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Hello, and welcome to Noon Conference hosted by Modality.

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Noon Conference connects the global radiology community through free live

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educational webinars that are accessible for all and is an opportunity to learn

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alongside top radiologists from around the world.

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Today, we are honored to welcome Dr.

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Benjamin Strong for a lecture entitled "137 Years of

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Malpractice." Dr. Strong completed residencies in both internal

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medicine and radiology and completed a fellowship in body

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MSKMR. He worked as an emergency physician for three years,

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private practice radiologist for two years, and academic radiologist for

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two years. He has worked in various capacities for virtual

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vRad, excuse me, for the last 21 years and holds licenses to

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practice in all 50 US states. At the end of the lecture,

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please join him in a Q&A session where he will address questions you may have on

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today's topic. Please remember to use that Q&A feature to submit your questions

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so we can get to as many as we can before our time is up.

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

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Strong, please take it from here.

1:04

All right, folks. I'm going to go through this pretty quickly.

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Thanks so much for the invitation to speak.

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But this lecture tends to run about an hour 15, and we're going to try and

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do it in an hour. So to explain the topic, the

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title of this presentation, the bottom line is I did some

1:22

math. And, what I did is I took

1:26

almost four years, 41 months, of

1:30

closed cases,

1:32

and I have processed all of those. I had all the information,

1:36

reports of counsel, depositions, images, reports, witness

1:40

testimony, on and on.

1:43

And when I compiled all this, I realized, huh, this is

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an unusual thing. This is in fact unique to have

1:51

this much exposure to radiology medical

1:54

malpractice. In fact, if you were to read an average

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workload for an average radiologist in an average-sized

2:02

practice for any period of time, you

2:06

would have to read for 137 years to have

2:10

acquired this much medical malpractice exposure.

2:15

All right. Since we are talking about misses, I want to level

2:18

set everyone. You're probably thinking, "Well, I'll watch from

2:22

intellectual curiosity, but certainly this will never happen to

2:25

me." Especially if you're a resident, you may think you've never made an

2:29

error. Well, that's absolutely untrue, and I want to

2:33

level set everybody's expectations.

2:36

So the vRad error rate has been very

2:39

consistent at about 1.3 major

2:43

misses, that's something affecting patient care,

2:46

per thousand studies. That is our standard error rate.

2:51

The studies that have been published with regard to

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actual QA rates are the Wilson Wong study.

2:58

That's probably the largest, although it's now more than 20

3:02

years old. But it brought the error rate in at about

3:05

1.5 per thousand. There was the SAPA

3:09

study, which was predominantly trauma patients and obviously

3:13

had a much higher error rate, close to 30.

3:16

And then there was the Wu meta-analysis, garbage in,

3:20

garbage out, which yielded this garbage result of close to

3:24

25 misses per thousand. So,

3:27

although we're looking at a lot of misses by radiologists in my

3:31

practice, they do actually very well

3:34

compared to published standards.

3:37

So the typical teaching on this, which I've found to be pretty

3:41

well borne out, is that a typical radiologist will read

3:45

14,000 studies in a year, will have one claim, that's

3:49

a filed intention to sue, every seven

3:52

years or every close to 100,000 studies, and there will be

3:56

one settlement or indemnity. Indemnity is the

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phrase used for either a jury award or a settlement,

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but a payout of some kind, one in every five

4:08

claims.

4:10

So,

4:11

vRad and any other emergency radiology

4:15

practice is at slightly higher risk.

4:17

We read a higher study volume. We have a distributed model, so you

4:21

can't count on your colleagues to defend you.

4:25

And we have greater exposure because ER cases

4:28

undoubtedly bring the highest risk of medical

4:32

malpractice suits. There is a great study from University

4:36

of Washington that showed 46% of radiology

4:39

malpractice actions will stem from emergency departments,

4:43

even though that only makes up about 18% of all

4:47

volume.

4:49

I did an assessment of the entire medical

4:52

malpractice histories of every radiologist that had worked for

4:56

vRad over about a decade.

4:59

And these are the numbers. Now, you have to take this with a grain of salt because

5:02

these were people in all stages of their career.

5:06

So we had people who'd worked 30 years, and we had people fresh out of

5:10

training. So just a snapshot of a

5:14

large number of radiologists, over 800 radiologists, shows you

5:18

that about half of them have a claim of some kind,

5:23

again, in all phases of career. Right?

5:26

But the number I really want to point out here is these two at

5:30

the bottom. The number that actually went to trial,

5:34

26, and the number that actually resulted in a

5:37

plaintiff verdict,

5:40

one.

5:41

So going to trial is exceedingly rare.

5:45

In fact, most medical malpractice defense lawyers are

5:49

very reluctant to go to trial. Your handling of any given

5:53

case has to have been absolutely perfect.

5:57

You have to have opened that study in a timely fashion with no delays.

6:01

You have to have rendered an accurate report

6:05

describing the important findings in clear and succinct

6:09

diction. There can be no typographical errors in your report,

6:13

and you have to have phoned in and made verbal communication

6:17

of those critical findingsTo the relevant clinician.

6:20

And if you haven't ticked every single one of those boxes, I guarantee

6:24

you they will never take that case to trial.

6:29

All right. So over this period of time, VRad read close to 20 million

6:33

studies, and given the stats we just looked at, the expected

6:37

number of claims, 195, expected settlements or

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indemnities, 39. And we came in slightly higher than

6:45

that. And again, I attribute that to the fact that we read predominantly ER

6:49

cases. So we're looking at 48 studies with

6:52

indemnity.

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Of the 220 total claims, there were 36 that

6:58

were opened and shut, meaning just thrown out by the court as

7:02

unsubstantiated. There were 136 that were closed

7:06

without indemnity, and the total cost in legal costs for us

7:10

in those 136 cases was $6

7:13

million. And that was money very well spent.

7:18

All right, so let's look at our 48 indemnity cases.

7:21

I took out three procedural cases.

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We are predominantly a diagnostic

7:27

radiology shop. But we did run some on-site

7:30

practices, and you can see the three procedural cases that

7:34

I discarded. So what that leaves us with is

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45 cases that I went through in

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painstaking detail and charted in the following

7:45

fashion. So we'll take a look at these.

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How did they break down? Clearly, the most expensive

7:53

of all med mal cases are CT of the abdomen, pelvis,

7:57

and chest X-ray. Those average indemnity and

8:01

legal costs combined about $1.2 million

8:05

each, whereas all of the other procedure types averaged

8:09

about $800,000.

8:14

How did they break down geographically? Well, what is up with the Northeast?

8:18

There is no question the Northeast states, especially New York,

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Pennsylvania, and New Jersey, have the highest risk of medical

8:26

malpractice proceedings. But there is another funny outlier, and

8:30

that's New Mexico, and I know exactly why that was.

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New Mexico has legislation that has suspended

8:38

most venue regulations, meaning you do not have to file

8:41

suit in the actual region in which your medical

8:45

malpractice action took place. So what these

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states do, and Pennsylvania now has the same suspension

8:53

of venue. What these lawyers in these states do is

8:57

they file in the most liberal and affluent

9:00

city in any given state, because that is where you tend

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to get the highest jury awards. So, New

9:08

Mexico is currently debating that, the legitimacy of that

9:12

legislation right now. But over many years, over a decade, it's

9:16

been that way. Pennsylvania has gone that way, and as

9:20

one of my lawyer colleagues said recently, guaranteed,

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every single Pennsylvania case will now be tried in Philadelphia.

9:30

But that's not the whole story. Those were just absolute numbers.

9:34

Here were the total awards over this time period, and the clear winner

9:37

is Pennsylvania. But let's go further

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with this and actually look at the percentage of volume that

9:45

we had. So this is the percentage of our medical malpractice expense

9:49

by state. And we do cover all 50 states, and

9:53

therefore, if there's no number in a given state, there were no medical

9:57

malpractice

9:59

actions in that state. But let's take that and divide it by

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the percentage of our total volume by state,

10:07

and that gives you a relative risk ratio for every state.

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Now, I want to quickly point out, I believe

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Nevada, Wisconsin, and Connecticut are

10:19

all spurious values. They are related to single

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cases that were particularly expensive and therefore

10:27

don't really reflect the risk. So I had a recent

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residency graduate contact me and express his

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concern over Nevada, Wisconsin, and Connecticut, and I told him,

10:39

"I don't think you listened closely enough," because Nevada,

10:43

Wisconsin, and Connecticut in this analysis were

10:46

spurious. But that leaves us with New Mexico,

10:50

Pennsylvania, and New Jersey as the highest risks.

10:54

And I will tell you that New York is now making a run for it.

10:58

I'm evaluating our medical malpractice

11:02

proceedings

11:04

for the next four years, and New York has taken off and is clearly

11:08

going to be the winner. So ultimately, New York, Pennsylvania, New

11:12

Jersey, and New Mexico are your greatest risks.

11:16

So let's look at total costs. Legal costs, I will tell you

11:20

this very simply, track to the duration of the

11:23

proceedings. The longer any given proceeding goes on, the

11:27

more you rack up legal costs, and it's

11:30

striking. So the best way to handle a medical malpractice

11:34

case is to get out.

11:37

As far as indemnities go, the biggest one was the one case

11:41

we had that went to trial and resulted in a jury award of

11:45

$5.6 million. So that was the clear winner there.

11:49

If we add these all up, you can see over a period of

11:53

41 months,

11:56

we spent a total of about $44 million.

11:58

So a little more than a million a month is the cost

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for doing business if you're reading 7 million studies a

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year.Sorry,

12:10

that hung up a little bit. All right.

12:13

Let's next look at

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error rate and reading speed. Now, I didn't have

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data for every single radiologist here for a variety of

12:23

reasons, but we certainly have enough to spot the trends.

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People tend to think, "Oh, if you get sued, it's because you are

12:30

inaccurate at a baseline, or perhaps you

12:34

read too fast." And I will tell you, there is no real

12:38

correlation between reading speed and

12:42

error rate. We've been tracking that data for more than 20 years, and

12:46

I can tell you definitively that is not the case.

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However, every individual has their own

12:53

reading rate at which their accuracy drops off, and that

12:57

number might be five studies per hour.

13:00

It might be 25 studies per hour. It varies

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by individual, and it's dependent, really, on your adherence

13:08

to a structured search pattern for any given

13:11

procedure, and just your ability to cognitively focus

13:15

as far as I'm concerned. But the important point about this is

13:20

you can see two-thirds of all our medical

13:23

malpractice cases were radiologists with

13:27

better than average error rates, and two-thirds

13:31

are radiologists with slower than average read rates.

13:35

So reading slowly or inaccurately, not really the

13:39

point.

13:41

It seems to descend more randomly than that.

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All right, if we look at my master chart, you can see the standard of

13:49

care column right here. If there's a red X, that means the

13:52

finding was missed in the standard of care, thus not met.

13:57

If there's a green plus sign, that means the standard of

14:00

care was met. The actual read was

14:04

accurate. So there were 10 out of 45 where the

14:08

standard of care was met, where the actual read was accurate.

14:11

And these broke down very nicely into, was

14:15

communications an issue or was it not?

14:19

In these top five, communications was an issue, and

14:23

that's actually a very low percentage, five out of 45, about

14:26

11%.

14:28

And that's actually quite low compared to the national

14:32

average. When you look at national samples, the communication

14:36

of a finding is actually relevant, and

14:40

salient for that matter, in about 30, sometimes even

14:44

as much as 40% of med mal proceedings.

14:47

For us, we have all these communications automated.

14:50

You can actually work for vRad and never dial the

14:53

phone. We use natural language processing and now large

14:57

language models to identify critical findings within your report and

15:01

automatically trigger a call to the facility.

15:04

So it's much lower than a typical practice

15:08

might see. In addition, I would say of these

15:12

five where communications was an issue, there were only

15:15

two cases where it was a straightforward,

15:19

the radiologist described the finding in the report, failed

15:23

to call the referring clinician, right?

15:26

And both of those cases were pneumonia.

15:31

So I'm saying it now. If you see the initial

15:35

diagnosis of lobar consolidation in the

15:39

proper setting, fever and cough, in a patient from an

15:43

ER or urgent care, you must call that

15:47

finding in. That qualifies as a critical

15:50

finding and must be verbally communicated.

15:53

And I know when I give this lecture live, hands go up all around the

15:57

room. For one thing, many residencies do not

16:01

emphasize that requirement enough.

16:03

You have the ACR to thank for that. More than 20 years

16:07

ago, they rolled to the legal community and said,

16:11

"Okay, we'll add that to the standard of care that a verbal communication

16:15

must be made." It was something that should never have been done, but you have

16:19

them to thank for it, and it is now firmly established as

16:23

standard of care.

16:24

The other question that people always ask is, "Well, but what about left

16:28

lower lobe atelectasis in an ICU patient?" Well, obviously,

16:32

that's not what I said, right? I said initial

16:36

presentation of lobar consolidation with the right clinical history and the

16:40

right clinical setting, ER or urgent care.

16:44

When you make that initial diagnosis of lobar pneumonia, you need to

16:48

call.

16:49

All right. Oh, so let's talk quickly about these ones where what about

16:53

this last group of five, this 11% where the

16:57

report was accurate, the communications were appropriate,

17:01

and causation was to the favor of the

17:05

radiologist? So the radiologist did nothing wrong at all,

17:09

and that's absolutely the case. You can be sued when you've done nothing

17:13

wrong at all. And most of these come down

17:17

to a radiologist being what they call the last

17:21

one at the table. So when they do a med mal proceeding, they will

17:25

typically run around and name every radiologist that had anything to do,

17:29

or every doctor that had anything to do with that patient.

17:33

And then one by one, they tend to settle out, come to an indemnity

17:37

agreement, and drop out of the case.

17:39

And defense lawyers absolutely abhor being

17:43

the, quote, "last one at the table." You're the one that's going to bear the brunt

17:47

of all testimony, and for that matter, any indemnity

17:51

that's handed down by a jury. So they're very reluctant to do that, and most

17:55

defense lawyers will simply settle out when you're the last one

17:59

standing. So that takes those 10 off the

18:02

table, and that leaves us with 35

18:06

cases of straight-up diagnostic error.

18:10

So let's pull those out

18:13

and look at the trends here.Bottom line

18:17

is this, there are three clear standouts in

18:21

terms of the pathology that was involved in all

18:25

of these cases. Epidural abscess, that's

18:28

spinal epidural abscess accounted

18:32

for three.

18:35

Aortic dissection accounted for four, and ischemic

18:39

bowel, usually due to superior mesenteric artery occlusion,

18:43

accounted for six. And if we look at that, it makes up

18:47

about 40% of our medical malpractice

18:51

expenditure, as well as about 40% in absolute

18:55

numbers. So those are the three,

18:58

I call them the big three, that we're going to focus on here.

19:04

Just quickly, we do a very robust QA

19:08

review. Our radiologists are over-read to the tune of about

19:11

10% practice-wide, and we have identified the things

19:15

most commonly missed. So large classes, fracture,

19:19

and mass nodule adenopathy, those are the most commonly missed

19:23

things. But if you look at more specific pathologies,

19:27

it's very clear. Intracranial hemorrhage and pulmonary

19:31

embolism are the big outliers. So I'm not going to run through all this

19:34

math, but I do want to point out that we then established what we call

19:38

the big five, the five pathologies that are

19:42

either most likely to convert to a medical malpractice case

19:46

or most frequently missed. So you see them here, aortic dissection,

19:50

spinal epidural abscess, superior mesenteric artery occlusion,

19:54

intracranial hemorrhage, and pulmonary embolism.

19:56

And by running the math on this, we can actually determine what is

20:00

the percentage likelihood of any given finding being

20:04

missed, what is the percentage likelihood that it converts to a medical

20:08

malpractice case when missed, and from that,

20:12

we can determine the actual cost to the practice for any given

20:15

miss.

20:18

We use that actually to direct our efforts in building AI

20:22

algorithms to identify pathologies.

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All right, so now we're on to the actual cases.

20:29

So let's look, I picked representative cases from each of

20:33

these pathologies, and so these are what we will look at.

20:38

And our first one is a spinal epidural abscess.

20:44

First movie of the day never runs well, so we'll give it another

20:49

shot here.

20:53

There we go.

20:55

All right. So the thing to note about spinal epidural

20:58

abscess is this.

21:00

In every case

21:02

of CT for spinal epidural abscess, there has been

21:06

another finding that should have tipped the

21:09

radiologist to the fact that there is an infectious process

21:13

in the neck.

21:15

Prevertebral edema, tonsillar abscess, or as in

21:19

this case, a septic facet joint.

21:24

So you can see on the axials, there are these little lobulated

21:28

fluid collections immediately adjacent to the facet joint there.

21:31

The facet joint was only a little bit degenerated. There was no erosion.

21:35

In fact, the bone windows were so unremarkable, I didn't bother

21:39

saving them. Right? But you can see related to that, there

21:43

is an enormous epidural fluid collection.

21:46

It's going to be in the posterior left aspect right here,

21:51

and there you can see it, that thickened dura and the displaced

21:55

cord anteriorly,

21:57

clearly present. And then let's go to the sagittals.

22:00

You can see again those lobulated fluid collections, and there

22:04

is the bulging epidural fluid collection right there.

22:09

All right. So here is the report. I religiously

22:13

duplicated all of the reports here.

22:16

These are the complete reports without correction of

22:19

typographical errors or any other such things. Right?

22:22

And I've just put in yellow the salient features.

22:26

So you can see the facet joint was called correctly.

22:30

Oh, there was a typo there.

22:33

Right? But basically, the epidural fluid

22:37

collection was not described. We have a grading system for our

22:40

reporting, a 10-point system where we just

22:45

actually randomly pull radiologist reports and give them grades.

22:48

We usually use this when they're first starting with us.

22:52

But I had every one of these reports reviewed

22:55

blindly by our medical directors and graded.

22:59

So this one only got dinged on structured reporting and was otherwise

23:03

a fairly high-scoring report, and that's obviously just report

23:06

content and not with specific reference to the accuracy

23:10

of image interpretation.

23:13

All right, so what happened with this patient? Well, they came in at 5:00 p.m.

23:17

with left upper extremity weakness and fever, and the CT was

23:20

interpreted as a paraspinal soft tissue abscess.

23:24

At 8:00 a.m., this was a preliminary study, so it was

23:28

over-read the next day by the finals reader on-site, and

23:32

they missed it again. And that's commonly the case with

23:36

prelim reading, and it gives me pause when we talk about

23:40

AI giving you an initial read because when I look at

23:44

prelims being over-read the next day, easily

23:47

50% of misses are missed a second time because of the

23:51

cognitive complacence of a radiologist reading in that

23:55

environment.

23:57

So by 10:00 p.m. the next day, the neuro symptoms had progressed, and this

24:01

patient went for a decompression surgery.

24:04

They are now a partial quadriplegic, wheelchair-bound.

24:08

The estimated verdict was $5.5 million.

24:11

That's what the defense counsel will generate based on a whole bunch of

24:15

inputs that we will get to. The chance of success was

24:19

deemed 60%.The apportioned liability,

24:23

usually determined by the counsel of both the plaintiff and

24:27

the defendant, as well as the judge in conference, will apportion

24:31

the liability. Any given indemnity that results will be

24:35

apportioned in those percentages to the involved physicians.

24:40

The estimated settlement was therefore 1.1 million.

24:44

They actually have a mathematical equation.

24:47

They invert the chance of success.

24:49

So you would call this 40% chance of a bad verdict, right?

24:53

And you multiply 40% by 40% apportioned

24:57

liability times the estimated verdict, and that will

25:01

generally render the estimated settlement of $1.1

25:04

million.

25:06

So the jury verdict came in at $14 million.

25:10

This was that one case, it was from Wisconsin, that should

25:14

never have gone to trial. In fact, I was in the conferences when

25:18

this was determined, and I was quite vocal about the fact

25:22

that there's a clear miss, there's a typo in the report.

25:25

There's a bad outcome. This should never have gone to

25:29

trial. So the doctor that pushed this through, I still refer

25:33

to him today as the $6 million man.

25:38

So there you go. Now, I did copy and paste

25:42

comments from depositions, and it gives you an idea as to

25:46

the way med mal lawyers think about these things.

25:50

The red text is stuff that's obviously not in favor of the

25:54

radiologist. The green text is things that are in

25:58

favor of the radiologist.

26:00

So you can see the trial judge ruled that VRAT, the radiologist's

26:03

agreement with this discrepancy inside the QA system was

26:07

admissible in court. And that is actually

26:11

a terrible judgment on the part of the judge

26:14

because that is not the case in the vast majority of

26:18

states. Only in Kentucky, and I believe Michigan is

26:22

working on it, are

26:24

internal QA proceedings actually disclosed or

26:28

discoverable in med mal proceedings.

26:32

Most states agree that internal quality assurance systems should be

26:36

separate from that, and in order to maintain the quality of

26:40

care, we ought to be able to objectively

26:44

look at any miss and handle it internally.

26:48

But this one judge came along and said, "No, I think it's okay." And as a result

26:52

of this, we actually changed the agreement

26:55

diction in our quality assurance system to be sure that that

26:59

will never happen again. The other thing you can do is establish a

27:03

national patient safety organization, a PSO,

27:08

that reviews internal quality data, and that provides significant

27:12

protection against disclosure or

27:15

discovery of quality assurance proceedings.

27:19

An unusual comment was made here that one of the experts opined that

27:23

total recovery, even with immediate diagnosis, would be an unreasonable

27:27

expectation. And that doesn't come up as often as you'd

27:31

like to think. In fact, there are many states that do

27:35

abide by the lost chance

27:39

doctrine, which means you don't get to say, "Oh, this patient

27:43

would have died anyway," or, "This outcome would have been terrible

27:46

anyway." It's called the lost chance doctrine.

27:49

If the patient had had a timely access to the appropriate

27:53

treatment, it is assumed, in most cases, and in most

27:57

states, that the treatment would have been successful.

28:00

And that's obviously a fever dream, but it is the case in

28:04

med mal proceedings.

28:07

All right, so that's our first spinal epidural abscess.

28:10

Our next one

28:12

is an MR. And this MR demonstrates what I

28:17

like to refer to as the reversal phenomenon,

28:21

where an MR, one of the series on your MR

28:25

is so abnormal that it looks normal.

28:29

So on the T1, just a little hint of high

28:33

signal right here in the anterior epidural space.

28:37

Not anything you'd probably call, unfortunately.

28:41

And here on the T2, it looks almost like it's an artifact, although you

28:45

can see a little cord signal there.

28:47

But let's go to the enhanced. When you go to a Gad-enhanced MR, you

28:51

need to note that mentally and think to yourself, I'm

28:55

reading a Gad-enhanced MR, which means fluid collections

29:00

should be low signal intensity,

29:03

including the CSF. Look at this. The

29:07

entire CSF is lighting up, all this patient's meninges.

29:11

This is way too much gadolinium enhancement.

29:14

In fact, there should be none.

29:16

But it's so extensive that it looks normal,

29:20

and by virtue of that, this enhancing fluid collection here in the

29:24

anterior epidural space was missed.

29:27

So let's look at those on cine.

29:32

Again, the reversal phenomenon. I see this with marrow,

29:35

diffuse marrow infiltration in widely metastatic

29:38

disease. The T1s will be dark, the T2s will

29:42

be bright, but so diffusely so

29:46

that people will mistake them for normal.

29:49

The last one is in neonatal brain MR for global

29:53

hypoxia or anoxia, global ischemic damage.

29:57

That can cause such widespread changes that you

30:01

may fall prey to this phenomenon there as well.

30:05

All right, so here is this patient's report.

30:08

You can even see in the clinical history, this patient was being evaluated for an

30:12

epidural abscess,

30:14

but it was clearly missed. And the thing that's amazing here is

30:18

this was an MR of the CT and L spine, as well

30:22

as brain MRs were done on this patient.

30:25

And all of them looked exactly like this enhanced one

30:28

here, where the entire CSF space lit

30:32

up.So very extensive infection.

30:36

So you can see this one got dinged just for structured reporting.

30:39

And actually now structured reporting is standard in our system, so

30:43

it wouldn't even have been dinged in modern days.

30:48

This patient came in at 12:00 a.m., left upper extremity

30:51

weakness, and the brain CT and L spine were all read as

30:55

normal.

30:57

It was a prelim, so the final read at 8:00 a.m.

31:00

the next morning, also normal.

31:04

It was discussed with the local neurosurgeon.

31:06

This patient was decompensating quickly and they

31:11

consulted a neurosurgeon who said, "You need to get this guy over to my hospital."

31:14

So he was transferred that night and had an epidural

31:18

abscess evacuated and the cord decompressed at that time.

31:23

The patient's now quadriplegic and wheelchair bound, spent a long

31:26

hospitalization with many complications.

31:29

The estimated verdict was between $9 and $10 million.

31:33

Chance of success, 50. Apportioned liability,

31:37

100%. That's fairly unusual for the

31:40

radiologist to bear the entire brunt of a potential

31:44

indemnity. In fact, out of the 45 cases I reviewed,

31:49

six had an apportioned liability of 100%.

31:52

So typically, they like to share the pain.

31:55

The estimated settlement came in at $2.25 million.

32:00

And as you can see, the indemnity that we ultimately paid was much, much

32:04

less than that.

32:06

So the plaintiff is an incomplete quadriplegic who requires total care.

32:12

The wife is his primary caregiver.

32:13

They've been married since '83, and a jury will like them.

32:17

So that's one of the things that lawyers do in these situations,

32:21

is they do a very thorough assessment of any potential witness,

32:25

and they include those evaluations in their reports of counsel.

32:28

So they will frequently talk about the credibility, the

32:31

believability, the compassion imparted by

32:35

given witnesses, whether that be the plaintiff or the radiologist.

32:40

They also do an in-depth evaluation of the

32:44

region and say, as in this case,

32:48

in general, the judges in Lake County are fair.

32:51

The juries tend to be conservative, made of middle-class workers, commuters to

32:55

parks, and retirees. So that factors heavily into

32:58

expected indemnities because the more

33:01

conservative locations tend to give lower

33:05

awards. And then lastly, what lawyers will do is

33:09

they will compare your given case to other

33:12

indemnities from that region of similar

33:16

pathologies. And you can see they were worried here because

33:20

adults who became paralyzed after spinal epidural

33:24

abscesses settled for large numbers

33:28

in similar cases.

33:30

So it was curious. This patient actually,

33:34

his job was he was the producer of documentary

33:38

Christian movies.

33:40

And I just wonder, was he one of those rare people that just practiced

33:44

what he preached? Because they only demanded the indemnity that would be

33:48

required for his ongoing care. And that's the reason there's such

33:52

disparity between the estimated settlement and the actual

33:56

indemnity that was paid. All right, so those are our

34:00

spinal epidural abscess cases. Let's move on to aortic

34:03

dissection.

34:05

Aortic dissection is similar to spinal epidural

34:09

abscess in that in every case of

34:13

aortic dissection that I saw that has gone to

34:16

MedMal, there have been other findings that

34:20

would clue you to the fact that there is an aortic

34:24

dissection present beyond just seeing the linear

34:27

intraluminal filling defect.

34:30

And in this case, that finding was the asymmetry of the

34:33

nephrograms. Those nephrograms are markedly

34:37

asymmetric. And when you see a delayed nephrogram like

34:40

that in a non-hydronephrotic kidney,

34:44

you have to suspect a vascular cause.

34:47

Either this patient is having a renal artery dissection or thrombosis,

34:51

or an aortic dissection,

34:54

that might either be involving the ostium of the renal

34:58

artery or might have thrown clot to the renal artery.

35:02

But when you see an asymmetric nephrogram like that,

35:06

you've got to start thinking something else is going on.

35:09

If that kidney happens to be hydronephrotic, certainly you can blame

35:13

it on obstruction. That will delay your nephrogram.

35:16

But in a non-hydronephrotic kidney, you've got to assume a

35:19

vascular cause.

35:22

All right, so this one is incredibly subtle.

35:26

The other thing I will say about the aortic dissection cases that I've seen,

35:30

of the four we had, there was only one

35:34

that was an appropriately protocoled and performed

35:38

study for the diagnosis of aortic

35:41

dissection, meaning it was in aortic phase, a

35:45

CTA of the chest with proper contrast bolusing, et

35:49

cetera. Right? In all the cases we're going to be looking at,

35:53

it's not an optimal study for aortic dissection.

35:56

So here's the warning. That's not a defense.

36:01

It doesn't matter. The radiologists go crazy over this.

36:05

They say, "Well, it's not a CTA. The contrast bolus wasn't

36:09

optimally timed. It was a study of the neck or a routine

36:13

of the abdomen pelvis, for that matter." Doesn't matter.

36:16

If the aorta is on the images, you need to look at it.

36:20

And I consider the aorta to be the greatest risk to any given

36:24

patient in both traumatic and atraumatic

36:28

cases. So look at that aorta every single time, and it does not

36:31

matter if the study was optimally protocoled to show you

36:36

an aortic dissection.

36:38

So an incrediblySubtle dissection here.

36:41

The more you look, the more you see, though.

36:43

It's basically on every single slice, and you can

36:47

even, once you start to appreciate it, see it waving in the

36:51

systolic breeze. And we'll look at a magnified view of that so

36:55

you can get a better idea of it. So in this one, I did

36:58

have to actually parse out some of the dictation because it

37:02

was so long. And that's another warning I have

37:06

for you. When you find yourself going on and on and on,

37:10

describing findings without attributing the appropriate

37:14

significance to them, stop yourself, because you are making

37:18

notes but not music.

37:21

And you're probably missing something in the big picture.

37:24

My dad was a lawyer, and his favorite phrase was, "The truth

37:28

is infinitely compressible." If you are looking at a

37:32

straightforward finding and you're attributing the right significance to it, you

37:36

get very succinct, if not laconic, in your description

37:40

of it. If you find yourself going on and on like this, something is

37:44

wrong. In fact, this radiologist still was

37:48

concerned over this, still dissatisfied, and so he went

37:52

and issued an addendum that's as verbose as

37:56

his initial report. But in all cases, he just doubles

38:00

down for some unknown reason on the left kidney being

38:04

the abnormal one, and it clearly is not.

38:08

All right, so we dinged him in a report review for not citing

38:12

comparisons and for hedging. That's the on and on phenomenon.

38:17

So this patient came in at 1:00 PM with left flank pain.

38:21

They did a routine contrasted abdomen pelvis CT,

38:25

and maybe the flank pain history is why the radiologist was

38:28

so concentrated on potential of a

38:32

stone or a recently passed stone. So this happened in the

38:36

week between Christmas and New Year's Eve, and therefore, no final

38:40

overread was even issued. And then the patient died about

38:43

36 hours later in front of his wife and small daughters

38:47

on New Year's Eve.

38:49

The estimated verdict was $5 to 7 million, chance of success,

38:53

60, apportioned liability only 25%,

38:57

and the estimated settlement came in at 5 to $700,000.

39:01

And as you can see, our indemnity was just slightly higher at 850.

39:06

So here is the mag view on that, and I'll let that run a couple

39:10

of times so you can see that flap

39:13

clearly present throughout the entirety of the

39:17

abdominal aorta.

39:23

So that's a scary one. But the fact that it's not protocoled for arterial

39:26

phase, that it's not thin-section for CTA,

39:30

not a defense. If it's present on the images, you are

39:34

going down for it.

39:37

So the deposition testimony, we had devastating

39:41

testimony from the wife and daughters. He was a perfect husband and father.

39:45

The damages were heavily weighted by lost wage and loss of

39:48

consortium. So loss of consortium used to be a legal

39:52

term that referred specifically to sexual congress, so

39:57

groin injuries and the like, where a patient could no longer

40:00

enjoy said with their

40:04

mate. That was what

40:07

loss of consortium typically used to mean.

40:09

Its definition has been broadened significantly

40:13

in previous decades to now include interpersonal

40:17

interaction of any kind, with family members, friends,

40:21

all of those sorts of things. So,

40:24

that is a significant change over time.

40:28

We did get a positive comment that there was an intelligence, experienced, and

40:32

well-spoken radiologist. You'd be surprised, or maybe not,

40:36

how infrequently you see that kind of thing.

40:39

And then lastly, New Hampshire is trending more toward plaintiffs but has

40:42

traditionally been the most conservative of the New England states.

40:45

I did my internal medicine at Dartmouth, and I can definitely tell you that

40:49

is the case. They are the live free or die state in New

40:53

England.

40:56

All right, let's look at another aortic dissection.

40:59

This is another one, and again, you'll see all of these cases

41:03

are not optimally protocoled or performed for the

41:06

identification of aortic dissection.

41:09

So this patient actually had a history of a

41:12

previous aortic laceration, which had been surgically

41:16

repaired. So kind of like a cat in having

41:20

multiple lives, although they clearly ran out at this

41:23

point.

41:25

So this is a non-contrast study of the neck.

41:29

And again, not optimal for aortic dissection, but you can

41:33

clearly see it. Even on the non-contrast, you can see it in the

41:36

ascending aorta. You can see it in the arch.

41:39

There's even some sub-intimal clot in the

41:43

posterior aspect of the arch right there.

41:47

So it is undoubtedly visible, even though it's clearly not an optimal

41:51

study. All right, so in terms of the report grade,

41:55

this got a 10 out of 10. I remember this radiologist very well.

41:59

She's retired now, but she was an outstanding

42:02

radiologist. And you can see her major miss

42:05

rate was about half that of the practice average.

42:10

All right, so this patient came in at 3:00 PM with neck

42:14

and jaw pain

42:16

and died at 2:00 AM before additional testing could be

42:20

performed.

42:22

The initial demand was $18 million.

42:26

Okay, so the initial demands in these cases, they come

42:30

in with the initial claim, a

42:33

declaration of intent to sue, and they will throw out

42:37

these crazy numbers. And radiologists call

42:41

me all the time and say, "Oh my god, there's an initial demand of $100

42:43

million."That never happens.

42:47

Sometimes a jury award will even be given on that level,

42:52

but it never actually comes to fruition.

42:54

You don't have a million dollars. The insurance companies don't have a million

42:58

dollars, $100 million, sorry.

43:01

And it really is all for show. And these initial

43:05

demands are just legal posturing to scare

43:08

everybody into submission. Right?

43:11

So, people ask me all the time, "How do I get medical malpractice

43:15

insurance to cover me for those 100 million runaway jury

43:18

verdicts?" And the answer is you can't.

43:21

You could never pay the premiums to get that level of coverage.

43:25

You're just going to have to take your licks when it comes to crazy

43:29

runaway jury verdicts like those.

43:31

And again, they rarely come to fruition.

43:33

Even if a jury hands down a verdict like that, it

43:37

generally gets negotiated down after that.

43:42

And I will add, your personal assets are never at risk.

43:46

That's what medical malpractice insurance is for.

43:50

So I've had older radiologists call and say, "Oh, I've got to retire now because

43:53

I'm afraid I'll be sued and lose my house." That never

43:57

happens. You have to literally be criminally, not just

44:01

negligent, but actually bent on the demise of your

44:05

patient to a criminal degree before your

44:08

personal assets are at any kind of risk in a medical

44:12

malpractice proceeding. Right? You have to be the kind of doctor that they

44:16

make miniseries about,

44:19

to get to that level. So don't worry about that, don't worry about

44:22

initial demands, and don't worry about runaway jury verdicts.

44:27

The bottom line is, no matter what the initial demand is,

44:31

that plaintiff is eventually going to come in at what's called a

44:35

policy limit demand, and that's what the settlement will

44:39

be for.

44:40

All right. So initial demand, crazy.

44:43

The estimated verdict, we put at $1 to $2 million.

44:47

Chance of success, 30. Apportioned liability was 60.

44:52

Financial indiscretion on the part of the plaintiff.

44:56

This

44:57

patient actually lived a profligate

45:01

lifestyle, had immense gambling debts,

45:05

and owned a house that was worth less than its mortgage.

45:10

And so due to his financial indiscretions, the judge

45:14

up front ruled that there would be a 25% reduction

45:18

in any indemnity given to him because for all

45:22

that the medical-legal system exists to

45:25

act as a safety net for the uninsured or under-insured, right,

45:29

patients with terrible outcomes, they tend to get awards even

45:33

if uninsured. Right?

45:36

Just because who else is going to pay for it? Right?

45:39

So I kind of almost like that about the medical

45:42

malpractice system, but I'm pleased also to see that it's not here

45:46

to pay off your gambling debts. Right?

45:48

So there is someone out there with a functioning brain and rational

45:52

thought.

45:53

The chance of surgical success was put at only 75% as

45:57

well. And again, this is somewhat rare to see that incorporated

46:01

into the reasoning, but it was nice to see.

46:04

Therefore, the estimated settlement came in at $4 to $500,000, and you can

46:08

see we ended up paying $400,000 here.

46:12

So the commentary from the deposition, the plaintiff family is incapable

46:16

of saving, mortgage value higher than house value, patient lifespan

46:20

adjusted down for smoking and obesity.

46:23

And that would reduce your indemnity because they base the indemnities

46:26

on your potential lost years of life and potential

46:30

earnings.

46:32

Surgical correction, again, at 75% likelihood.

46:35

The one interesting thing was the referring physicians did take

46:38

deposition shots at the radiologist, and one suggested

46:42

that a CT of the neck without contrast is a perfectly

46:46

adequate study for excluding aortic dissection.

46:49

So it's pretty clear people will say anything when being deposed,

46:54

and for the most part, the other doctors at the table are

46:58

not your friends.

47:02

All right. So our last aortic dissection.

47:05

Again, there are findings that should have triggered a

47:09

more intensive search for an aortic dissection.

47:12

You can see again, this is one that's not optimally protocoled.

47:16

This is a CTA for pulmonary embolism, so there's barely any

47:20

contrast in the aorta itself. But look at all the

47:24

additional findings you've got. There's prevascular

47:27

mediastinal stranding right there.

47:30

Clearly, you have to describe that.

47:32

There is disparate contrast density in that ascending

47:36

aorta. You can see there's a dissection there.

47:39

And there's a hyperdense pericardial fluid collection that can only

47:43

be a hemopericardium. If you see a pericardial fluid collection that

47:47

dense, you need to think hemopericardium, and you need to go look at the

47:51

aorta because aortic dissections that get down to the root,

47:55

they're within the pericardial sac due to the high extension of the

47:59

superior pericardial recess. So it's a common complication

48:03

of aortic dissection that you'll get a hemopericardium, and all of

48:07

these findings should have triggered these thoughts in the radiologist's

48:10

mind. You can even see there's probably early tamponade

48:14

because you've got so much IVC and hepatic venous backflow here.

48:19

All right. So this was read as a small to moderate pericardial

48:22

effusion

48:24

and nothing else. Got a nine out of ten, failing only on

48:28

recommendations for follow-up.

48:32

So this patient came to the ER with chest pain.

48:36

A CT of the neck was performed 10 days later for neuro

48:39

symptoms at which the dissection was identified, but the

48:43

patient could not be saved. They did operate, but he died

48:47

post-operativelySo the initial demand, again, over the

48:51

top, $9 million. The estimated verdict came in at $5

48:55

million with a chance of success being 40, apportion

48:59

liability of 45.

49:01

The estimated settlement therefore came in at $1 million.

49:04

So we had a demand on the table for $1.4 million

49:09

and our defense counsel, actually the

49:12

ill-advised parent company, had said, "We're going to the

49:16

mattresses on this. We want to defend it." And

49:20

I, of course, was vocal in opposition to that,

49:24

but I remember very well, I had my bags packed.

49:27

I was flying to Santa Fe at 6:00 a.m.

49:31

the next morning, and I got a call at 5:30 a.m.

49:35

and they said, "Cancel your flight.

49:36

We settled." So that's known as settling on the courthouse

49:40

steps, and it's a frequent occurrence.

49:43

So I was all ready to go

49:46

in spite of my better judgment.

49:49

All right. So the findings were missed repeatedly on multiple

49:53

studies, and asymmetric pulses were noted on clinical exam.

49:57

The finding was missed by the defendant's expert, so that's

50:01

always helpful. The defendant's surgical expert, again,

50:04

unusually predicted a 25% to 40% operative

50:08

mortality.

50:09

The opposing counsel is established, well-respected, and successful.

50:14

I actually was deposed by this guy, and I have to say that is a very

50:17

accurate description. He was a silver fox, and

50:21

he actually brought home to me the important rule of

50:25

depositions, which is answer the question and do not go on

50:29

and on. And I, at this point, was pretty well

50:33

coached up for depositions, so I would answer the question and stop.

50:37

One sentence is what you should limit yourself to when answering

50:41

deposition questions. And every time I stopped talking,

50:45

he would go like this. And it was clear he was used to

50:48

drawing out more self-indictment from witnesses.

50:52

And it really brought home to me the

50:56

quality of the coaching I had received, which was just answer the question and no

51:00

more.

51:01

The radiologist acknowledged the error and was a reluctant witness.

51:04

This brings up an important point.

51:07

I have radiologists screaming at me all the time saying,

51:11

"I did nothing wrong. It was the wrong study. It was the wrong protocol.

51:14

It had no contrast. They didn't give me reformats," whatever the

51:18

case may be. They always want to go to trial.

51:22

It's professional pride, personal pride, what have you.

51:25

They always want to go to trial. But you saw the numbers.

51:28

Going to trial is exceedingly rare, and it's not going to

51:32

happen if there's the slightest incongruity in

51:36

the whole

51:38

case.

51:39

So you really, interestingly, that's

51:43

not a right of the radiologist to demand that it go to

51:46

trial. In most medical malpractice insurance agreements,

51:50

it's the insurance company that gets to determine the final

51:54

outcome as to whether or not it's settled or goes to trial.

51:57

The radiologist has no voice in that matter whatsoever.

52:01

So most of these people are just screaming into the void because

52:05

it's not a right that they actually have.

52:08

So you don't have the right to insist that your case go to

52:12

trial. However,

52:15

if you want to make it so that your case does not go to trial,

52:20

that's easy. You can sandbag it. You can go into your deposition and

52:24

say, "There it is. I see it now. I should have seen it.

52:27

It's present on the images." If you go in and do that,

52:31

they're never going to take it to trial.

52:33

They're not going to put that radiologist on the stand. Okay?

52:37

So you don't have the right to force trial, but you

52:41

can, through your own efforts, or just honesty for that matter,

52:45

make it so that your case never goes to trial.

52:51

All right. Let's look at a couple ischemic bowels.

52:53

They break down into two basic groups,

52:57

bariatric surgery

52:59

and thromboembolism. Okay? So in

53:02

bariatric surgeries, here is my advice.

53:05

Whenever you see those gastric staples,

53:08

make sure that that study is done with oral and intravenous contrast.

53:13

In this particular case I'm showing, intravenous contrast would've been the

53:16

telltale

53:18

act that would've made this diagnosable.

53:21

But the bariatric surgery patients, they tend to

53:25

obstruct and perforate and have staple line dehiscence, and on and

53:29

on. The list of complications is massive.

53:32

And so oral and intravenous contrast for every one of

53:36

these patients, and make it a hard and fast recommendation.

53:41

So you can see here, actually, this radiologist actually

53:44

complained in his deposition that, "Oh, well, they didn't say anything about a

53:48

history of bariatric surgery." Well, don't say that.

53:51

You'll sound like an idiot. It's very clear that there are gastric

53:55

staples here, and the previous history of bariatric

53:59

surgery could not be more obvious.

54:02

All right. So no evidence of bowel obstruction, et cetera.

54:06

No description of the potential for mesenteric

54:10

volvulus and ischemic damage. I want to also point out here,

54:14

masses in the solid abdominal organs can be missed without intravenous

54:18

contrast. Boilerplate disclaimers are worthless.

54:22

Something like that does you no good whatsoever.

54:26

So if you're throwing those out, "Oh, acute ischemic changes can't be

54:29

identified in 24 to 48 hours on a non-contrast head CT."

54:34

Worthless. It's worthless. Nobody will ever point at that and say,

54:37

"Oh, but this disclaimer should get our radiologist off."

54:41

The reason it's worthless is you don't make a specific

54:44

recommendation. Okay? If you really feel like the

54:48

lack of intravenous contrast is hampering your diagnostic

54:52

accuracy, then you have to sayI recommend this

54:56

study be repeated with oral and intravenous contrast.

54:59

If you put that in, that holds up. If you make a

55:03

specific recommendation that the referring clinician does not carry through

55:07

with, that will aid in your defense.

55:12

All right. So this is a swirl sign, is the bottom line.

55:15

And when we talk swirl sign, we don't mean bowel, we mean vessels.

55:20

Right? And the swirl sign, look at them spinning over one another there,

55:24

is probably the most specific finding in

55:27

post-bariatric patients for vascular compromise.

55:32

So it's a very important finding to make.

55:35

This report did not do very well,

55:37

didn't address clinical concern, full of disclaimers, didn't have

55:41

recommendations. See the intelligence behind our grading system.

55:45

All right, so this patient came in with severe abdominal pain.

55:48

Read as no bowel obstruction. Returned three days later

55:52

with necrotic bowel requiring excision.

55:55

Hospitalized for six weeks. Now has short gut and is

55:59

TPN dependent. And that's why abdominal pelvic

56:03

CT scan,

56:05

medical malpractice indemnities are so expensive.

56:07

These patients,

56:09

they're usually younger. They end up with needs for long-term

56:13

care that are extremely expensive.

56:16

Estimated verdict, $5 to 10 million. Chance of success, 40%.

56:20

Lots of people named, six defendants, so apportioned liability was only

56:24

17%, and the estimated verdict came in at 500 to

56:28

1 million. They were way low because this indemnity ultimately

56:32

was 1.3 million.

56:35

So in our favor, the discharge summary was cut and pasted,

56:39

giving the impression of inattention by the hospitalist.

56:42

The referring was a bit evasive and did not make a great appearance

56:46

as a witness. Too bad. They can drag you down even if

56:51

it's not your own testimony that was suboptimal.

56:57

All right.

56:58

Our last one, thromboembolism. In thromboembolism cases,

57:02

yet again, there's always an indication that thromboembolism has

57:06

occurred, usually in the form of a wedge-shaped, hypodense,

57:10

subcapsular kidney or splenic lesion. Right?

57:15

So you guys saw my trauma lecture before.

57:17

When you see those in a trauma, go find the vessel laceration that caused

57:21

it. When you see them in a non-trauma,

57:25

look at the superior mesenteric artery because this patient had

57:29

an upstream, either aortic or cardiac source,

57:32

thromboembolic shower.

57:35

And so when you see these lesions in the kidney or

57:38

spleen, you need to go and look at the SMA because the SMA

57:42

is a magnet for thromboembolism. It's got the right

57:46

orientation, it's aided by gravity, it's high flow, and the

57:50

consequences of acute occlusion of the SMA are

57:53

devastating. And you can see it right here.

57:57

Right? But there are the renal lesions that should have been called.

58:02

So look at this report. Talk about going on and

58:05

on and on.

58:08

Notes but no music. Look at that. It just

58:12

doesn't seem to end. In fact, it never does because

58:16

this radiologist ended his report with the word et

58:19

cetera, the abbreviation, et cetera. Can you believe it?

58:22

As though that hadn't been enough.

58:25

So this was a prelim, and the next day,

58:28

so this got the lowest score of five out of 10.

58:31

Bad typos, no structure, no comparisons, plenty

58:35

of hedging, and lots of disclaimers.

58:38

So the next day, the on-site clinician comes in

58:42

and issues a similar final report and misses all the same

58:46

relevant findings. I think these two should probably share a

58:50

jail cell.

58:53

And look at that. As a last thought, a parting shot,

58:57

he says, "Oh, there are a couple wedge-shaped areas of diminished profusion,"

59:01

diffusion, or sorry, profusion, "but suggestive of

59:05

small infarcts." Well, he failed to put it all together.

59:08

Failed to look at the SMA even after saying something like that.

59:13

All right, so this patient came in for a hernia repair.

59:17

The final read did note the renal abnormalities, but not the SMA.

59:21

She was treated for a post-op myocardial infarct.

59:24

Two additional CTs failed to identify it, and

59:28

finally,

59:30

an emergency laparotomy revealed ischemic bowel.

59:33

So the estimated verdict was 1.5, chance of success 51,

59:37

apportioned liability 25%, and the estimated settlement,

59:42

625 global, of which we ended up paying 200.

59:47

So this matter is

59:49

in a rural area in Illinois. The rural aspects of Illinois tend

59:53

to be conservative. The decedent worked at Sunset Lakes

59:57

Resort. She was paid in cash and credit toward discounted camping

60:01

costs. It's really kind of sad, but they look at your

60:05

earnings, and they actually compute how much lost

60:09

life you had and how much you would likely have earned during that time,

60:13

and that's how they partially calculate these indemnities.

60:16

And she also worked as a Mary Kay cosmetics consultant, which we all know is a

60:20

pyramid scheme.

60:23

All right, so multiple people actually missed this,

60:26

and then the only negative aspect is the plaintiff's expert apparently did

60:30

identify it.

60:33

All right, so that is our run-through.

60:35

I do want to run our takeaways. There's our 35

60:39

diagnostic errors,

60:42

and in the 10 communication issues.

60:48

Ah, here we go. Here are our takeaways.

60:51

So what did we learn?

60:54

Always communicate critical findings through multiple channels.

60:57

You need to call on critical findings, and the example of lobar

61:01

pneumonia, I think is the most important thereDo

61:05

not rely on preliminary status of a read as any kind of defense.

61:09

Half of the time, the next guy is going to miss it too.

61:13

Get oral and IV contrast on all post-bariatric

61:16

surgeries.

61:18

Beware that long and rambling report, an indication you've

61:22

made multiple findings but aren't putting things together into a unifying

61:26

diagnosis. Beware that total reversal phenomena,

61:31

meningitis in the spine, marrow

61:34

infiltration on MSK studies, global

61:37

hypoxia in neonates. Those are the MR studies that tend to

61:41

do that to you.

61:44

Job one is the aorta. Evaluate the aorta vigilantly, no matter what the

61:48

circumstances. Contrast, non-contrast, CTA, routine,

61:52

neck, abdomen, whatever it is. If the aorta is on your

61:55

images, you need to look at it, and carefully.

61:59

All right. And lastly, adhere to your established anatomic search pattern for

62:03

every procedure type. I can't emphasize this enough.

62:07

I spent a decade on the VRAD Quality Assurance Committee, and I came

62:11

away fully convinced that 90% of all

62:14

radiologic error is due to failure to adhere to an

62:18

established, methodical, regimented, repeatable

62:22

search pattern. So that's how you should proceed with every one of

62:25

these cases that you read.

62:28

All right, folks, I will stop there, and we may have a little time for

62:32

questions, so I'll turn things back over to Ashley.

62:36

Awesome. Thank you so much for that really in-depth and informative

62:40

lecture, Dr. Strong. We have a question in the Q&A

62:44

box and then a couple in the chat that I can

62:48

read to you if you'd like.

62:49

Sure.

62:50

All right, so there's one. Let me see.

62:54

"How

62:59

do juries justify and work

63:02

out giving such high amounts, such as tens of millions?"

63:07

Pulling at their heartstrings.

63:09

Perfect.

63:10

The simple answer there. We go in with very objective assessments.

63:14

In fact, I often joke that it's the only productive work

63:18

economists are ever called on to perform.

63:21

Mostly, they just theorize and are wrong.

63:25

But the one actual job they do is they come in on these medical

63:29

malpractice cases and they calculate lost earnings.

63:32

They calculate from actuarial data what the likely lifespan

63:36

of that patient would've been, what their earnings would've been, what their

63:40

investment returns might've been, and that is a big part

63:44

of how they calculate the actual

63:47

indemnities. But the plaintiff lawyers

63:51

try and escalate that, take that to a much higher level

63:54

by emotional appeals, basically.

63:57

Pain and suffering, loss of consortium.

64:00

Those are all things that are harder to quantify, and

64:03

therefore, they're the ones that the plaintiff attorneys like to play with the

64:07

most.

64:09

Great answer.

64:11

Any advice for pediatric radiology?

64:14

Oof. Get out.

64:17

Pediatric radiology is a particular risk.

64:20

They are the obstetricians of

64:24

radiology.

64:26

Because any pediatric case, typically,

64:31

most states have a two-year statute of limitations, two years from the

64:35

time either that the event occurred or the time that the patient was

64:38

aware that the malpractice occurred. That varies state by state.

64:43

But for pediatrics,

64:46

that two-year statute of limitations begins at the

64:50

time the patient turns 18. And so,

64:54

I guess, be all the more vigilant because your risk is far

64:58

greater. There's no doubt.

65:02

Another great answer. Can you clarify more regarding the disclaimers?

65:07

For example, stroke cannot be ruled out on CT, as this is a clinical diagnosis.

65:11

Is there genuinely no role for them?

65:13

Yeah. They are not helpful. The only role

65:17

I see for disclaimers like that are basically to

65:21

help with the education of mid-level providers.

65:26

We've got a lot more nurse practitioners, physicians assistants

65:30

working in the role of the referring clinician, and they're

65:34

not as steeped in medical knowledge, and especially around issues

65:38

like this, that a stroke can be negative for 24, 48 hours on

65:42

a CT scan. They don't necessarily know those things.

65:45

So it depends on the referring clinician population that you're working with.

65:50

That might be helpful here and there to say, "Hey, by

65:54

the way, you're not going to see an acute stroke on a head CT without

65:58

contrast."

65:59

That's the only way that I see them being helpful.

66:02

And ultimately, you could argue, if you avoid a

66:06

devastating outcome, you're probably going to avoid a

66:10

medical malpractice case. You may have noticed you wouldn't want to switch

66:14

places with any of these patients in spite of the

66:17

relatively large indemnities that were awarded.

66:22

There is a devastating outcome. It's almost a prerequisite for there

66:26

being a med mal case of any size. And so

66:30

anything you can do to avoid that devastating outcome, just by

66:34

definition, will reduce your medical malpractice risk.

66:37

So if you're dealing with mid-level providers and they probably need a little

66:41

additional education on certain aspects of

66:45

imaging sensitivity or specificity, if you're using it in that

66:48

capacity, fine. That makes perfect sense to me.

66:52

However, I see people pointing at those disclaimers all the time and saying,

66:56

"But I have that disclaimer." Again, if it's not associated with

67:00

a specific recommendation, it is worthless in the

67:04

med mal world.

67:07

Great. Thank you so much for answering that. I think we'll wrap there.

67:11

So we appreciate you coming back on and doing this really

67:15

in-depth review.

67:18

Absolutely. It was a pleasure to be here as always, Ashley.

67:21

Yeah.

67:21

And a pleasure to see you and Ben, and I look forward to next time.

67:25

Thank you so much. And thank you for everyone else for participating in today's

67:29

noon conference. You can access the recording of today's

67:32

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67:36

also email out a link to the replay later today.

67:39

Be sure to join us next week on Thursday, April 23rd at 12:00 PM Eastern,

67:43

where we will replay Dr. Steven Pomeranz's lecture, MRI of the

67:47

Hip. You can register for that at medality.com.

67:50

Follow us on social media for updates on future noon conferences.

67:53

Thanks again for learning with us, and have a great day.