

of their breast density so

28:08

that they could seek additional screening

28:10

or reduce their chances of cancer just then,

28:13

also these women who wanted relief from pain during child's,

28:18

uh, childbirth, they sought to do so by means

28:21

of disorganization.

28:23

Their stated mission was to increase the practice

28:25

of any safe method for securing to all women who need it,

28:28

the boon of painless childbirth.

28:31

And a lot of these, uh, comparisons were made

28:34

to the use then, which was just beginning of morphine

28:38

for relief of pain, uh, from wounds on the battlefield.

28:41

And so women pointed out this apparent, uh,

28:44

different standard saying,

28:45

if men on the battlefield sustain a wound or need surgery

28:48

and they can have pain relief from morphine,

28:51

why can't women in childbirth also benefit from this?

28:56

So, and again, uh, just in case you're not aware,

28:58

so Twilight sleep was the, the title

29:00

for usually the combination of scopolamine

29:03

and morphine used together to accomplish, uh, both amnesia

29:07

and, uh, anes and, sorry, anesthesia during childbirth.

29:12

So there was a physician who was opposed as,

29:17

as were several, two women who came

29:19

to their offices and demanded this.

29:21

And his quote in a, uh, popular book at that time was,

29:24

listen, I could not help going, uh, he went to Germany

29:27

to learn this technique from two German scientists

29:30

who originally pioneered it.

29:32

He said, I was in Berlin

29:33

and I received no less than six copies

29:35

of one magazine from my patients with instructions not

29:38

to show my face in America until I had been to Freiberg.

29:41

So freiberg in Germany was the place

29:44

where these two male physicians actually

29:46

developed twilight sleep.

29:48

And so people went over to Germany to learn it

29:51

and then came back and taught each other,

29:53

wrote articles, et cetera.

29:55

So there was a lot of emotion about this.

29:58

And, um, people reported

30:00

that women were angry demanding this of their physicians.

30:04

And again, when we look back then

30:07

and look forward a hundred years, what we see is a lot

30:10

of similarity in this language.

30:13

So as Nancy Capello stated in the Journal

30:15

of American College of Radiology in 2013,

30:19

my radiologist knew that I had dense breasts.

30:21

My doctor knew that I had dense breasts.

30:23

The only person who did not know was me, the woman

30:26

with the dense breasts.

30:27

This is the core foundation of the entire history

30:30

of the breast density movement was knowledge

30:32

about breast density.

30:34

And so, again, as we

30:35

as breast radiologists can quote relative risk ratios,

30:39

we can understand the impact of screening.

30:41

What we need to acknowledge equally

30:45

is this knowledge gap is a focus of this advocacy movement.

30:51

So let's return back to with perspective to this expectation

30:55

and performance mismatch.

30:58

So the medical malpractice cases that I see, again, I,

31:02

I've been retained now in hundreds

31:03

of medical malpractice cases, um, half

31:06

of which about have been involving breast.

31:08

And even though each case is a little bit different,

31:11

there are some clear patterns that we can learn from

31:14

to keep in mind as we go through our workflow

31:17

and can hopefully apply these principles to read

31:20

with more confidence and clarity

31:22

and to reduce our risk while improving patient care.

31:26

So one thing to be aware

31:27

of is heterogeneously dense breast tissue.

31:31

And as we know, this can appear many

31:33

different ways on a mammogram.

31:34

It can be, um, relatively more homogeneous for even though

31:39

that seems like it doesn't fit with heterogeneous,

31:42

but we know it can look mostly white

31:44

or you can have different, uh, clumps

31:46

of white different ways that the whiteness can appear,

31:48

but yet still fall into the category

31:51

of heterogeneously dense tissue.

31:53

And that's part of the reason that it can be difficult is

31:55

because visually it can be very busy

31:58

and it can be harder to detect malignancy.

32:01

So when I see heterogeneously dense tissue, um,

32:04

in a medical malpractice case,

32:05

I consider whether that may be a factor.

32:08

So patients, sometimes, uh, they're their best advocates.

32:11

They come yearly for their mammograms.

32:13

These are the patients we love.

32:14

They're very dedicated to the technology.

32:17

We feel that we're partners in this fight

32:19

against breast cancer together.

32:21

And then sometimes patients will feel a lump

32:23

after many years of having had normal mammograms.

32:27

And so again, with that expectation, that

32:30

and their faith in the technology

32:31

that if cancer is there, mammograms will find it.

32:34

Sometimes these are the same patients

32:37

who have a hard time understanding

32:39

how even a normal mammogram may not show cancer.

32:43

'cause as we know, no technology is perfect

32:45

and there are a lot of different ways in which it may, um,

32:48

have reduced sensitivity or specificity.

32:52

So there are patients at in whom their mammogram is normal

32:56

and it's simply a false negative for cancer.

32:59

And now fortunately, especially with the use

33:02

of tomosynthesis and other technologies over time

33:04

that continue to improve the technology, we can reduce

33:08

that false negative risk, but it's not zero

33:11

and it's likely that it will never be zero using technology

33:15

that we can predict in the future.

33:17

So whether it's developed in the interim

33:20

or the interval between a previous normal mammogram

33:23

and the current one, or whether it's manifested some other

33:26

way, there are simply just going

33:27

to be some times when no imaging study could find cancer.

33:33

What I find in a lot of cases is it is more common

33:38

to have a problem with underdoing than overdoing.

33:42

So most cases can be problematic in the legal field,

33:47

even if that did not cause the direct harm in real life,

33:52

if additional views such

33:54

as spot compression views were not performed

33:57

or if ultrasound was not performed.

34:00

And so that kind

34:01

of potential corner cutting can be very problematic in a

34:05

legal case where especially if the appropriateness criteria

34:10

or other white papers

34:11

or consensus documents may indicate

34:14

that there was no good reason not to do additional studies.

34:19

Um, I'm, I've seen from time to time that facilities

34:22

that perform digital mammography with tomosynthesis

34:25

for which a patient is called back from screening

34:28

for a possible abnormality are going straight to ultrasound

34:31

and skipping diagnostic mammography.

34:34

And this is something I would caution against from a medical

34:37

malpractice and from a practical standpoint that it,

34:41

it is not a substitute to do tomosynthesis, uh,

34:44

not a substitute to eliminate diagnostic mammography.

34:47

And so I would advise people to consider why

34:51

that's not being done

34:53

and to consider the information that may be added from doing

34:56

that and how it may look retrospectively if later cancer is

35:01

discovered and that step was skipped.

35:03

Likewise, also with ultrasound, there is legis, um,

35:08

excuse me, literature

35:09

that can support following palpable abnormalities.

35:14

Uh, even if ultrasound is performed

35:17

and shows, uh, something that looks probably benign,

35:20

but from a patient perspective,

35:22

this can be seen as problematic.

35:26

So, um, notification

35:29

and MQSA legislation in terms of reports that go to patients

35:33

and reports that go to physicians is something

35:35

that I've seen a number of, uh, litigation cases come

35:39

to light regarding just the mechanics of communication.

35:43

And so this is why I teach people in dedicated modules

35:47

how exactly it is necessary

35:49

to notify patients, to notify physicians.

35:51

And the components of the MQSA legislation

35:54

that indicate especially your role,

35:57

if you are the lead interpreting physician

35:59

or a medical director, those have specific responsibilities

36:02

for oversight of these processes.

36:07

So patients may return, uh, later maybe in follow up

36:11

or just for their normal routine

36:12

and a workup may find cancer then.

36:15

And so then patients always will start to look backwards

36:18

and say, what could have added up

36:20

to a potential miss in this case?

36:23

And so the question then becomes, in this complex system

36:28

with a lot of imaging tools, patients will ask,

36:31

how did they miss it?

36:32

After I did everything I could, I came for my mammogram,

36:35

I told 'em I felt a lump,

36:37

how did we still not find a cancer?

36:40

So this is a case where a patient had a palpable abnormality

36:44

over a number of different years,

36:46

and the mammogram was normal.

36:48

And so over time, mammograms were done

36:51

and the cancer was only diagnosed later

36:54

after there was new increased density,

36:57

some skin retraction here, dimpling

37:00

and some other clinical signs,

37:02

at which point cancer was already metastatic.

37:05

The ultrasound in this case, uh, was very, uh,

37:10

ill-defined, very subtle, maybe with some abnormality,

37:14

maybe some normal tissue questioned,

37:16

but uh, was read at normal.

37:18

So it's important to just understand again that despite all

37:22

of our best efforts, sometimes cancer is still there

37:25

and technology isn't seeing it yet.

37:28

So then that leads to the situation

37:30

where the patient again says,

37:31

how did they the doctor miss it

37:33

after I did everything I could?

37:35

And the radiologist is scratching his

37:37

or her head saying, how could I find it?

37:39

I did everything that I could. So herein lies the mismatch.

37:45

And one principle that I have found that

37:48

could have made a difference in a number of cases is

37:52

to remember, you are looking for cancer.

37:56

I know this is a talk about breast cancer

37:59

and about breast imaging.

38:00

And so Captain obvious seems like he's talking here.

38:04

Of course we're looking for cancer,

38:05

is probably what's going through your mind.

38:07

However, I've seen a number of cases in which hope,

38:12

a wish and a prayer was the, uh, the rule for the day

38:16

and even suspicious findings may have been reported

38:21

as not suspicious.

38:23

As we know, malignancy can be easy when it's easy

38:27

when masses turn up at yeah, as speculated masses

38:30

with fine pleomorphic calcifications,

38:32

then we can have a strong suspicion of cancer

38:35

and we can feel pretty confident with the diagnosis.

38:38

But as we know, if it all looked like this,

38:40

our job would be easy, but it doesn't always look like this.

38:43

And that's part of why our job is hard.

38:46

Of course, there's always this, uh, feeling of of liability,

38:50

this, this, uh, risk of being sued

38:53

and the concern over that,

38:55

and for good reason that when you look at all medical

38:58

malpractice claims missed, uh, breast cancer

39:02

allegation is the top of these lists

39:05

and others fall, you know, pretty predictably down, uh,

39:08

towards less common.

39:10

So this is top of mind did a lot of cases,

39:15

but often, um, communication is one

39:18

of the most important components in these cases for why

39:21

a cancer was allegedly not found.

39:25

So if you ask yourself, is it possible that this is cancer?

39:31

Remember that your job is to prove that it's not

39:34

without an assumption or a hope that it's benign.

39:38

And again, if you apply this as you're going along,

39:42

it may be helpful for you to reduce that risk

39:45

of a potential malpractice claim

39:47

because it may prompt you to ask more questions.

39:51

Do additional imaging recommend follow up

39:53

to think more creatively about

39:55

how it could still be possible even if you're not seeing

39:59

evidence of it at that time.

40:02

So your, um, impression should state something like,

40:06

you know, speculated mask concerning for malignancy.

40:09

That's a match between suspicious findings

40:12

and an appropriate recommendation for a biopsy

40:16

or other action.

40:18

And when you have suspicious findings,

40:20

those should ultimately correlate

40:22

with the birads category that you assign.

40:24

In this case, that would be a birads four or five

40:27

and biopsy would be the appropriate recommendation

40:30

for a suspicious finding.

40:31

So let those words and the categories

40:35

and actions flow with each other.

40:38

If you find yourself saying things that don't tend

40:40

to match up in those categories, then ask why that is.

40:43

And if you may choose to word

40:45

or phrase things a little bit differently,

40:49

what I sometimes see is reports that are over time

40:53

and that a later reader might say something like, again,

40:56

noted is an increasingly speculated mass,

41:00

and that's not going to help anyone.

41:02

Your report should concern the current findings.

41:06

So it does no one any good

41:08

to either point out an abnormal finding on a previous study

41:11

because you were not there at the time that

41:13

that original study was interpreted to know if

41:16

that was prospectively visible.

41:18

And it also doesn't help to try to soften it

41:21

by describing it differently on a current exam to try

41:24

to lessen suspicion that something may have been missed.

41:27

So your best bet is simply to report the findings

41:31

as you see them in the current exam.

41:33

Using that by RADS terminology, there are some terms

41:38

that are simply not going to be a good match for a, uh,

41:43

less aggressive approach.

41:45

So for example, if you have stable architecture,

41:47

world distortion, you should not be assigning by RADS three

41:51

or other by rads two or one categories

41:54

unless there is a reason that you can describe

41:57

that is the case.

41:59

For example, there was prior surgery,

42:01

in which case you may be better off simply stating

42:04

post-surgical findings are again noted rather than using a

42:07

concerning or suspicious term.

42:10

And yet having that mismatch

42:11

of reporting using more benign language,

42:15

and again, stability

42:16

of a worrisome finding is not reassuring.

42:19

So you don't have to worry about

42:21

what has happened in the past, whether or not it was there

42:24

or visible because each exam is interpreted on its own at

42:28

the time it is performed in the current circumstances.

42:30

So you just focus on the current situation

42:33

and then report what you see and recommend moving forward.

42:39

If you have a discussion with a patient about findings,

42:42

documentation is very important.

42:44

And again, you know, if if I had to do it all over again,

42:47

I at least ask the question of

42:49

how things might have been different if I had document my

42:52

patient's fear of needles.

42:54

But you can't control what happens

42:56

after the fact or actions.

42:57

Everything may have happened exactly the same,

42:59

even if I had documented that you just never know.

43:02

However, it's very helpful to be proactive in terms

43:05

of your documentation, in terms of what you say

43:10

and to whom when you've said it, how it's been documented,

43:15

and exactly the course of treatment

43:17

or action that you're describing.

43:18

So this often comes when we assign a bi res four

43:22

or five and we recommend biopsy.

43:24

Your recommendation of the specific type of biopsy

43:28

to be performed helps scheduling

43:30

and other people communicate more clearly about what is

43:33

to be done, what day it's been scheduled for,

43:37

for the finding in the specific location,

43:40

and then discussed with the patient

43:42

and talking to the referring clinician,

43:45

document your date and time.

43:46

These are all components of documentation that can help you

43:51

to be clear in the communication

43:52

and again, get a better match

43:54

between expectation and performance.

43:58

These, um, specifics are important again, not only for you

44:03

and for the person who's following you,

44:05

but also scheduling can be more efficient if they are seeing

44:09

this report or referring, clinicians can know what to order.

44:12

So this documentation goes far

44:14

beyond just the written words on paper.

44:24

So another, um, standard

44:30

verbiage that might be be helpful to you

44:31

for documentation is to document

44:34

that all questions were answered

44:35

and to the patient indicated understanding.

44:38

I'm not a big fan of a lot of disclaimers, mostly the ones

44:42

that say mammography may not find all cancers,

44:45

but this is one that

44:46

where you've documented having a discussion

44:48

with the patient, this can be helpful

44:50

because it does document that there was direct communication

44:54

and that you had that attempt at coming

44:56

to a good understanding together.

44:59

There is a disclaimer I like to include

45:02

and that I've seen successfully used in medical malpractice

45:05

cases for clearer communication,

45:08

and that is what I call the palpable disclaimer.

45:11

So this one, as I term it is any decision

45:15

to biopsy should be based on clinical assessment

45:17

as malignancy may, might, may not be detectable

45:20

by imaging alone.

45:22

And what this does is it raises awareness on a couple

45:25

different levels that even if you don't see evidence

45:29

for something, abnormal cancer could still be there

45:32

and that you may need follow up

45:34

or a biopsy if the findings are clinically suspicious

45:38

despite your imaging findings.

45:40

So, and this is I think, generalizable to a lot

45:43

of different medical specialties that if there is a problem

45:47

and you haven't gotten to the bottom of it

45:48

or have an explanation at that time, you shouldn't assume

45:51

that it's nothing again, prove it's not cancer.

45:55

Schedule a follow-up. Ask again in the

45:57

future, try different imaging.

45:59

Consider if there are more tax that you might take

46:02

to be clearer in your characterization

46:04

and how you might help to get to the bottom

46:07

of a patient complaint.

46:08

Again, where that helps is they, they feel

46:10

that they have been heard and that they,

46:12

they don't feel that they've been blown off.

46:16

Um, I do see a lot of disclaimers

46:18

and it's always a red flag when the,

46:20

the mammography failed disclaimer, as I call it,

46:22

is longer than the actual mammography report itself.

46:26

So be a little wary of including statements

46:30

that go into great detail about how X percentage of

46:33

of cancers are not seen in mammography,

46:35

because sometimes it has the opposite effect.

46:38

Again, knowing that patients really want us

46:40

to have an authority, they want us to be that,

46:43

that information a expert on these cases,

46:46

but to then say that despite all

46:49

of our efforts mammography may not work,

46:52

it can undermine our credibility in a way

46:54

that we sometimes don't anticipate

46:56

and it's not very effective to give this statement.

46:59

So it's more important, I think, to tailor any disclaimers

47:03

to the specific situation rather than giving a bunch

47:06

of boilerplate uh, disclaimers at the end of your report

47:11

when you notify the referring clinician.

47:14

This is very important in terms of documenting communication

47:18

and communication is a large subtopic in mammography

47:23

and especially in malpractice risk.

47:25

Um, it can make your life easier

47:26

to have better communication.

47:27

Certainly it can make patients happier

47:30

and it can make your workflow your efficiency much more, uh,

47:34

useful just in terms of your daily, daily work

47:37

and that type of fatigue that sets in from,

47:39

from constantly re renegotiating reating the wheel here.

47:43

So you do have options with communication

47:47

and it's important to document how this is done

47:49

and to make sure that you're using HIPAA compliant

47:53

and trackable ways of communicating.

47:58

So patients do need to be notified directly

48:02

of results by mammography.

48:03

And the MQSA legislation is very specific on these

48:07

requirements, so we don't have time today

48:10

to go into detail about that,

48:12

but just be aware that there are very specific format

48:16

and time requirements by which you are required

48:18

to notify pa the patients of their results

48:21

and also the referring clinicians.

48:25

When you are looking for answers to these questions,

48:28

the best resource is the policy guidance help system.

48:33

This is a website that is maintained by the FDA,

48:36

but as you can imagine, it's pretty lengthy

48:39

and there's a lot of different information.

48:41

So this is something that has been one of my goals is

48:44

to help educate people based on what I've learned about it

48:47

and also how I've seen it come

48:49

to pass in medical malpractice cases.

48:53

The A CR American College

48:54

of Radiology has a practice parameter as well

48:57

for the communication of diagnostic findings.

49:00

And this will govern a lot of your choice

49:03

for communication of findings.

49:05

And so it's good to have an awareness

49:07

that resources like this exist

49:09

and how they might apply to your practice results.

49:14

Communications depending on your community,

49:16

this can be very, um, contentious or it can be very easy.

49:19

It depends how much control

49:21

and what kind of structure you're referring Clinicians

49:24

want to have over this.

49:25

Some are delighted

49:27

to have the radiologist handle communications

49:30

and to talk with the patients and give them the information.

49:33

Others may be in the middle

49:34

and you may have other clinicians who are very opposed

49:37

to the radiologist giving a cancer

49:39

diagnosis from a biopsy directly to the patient.

49:42

And that's just going to be an individual preference.

49:45

But what you should know is

49:46

that the literature strongly supports the radiologist

49:50

as the key provider of diagnosis

49:52

and information from breast imaging

49:54

and other radiology studies.

49:56

And so from a malpractice standpoint, this is the standard

50:00

to which you are likely to be held, that you have

50:05

a responsibility to communicate these results

50:07

and not assume that someone else will

50:09

or rely on someone else.

50:11

So some of this gets into the practice

50:13

to practice communication,

50:15

but you should know that even in 2012, 60%

50:19

of patients then according to that biopsy data,

50:22

received their diagnosis of cancer by the phone.

50:25

And this is highly accepted by patients.

50:29

So you'll have sometimes, uh, referrers who state

50:32

that they will never give a diagnosis by telephone,

50:35

that you should only do it in person, um,

50:37

and that you should have a

50:38

longstanding patient relationship.

50:40

But when you look at patient preference,

50:44

patients just want it right now.

50:46

They want their results

50:48

and they want them as soon as possible.

50:50

They also don't like sometimes having to come in

50:53

for an additional visit, paying another copay,

50:56

having the delay in the scheduling.

50:58

And generally by that point, if they're going

51:00

through those hoops, they probably have a clue

51:02

that they have a diagnosis anyway.

51:04

So I think this older feeling that we have

51:07

to protect patients from the scary information is hopefully

51:10

going away, um,

51:12

because patients are simply getting used to the speed, uh,

51:15

having increased through a lot

51:17

of different means of communication.

51:19

So again, if you're looking for support for radiologists,

51:24

communicating information directly, this is amply available

51:27

in the literature.

51:30

And this flow chart I really like from the Journal

51:33

of American College of Radiology

51:35

because it shows the potential breakdowns in communication.

51:39

If you look at a, the suboptimal scenario on the top,

51:42

these little explosions, hopefully my mouse is showing up,

51:46

these are times when you can have breakdowns in

51:48

communication that lead to the patient

51:50

not knowing they have cancer.

51:52

And that's something that you

51:53

just don't want to have happen.

51:55

So the optimized scenario

51:56

where the radiologist delivers the diagnosis

51:59

of cancer is not only helpful for speed,

52:02

it also helps a multidisciplinary approach.

52:05

And this is a great way to really fly the flag for radiology

52:09

as a breast imager, is to demonstrate our authority

52:13

and our expertise

52:14

and communication, which is something they think maybe some

52:17

people don't anticipate for radiologists

52:19

who they think are just reading a lot

52:21

of studies in a dark room and never seeing people.

52:24

But this is a real opportunity for us to shine in radiology

52:27

and to be strong communicators

52:29

and members of that multidisciplinary team

52:32

for patients with breast cancer.

52:40

There have been some questions, certainly, um,

52:43

in the medical-legal environment about whether

52:45

stopping screenings or having delays

52:47

during the covid pandemic has been a factor in a delay in

52:51

diagnosis and early information shows that

52:55

probably it is a factor, but probably not important in terms

52:58

of overall mortality.

53:00

However, we do need to keep following this to make sure

53:03

that we're aware at least of different factors

53:06

that may affect mortality from breast cancer due

53:09

to lapses in screening.

53:11

I suspect however, that the, the impact has been far worse

53:15

from the variability in screening from

53:19

every other year at 40 to beginning at 50, uh,

53:23

rather than the a CR recommendation and,

53:26

and breast radiology recommendations

53:28

for annual screening mammography at 40,

53:30

I think we will see a far greater negative impact,

53:33

unfortunately, at that delay and those two year intervals

53:36

and screening than we will from other factors.

53:38

But fortunately, these are all information, um,

53:41

that will come out with continued research.

53:45

So finally, use the BIRADS card.

53:48

This is the last part of our awareness haiku,

53:51

and so I love to think of it

53:53

as the Bible for breast imaging.

53:55

You know, there's the Holy Bible in religion

53:57

and then there's the birads Bible.

53:59

And what that means is that these words

54:04

and categories descriptors in the Birads manual

54:08

have been established over decades of research,

54:12

and they provide a consistent method for communication

54:16

of appearances and recommendations.

54:18

And so I always recommend that you laminate

54:22

or have this quick reference the actual manual itself in

54:25

your office so that you can refer to this.

54:27

It's not a test, it's, it's an open book test.

54:30

You can always look at this to refer just so

54:33

that you have the best chance

54:34

of clear communication in your reports.

54:36

It's surprising how many malpractice cases I see in which

54:40

by Ed's terminology is simply not used.

54:43

And so it's very difficult then to evaluate how, um,

54:48

that care may have been optimal when it doesn't start out

54:51

with the appropriate communication with a report.

54:56

Again, remember that the categories must be stated

54:59

specifically in the, from the birads terminology

55:02

and that your recommendation for action should fit

55:05

with those categories.

55:08

If you assign a birads four or five, recommend a biopsy

55:14

and use as few words as possible,

55:16

but enough to communicate clearly your

55:19

recommendations and assessment.

55:21

I know that sounds easier said than done,

55:23

but if fewer words can say it more clearly, especially using

55:27

by Ed's terminology, that's probably the best way to go.

55:31

And again, if you ask yourself, should I do a biopsy?

55:35

Should I do additional views? Should I do something else?

55:38

Something in your mind is prompting you to ask that question

55:42

and it's a good, uh, something to keep your mind on and,

55:46

and to act knowing that doing more is

55:49

probably better than doing less.

55:52

And it's, this is the name of the game

55:53

as we're always trying to balance the pros

55:56

and cons of intervention additional imaging,

55:59

but just use that as your own internal barometer.

56:03

If that question is occurring to you,

56:05

your subconscious brain may be trying to tell you something

56:08

and you may be better off going ahead

56:10

and doing that additional, um, screening

56:12

or whatever it is that your, your brain is suggesting

56:15

that you may be doing to avoid problems in the future.

56:19

So a special situation can occur if the

56:22

patient refuses a biopsy.

56:24

And here I will just advocate for very specific

56:28

and very clear documentation.

56:30

Specifically state that you recommended a biopsy

56:33

and the patient refused

56:35

and it's appropriate to give the patient's reasons in order

56:38

to document that you discussed their thought process

56:40

with them, that you attempted to get an understanding

56:43

and to help them through that discussion.

56:46

And yet they still chose otherwise.

56:49

And again, we, we wanna be nice people, we want

56:52

to be patient advocates.

56:53

And yet it is important to document not only to the patient

56:57

but also in writing that if cancer is present

57:01

and not treated, that there is a potential risk of death

57:04

through not having a biopsy

57:05

or not performing an additional action.

57:07

As you've stated, it sounds very heavy handed.

57:10

However, this is the only way that you have to document

57:13

that discussion and to hopefully have

57:15

that introduced into the record if there is a potential

57:19

lawsuit later when you have multiple findings.

57:23

This is also one of these special situations

57:26

where you should have the care

57:28

and management dictated by the most suspicious finding.

57:32

So it's not an averaging

57:34

and it's certainly not looking at the least suspicious

57:37

finding and hoping that the others are also less suspicious.

57:41

It truly is looking carefully for the bad actor

57:44

and having the most suspicious finding

57:46

dictate what you do next.

57:49

Again, as I uh stated briefly

57:50

before, there is literature that supports that a

57:54

probably benign appearing palpable mass

57:56

that is documented on, on imaging may be able

57:59

to be successfully followed.

58:02

However, I've seen this occur in medical malpractice cases

58:06

and it is more difficult to find literature support

58:09

for following it than it is for

58:12

biopsying what could be cancer.

58:14

And so from a practical standpoint,

58:17

this may be a more challenging viewpoint to support

58:21

and we, we always have to let our medical judgment

58:25

be in charge of how we operate, not our fear

58:28

of the legal ramifications,

58:30

but just be aware that from a legal standpoint,

58:33

then looking backwards from a cancer diagnosis,

58:36

this is simply a more challenging position to support,

58:39

even though there is literature

58:41

that can support you doing it for resources,

58:45

there are fortunately so many resources out there

58:48

to remember that are here to help you.

58:50

These can include the appropriateness criteria

58:52

and practice parameters

58:54

by the American College of Radiology.

58:56

These are updated from time to time,

58:58

as are consensus guidelines

59:00

by other specialty organizations like the

59:02

Society for Breast Imaging.

59:04

The FDA administered website

59:06

for the Mammography Quality Standards Act is the other Bible

59:11

besides birads, which have already referenced

59:14

and remember that peer reviewed journals can also be a great

59:18

resource for information to support your practice.

59:22

So just to recap again, the haiku density is key.

59:27

You are looking for cancer and use the birads card.

59:31

It has been such a pleasure to be here today.

59:34

I am happy to answer questions.

59:36

You can email me at

59:37

admin@theexpertresource.com.

59:41

I also have provided my link to my website

59:44

where I offer my courses and other information.

59:47

If you want to be involved as an expert witness,

59:50

learn more about it, um,

59:52

or also to learn from my mammography

59:54

malpractice masterclass.

59:56

I would love to see you there and I am happy to stay here

59:59

and answer questions now. So thanks so much.

60:02

Oh, thank you so much for that great lecture, Dr. Green.

60:06

And yes, we will open the floor for questions.

60:09

Now you can submit your questions

60:10

through the q and A feature.

60:13

And Dr. Green, do you see the Q and A box?

60:16

I do. So I see a question.

60:18

Are you recommending biopsying all palpable new lumps even

60:21

if they look benign lipoma, breast hematoma,

60:24

especially if multiple?

60:26

So yeah, this is a great question

60:28

because this question brings up some

60:31

of the typically benign findings

60:34

that we can make even on the basis of mammography.

60:39

So there are findings that we can categorize

60:42

as confidently benign on mammography,

60:45

which might include hamartoma or lipoma.

60:48

Galacto seal comes to mind.

60:50

You know, there are a number of those that yes, if you

60:54

are confident with a quality workup showing the BB marker on

60:58

the mammographic finding, showing

61:00

that it's confidently benign, that the,

61:03

the question is always what's the chance you're wrong.

61:06

So if you are confident that these are benign findings

61:10

and that even ultrasound is not indicated,

61:13

then you can describe it as such and you're gonna be right.

61:17

The problem comes with when they're not typically benign,

61:21

and there's a lot more of those than there are

61:24

of the very typically benign findings.

61:26

So if you have an oval circumscribed

61:31

hypo hypoechoic mass on ultrasound, that's palpable,

61:36

most likely it's going to be benign.

61:39

And this may be a time again,

61:41

where you document in your report

61:44

that you have discussed the option

61:45

of biopsy versus follow up with the patient

61:48

and the patient chooses follow-up,

61:51

which you feel is appropriate,

61:54

that is very effective at documenting

61:57

that you considered cancer,

61:59

that you've discussed the options

62:01

and the patient has chosen a reasonable course of action.

62:04

And you may have patients who choose biopsy

62:07

and you think that follow-up would be a more appropriate

62:10

based on your imaging findings,

62:11

and that's okay too, in which case you document specifically

62:15

what that request is.

62:17

And if the patient requests biopsy, try try to find a way

62:21

to do the biopsy because you are,

62:23

you are doing the definitive answer to a question

62:27

without a substantial risk of harm.

62:29

Again, this is a case by case basis.

62:31

It's always a risk benefit ratio calculation based on your

62:34

experience, but these are your options that you have.

62:39

So I'm, again, not saying that you have

62:42

to biopsy everything,

62:44

but just if you have findings that are not those, uh,

62:48

typically benign findings that you lean towards at least

62:53

offering, discussing, biopsy,

62:55

and documenting the thought process

62:57

and reasoning that goes into the final determination

63:00

for multiple findings.

63:02

Um, some of those things would be unusual to be multiple,

63:05

maybe fat necrosis

63:06

and trauma, for example, like a, a car accident

63:09

where someone has a seatbelt injury, multiple areas of

63:13

very benign appearing fat necrosis.

63:15

At that point, it's going to be a combination

63:17

of clinical factors and judgment.

63:19

So, um, multiplicity though should not be the factor alone

63:23

that chooses that, that prompts you to choose inaction,

63:28

if that's, hopefully that's helpful.

63:31

So the next question,

63:34

can a diagnostic radiographer communicate

63:37

to the patient about the biopsy recommendations?

63:41

Yes. And in most locations,

63:43

if you're doing diagnostic mammography

63:45

and ultrasound, you are probably

63:47

there physically with the patient.

63:48

I hope so, because, um, remote diagnostic

63:53

mammography and ultrasound is highly problematic, um,

63:58

because you lose the opportunity for very real time

64:03

and hands-on correlation of those modalities

64:06

and interaction with the patient.

64:08

So yes, there are certain instances

64:12

where remote interpretation is allowed,

64:16

and communication typically within 30 minutes

64:18

to the patient using an approved HIPAA compliant channel

64:22

is okay to do.

64:24

Um, and that's very location specific.

64:27

So if you are in a very rural area,

64:29

and this is the normal means of communication

64:32

and how care is rendered because of a lot of challenges

64:35

or geographical or other constraints,

64:38

then your local practice is going to be most important

64:41

to determine how you do things.

64:43

But it's very important that practice is not,

64:45

choose remote imaging for convenience instead.

64:51

And so it's just something that each practice will have

64:54

to evaluate, um, for their risk

64:56

and benefit based on their local geography

64:59

and practice considerations.

65:00

But in assuming that, yes, it's the norm that you're there

65:04

and you're talking with the patient,

65:07

absolutely it is appropriate, as I've shown

65:09

with the literature and with patient expectations,

65:12

that the radiologist is probably the best qualified person

65:17

to talk with the patient about image guided biopsies

65:21

who could be better than the radiologist who's trained,

65:24

knowledgeable and skilled in performance of those exams.

65:28

And so that's an opportunity for communication that

65:33

patients will really value

65:34

and that can be a very important means for radiologists

65:37

to present to patients as authorities in the field.

65:43

On the next question, if your colleague

65:44

or you as the previous reader missed the finding

65:47

and in follow up, you saw it,

65:49

how will your report look like without putting your

65:51

colleague or yourself in a tight spot?

65:54

Your report will will read as though

65:59

you are only reading the current findings.

66:02

And I, I love this question. I get this question a lot.

66:04

So it's something that's on a lot of people's minds

66:06

because we do worry, how do you put it in context when

66:09

there are prior exams?

66:11

So your history or your, uh, if you list comparison exams

66:15

and there's pros and cons to listing specific dates,

66:17

you can, if you want, there's no specific mandate

66:20

that you give the precise date for every prior exam

66:24

that you want, just be consistent with how you report that.

66:27

But you will list your prior comparisons

66:30

and then you will state the current findings,

66:32

your assessment and your recommendation,

66:34

and you need not comment at all about

66:38

what was present in the past

66:39

or if there is a change, if the findings were

66:46

not suspicious previously

66:47

and they are suspicious now, then you have

66:51

to use your judgment.

66:53

And it's probably best

66:54

to just simply state the current suspicious findings

66:58

and again, without increasing worsening, um,

67:04

you know, going back

67:05

and un giving measurements of things that show it's larger.

67:09

One exception to this is if the previous person

67:13

documented the abnormality, they told the patient about it

67:16

and they recommended a biopsy

67:18

and it wasn't done, then you may

67:23

consider whether you emphasize

67:25

that it was previously discussed with a patient,

67:28

especially if the patient,

67:30

and this is where the documentation comes in,

67:31

if the patient previously stated they didn't want

67:34

to have a biopsy and then the finding has increased.

67:38

It is especially important to say.

67:40

Again, I discussed with the patient

67:42

that this is a suspicious finding and biopsy is warranted.

67:45

Cancer could be there missing,

67:48

it could result in delayed diagnosis

67:50

or death if biopsy is further, uh, delayed.

67:54

So that's a very rare, um, unfortunate, um,

68:00

instance where it's especially important to emphasize that

68:04

communication of this has been consistent

68:07

and yet the patient has not had that care yet.

68:10

And so at that point also pick up the phone,

68:12

call the referring doctor

68:13

and tell them exactly what's going on.

68:19

So questions here for the moderators.

68:23

I see three open questions.

68:26

I thought there were ones above

68:27

and so I'm going to just read them in order,

68:30

but I don't know if I had missed some.

68:31

So if I did, if they have disappeared from my view, please,

68:34

um, go ahead and let me know.

68:36

So next question,

68:37

if one is interested in being an expert witness,

68:39

what is the typical number

68:40

of cases one would participate in a given year?

68:43

Totally varies. Um, and the great thing is that the,

68:49

although the work tends to be kind of sporadic, i'll,

68:51

I would have typically gotten a few cases at one time

68:54

and then sometime passes and then I get some more.

68:57

Um, it is the kind of work that is great

69:00

to do on your own time, almost.

69:02

I'd say 99%

69:04

of expert witness work can be done totally on your own time

69:07

from home using a normal computer without additional

69:10

equipment and using your skills, training

69:13

and expertise to review cases.

69:15

So, um, it is one of the best ways

69:17

that you can put your skills to use that not only help us

69:21

to educate people in the legal profession

69:23

and help with judges and juries.

69:25

Rarely, you know, only one to three cases out

69:27

of a hundred might go to trial.

69:29

So again, you know, the great majority

69:31

of this is on your own time and very flexible,

69:34

but it is truly a service to representing good information

69:38

and important educational skills to the legal profession

69:41

and also helping us become better doctors

69:43

by really being knowledgeable about the information.

69:46

Um, but I've never, I was never too busy

69:48

to do the work in addition

69:50

to my regular clinical responsibilities

69:52

because of the flexibility.

69:55

Um, next question. You probably practice in an academic

69:58

center, but most work in clinics that don't see patients.

70:00

So are your suggestions practical?

70:03

So even though I did went, I went to Brown, Yale

70:07

and Harvard, I am a lifelong private practice, um,

70:10

radiologist in communities.

70:13

So I've worked in, in hospitals with 50 beds up to, uh,

70:17

you know, a thousand people on the, uh, total

70:20

for the medical, uh, roster.

70:22

And, uh, my city has about 200,000 people.

70:24

So, um, I have never been in a really big city environment.

70:28

I've always been community practice.

70:30

And so as with most physicians, you know,

70:33

we're boots on the ground practical, knowing the realities

70:37

that we face and dis you know, in a busy, uh,

70:39

private practice environment.

70:41

And so all

70:42

of this information definitely comes not only from the

70:47

academic and literature,

70:49

but also knowing firsthand how it is

70:51

to see patients in a busy private

70:53

practice in a community setting.

70:57

What about the benefits of FNA in low, uh,

71:01

suspicion lesions?

71:02

So finding needle aspiration has really, uh,

71:06

I think gone away with the advent

71:08

of ever improving core vacuum assisted needle

71:11

biopsy technique.

71:13

And so there's, there's essentially I think no role in doing

71:16

f and a, um, at this point, given how many options we have

71:21

for much more, uh, effective

71:23

and diagnostic corn needle biopsy, which is going

71:26

to have a much lower upgrade rate.

71:29

And some people will ask, what about lymph nodes?

71:32

And again, you know, with the tools we have now

71:34

and opportunities for hands-on, you know,

71:36

image guided approach for that, uh, FNA is,

71:39

is basically just not going to be indicated.

71:42

Aspiration of fluid will still help.

71:45

And so you may choose sometimes to send that for cytology.

71:48

So a little bit different angle on that.

71:53

Do you get sued for typographical errors?

71:58

I don't recall any case in which

72:02

a typographical error was the primary determinant

72:06

for why something went wrong and a patient got sued.

72:11

However, it is possible that if it had the form

72:15

of a medical error, it was a typographical error.

72:19

I could imagine a case, maybe medication dose

72:22

or maybe something in an order was

72:26

done incorrectly through, uh,

72:28

because it was typed incorrectly as a typographical error.

72:32

I can imagine a case is possible with that.

72:35

Most of the time I, you know, as, as most

72:37

of us now are using computer platforms increasingly

72:39

with voice transcription, I think a lot

72:42

of us have a higher tolerance for typographical errors.

72:45

However, this is one good reason

72:47

to keep your reports shorter rather than longer

72:49

because the more you have in there in terms of words,

72:52

the more opportunities for typographical errors exist

72:56

and your life will be a lot easier when

72:59

you're proofreading less.

73:01

And yes, I see disclaimers of this is done

73:04

by voice transcription, so errors are not my fault,

73:07

but ultimately you're responsible

73:09

for proofreading and signing it off.

73:11

So that disclaimer is not effective ultimately in the multi,

73:14

in the medical-legal system

73:16

because the responsibility ultimately relies on your records

73:20

being accurate, reflections of what was discussed, uh,

73:23

and decided and treated.

73:25

So from a practical standpoint, we do the best we can.

73:29

You can stack the deck in your favor by using fewer words

73:32

by templating language.

73:33

So take a little time, especially with someone maybe

73:36

that you work with or you know,

73:38

who's really technologically savvy

73:40

and help learn tools to use templates

73:43

or chunks of text that when you're dictating

73:46

or formulating reports that you have a as low a chance

73:50

of possible of making an inadvertent error.

73:54

But watch for laterality, um, you know, left,

73:56

right errors are still potentially there.

74:00

So be careful of that

74:02

and do your due diligence for real reports in general.

74:06

Great questions. I I think

74:08

You got 'em all.

74:10

Thank you so much Dr. Green.

74:12

Um, and thank you so much again for like taking the time

74:14

to answer everyone's questions as well.

74:16

It was a really great lecture today.

74:18

My pleasure. Thank you so much.

74:21

And thank you to everyone

74:22

for participating in our noon conference.

74:24

You can access the recording of today's conference

74:27

and all our previous noon conferences

74:28

by creating a free MRI online account.

74:32

Be sure to join us next week on Thursday,

74:35

May 9th at 12:00 PM Eastern, where Dr.

74:38

Alka Singal will deliver a lecture entitled ultrasound,

74:41

gallbladder, and Biliary Tree Common and Uncommon Diagnosis.

74:46

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74:48

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74:50

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74:52

Thanks again and have a great day.