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Hello and welcome to Noon Conference, hosted by Modality

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Noon Conference connects the global radiology community

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through free live educational webinars that are accessible

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for all and is an opportunity

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to learn alongside top radiologists from around the world.

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Today we are honored to welcome Dr.

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Magic Khan for a lecture entitled,

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understanding Medical Malpractice Lessons From Serving As an

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expert witness, Dr.

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Conn completed his radiology residency at NUMC Stony Brook

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University and subspecialty training in neuroradiology at

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Johns Hopkins, where he's presently on the neuroradiology

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and interventional radiology staff.

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He's a nationally and internationally recognized expert in

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spine tumor ablation

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and spine cement augmentation procedures,

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and has published extensively in these areas.

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At the end of his lecture, please join him in a q

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and a session where he will address questions you may

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have on today's topic.

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Please remember to use that q

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

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as many as we can before our time is up.

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

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Kahn, please take it from here.

1:05

Thank you very much. Really appreciate that.

1:08

Okay, let's get going.

1:12

So, I, I, I don't profess to be a real expert, uh, in this,

1:16

but I have, I've been, uh, as an expert witness in a number

1:21

of cases, and so I'm gonna share my experience with you, uh,

1:25

things that I have learned

1:26

and hopefully can help you also, uh, if you really want

1:31

to become an expert witness.

1:35

Okay, so these are my disclosures.

1:39

So why do we really need

1:40

to understand the medical malpractice?

1:43

Uh, it's, it's very important

1:46

because most of the time, the many radiologists

1:51

first foray into this legal world is when they get certain

1:55

notice, uh, of, uh, of a claim.

1:59

And a recent study had shown that

2:02

although radiologists do know

2:05

a good bit about the medical malpractice scenario,

2:08

but they are still, 92%

2:10

of the radiologists are very surprised when they are served,

2:14

uh, a notice.

2:16

And, and radiologists do under underestimate their risks,

2:20

uh, especially in this day

2:22

and age when our work volumes are significantly increasing

2:27

and hence, our error rates will also be increasing, which

2:32

we may or may not be, uh, aware of.

2:36

But definitely it's, it's, it's proportional.

2:39

If we are reading many, many studies, definitely our,

2:42

our error rates are also bound to go high.

2:47

Uh, the other thing is

2:48

that we don't really teach our trainees about the medical

2:52

malpractice scenarios.

2:53

Uh, uh, there, there's absolutely no training that we

2:58

let them have in these four

3:00

or five years of radiology residency.

3:03

Uh, and then once a lawsuit does happen, our trainees,

3:08

be it fellows or, or our residents, are really protected

3:12

by the supervising physicians, by the doctrine

3:15

of the respondent, uh, superior.

3:17

Let the master, uh, answer the question.

3:20

So, so what that means is that most

3:23

of our younger radiologists are getting into the workforce

3:27

with an incomplete appreciation of the medical-legal hazards

3:32

that are associated with their, uh, radiology practice.

3:39

So this is a recollection by a radiologist

3:43

who was sued for the first time in the career.

3:46

And, and, and what I'm going to tell you is, is I,

3:49

I got in touch with, uh, that person,

3:52

and this is verbatim that he told me

3:57

and wanted me to share with all of you as to what happened,

4:01

uh, during the course of the lawsuit

4:04

that he was involved in.

4:06

So, uh, it went like this. He got, it gets an email.

4:11

The subject line is medical legal, uh, negligence claim,

4:15

and its cases from six years ago from, uh, the lawyers,

4:20

uh, that were involved in the case from the

4:22

plaintiff's side.

4:23

So he said that he started to feel nauseous right away

4:27

as he was reading that letter

4:29

and just wanted to run away from the hospital

4:32

as fast as he could.

4:34

Uh, his, his bowel stopped working.

4:37

I don't know what that's really supposed to mean.

4:40

Uh, so the next thing he does, so the next day he did not go

4:45

to the hospital because he was so depressed

4:47

that he didn't want to come out of the bed

4:49

and continuously kept on thinking about, uh,

4:53

this, this case.

4:56

Uh, but the day after he goes to the case manager

4:59

and the risk management in his, uh, hospital,

5:02

and they ask him that, do you remember the case?

5:05

And they said, asked him what the,

5:08

my mental state was in the last couple

5:11

of days since this notice was, uh, served to him,

5:15

and did he wake up 3:00 AM worried about this case,

5:18

and did he have any self doubts about his ability, um,

5:23

to be, uh, radiologist?

5:25

And, and most of the answers were yes, uh, yes,

5:29

because that's exactly what happens when you, when you get

5:33

that letter first time in, in your hands, that you,

5:36

you start to have self doubts about your ability to being,

5:41

uh, being a radiologist.

5:42

And, and because we sometimes hold our, we most

5:45

of the times hold to a very high standard of care.

5:51

So the case goes like this.

5:52

It's a 46-year-old with upper arm radiculopathy.

5:56

The scan was ordered by a neurologist, and here is the scan.

6:01

Uh, and these are images from the real scan that was shown.

6:04

And as you can see that there is, uh, C five six, uh,

6:08

moderate to severe cord compression,

6:10

depending upon whether you are under color and over color.

6:13

There is some cord signal abnormality there.

6:16

And of course, there is some foraminal stenosis, again,

6:19

moderate to severe based on, uh, what your preference is.

6:23

But the point is that there is good bit of cord compression

6:27

and good bit of foraminal stenosis responsible

6:29

for this patient's, uh, upper arm radiculopathy.

6:34

So reported moderate cord compression

6:37

with mild focal edema at C five six.

6:40

No one, no one can challenge that.

6:43

The accuracy of the report was never in the

6:45

dispute In this case.

6:47

Uh, patient was had bad outcome

6:51

as surgery was delayed for about six months from the time

6:56

that the MR was, uh, opined on

7:01

and, uh, the whole case

7:05

against the radiologist.

7:06

There were other people also in the case,

7:08

but against the radiologist, it was attributed to the fact

7:12

that the report was not called through

7:15

to the ordering physician,

7:18

and it was the, an type report,

7:20

or I mean, uh, type report scanned on a Friday,

7:24

reported on Saturday, and the fax was delivered

7:27

on on Monday.

7:31

Uh, so when the co uh, the case went, uh,

7:35

and was discussed upon,

7:37

and the plaintiff had their medical legal expert opine on

7:41

the case, the medical legal expert on the side said that

7:47

based on what he

7:49

or she is seeing, uh, this non-routine communication

7:54

of the finding, the doctor,

7:56

referring doctor should have been, uh, called

8:00

and should have been made aware of

8:02

because this is a significant, uh, finding.

8:07

So that was the, and, and that's

8:08

what brought the case into the legal foray,

8:11

and it was pursued upon based on, on that fact.

8:15

Uh, now the defendant, medical-legal experts, both radiology

8:20

as well as neurosurgery,

8:21

and actually three neurosurgeons were sought.

8:24

Uh, and, and, and,

8:26

and all of them had this clear impression that, okay, the,

8:30

the, the, the scan was read the way it should have been

8:34

read, uh,

8:36

and all the three neurosurgery, uh, neurosurgeons opined

8:40

that this is not something

8:43

that they would expect a phone call from the

8:46

neuroradiologist or for that matter, a general radiologist

8:49

who is reading the case,

8:50

because this is an ongoing chronic process,

8:54

and it will gradually worsen with, with time.

8:57

So there was no acute injury that need to be called out at

9:02

that at that time point.

9:04

So, uh, but nonetheless, the ca case, uh, went to deposition

9:09

and all the remos that are involved with, with the case.

9:13

But finally, the final opinion for the radiologist was

9:15

that the radiologist was, was dropped from the case

9:18

because, uh, the, actually the neurosurgeon

9:21

who ended up doing surgery also said the same thing that,

9:25

uh, it's not, it's not usual for them

9:28

to get a phone call from, uh, the radiologist, uh,

9:32

about, uh, such a case.

9:33

So, but nonetheless, it took about 3.5 years

9:39

from the start to finish with the radiology where the, this,

9:42

uh, radiologist have was, was withdrawn from the case.

9:46

Imagine the physical and mental anguish

9:49

and many sleepless nights and anxious days.

9:51

This is, these are, hi, the exact words

9:54

that the radiologist shared with me that he went through

9:57

during all this time.

9:58

And the self-doubt he had, didn't, didn't, couldn't talk

10:03

with most of, most of the people that were

10:05

around him, his friends.

10:06

And because obviously you can't talk

10:09

to your colleagues in radiology.

10:11

So, uh, even though the case had favorable result

10:15

for the radiologist,

10:16

but 3.5 years he had to go through this.

10:19

So you can, you can well imagine the toll

10:22

that a case such as this can take.

10:24

And in this, in this case, I, I feel

10:27

that the medical-legal expert

10:30

opinion was not really objective.

10:33

And, and,

10:35

and the, the, the, the point that he was trying to make,

10:38

that this type of finding should be called,

10:40

if this happens in real world

10:42

and all of, I'm pretty sure all of you have seen cases such

10:46

as this, if we start doing this, we'll be probably making 10

10:49

to 12 phone calls a day, uh,

10:51

to our neurosurgery colleagues about such cases, and, and,

10:55

and, and they will not even want

10:56

to pick up our phone after that.

10:58

So, so I think there was a slight deviation from the

11:01

standard of clinical care when it was suggested

11:04

that such phone calls should be, should be, uh, made.

11:08

And, and we'll, we'll talk about the medical-legal expert,

11:12

uh, duty, uh, later on in this talk.

11:18

So let's do some numbers.

11:19

Of course, we know that litigation is very,

11:21

very pervasive as such.

11:24

But overall, according to a study that was published in a m,

11:27

a, 52% of radiologists over the age

11:31

of 55 have been named in a medical mal practice lawsuit.

11:35

So it's, it's not uncommon, as you can see,

11:37

one in two will have, uh,

11:39

at least being named in a, in a lawsuit.

11:43

Uh, radiology is right in the middle of,

11:47

uh, middle of the lot.

11:48

We are lower than proceduralist or surgeons,

11:51

but we are definitely higher than the primary care

11:54

specialties in, in, in, in medicine.

11:58

So what are the outcomes of these lawsuits

12:02

that happen in radiology?

12:03

So 63% are abandoned or dismissed right away

12:08

after the initial, uh, investigation.

12:11

28% of the lawsuits end up in settlements

12:16

outside, uh, the court, 5% actually proceed to trial.

12:21

And, and of those 89%, so overwhelmingly,

12:25

they are in favor of the radiologists, then the,

12:28

then the plaintiffs, uh,

12:31

and then there has been a significant decline in the number

12:35

of, uh, medical mal, uh, malpractice litigation

12:38

with 55% drop, uh, up to 2014, as was,

12:43

uh, seen in this study.

12:44

And the reason for that is really multifactorial.

12:47

There is increase in defensive medicine that has happened,

12:51

which has definitely caused a decrease in the litigations.

12:56

Uh, hospitals

12:58

and departments have come up with better communication

13:01

and resolution programs.

13:03

So that's very, very helpful.

13:05

Many states have taught reforms, uh, and,

13:08

and that has prevented some lawyers to go

13:13

after, uh, small cases, uh,

13:16

which they were going after before.

13:19

And then overall improved.

13:20

Uh, patient safety measures have been put in place, which,

13:23

which have led to decrease in this, uh,

13:26

number, oops.

13:30

So this is just giving you a history of radiology

13:34

and litigation as such.

13:36

I found it very interesting that in 1915, uh,

13:40

the x-rays were first done, and right

13:43

after that, now that we had, we were saving,

13:46

archiving those x-rays, uh, medical mal practice,

13:50

radiology lawsuits, uh, uh, peaked.

13:55

And then up to 1970, there was, there was significant

14:00

skyrocketing of these mal practice cases.

14:02

And then that's when defensive medicine,

14:05

especially when it came to radiology, uh, was, was came,

14:10

was the birth of it.

14:11

Then about 50 years later, then in 1980s,

14:16

trauma and fractures became, uh, a very common source

14:20

for mal practice litigation.

14:22

And then in 1990s, up to right now, one

14:26

of the biggest areas of medical,

14:29

of mal practice litigation in radiology are cancers.

14:32

And of this breast and lung are probably, uh, way up there

14:36

because we, no lung nodules are missed,

14:39

which turn our a year later into,

14:41

into spiculated mass masses

14:43

or these small punctate calcification are missed on a

14:47

mammogram that turned out

14:48

to be a year later into breast masses.

14:50

So those are two, uh, very important or,

14:52

and common cancers in, uh, in which, uh,

14:55

the litigations are quite common.

14:58

And then, uh, in 2010 to 2015,

15:02

we had some hospitals have issues with radiation, do doses,

15:06

especially while, uh, performing interventional procedures

15:10

or neuro IR procedures.

15:12

Some, uh, hospitals had some faulty equipment that also led

15:16

to, uh, medical malpractice, uh, lawsuits, which is also one

15:21

of the common reasons, as you will see in a little bit.

15:25

So let's, let me go over quickly the medical, uh,

15:30

lawsuit steps.

15:32

So once an alleged injury has been discovered,

15:36

what happens after that?

15:38

So there is filing of the lawsuit

15:41

after it has been discussed by the plaintiff

15:43

and the plaintiff lawyers.

15:46

And at that time point also, as they are discussing this

15:50

amongst themself without having served, uh,

15:54

the responsible physician, uh, they, they,

15:58

they make a judgment whether they should proceed or not.

16:01

So it can be definitely dropped or dismissed at that point.

16:05

But once they decide to go on, then the defendant,

16:08

which would be a radiologist in this case, is, is served,

16:14

uh, above with the notice that, uh, there is a intent,

16:17

uh, for, for this.

16:20

And at that point, the defendant talks

16:23

with the risk management in the hospital

16:26

or in, in, in the practice they are in and, and,

16:29

and alerts the, uh,

16:31

lawyers at the hospital about, about the case.

16:35

Then, uh, there's a talk amongst them.

16:39

Now, the defendant lawyers, the risk management

16:42

and the responsible person about the response to the case.

16:46

If the response is not really good, if there is something

16:49

that cannot be really defended upon, obviously it'll go

16:52

to a default judgment.

16:54

But if the response is yes,

16:57

and they're going to pursue further, uh, the case at

17:01

that point, also

17:02

after discussion with the plaintiff's lawyer,

17:05

the case can be completely dropped.

17:07

Or at that point, they'll say, yes,

17:10

the mistake has been made,

17:11

and it, it's, it's quite clearly a mistake.

17:13

And this can be settled

17:14

and agreed upon at that point also, uh,

17:18

if they want to go still further.

17:22

And then the phase of bringing all the imaging,

17:26

the patient charts

17:27

where whichever hospital the patient was at,

17:30

all those documents are, are obtained.

17:32

And then review.

17:33

This is the point where the medical, uh,

17:35

legal experts come into play from the plaintiff's sides,

17:39

from the, from the defendant's side, depositions are done.

17:43

And at that point also there, uh, there can be two scenarios

17:47

that it could be dismissed

17:48

and dropped, uh, based on all the discussions

17:51

and everything, or they can settle outside of court, uh, at

17:55

that point also.

17:56

Next would be that if, if none of these can be,

17:59

can be obtained among mutual agreement,

18:02

then the case obviously goes to trial.

18:05

And then at that point, also, these two,

18:08

they can be dismissed, drop or settled outside of the court.

18:11

But once, uh, it goes toward it, you can have a defense win,

18:14

or, and you can have a plaintiff win.

18:17

And overall, if you look at the numbers again,

18:21

63% are dropped or dismissed.

18:23

So that's a very high number.

18:25

Uh, 28% are settled outside of the court,

18:30

five to 6% go to trial.

18:32

And of that, about 5% is a defense win,

18:36

and 1% is, uh, plaintiff win.

18:39

So, so just from these statistical numbers, you can,

18:43

you can realize that lawyers really do not want the

18:47

case to go to trial, uh,

18:50

because they know that they do not have,

18:52

statistically speaking, they do not have a good chance

18:55

of winning, winning, winning this.

18:56

So most of the time, and that's the reason that, uh,

18:59

28% settlement is a very, very high number compared to

19:03

that 1%, uh, that they get out of, uh, from the judge at,

19:08

at, at the wording.

19:10

Uh, and, and, and another another thing

19:12

to realize from this is that we do talk about lawyers

19:16

that they do this and they do that,

19:17

but really they only want to put their time

19:22

and money in, in a case, which is totally legit.

19:25

It's not, it's not good for them to take a case just

19:28

for the sake of taking the case.

19:30

So keep keep that in mind also.

19:34

So, uh, when it comes to the medical liability formula,

19:38

there are four things that needs, need to be proved.

19:41

First is, and foremost is the duty.

19:44

Did the physician patient relationship exist when you

19:48

take care of the patient?

19:50

This, this relationship automatically forms between,

19:53

between you and your patient.

19:55

Second thing is that is, has there been a breach

19:59

of this duty?

20:00

Has the physician deviated from the standard

20:03

of care in performing the duty to the patient?

20:06

So this breach of duty has to be proved second,

20:12

once the breach of duty has been proved.

20:14

The third thing is that did that breach in the standard

20:19

of care actually lead to the patient's injury?

20:23

So is it, was it directly responsible

20:25

for the patient's injury or not?

20:27

So causation has to be proved from that, uh, deviation.

20:32

And finally, the damages,

20:33

once everything at the CAUS causation has been improved.

20:37

So what were the damages that have been caused

20:39

to the patient, both physically, both mental, mentally,

20:44

wages, medical expenses, all of that come into, into play.

20:48

And then finally, obviously the liability decision is,

20:51

is, is made through.

20:54

So in ra talking just about radiology,

20:58

what are the common mal practice allegations

21:00

that we are used to seeing?

21:03

Of course, one of our biggest area is misdiagnosis

21:08

or misinterpretation.

21:09

A crucial finding is missed,

21:11

and that can lead to a bad outcome for a patient.

21:15

And I'll, I'll, I'll share some examples.

21:18

Over the years, having done, uh, a fair number

21:21

of these cases and looking at the literature,

21:25

these are the four areas that lead

21:29

to the maximum number of, uh, malpractice cases

21:35

in a radiology, oncology, vascular events missing,

21:40

uh, aneurysms, missing dissections is, is pretty common.

21:46

Fractures is still very, very big in, uh,

21:49

in, in, in radiology.

21:50

And of course, infections that I have been involved with,

21:54

uh, I would say probably maximum number

21:57

of infections are in the spine, missing an epidural abscess,

22:01

missing discitis osteomyelitis

22:03

or infections, uh, in the abdominal cavity

22:07

that are, that are missed.

22:08

So, so this, this gives you an idea that these,

22:11

these are the four areas that you have

22:13

to be particularly very, very careful about.

22:16

As, as these four areas are quite high when it comes

22:20

to a radiology, um, uh, malpractice.

22:23

And amongst the cancer, as I already previously said, breast

22:27

and lung are very high up on the list.

22:30

A, they're, they are the most common cancers.

22:32

And B, we all know these lung nodules, especially now

22:37

most of us do these, uh, sub-millimeter scans,

22:41

and these, these lung nodules,

22:43

which we sometimes completely blow off.

22:45

Unfortunately, there have been examples, uh,

22:48

where they turn out to be lung cancers, uh, a year, year

22:51

and a half from the initial, uh, scan.

22:55

And, uh, sometimes really unfortunate, uh, uh,

23:01

so, okay, now this is a, this is a case

23:03

that I was involved in.

23:05

Patient had headaches and seizures.

23:08

Patient had a nasogastric tube placement

23:12

for some abdominal, uh, pathology

23:15

that was totally unrelated

23:17

to the headaches and, and, and seizures.

23:19

And, uh, uh,

23:21

physician assistant puts in an NG tube, has

23:26

to struggle placing that NG tube.

23:28

The NG tube is curled multiple times in the nasal pharynx,

23:32

and the, the NG tube is pushed in,

23:35

the patient bleeds from the nose, bleeds from the mouth.

23:38

So basically, uh, a lot

23:40

of struggle while putting this nasogastric tube in.

23:45

So what happens next is that, of course,

23:47

the patient is having seizures also, so they get an MRI

23:50

of the brain, and MRI brain shows this.

23:54

So there is, there is, uh,

23:57

T two signal within the sphenoid sinus,

23:59

but there is this soft tissue density within the sphenoid

24:02

sinus also,

24:04

and there does appear to be focal encephalomalacia

24:07

of the frontal lobe, uh, at that level.

24:09

And then on this axi T two image, you can again see

24:13

that there is some soft tissue density within

24:15

this sphenoid sinus.

24:18

So the case was brought that, Hey, this is all related

24:21

to the nasogastric tube,

24:23

because this was very a traumatic, uh,

24:25

episode for the patient.

24:27

It was the patient bled from the nose,

24:29

bled from the mouth, and blah, blah, blah.

24:32

Uh, but we all know it's very highly unlikely

24:35

for nasogastric tube to go up into the sphenoid sinus and,

24:39

and then come out through the, uh, roof of the sphenoid, uh,

24:43

sinus so that you can have herniation

24:45

of the brain program come out with a, uh, encephalocele.

24:49

Uh, so as, as I said, the next step would be

24:53

that you would be getting records from

24:56

the prior records on the patient if any other hospital was

25:00

involved, if the patient had gotten

25:02

scanned and all that stuff.

25:03

And that was, was done.

25:05

But unfortunately, the patient was scanned at the same

25:09

hospital, uh, about two years ago.

25:12

And so this is the head CT that was, uh,

25:15

from two years ago on the patient.

25:17

And you can see that, uh, there is, again,

25:21

sphenoid sinus is not clean,

25:23

but even, even on a CT head, you can make out the density.

25:26

Soft tissue density is pretty much similar

25:28

to the brain density here.

25:31

Uh, this was the bone window,

25:33

and you can see again that encephalomalacia

25:37

of the inferior frontal lobe is also there.

25:40

And then of course, you can see the breach, um,

25:43

along the floor of the anterior cranial fossa, uh, roof

25:47

of the sphenoid sinus with herniation of the brain pro.

25:50

So this was, uh, meningo, encephalocele

25:53

that was present two years ago.

25:58

So what do you do in a case such as this, now that,

26:01

you know, a colleague

26:02

of yours had read this CT about two years ago,

26:06

and you are reading obviously that MRI

26:08

that I showed you earlier, what would you do with

26:12

that, with that report?

26:13

It becomes, sometimes it becomes a very

26:16

challenging situation.

26:17

Most of the times I think that you, you report it,

26:21

the patient, the, the, the, the colleague

26:24

that had missed it doesn't get sued,

26:26

but obviously there is a good chance that they, if there is

26:29

outcome, the patient knows about it.

26:31

They may, they may go after the physician.

26:33

And, uh, so really, in, in, in, in, in a situation such

26:38

as this, there are things that you have to do

26:41

and things that you should not be doing.

26:44

Uh, when you are dictating, uh, a case in which, you know,

26:48

the previous, uh, the,

26:51

the finding was missed on the prior scan, just use neutral

26:55

language, fact-based language.

26:57

So like, just like, like in retrospect,

27:01

the finding was present on the date of the study,

27:04

whatever date, date was,

27:05

or like on further review,

27:07

the abnormality is visible on the prior exam, uh, that

27:12

that's a better way of putting it, rather than, uh,

27:17

saying that the finding was missed

27:21

or there was an error made on the prior, uh, exam,

27:25

or the finding was completely overlooked on the, uh, on, on,

27:28

on the prior exam.

27:30

So, uh, try not to say those words rather than stick

27:34

to these, this neutral, uh, fact-based, uh, words

27:40

document the objective finding you, you,

27:42

you see a meningo encephalocele, you see fluid within the,

27:45

within the sphenoid sinus,

27:47

and just stick to that, uh, rather than

27:50

why it was not reported on the prior scan.

27:53

Don't, don't try to rationalize that.

27:56

Just stick to your findings and,

27:58

and just the objective finding on your scan.

28:02

And then of course, you have to communicate this

28:05

to the patient's care team.

28:06

That is, that is your responsibility.

28:08

If you feel like, uh, a significant finding

28:12

has been missed on the prior scan, no matter

28:14

how you like the way you dictated you, you have

28:17

to call up the team and let them know.

28:19

Uh, also, and as I said, don't use

28:23

accusatory terms error, mistake, missed overlook.

28:28

Don't, don't use those terms in your, in your report, uh,

28:32

and, and, and, and, and avoid speculating on why it

28:37

was missed on the prior scan and,

28:39

and don't offer personal opinions that maybe

28:42

the scan had a bit of a motion and that's why it was missed

28:47

or, or, or something like that.

28:49

So don't, don't try not to do it.

28:50

And, and never, ever, ever put something in the chart

28:54

or in your report, uh,

28:56

in which there will be a professional disagreement, uh, that

28:59

that's, that's really not good.

29:02

Uh, so that's probably how you should, you should deal

29:06

with a situation such as this, uh, and, and, and, and,

29:10

and not try to throw your colleague completely under the

29:13

bus, but obviously you have to communic communicate the,

29:18

the fact-based finding, the objective finding

29:21

and communicate with the, with the team.

29:23

Also, if you think that this miss is significant

29:27

and not an insignificant one,

29:30

let's go over some examples where

29:34

missed findings happen,

29:36

and that led to medical malpractice, uh, litigation,

29:41

uh, which some are quite obvious and hard to defend, uh,

29:46

and, and some can be defended.

29:50

So this is a patient

29:51

who was involved in a motor radicular accident

29:54

and had head trauma.

29:56

And obviously, uh, you have picked up on the finding

30:00

that there is a non-displaced fracture,

30:03

greater sphenoid wing fracture involving the

30:06

lateral wall of the orbit.

30:08

Uh, there is a bit of, uh, pneumo, ence ephalus there,

30:12

and then I don't know how well it projects on your end.

30:14

You can see a teeny tiny, uh, x extra axial hemorrhage.

30:19

And then there is some layering fluid within the, uh, uh,

30:24

sphenoid sinus right there.

30:26

Uh, this was read as no acute intracranial event

30:30

and the inflammatory changes within the sphenoid sinus

30:34

and the posterior ethmoid air cells by

30:37

the radiologist who was reading it.

30:39

So, uh, the ER saw this report and let the patient go home.

30:44

Two weeks later, the patient comes back to the hospital

30:48

with intractable headache, fever, and now neck rigidity.

30:51

So you already know where this is going.

30:54

Uh, you can see this is the head CT

30:57

that was obtained only two weeks later.

31:00

And you can see developing now, this is hydrocephalus,

31:03

there is transplantable flow of CSF, there is

31:06

cerebral edema, there is some hyperdensity in the region

31:10

of the basil or IDE there, and a CT angiogram was obtained.

31:14

And you can see this baslow tip aneurysm patient

31:17

unfortunately had meningitis hydrocephalus, uh, had,

31:22

which led to development of a mycotic aneurysm,

31:26

and overall was not a good, uh, outcome for the patient, uh,

31:31

in which the, the first initial, uh,

31:34

finding was, was missed.

31:36

So this is definitely a perceptual error or misdiagnosis.

31:42

Uh, i, I told you one of the calmest areas is spine,

31:45

and especially infections in the spine.

31:47

Sometimes we don't get good history,

31:49

but if you get a history such as this neck pain, fever,

31:54

arm weakness, all three are, are really good,

31:59

like red flags in a, in, in, in a patient.

32:02

So that, that's not like normally

32:04

how we get our histories most of the time these days.

32:07

But, but fever arm weakness, that is,

32:10

that is very important.

32:11

So you are, once you, once you read fever, your, your

32:16

suspicion about infection, inflammation,

32:18

especially in the spine, should be high

32:19

and completely cleared out.

32:21

So you can see that there's a protrusion at, uh, six seven.

32:26

It's, it's emotionally scan.

32:28

Also, we don't know if this is real

32:30

or not, it's hard to say,

32:31

but there is something brew up behind that.

32:35

Uh, C two vertebra.

32:36

Again, this is not clear,

32:38

but there were other images

32:39

that were also obtained on this patient, uh,

32:41

especially the post contrast, which I'll show you.

32:44

Uh, but impression on this scan was this protrusion C six

32:47

seven level and this finding that was completely missed,

32:52

that there is an epidural abscess, uh, at,

32:55

uh, in this patient.

32:57

So patient pain, fever, weakness, uh, was

33:03

read overnight by a trainee

33:06

and was read as pretty normal

33:08

with some degenerative changes.

33:09

Overall, final read was next day at 9:00 AM was read the

33:14

same way without any mention of

33:17

that epidural abscess patient's neurological status

33:21

kept on worsening, so patient was transferred over

33:24

to a tertiary care center.

33:26

Patient was operated 2.5 days

33:29

after the initial presentation in the, in the, uh,

33:32

in the first hospital.

33:34

Uh, and of course, this was an abscess, turned out

33:38

to be RS asepsis and after surgery,

33:41

and all that is quadriplegic and, and wheelchair bound.

33:45

Uh, so be very, very careful when you get your histories,

33:49

uh, like that.

33:50

And, and this day

33:52

and age, we know how common, uh, uh, spine infections dys

33:57

to osteomyelitis are.

33:59

This is a very sad case.

34:00

Uh, a 47-year-old with shoulder pain after trauma.

34:03

Obviously very hard to pick up the, the fracture

34:06

that is in the spine, but somehow, again, a smaller hospital

34:09

where instead of getting a shoulder MRI,

34:12

they ended up getting the whole chest, uh, ct.

34:15

And obviously this, uh,

34:16

this shows the non-displaced fracture through the scapula.

34:21

And I won't, I won't, myself won't be able to pick this up,

34:26

and I won't blame anyone for missing it.

34:28

But there is a finding on this one.

34:29

So the patient was sent back home, patient was continuing

34:32

to have some, uh, shoulder pain.

34:35

So four to five months later, uh, patient was re-scanned.

34:40

And, and unfortunately, unfortunately, uh, again,

34:45

a chest CT kind of, uh, uh, field of view was obtained.

34:49

And you can now see that there is a mass that is along the,

34:54

uh, uh, superior aspect of liver under the diaphragm,

34:58

which was not called, uh, at this time.

35:02

Uh, and, and then about six

35:04

or seven months later, patient was,

35:08

had severe abdominal pain

35:09

and all that turned out to be, uh, colon cancer.

35:13

And at that point, this, uh, CT was again obtained.

35:17

And you can see now, uh, this has almost, uh,

35:20

five times the stro.

35:22

So going back to the original ct, in retrospect, you can see

35:26

that there was something there,

35:27

but obviously that's, that's very hard to pick.

35:30

So this, this, this, the, the radiologist

35:34

who read the second CT obviously had a

35:37

definite, a definite miss.

35:39

Uh, so he was involved in the, in the, in, in the lit,

35:43

uh, litigious process.

35:44

But it, it was, it was not all radiology, uh, fault.

35:49

And the other thing was that, yes,

35:51

it was missed on the first scan,

35:53

but by that point, patient was already stage four

35:56

because you could, in retrospect,

35:58

you could see something in the, in the, in the liver,

36:00

but still this is a miss that,

36:03

that you really can defend.

36:06

Uh, that, and there was almost eight to nine months, uh,

36:09

difference, I think between,

36:10

between the two scans when finally the colon cancer was, uh,

36:14

diagnosed in this patient.

36:17

This is one area that I am very, very scared of, uh,

36:21

because when we are reading these lumbar spine,

36:25

cervical spines, thoracic spines, we are so honed down

36:28

and focused on our, our, uh, spine,

36:32

our thecal sacs, our spinal canal, our foramina,

36:36

that there are elephants around us,

36:38

and we completely, uh, completely miss, uh, those elephants.

36:41

And this is a great example of that.

36:43

And many, many, many times we have seen this, I'm sure

36:48

in the audience there, there are people who have examples

36:51

of this who, and they have called, uh,

36:54

so something like this out,

36:56

but should be very, very careful, either first

36:59

or last, just forget about the spine

37:02

and look at the surrounding soft tissues, abdominal neck,

37:06

uh, or, or chest if you're reading the thoracic spine.

37:10

And because you do not want to miss something like this.

37:12

And in this case, it was particularly bad

37:15

because for some odd reasons

37:17

for low back pain contrast was given.

37:19

And this makes the miss look even worse

37:22

because there was significant enhancement, uh, of

37:25

that incidental RCC that was seen in this, uh, scan.

37:30

And the patient, uh, there was a, there was a delay

37:34

of at least six to seven months be between this scan

37:38

and the scan when it was finally picked

37:40

up, uh, in this patient.

37:41

So always make sure on these spine ms, so look at aorta,

37:45

look at the surrounding structure so that it, it,

37:48

it is in your report.

37:51

Uh, this is another case that I was involved in.

37:55

So this is a CTA on a patient with history

37:57

of dizziness and headaches.

37:59

Uh, so CTAs, and this is the scout film of the CTA.

38:03

The CTA was normal

38:04

and was read as normal,

38:06

so there was nothing wrong with that.

38:08

Uh, but on the scout image, you can see that there is

38:13

elevation of the hemi diaphragm,

38:15

or there is a, uh, opacity in the left, uh, lung,

38:20

which obviously was not called.

38:22

So I had, I showed this, this scout image and,

38:27

and gave the exact same history to about eight

38:31

or nine of our neuroradiologist here in our department.

38:35

And none of them said that they would be commenting on this

38:40

barring, uh, one person who said that he might have.

38:44

So, so really very hard.

38:46

So this is truly, truly

38:49

a blind spot when we are reading a radiological, uh,

38:54

scans, uh, looking at the scout images.

38:57

Some people do, but most people do not look

39:00

at the scout images.

39:02

And this was very unfortunate for this patient.

39:05

Uh, and, uh, this is a scan seven years after.

39:10

Now you can see that there is big, huge density in

39:13

that left hemithorax.

39:15

Uh, there's a shift of the mediastinum,

39:17

and then finally the CT was obtained.

39:19

You could see this big, huge, uh, lipo, uh, in this patient.

39:24

But so how are, how do we want

39:28

to correct these mistakes, uh, from being made?

39:33

Uh, so one of the things

39:36

that we always tell our trainees that have a checklist

39:41

at looking at the scans right from day one,

39:44

right from the day they start to look at their first scan,

39:49

have a checklist and a systematic way of approaching a scan,

39:54

be it a head ct, chest ct, abdominal ct,

39:57

and then consistently follow that checklist

40:02

or that approach that you have devised, uh, and,

40:05

and throughout your career,

40:07

you really cannot deviate from that checklist.

40:10

So that's, that's very, very important.

40:11

First point I wanna make here.

40:14

Then the other thing is

40:16

that once you have picked up a primary, uh,

40:20

diagnosis, don't deviate from your checklist

40:24

because we think that we have made the diagnosis

40:27

and then we want to go fast through that case

40:29

and go to impression.

40:31

And that's, that's an area that I think problems arise

40:34

because we have not satisfied our,

40:39

the satisfaction of search is not completed

40:42

and hence, uh, a secondary finding,

40:45

which can be equally important

40:48

or perhaps even more important than the primary finding

40:51

that you have picked up and,

40:53

and can lead to problems in the medical legal arena.

40:57

So, so, so, so do not deviate from that systematic approach,

41:02

even though you have seen a finding, you have

41:04

to complete the whole process.

41:06

Uh, these days, uh, we use the standardized reports.

41:10

Uh, so if you are a person who, who is in favor

41:14

of standardized reports, use them.

41:16

They can be very helpful.

41:17

One of the things that I, honestly, I also sometimes,

41:21

and most of the times I'm, I'm,

41:22

I admit I do not look at my scout images.

41:25

So to prevent something like that,

41:27

the case I showed you about that lipo sarcoma,

41:30

maybe we should have scout image also in the standardized

41:35

template so that that forces us.

41:37

But the other thing that I have realized with our trainees,

41:39

that even though sometimes we have our standardized reports,

41:43

but we don't follow the standardized report,

41:45

how many times have, have we seen that paranasal sinuses?

41:47

They're all filled up with junk,

41:49

but our reports says normal,

41:51

because that's how the macro has been put in.

41:54

So be very careful if you're using them, use them fully,

41:58

just not for the sake of just having

42:00

that line in the report,

42:02

because that'll make you feel even worse.

42:05

If God forward forbid, that case goes to a medical, uh,

42:08

legal lawsuit that you mentioned it

42:12

and you wrongfully mentioned it, uh, with a and,

42:14

and you didn't mention the finding

42:16

that was associated with that heading.

42:18

You had in your, uh, uh, macro, uh,

42:23

many hospitals, many practices have these random peer

42:26

reviews, and that's also very good way of, uh, picking up,

42:30

uh, findings that have been missed by your colleagues

42:34

or your findings that you have missed.

42:36

So that's a good process to have in place at as a added, uh,

42:40

check, check-in measure.

42:42

I know some of the large prior practices now have started

42:46

the use of computer rated, uh, AI detections,

42:49

and that really serves as a technological second opinion,

42:53

but be very, very careful.

42:55

There are many, many systems out there,

42:58

and some of them are not standardized yet.

43:01

So be sure that if you are using a system

43:03

that is standardized, uh, we are not really up there

43:07

with the, with this AI generated, uh, detection systems yet.

43:11

But that's definitely something to think of

43:14

in your practices, uh, in future.

43:18

Okay, so moving on to the second most common error

43:21

that we see in radiology is the communication failure.

43:26

And unfortunately, in my opinion,

43:30

in my experience,

43:33

these errors are the least likely to be dropped,

43:37

denied, or dismissed.

43:38

So in most of the cases, if, uh,

43:43

this type of communication failure has happened,

43:47

it is really indefensible most of the times in my, in my,

43:51

uh, experience that I have seen.

43:55

Uh, and, and then as I said, that, um, uh,

43:59

radiation doses, improper inspection

44:02

of the equipment are the third most common type of, uh,

44:06

cause for, uh, the medical-legal malpractice claims in, in,

44:10

in us, like the manufacturer settings were not

44:13

subsequently updated.

44:15

That's one of the reasons, uh, that, uh,

44:17

these things happened.

44:18

Most of these are also settled outside of the court.

44:23

So let me give you a few examples of communication failure.

44:27

So again, this is the same thing.

44:29

Lumbar spine, MRI herniated disc interpreted

44:33

as a herniated disc, four five, great, that looks,

44:36

but in, in this, in the report,

44:40

there was a small space occupying lesion in patient's left

44:44

kidney, most likely appearance of a cyst.

44:46

But ultrasound is suggested for further evaluation,

44:51

no direct communication was made to the referring physician.

44:54

And then 18 months later, the patient underwent a CT

44:58

that disclosed an RCC with numerous meds

45:01

in the mal practice lawsuit that came up.

45:04

The referring physician claimed that never

45:07

to have received the written report from the radiologist.

45:09

And this does happen.

45:11

This has actually happened to me, uh, personally also where,

45:16

where there was a systems failure that the hospital had,

45:19

that the fax reports were not going out to the

45:23

outside physicians.

45:24

And, uh, uh, there I was also involved in such a case.

45:29

Fortunately, it was dropped,

45:30

but this is, I have personally experienced this,

45:33

and again, in this case, the referring physician,

45:36

the radiologist and the hospital for the systems failure

45:40

that was in place, uh,

45:42

were implicated in the, in the lawsuit.

45:45

And, and, and so, so this is, this is something

45:48

to learn from, but

45:49

because there have been multiple, multiple,

45:52

multiple examples such as this,

45:54

and the next one will really drive the point home is this

45:58

patient with the 34-year-old with chest CT

46:03

radiologists at the end of the day issues a verbal report,

46:07

uh, to the clinician and tells essentially normal ct,

46:11

and then gone for the day following morning,

46:15

another radiologist comes to read,

46:17

to render the official reading on that case

46:20

and reads it as probably normal,

46:23

but there is a small anterior media staal soft tissue

46:26

density or mass likely hy six months follow up.

46:30

How many times have we have? We, have we done that?

46:33

Seen that, right? Uh, unfortunately,

46:37

the radiologist does not communicate this

46:40

to the referring physician now who later claimed

46:44

that he had a verbal

46:45

of a normal chest CT from the radiology, uh,

46:50

department, right?

46:51

Which is totally legit.

46:53

In this case, two years later, the patient was diagnosed

46:56

as a large stage four malignant thymoma

47:00

and eventually died.

47:02

And the medical mal practice lawsuit was,

47:05

was against both the physicians, uh,

47:07

that were involved in the case, the, the one that who had,

47:11

who had given the verbal for missing the finding,

47:13

the second one who had picked up the finding

47:16

but never communicated the finding.

47:17

And of course, other physicians in the hospital were

47:20

also involved in this case.

47:21

So it's, it's vitally important that we have such type

47:25

of communications in place, and

47:29

because we do not want miss something like this.

47:31

So what can we learn from,

47:34

from this communication failure Examples that I,

47:37

I showed you is that communication

47:41

of the non-routine,

47:43

but perhaps life-changing results of a radiological

47:47

examination are becoming equally a duty

47:52

of radiologist, as is our duty

47:55

of interpreting such studies.

47:57

So it's, it's, it's, the onus is falling on us on,

48:00

unfortunately, now, in this day

48:02

and age, if we think that a non-routine,

48:05

but something that can significantly alter patient's life

48:10

or, or, or,

48:11

or the physical state of the patient, if missed

48:15

for a considerable period of time,

48:16

that onus will fall on us also.

48:19

And, and, and, and, and, and both the, the courts as well

48:22

as a CR has clear, clearly said

48:27

that radiologists must verbally communicate urgent

48:32

or significant unexpected findings

48:34

to the referring physicians.

48:36

So, so that is a broad term, right?

48:39

So all the lawyers have to do is that

48:43

it is a significant finding.

48:47

And, and, and, and then you, you fall in that, in

48:50

that picture because say this was RCC,

48:55

potential RCC, potential time

48:58

is a significant life altering finding

49:01

and should have been communicated with the physician.

49:06

So what I, I have learned

49:08

and looking at, uh, these, having gone through these cases

49:12

and then, and then then doing some, uh, lit search on this,

49:17

uh, is that if a radiologist

49:20

or a trainee who's working with the radiologists, uh,

49:24

cannot give the referring reach the referring physician

49:26

that we can, we can call up their np, their PAs,

49:29

that even their nurse who is associated with that case,

49:32

even though she's not ready to take this, just you have

49:34

to tell them that you were with this, uh, with this patient,

49:37

you, you, you have to tell them

49:39

and tell her to tell the, uh,

49:41

referring physicians about that.

49:43

So you can do that.

49:45

But if you are not able to reach any of the team members,

49:51

then it becomes your responsibility in such scenario

49:55

where you think that this finding can alter patient's,

50:00

uh, uh, state, physical state

50:04

or, uh, for a, if, if, if it's missed

50:07

for a considerable period of time,

50:09

you can directly communicate with the patient,

50:12

call the patient up, tell them that, Hey, I'm seeing this.

50:15

I'm not sure about this.

50:16

Make sure you go to your PCP make,

50:19

or if it's something more urgent, make sure you go to the,

50:22

uh, uh, ED and get this taken care of, so,

50:26

and document it that you call the patient up, you talk

50:30

with patient's wife or family member

50:32

and let them know you can, you can do that.

50:35

Absolutely. I have done it multiple, multiple times, uh,

50:39

communicated directly with the patient when I could not get

50:41

hold of any team member.

50:45

Okay, now, moving a little bit away from the radiological

50:48

diagnostic radiology, uh, practice.

50:51

Let's, let's see some examples on the interventional side.

50:55

Uh, of course, the most common reason is impro,

50:58

improper performance of these procedures.

51:01

Mostly vascular procedures in biopsies

51:04

retain foreign bodies, I would say is more for surgeons.

51:07

But obviously we are also culprits in

51:09

that in the interventional world, consent is improper.

51:13

It's not a common, but definitely a reason for getting sued.

51:17

Uh, and then of course, not taking care of the complications

51:22

that you may have caused a new procedure may have caused

51:25

to the patient, uh, as such, uh,

51:30

so this is is a quick, quick example.

51:32

Now here, this is a, a patient

51:35

who had radiculopathy injection was done,

51:37

and you, you have to know the flow pattern

51:39

of the injection in this patient.

51:41

Patient developed weakness, respiratory as

51:46

vital signs were unstable.

51:47

Eight hour later scan was obtained

51:50

and the patient had a big, huge cerebellar in fog.

51:53

Uh, so you can see the cerebellar in fog, so you have

51:55

to know really the ate line right lateral

51:58

to the insulate lines of the EB artery.

52:00

So when you give the contrast under fluoroscopy, you have

52:03

to know the flow pattern of the contrast.

52:06

It should be at the level and going inferiorly.

52:08

But in this case, the contrast was going more superiorly.

52:11

That should not be happening.

52:13

It was lateral to the sate line.

52:15

It never crossed medial to the insulate line.

52:17

That's a very dangerous pattern of contrast.

52:20

And that's where when it entered into the vertebral artery

52:23

and caused spasm of the vertebral artery,

52:25

and the patient had this big huge hemorrhagic infarct

52:27

and ultimately died in six days.

52:30

So this is improper technique used during the procedure.

52:34

So how do we avoid it?

52:36

Whenever you are, especially in the cervical spine,

52:38

make sure that you are in the epidural space

52:41

or whichever space you want to be.

52:43

We usually aspirate, we inject contrast

52:46

before we put in the medicine.

52:47

We, if, especially in the cervical spine,

52:49

and you are doing under fluoroscopy, make sure you do,

52:52

uh, subtracted images.

52:54

And here's an example.

52:56

You just do a, a straight, uh, image

52:59

and you can see a little bit of vascular internalization

53:02

and, and a good flow in that epidural transforaminal space.

53:06

So if you inject it, it can be catastrophic

53:09

because if you do a DSA image,

53:11

you can now see the anterior spinal artery in that patient.

53:14

And if you had injected in this, this would have had

53:18

devastating outcome for the patient.

53:22

Uh, this was a patient with back pain.

53:24

Uh, patient was in severe pain.

53:27

The interventionalist looked at this.

53:29

They saw some, uh, disc hyperintensity

53:33

infection crossed their mind,

53:35

but the patient was in severe pain.

53:36

The team was really pushing it, so they said,

53:39

okay, we will take care of it.

53:40

And they ended up putting cement in there.

53:42

But two or three days later,

53:45

infection was all over the place.

53:47

Now you can see abscesses, uh, formed in the, in the,

53:50

in the interlateral paraspinal space, there is retropulsion,

53:54

and the patient ended up having surgery

53:56

and sepsis and all that.

53:58

So, so never ever do this when you are even suspicious

54:02

of having, uh, infection in the spine.

54:04

You do not want to put anything, uh, uh,

54:08

into the spine at that point.

54:11

This was very, very unfortunate patient

54:14

that I was involved in.

54:15

So this was a compression fracture.

54:18

Patient was taken for vertebroplasty

54:20

kyphoplasty procedure was done.

54:22

Patient was not moving the legs, uh, in,

54:25

in PACU right after the procedure.

54:27

And, and you can see this, this was a CT that was obtained

54:30

after, you can see that instead of going through the lamina,

54:35

which is now broken, they went in through the pedicle

54:37

and they transected the spinal cord.

54:40

And you can see a complete transection of the spinal cord.

54:43

So obviously indefensible seizure error.

54:47

This is what's called a gross negligence, uh, uh,

54:51

unfortunately unfortunate for the patient.

54:54

This is also very interesting case.

54:55

This was, uh, uh, incidental finding on an

55:00

outside hospital in a patient who had a fall,

55:03

and they saw this and biopsy was done, which came out

55:06

to be non-diagnostic.

55:08

This, the patient was referred to a tertiary hospital

55:11

for further evaluation.

55:13

The surgeon did not see the patient,

55:15

but wanted a repeat biopsy to be done at the hospital

55:19

of the surgeon, which was a, a tertiary care center.

55:22

Uh, the interventionalist

55:25

who saw this scan looked at the older scans on this patient

55:29

and, and that these are some of the studies that they saw

55:31

that it is preva, uh, presacral.

55:35

T one hyperintensity mostly looks like a hematoma

55:39

enhancement pattern is not central.

55:41

It's more peripheral.

55:43

Uh, that's, uh, a patient has had trauma, blah, blah, blah.

55:46

And they, uh, looked at some of these images,

55:49

and this was one of the scans that they looked at.

55:52

It was really big presacral presacral hemorrhagic.

55:55

And then it changed a good bit,

55:58

and they decided that the biopsy is not really indicated.

56:01

This looks like hematoma may have been infected, that's why,

56:06

um, you see some changes within the bone.

56:08

And they decided not to pursue the biopsy and,

56:11

and the total patient as such

56:13

that it has improved significantly and no need to biopsy it.

56:17

Uh, but they did not tell the referring physician at their

56:21

hospital, and they did not call up the outside state,

56:25

state doctor where the patient was really, uh, following

56:29

with patient felt quite good

56:31

as the patient was not having a lot of pain, felt quite good

56:34

and did not pursue any further, uh, medical, uh, treatment

56:39

for this or medical opinion for this, uh, till.

56:43

Uh, but, but looking back, uh, at all the images,

56:48

now, obviously this is when the,

56:50

when the lawsuit was brought forth,

56:52

and when I looked at all these scans,

56:55

this was the initial scan, there was nothing in the,

56:57

uh, presacral region.

56:59

Everything is in the bone.

57:01

It is as bright as CSF, uh, so you tend

57:04

to think about chordoma as being the initial diagnosis.

57:07

And then you can see it growing from where it was.

57:11

And the patient then three years later, became, uh,

57:15

loses bladder bowel and has, uh, paraparesis,

57:19

and the patient ends up with ectomy,

57:22

and you can see the tumor within the sacrum cell.

57:25

That's tumor in the presacral space.

57:28

Brachyury was positive for this patient.

57:30

So obviously this was not good for the physician,

57:35

uh, interventionalist who did not do the biopsy,

57:38

even though was asked to do the biopsy,

57:41

but more importantly, did not talk with the teams

57:45

who had referred the patient over to let them know that,

57:49

Hey, I'm not doing the biopsy, uh,

57:51

for whatever reason came to mind.

57:53

So that, that's, that was, that was not good outcome for

57:56

that, uh, person, unfortunately.

57:59

Let me skip that. This for the interest of time.

58:01

This is another example of described as osteomyelitis

58:04

with an, with an abscess.

58:05

So let's skip that.

58:09

So what are the consequences

58:11

of the medical malpractice litigation disciplinary action?

58:14

Most of the time there are, there are no major consequences,

58:18

but sometimes, especially if there is a gross medical

58:21

negligence or repeated lawsuits have been brought against a

58:25

person over a period of few years, then the hospital,

58:28

the licensing board and the professionals societies come

58:31

into play, and then they can revoke the hospital privileges,

58:36

suspend memberships,

58:37

and at adverse, uh, take the license away.

58:41

Most of the time, the National Practitioner Data Bank has

58:44

to be involved about whenever a lawsuit is against a person.

58:48

So they get reported to the, uh, data bank.

58:53

Uh, this is a distinct entity, MAL practice stress syndrome.

58:56

This is just like PTSD.

58:59

Same features in, in, in these, uh, in these patients.

59:02

Also, financial impact, usually, uh, your,

59:06

your mal practice insurance covers this,

59:09

but there are certain rare situations, uh,

59:13

in which it can go beyond that limit,

59:16

and it can become a physician's responsibility.

59:19

Uh, and as I said, they're quite rare,

59:21

but if the physician is acting

59:24

outside the professional scope,

59:26

if there is intentional wrongdoing, if there are activities

59:30

that are influenced by intoxication

59:33

or narcotics, then, then, uh, the, the, the,

59:38

the verdict can be beyond

59:40

what the patient's insurance covers

59:42

and can become a personal, uh, liability for

59:45

that, uh, for that person.

59:47

But, but extremely rare.

59:50

And, and we, as we talked about,

59:51

the defensive medicine is increasing.

59:53

We all know we hedge, we recommend unnecessary follow up.

59:58

We shy away from little risky procedures

60:01

that can yield the diagnosis just

60:03

because we don't want any issues with that.

60:06

And, and although the medical malpractice piling, as I said,

60:09

is on, on a decline, yet,

60:11

we do not see a decline in the defensive medicine practices

60:15

that are being practiced.

60:17

A few questions that this is, I just wanted to put in there

60:20

that everybody has a question in their mind, is that,

60:23

is the peer review and tumor board immune from discovery?

60:27

Yes, you can do your peer reviews

60:30

and your tumor board reviews, uh, as they're protected.

60:34

Uh, but you have to be very careful in your,

60:37

in your processes, uh, that it, they should be in accordance

60:41

with your hospital guidelines

60:42

and your medical legal counsel guidelines.

60:46

There was a case in Pennsylvania where, uh, emerge the,

60:49

a group, uh, emergency room group that was contracted

60:53

by the hospital did not fall under this definition

60:57

of the healthcare provider.

60:58

And then they were not exempted from this peer

61:01

review protection law.

61:02

So you had to be very careful about that fact, uh,

61:06

or generalist like in a medical mal practice who, uh,

61:09

lawsuits or generalist held to the same standard

61:13

as the subspecialists.

61:14

So they're still being debated,

61:16

and many states have a different opinion.

61:19

Many lawyers still have a different opinion about this.

61:22

Uh, but overall, subspecialists are permitted

61:26

to testify against generalists.

61:28

But the subspecialists should keep that in mind, that,

61:32

that they should mention this in their, in their, uh,

61:35

expert opinions, that there are certain things

61:38

that they don't expect.

61:40

A person who is doing general radiology to know,

61:42

and they should at least be brought forward when they are

61:45

putting their case, uh, forth, uh, double rating,

61:50

uh, preliminary reports, uh,

61:53

they really don't offer any protection.

61:55

Both people are liable for this.

61:58

So this sometimes becomes a, a, a risk

62:01

because there's a false protection part that comes in

62:04

where the secondary things, the primary is more responsible

62:07

and the primary things

62:08

that the secondary is more responsible.

62:11

So be careful about that because both are equally liable

62:15

and both can be sued, uh, for the, for the same, uh,

62:18

offense if it's missed by both.

62:22

So what I, I really learned from vegan expert witness is

62:26

really critical law role of clear communication.

62:30

It's, it's very, very important

62:31

because miscommunication will lead is the heart

62:34

of the mal practice.

62:36

Uh, lawsuit claims in radiology and,

62:38

and radiologists must ensure their findings are clearly

62:42

and accurately conveyed to the referring physicians

62:46

importance of thorough documentation, uh, self explanatory

62:50

that you have to document everything.

62:52

If it's not document, it did not happen, okay?

62:55

Uh, they, these things not only support the clinical

62:59

decision making, but they can serve as crucial evidence when

63:03

all the documents are are, are reviewed in a medical,

63:06

uh, uh, lawsuit.

63:09

Uh, understanding the legal perspective.

63:12

That's also, as I said, that we do not

63:15

know much about the legal.

63:16

We are not trained into this.

63:18

So get a handle on the legal perspective that I,

63:21

that I tried to give you, uh, a few examples of, uh,

63:25

in this, in this talk.

63:27

Value objectivity when serving as a witness,

63:30

I think is very, very important.

63:32

As an, as an expert witness, you have

63:35

to maintain impartiality.

63:37

You are being hired by either the plaintiff side

63:40

or the defense side.

63:41

You get paid for this,

63:42

but still, you are, you are, you are serving your

63:47

subject matter, and you have to be very objective about

63:51

what you see on the scan.

63:53

Because remember, even though we are doing blinded reviews

63:56

and all the different types of reviews, we know

63:58

that there is something on these scans, uh,

64:01

and we are not completely a hundred percent blinded,

64:04

uh, to, uh, to this.

64:05

And, and it's very easy to be

64:07

among Monday morning quarterback.

64:11

Uh, and then continuous learning

64:13

and improvement, learn from the cases

64:15

that you are involved in, in the, in the, uh,

64:20

medical legal arena.

64:22

It, it's, it's, it's all these cases have been

64:25

really good individual teachers for me to improve myself,

64:29

uh, when I'm reading, uh, my scans.

64:34

So it has, it has really deepened my appreciation.

64:37

Uh, it has helped me with the communication that I have

64:40

with the physicians and overall made me

64:43

to have a better professional integrity.

64:46

Uh, it, it reminds me the impact our work has on patient's

64:51

outcome and what bigger issues are in play if we

64:54

deviate from that.

64:56

And we have to maintain the highest standard of care, uh,

64:59

when, when we are reading our scans

65:01

and helping out our patients, uh,

65:03

and deviation from that standard of care can be, uh,

65:07

a big factor that can lead us

65:10

into these medical malpractice lawsuits and, and,

65:12

and be mindful that our volumes are increasing,

65:16

our error rates are going high.

65:18

So you have to devise a plan that, how you will

65:21

strike a balance between these two.

65:24

Thank you very much. I know I'm a little bit over

65:26

time, but I'm sorry.

65:28

Uh, any questions?

65:30

Thank you so much for that lecture, Dr. Kahn.

65:32

Yeah, we've got a couple questions if you've got a moment.

65:36

Um, let's see. Here we go.

65:40

When you give your expert opinion

65:42

and it doesn't support the law firm's case,

65:45

do you get the sense that they just move on

65:46

to find another person who will agree with them,

65:49

or do you get the feeling that the case may be dropped,

65:51

settled based on your input?

65:55

So honestly, it depends upon how confident, uh, you are

65:59

of their opinion.

66:01

There's a lot of back and forth.

66:02

They try to finagle their way in with questions that, hey,

66:06

could, could be this, could be that, could be this.

66:09

You can't completely exclude this

66:11

or you can't, uh, uh, include this.

66:14

So, so they, they, they try, which is their job.

66:17

They try, they, they try to do their job

66:20

the best as they can.

66:21

And we have to, just, as I said, you, you have to be

66:25

very confident.

66:26

You have to be very objective about your subject matter,

66:30

and you don't really have to think that, okay,

66:34

this person is paying me, so I should try

66:36

to help this person.

66:38

Uh, you should be very, very faithful to your subject

66:43

and you opine on what you see.

66:46

And most of the time, uh, I I

66:48

what I can see from the involvement of the cases

66:52

that I have been in, that

66:54

whenever we have decided whether to move forward

66:57

or not move forward, uh, that decision has been adhered to.

67:02

But if you are, if they find you

67:04

that you're not very confident in what you are saying,

67:06

I'm a hundred percent sure that they will go

67:08

and ask someone else and get a second opinion,

67:10

third opinion, uh, to be sure that, uh,

67:13

they're not missing on something.

67:17

Do you call clinicians for incidental noncompressive?

67:20

Small meningiomas,

67:24

Incidental small meningiomas, like de depends upon, uh,

67:29

meningiomas are something that, that really don't grow over

67:35

weeks or few months.

67:37

But yeah, if, if you are reading a scan,

67:39

you see a meningioma that is causing, uh, cord compression

67:43

and it's an incidental finding, yeah.

67:46

That, that is something that can, if, if,

67:50

especially like I always tell our trainees that in, in, in,

67:54

in the university settings, we are very, very fortunate

67:58

because, uh, there are physicians

68:02

or clinicians who can read their, uh, the scans,

68:06

uh, very well.

68:07

Uh, and, but out there in prior practice, if you miss it,

68:12

as I showed in multiple examples that I showed that

68:16

that can delay care for months, sometimes years,

68:21

and that can have a significant impact, uh, on, on,

68:25

on patient's outcome.

68:27

Uh, so if you feel like you are in a place in which

68:32

you are it, uh, when it comes to radiological interpretation

68:36

of images and uh, I would, I would just pick up the phone

68:40

and call, as I said that if you can't get to them, go ahead

68:43

and call the patient directly, please.

68:45

That's absolutely can be done.

68:47

And as a, as a legal legit way of doing it.

68:51

This is somewhat related.

68:53

You've talked about calling the physician or the patient.

68:57

Is it okay and is it sufficient enough

68:59

to also communicate this finding to a nurse if it's an

69:02

Dental? Absolutely. It's

69:03

absolutely it is.

69:04

Sometimes, most of the times you will see

69:06

that if you are trying to call a nurse, they will,

69:08

they will try to finagle their way out

69:10

that they are not really responsible for patient's care

69:14

and you have to call the NP or the physician.

69:17

Uh, but if it's up on the floor inpatient side,

69:21

you can absolutely talk with, with

69:23

that nurse and let them know.

69:24

If it's on the outpatient side, then you know

69:26

that physician chain every day with the clinic care.

69:29

So that nurse probably not as reliable

69:32

as the inpatient nurse is.

69:34

So, so you, you have to keep that in mind.

69:38

All right. Here's an AI question for you.

69:41

Do you expect in the future

69:42

that lawyers will obtain an AI report on a case

69:46

and use the discrepancy with the human as an example

69:48

of not meeting the standard of care?

69:51

What happens when we ignore

69:52

or dismiss as a false positive in AI reading,

69:56

but the radiologist says it's nothing,

69:58

is the radiologist then at greater risk

70:00

of suit if it turns out to be cancer?

70:04

Huh. Very interesting question.

70:06

Uh, I suppose I don't see this happening in next,

70:11

uh, 15, 20 years, uh, more

70:15

because where AI is right now, uh, in,

70:19

in the radiological world, but potentially it is possible.

70:23

But, but remember that there is, there, there are so many

70:27

ifs and buts when it comes to this, uh, medical,

70:32

uh, malpractice litigation processes and all that.

70:36

It's not black and white that AI said this,

70:40

and this is going to be this.

70:42

There are so many ifs and buts that come into play.

70:45

You have to take this scenarios.

70:47

So what, what I showed you here today is just plain, simple

70:52

radiological reads or radiological misses.

70:55

So, but that's really a tiny portion of the whole lawsuit

71:01

is you have to take the clinical into picture.

71:03

You have to take the, the,

71:05

the referring physicians into picture, uh, how,

71:09

how they come into play with,

71:11

with the radiological evaluation of the,

71:13

of the patient's scan and all that.

71:15

So all those things have to be taken into picture when,

71:18

when finally the case is driven forward towards deposition,

71:23

towards trial, it's, it's, it's not just based off, okay,

71:27

you person A read the scan like this person B read the scan

71:31

like this AI read the scan like this.

71:34

I don't think that'll cut it completely.

71:38

Excellent. All right.

71:39

Well, and with this one, as an expert witness,

71:41

do you represent both sides, plaintiff and defendants?

71:44

And if so, is this balance important for experts? Uh,

71:50

I personally tend to be overwhelmingly defendant.

71:54

Uh, I have done some plaintiff cases,

71:57

but I, I I, I, I tend to be more defendant.

72:00

Uh, honestly, I don't, I-I-I-I-I-I don't

72:06

feel that you shouldn't be doing plaintiff's cases.

72:09

This is something that I have done

72:11

and I have, I've, I've continued doing like that.

72:14

But, uh, it's a personal decision.

72:17

It really is a personal decision.

72:18

I know, I know my mentor, Dr. Sso, he does both equally.

72:24

Uh, and so there are mistakes being made

72:29

and calling out those mistakes.

72:31

There's absolutely no harm in, in that.

72:34

Sometimes we have this feeling that, hey, if we take, uh,

72:38

plaintiff's case, we are going against our fellow

72:42

colleagues or friends and all that.

72:45

But, uh, really as I, as I showed you multiple examples

72:49

that are, uh, indefensible

72:52

and, uh, in the end, it's the patient

72:55

that should matter more than, uh, anyone else.

73:00

Excellent answer. I think that's a good note to wrap on.

73:02

Dr. Kahn, thank you so much for sticking around

73:04

and answering some questions for us.

73:07

Absolutely. Thank you. Yeah,

73:08

and thank you so much for your lecture

73:10

and for everyone else for

73:11

participating in this NOOM conference.

73:13

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73:15

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73:16

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73:18

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73:21

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73:23

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73:26

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73:30

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73:33

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73:35

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73:39

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