0:02

Hello and welcome to Noon Conference, hosted by MRI Online

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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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by creating a free MRI online account.

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Today we are honored to welcome Dr. David SSO

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for a lecture entitled, how to Avoid Getting Sued.

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Dr. Ssom is a neuroradiologist

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and professor of radiology at the Johns Hopkins

0:36

University School of Medicine.

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Dr. Ssim is the author of over 350 scientific papers

0:43

and several popular books in radiology,

0:45

including Neuroradiology, the Requisites,

0:48

and is the series editor of the Case Review series Elsevier.

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He has served as the president of the A SNR

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and was awarded the Outstanding Educator Award from the RSNA

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At the end of the lecture, please join Dr.

1:02

UIM in a q and a session

1:03

where he will address questions you may

1:05

have on today's topic.

1:06

Please remember to use the q

1:08

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

1:10

as many as we can before our time is up.

1:12

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

1:16

uim, please take it from here.

1:19

Thank you very much and welcome everybody.

1:23

Well, this topic always is somewhat emotional

1:27

and frankly for me trying to put my talk together,

1:30

it was a little bit, uh, traumatic

1:32

'cause I had to go over a lot of my previous misses,

1:35

which I will share with you.

1:37

So let's talk about Dave's top 10 hints for

1:41

avoiding getting sued, uh, disclosures.

1:45

I do receive royalties from Elsevier,

1:47

and in fact, this book,

1:48

radiology Business Practice has two chapters on malpractice,

1:51

both malpractice insurance and medical-legal cases.

1:55

And I am, um, receiving, um, consulting fees

1:59

to Modality MRI online

2:02

and I do serve as a medical-legal expert witness.

2:05

I highly recommend that each of you sign up to do this.

2:09

You learn so much by being involved in the medical-legal

2:12

process and it's really helped me as far as my career.

2:17

So I'm not gonna be talking so much about the components

2:20

of a medical legal case, more as how

2:24

to avoid getting named in a suit.

2:25

And then once you're named in a suit,

2:27

what what you should do.

2:28

So we won't be talking about the four critical elements

2:31

of a medical legal suit,

2:33

those being duty breach causation damages.

2:36

Here is the typical radiology report.

2:39

There appears to be a possible borderline indeterminate,

2:42

equivocal, suspected pixel, probably

2:45

of questionable significance, clinical correlation needed.

2:48

Maybe unfortunately, some

2:51

of our reports do seem like that, don't they?

2:54

So I'm gonna give you my top 10 hints. Number one hint.

2:59

Number one tip for not getting sued is read less cases.

3:03

Okay? It's basically a numbers game.

3:06

So if in your career you have the possibility

3:08

to spend more time as an educator or researcher

3:12

or program director

3:13

and read less cases, you likely will be less likely

3:16

to be sued.

3:18

It really is a percentage of effort.

3:20

Uh, start late, retire early.

3:23

Uh, again, the numbers eventually catch up to you.

3:26

There are some modalities that have less overall studies,

3:30

uh, such as PET or ir.

3:32

You contrast that with someone who's reading

3:34

plain films or mammo.

3:36

Again, it's just a numbers game that eventually,

3:38

even if you're 99.9% accurate, you're gonna have a miss.

3:42

That's substantial. So I'm gonna tell some stories.

3:47

Uh, I'm gonna tell some stories about my own cases.

3:50

And, uh, storytelling

3:51

as a educational experience is supposed to be very effective

3:55

and giving you ideas

3:57

and storytelling can be a powerful way to teach,

4:01

help student learn new ideas,

4:02

information by telling stories.

4:04

So you're gonna hear some stories about my experience

4:08

in the medical legal world.

4:10

So lemme tell you a story.

4:13

Every day I read about 60 70 MRI and CT studies,

4:18

and I work four days a week.

4:19

I have 20% academic time.

4:21

So let's just say I'm 99.9% accurate. What does that mean?

4:26

It means that if I'm reading that many cases in a month,

4:30

I'm reading over a thousand cases.

4:32

And if I'm 99.9% accurate with my reads,

4:37

that means one case a month is a substantial miss.

4:41

And I've been doing this for 34 years.

4:43

That means somewhere out there are 408 major debut

4:48

of misses that are just waiting in the wings

4:51

for me to be sued.

4:52

It's a numbers game. When you look at, uh,

4:56

our paper on medical malpractice, that was a survey

5:00

of the As NR membership.

5:02

Turns out that around 50% of

5:05

as NR members had been sued.

5:07

And it relates to the patients, uh,

5:10

the the neuroradiologist age.

5:12

The longer you're in the business,

5:14

the more likely you're gonna be sued.

5:16

And it turned out that like 44.9% have been sued once,

5:21

but some people twice it happens.

5:24

And you shouldn't take it personally.

5:26

It, it feels personal when someone's

5:28

questioning your ability.

5:30

But, you know, it's, it's a reflection on

5:33

how many cases you've read more than anything.

5:36

Looking at radiologist age

5:38

and diagnostic errors in this paper, um,

5:41

there was a direct correlation between the patient,

5:44

the radiologist age and error rates.

5:47

And in part that is

5:48

because of some issues with detection errors

5:52

that people like me who are kind of confident

5:54

that they've read so many cases, they tend

5:57

to miss things on detection,

5:59

not necessarily on interpretation.

6:03

In uni variate models on this paper shift volume had an,

6:08

uh, odds ratio of 1.27

6:11

and weak weekend interpretation odds ratio of 1.69.

6:14

Why these are related, right?

6:16

On the weekends, you're reading a lot more cases while

6:18

you're on call and it's a long shift.

6:21

And in addition, you have higher volumes

6:22

'cause it's not being shared with other members

6:25

of the, of the group.

6:27

So the more cases, the higher the rate of

6:32

diagnostic errors and it correlates with malpractice suits.

6:38

So this is, these are the data.

6:39

Again, I'm, I'm trying to give a personal experience.

6:42

These are the data that are from this past academic year.

6:46

You can see that I read 1,200, I'm sorry,

6:49

12,994 studies.

6:52

So that's a pretty high number of cases.

6:55

It is, it works out to about a thousand,

6:57

a little bit more than a thousand each month.

6:59

I'm making errors every month.

7:01

Um, fortunately this is our peer review data

7:03

and none of the errors that I've made

7:05

that have been analyzed

7:06

by peer review were clinically significant.

7:08

So I'm, I'm proud of that number,

7:10

but I don't doubt that I'm making major errors each month.

7:15

It, it's just a numbers game.

7:18

Alright, Dave's hint number two, uh, strategize

7:21

for detection misses.

7:22

Now, this is something that I think is important,

7:25

that you have templates when you're starting out in your

7:30

career that account for your blind spots.

7:32

Every time that you miss a parotid lesion on a

7:37

MRI of the brain, go to your template

7:40

and add that parotid column, uh,

7:43

for your detection po potential detection Miss,

7:46

in your template, I don't use templates.

7:49

It slows me down. Um,

7:51

and I'm pretty sure I know where most

7:53

of my misses have been in my, uh, career.

7:56

But I think when you're starting out your career in

7:58

particular, modify your templates to make sure

8:00

that you don't do a sec.

8:02

You don't have a second miss on that.

8:04

So keep a record and, you know, develop a way

8:07

that you look at a study each time and don't vary from it.

8:13

The part B of this is satisfaction of search.

8:15

If I have to think about my major misses, a lot

8:19

of times it's because I give up on a case.

8:21

I find all kinds of great things

8:23

and I like say, all right, I'm done.

8:25

And then there's another finding. So satisfaction search.

8:28

So continue to maintain your concentration,

8:31

even if you found something really important

8:33

and you're so proud of yourself.

8:34

'cause it was relatively subtle, you better watch out

8:36

because there's, there may be another one.

8:38

So maintain your focus.

8:39

Every case should be treated like MAR fans or ALOS Danlos

8:43

or, or one of these syndromes that has multiple,

8:46

multiple potential findings.

8:48

Uh, just keep looking and again,

8:51

the detection templates will help you on that.

8:54

So let me talk to you about, um, this case of, of mine.

8:58

So I had a patient who came in with acute neurologic, uh,

9:02

deficit, uh, stroke workup.

9:04

And the patient got an M-R-I-M-R-A-M-R-P.

9:07

The patient was known to have fibromuscular dysplasia, known

9:10

to have multiple aneurysms intracranial

9:14

and had had a previous dissection.

9:17

And so I was sent this case

9:20

and I'll, I'll show you this case

9:21

and then I'll show you my, um,

9:22

van Hippo Lindel case two misses of mine.

9:25

So here was the case, okay?

9:27

Uh, you know, MR MRI M-R-A-M-R-P didn't, I'm not, uh,

9:30

projecting that, but lots and lots of pulse sequences.

9:35

I then get an email about eight months later.

9:39

My name is blank. And I have been a patient at Johns Hopkins

9:41

for various things including vasculitis, FMD,

9:44

brain aneurysm, several strokes.

9:46

Uh, it was reported two weeks ago when I went

9:49

to the ER and MRI was done.

9:50

And I have a right acoustic neuroma.

9:53

Specifically, the report states that there's a

9:54

heterogeneous enhancing mass.

9:56

This was my study was a non-contrast study.

9:59

And then the report said

10:01

that the lesion is increased in size since the prior MRI

10:04

of August 5th, 2019.

10:05

This is my study, the August 5th, 2019 study.

10:09

And the patient sends me a note saying

10:12

that you dig the unenhanced mr.

10:14

That you interpreted and personally reviewed,

10:15

did not reflect in na a narrative

10:17

or findings of an acoustic neuroma.

10:19

However, the er, neurosurgeon

10:21

and neurology state, there was a lesion there.

10:23

So I'm like, oh, no, this is not the email you wanna get

10:27

on a Monday morning.

10:29

Right? So, um, here is the study,

10:32

and, you know, I'm looking at for vasculitis, aneurysms,

10:36

FMD, strokes, et cetera, in this patient.

10:41

And, whoops,

10:44

missed the non-contrast.

10:46

It was done in non unconscious study,

10:48

but I, uh, missed the vestibular schwannoma.

10:52

So, um, she went on, the story on this patient was

10:55

that she went on and got a follow-up, MRI scan that showed

10:59

that the lesion had grown two millimeters in six months.

11:03

And she went to a neurosurgeon.

11:04

I'm telling a story here, listen to me.

11:06

So she went to a neurosurgeon

11:08

and a neurosurgeon said, look, you know,

11:09

your hearing is still pretty good.

11:11

It's only grown two millimeters in six months.

11:14

I think we should wait, you know,

11:15

because if I have to take this out,

11:17

your hearing's gonna be shot afterwards.

11:19

So let's do another study in six months.

11:22

So the patient doesn't get the study in six

11:24

months, waits a year.

11:26

And at that point, the study has gone,

11:27

the tumor has gone from 1.2 to two centimeters,

11:31

and she ends up going to, um, she ends up going to,

11:36

uh, Los Angeles to a skull base surgery center

11:40

to get the vestibular schwannoma removed.

11:42

When they remove the vestibular schwannoma,

11:44

they nail her seventh nerve and she's got facial droop.

11:48

She has to have the gold weight in her eye.

11:50

So she returns to Hopkins

11:53

and, uh, approaches our risk management team

11:56

and says, Hey, if this lesion had been detected when it was

12:00

only 1.2 sommes,

12:02

maybe my facial nerve would not have been injured

12:04

by the surgeons in Los Angeles.

12:07

And ask Hopkins for, uh, restitution.

12:10

Make a long story short, I was not sued.

12:13

Hopkins was not sued,

12:15

but Hopkins offered her a monetary, um, settlement,

12:20

uh, in advance of suit, um, for $50,000.

12:24

So I made a mistake, you know, was it my fault

12:27

that the surgeon nailed the seventh nerve?

12:30

They said, well, it got bigger, and

12:32

therefore, you know, it started to, you know,

12:34

be more opposed to the seventh nerve.

12:36

But that's the story. Here's another of my misses. Okay?

12:39

So this was a patient who had Bon Hippole disease,

12:42

and I was reading the MRI

12:44

and I read the CT and I felt pretty good.

12:46

This was an outside study, you know, I picked up the little,

12:49

um, s cerebellar Blas.

12:52

I thought this was relatively subtle,

12:54

but the patient did have an endo lymphatic sac tumor,

12:57

which I picked up on the c on the CT scan

13:00

of the temporal bone, which accompanied

13:02

the MR from the outside.

13:04

I then get a, uh, Dave,

13:07

whenever you have the, uh, Dave kind of, uh, conversations

13:10

with a clinician, you know, it's bad.

13:12

Um, I was told, you know, by the ophthalmologist,

13:15

you missed the retinal hemangiomas stoma.

13:17

And sure enough, I don't know whether this is,

13:20

can see this little guy right here,

13:22

a small enhancing area, which I missed.

13:24

Again, this is a satisfaction of search.

13:27

I saw the vasculitis, I saw the FMD,

13:29

I saw the aneurysm I gave up.

13:32

I missed the vestibular schwannoma.

13:33

I saw the cerebellar heman glioblastoma.

13:36

I saw the endo and f*g sac tumor I gave up

13:38

and missed a retinal heman glioblastoma in patient

13:41

with von Hippo limbal disease.

13:42

Fortunately, that didn't res result in any type of, uh,

13:46

medical legal issue.

13:48

Number three, don't miss big things. Okay?

13:51

So if you're gonna miss things, miss a retinal, heman,

13:54

neuroblastoma, don't miss a stroke or a cancer

13:56

or an aneurysm, et cetera.

13:58

Um, you know, last week I got it dinged on my

14:03

peer review that someone said I had a detection miss on

14:07

a Cy Nasal case.

14:08

And I looked at it, and the detect detection miss was hower

14:11

cells, uh, you know, maxi ethmoidal cells

14:15

that are a normal variant.

14:16

Um, this patient did not have any sinusitis,

14:19

but I got reprimanded for a detection miss.

14:22

'cause I didn't call how herself.

14:23

So those type of misses, I'd like,

14:26

I don't like missing the can, the cancers.

14:28

It may help here with AI detection software to reduce your,

14:32

uh, misses of big things like that.

14:35

Uh, double reads are also good,

14:36

particularly in the mammo area and,

14:38

and potentially with chest, um, chest review

14:42

of pain films for, uh, cancer in patients, you know,

14:46

with silicosis or asbestosis, et cetera.

14:51

So here's another story.

14:52

So the, we get a contract from RS NY in New York,

14:56

and, uh, it was when I was division chief,

14:59

and I was a big, you know,

15:00

big shot in head and neck radiology.

15:02

And the person who was involved there, uh,

15:05

Salvato contacted me

15:06

and said, I, I really am not

15:08

so comfortable with head and neck stuff.

15:09

Will you mind reading our head neck stuff

15:11

for our private practice group?

15:12

And I said, all right, sure, we'll take the con contract.

15:15

So there was a complex laryngeal cancer,

15:18

and, um, one of the members

15:20

of the RS NY team calls me up

15:23

and says, uh, Dave, um, on that laryngeal cancer case,

15:28

um, what's going on in the intraocular

15:31

cistern there on the brain?

15:32

First off, I was impressed

15:33

that they were double reading my

15:34

cases, which is a good thing.

15:36

Um, and this was a big basal artery aneurysm the first week

15:40

that we got the contract.

15:42

And I just script. So don't miss these things.

15:44

I'm really careful now on head

15:46

and neck cases to review the brain very carefully,

15:50

especially for vascular lesions.

15:53

Okay, tip number four, just checking the time.

15:56

Oh, I'm way ahead of time. Don't read tired, okay?

16:00

Take a nap if it, if, if you need to.

16:03

And I, and I sometimes do that on call when I'm doing the,

16:07

you know, 7:00 AM to 11:00 PM shifts.

16:10

Um, I'll take a break

16:11

and just take a nap for a couple hours.

16:13

Most misses occur at the end of the shift.

16:16

Most misses occur, as we saw with shift ba,

16:19

high shift volume with tired eyes.

16:21

And seriously, your eyes get tired, they get dry,

16:25

they get blurry.

16:27

Your, your foveal vision gets worse.

16:30

You know, there are exercises you can do

16:33

for your eyes to improve that.

16:36

So, you know, it may be appropriate for you to take

16:39

that weekend shift and split it with somebody, you know,

16:41

eight hours each rather than taking the full 16 hour shift.

16:46

Take a break. I, you know, caffeine does work.

16:49

And you know, if you need a little shot of your, uh,

16:52

power booster or, um, you know, six hour medic, you know,

16:57

medicate, caffeinated, uh, juice, go ahead and do it.

17:01

Um, some places actually restrict the number

17:04

of cases you read per shift.

17:05

I'm not sure that they do it because of that,

17:07

but I know that in, at Mayo Clinic, uh,

17:11

I believe they have a certain set number of cases you have

17:14

to read each day, and you could take as much time

17:17

as you want with that, and you could do it leisurely

17:19

and take your time and complete your assignment.

17:25

So radiologists make more errors interpreting off hours body

17:28

CT studies during overnight assignments

17:31

as compared with daytime assignments.

17:32

So overnight, you're more tired.

17:33

You, you know, your diurnal river rhythm is off.

17:37

And this was frequently on overnight,

17:39

more frequently the latter half of the assignment.

17:42

So the latter half of your shift, that's

17:45

where you make more errors.

17:47

So, you know, you need to take a break.

17:49

You need to do what it takes to caffeinate.

17:52

Uh, I do have my, my closest friend who, um,

17:56

I don't recommend this, who was kind of an Adderall junkie,

17:59

um, because he has

18:00

to do very long shifts at off hours not recommended.

18:05

So, um, this was a case where, um,

18:09

and this was the worst miss of my career.

18:12

So, as many cases as I've read in my career, this,

18:15

you're about to see my worst case.

18:18

And it was one where I was in the morning

18:21

reviewing Bayview studies, one of our sister,

18:23

sister institutions,

18:26

and there were like 40 overnight cases that I was reviewing.

18:29

And this was the 39th one.

18:31

I was kind of tired a

18:33

after, you know, having to look at someone else's studies.

18:36

And, um, it was a spine CT in an elderly demented

18:38

patient who fell at home.

18:41

Oh, lemme see what the joke was.

18:42

Here we're being sued by the big bad wolf.

18:44

Apparently he injured his back on our property while

18:46

he was trying to blow our health.

18:49

You just don't know what you're gonna be sued about.

18:51

So the patient had a CT scan of the spine

18:54

for the fall at home.

18:55

Patient was 83 years old and demented.

18:58

And it looked pretty good. And I was reviewing this.

19:01

I did my SI did my coronal.

19:02

I whoop, I'm stuck here. Let me see.

19:07

Oh, there it is. So I went through the axial,

19:10

and you know what I missed this, this is an oblique

19:14

sagittal image, and this is a facet fracture

19:17

of the superior facet.

19:18

I believe it was C six and I missed this right across here.

19:21

You know, the, the study has lot of noise.

19:24

It's DJ d it's 83 years old.

19:28

Um, there's shoulders probably co contributing to it,

19:32

but this is the fracture line right here.

19:35

And I missed it. And I didn't know that I missed it

19:40

until three hours later I'm on the shift by myself now,

19:45

and I get an MRI request and I look at this

19:49

and go, oh my God, what happened here?

19:54

And you can see that there's

19:58

offset here at the, uh, 2 3 4 5 C six, seven level.

20:01

Look at this. It was fine offset.

20:05

Look at the cord signal abnormality.

20:08

And the history was new onset paraplegia after fall at home.

20:13

So I go back to the CT scan, I go,

20:16

oh my God, I missed the fracture.

20:18

They took the patient out of the neck brace

20:22

and, um, she injured her spinal cord,

20:26

uh, out of the neck brace.

20:28

So, you know, obviously I called the clinician.

20:30

I said, there there was a fracture that was missed by myself

20:33

and the, and the resident on call.

20:35

And there's this displacement,

20:36

there's cord signal abnormality, et cetera.

20:38

You got the bright signal. I was horrified.

20:42

And as I said, this is the worst miss of my life.

20:45

Um, the patient was, um, basically, um,

20:49

paraplegic in the legs

20:52

and remained that way for the rest of her life,

20:54

which, uh, was nine months.

20:56

Um, the patient had to, um,

21:01

get, get the, the home redone with ramps and everything

21:05

'cause she was wheelchair bound, bound.

21:08

And, um, you know, I read this, I called the clinicians

21:12

and then I called medical legal risk manage

21:14

management at Hopkins.

21:15

And I said, I blew this.

21:17

I missed the case, and the patient has been damaged

21:19

and the court is injured.

21:21

I said, there's really no excuse.

21:23

You know, that there is a fracture on the CT that I missed.

21:27

And, um, risk management went to the family

21:29

and said, you know, we will cover all

21:32

of your medical expenses related to this as well as paying

21:36

for the architectural, uh, needs to adjust the house.

21:41

So I don't know how much this cost Hopkins,

21:44

but I was not sued.

21:45

The family never sued.

21:46

And, uh, it may be in part because the patient was demented.

21:50

Um, patient died nine months later from pneumonia,

21:52

not related, or I'm not, I doubt it, it was related to this.

21:55

But anyway, this is a story I'm telling you

21:57

because, um, you know, we make mistakes

22:00

and Hopkins is relatively proactive about recognizing its

22:05

mistakes and taking ownership with it

22:07

and offering the family money.

22:09

And I did not get sued.

22:10

Should have, you know, I could have been sued.

22:13

Um, so now, uh, the fellows and residents all know this.

22:17

Every single cervical spine case I do, I do an oblique

22:21

sagittal reconstruction to look at the facet joints

22:24

because I never want to have this happen to me again

22:27

and happen to the Haitian again.

22:29

So I think one point that I wanna make, and,

22:31

and that was probably a slip up

22:32

by me, think about the patient.

22:34

Don't think about you. You made a mistake.

22:37

We all make mistakes, it's going to happen.

22:40

And then you say, oh, I feel so bad for myself.

22:42

No, you have to feel bad for the patient.

22:44

I felt horrible for this patient

22:46

that I had caused this patient

22:47

to have loose function in the lower extremities

22:50

and became wheelchair bend, even if she's 83, even if she's,

22:54

um, demented, it's horrible for the patient.

22:59

Okay, tip number five, after that heartwarming

23:02

and uplifting story, oh my God, yeah, that 2012,

23:07

and I'm still kind of PTSD about that case.

23:11

Uh, number five, we look up prior images and reports.

23:15

Now, I am not a very good person about this.

23:18

I, I really should look up the prior reports more than I do.

23:23

I look up the prior studies,

23:25

but I don't necessarily look at the reports

23:27

of those studies when I'm doing a comparison.

23:30

And, you know, the other thing is

23:31

that the electronic medical record now is so accessible

23:35

to each of us that going into the electronic medical record

23:39

to find more clinical history is so important.

23:42

You know, if I see white matter disease in a 50-year-old

23:46

and I look up in the medical report

23:47

and the patient has hiv aids,

23:49

it's a lot different report than a patient

23:52

who has hypertension, hyperlipidemia, and is a smoker.

23:55

You know, it really helps to have that clinical information.

23:58

And of course, you're not getting it on the, on the, um,

24:02

you know, request slip.

24:03

It's gonna say change in mental status, right?

24:06

Uh, the patient's on Tysabri

24:08

and is a multiple sclerosis patient

24:09

and has all kinds of new white matter reasons.

24:11

Well, you know, if I know that I'm looking

24:13

for potential PML rather than, you know,

24:17

small vessel ischemic white matter changes.

24:20

So do take the time, particularly when it's a positive case,

24:23

it's a curious case or it's a little unusual

24:26

to spend the time in the EMR not only looking at

24:29

what the clinicians are saying,

24:30

but also what the previous report said.

24:33

This can help you have a directive reading.

24:35

If you know that the patient has bone hippo limbal disease,

24:37

you're gonna look at the retina for retinalblastoma.

24:39

You're gonna look at the temporal bone for,

24:42

and in fact, sac tumors, you of course go

24:45

and look at the cerebellum, but then you might even look in

24:47

the abdomen if you're a, uh, general radiologist and look

24:51

and see where there's pancreatic or renal problems.

24:54

So don't be overconfident in your own reads.

24:56

This is my issue, is that I look at the prior studies

25:00

and I think that I've read it

25:02

and I can read it myself better than I can read the report.

25:05

So why do I need to read someone else's report?

25:09

Except that you then get the, uh, Dave phone call

25:13

or email.

25:15

This one was by Justin MacArthur, the chair of neurology,

25:19

who is a multiple sclerosis, uh, specialist.

25:22

And he sent me a ba, you know, the case was an Ms. Case

25:25

where had lots

25:27

and lots of white matter lesions all over the place.

25:30

And, um, I get the, uh, request, uh, the email

25:34

or the phone call from Justin who says, uh, Dave, on

25:37

that Ms. Case, you didn't mention the meningioma

25:39

that NAFI called last year.

25:41

Okay? So why didn't you put it in the re in the request

25:44

MSM men and meningioma?

25:46

Nope, just follow up ms.

25:48

So I'm not blaming Justin, I'm blaming myself

25:51

because Nafi is a fantastic reader of cases of everything.

25:57

And in his report from the previous ms, uh, one,

26:01

he mentioned an incidental meningioma.

26:03

And fortunately, this meningioma did not grow on my

26:06

study a year later.

26:08

But, um, I hadn't looked at the report.

26:10

I was too busy matching up all the

26:13

damn Ms Plex right on the sagal flare.

26:17

Um, this was a case that I was asked as a medicolegal, uh,

26:21

case of a patient who had multiple sclerosis

26:23

and had Mike White w

26:25

and the report had said there's white mar disease in

26:27

the periaqueductal region.

26:29

Um, so here's the case that I missed the meningioma.

26:34

I was busy, you know, with all these other things

26:35

that are there and, and counting all the plaques

26:38

and matching 'em up.

26:39

And I didn't look for the meningioma.

26:42

This was the medical-legal that it was a patient who had MS

26:45

and had this bright signal over here.

26:47

And the radiologist did not know

26:51

that the patient had had bariatric surgery

26:54

two months earlier and was having all kinds

26:56

of nutritional issues.

26:59

I found that out when I was doing the medical legal case.

27:02

I read it blind and I said, you know,

27:03

this is periaqueductal gray mar.

27:05

That's not where we normally see Ms. Blacks.

27:09

This might be a case of thymine deficiency.

27:12

And I was reading this as a blinded case,

27:14

and, uh, you know, I'm worried about does the patient have a

27:17

symptoms of wares, um, you know, nystagmus

27:21

change in mental status, et cetera.

27:23

And sure enough, this was a patient who had MS

27:26

who had a bariatric surgery, and they did not.

27:29

The radiologist, the neuro radiologist who's reading this,

27:32

did not call and bring

27:33

to their attention the possibility of thymine deficiency.

27:36

And the patient never got thiamine replacement

27:38

and ended up with permanent benicky corso cough psychosis,

27:42

and, you know, lived with that.

27:44

And the, the, uh, radiologist was sued, uh, on that basis.

27:48

So, again, uh, a little bit

27:51

of clinical history there might have instructed the person

27:55

that this patient may have nutritional problems

27:58

after bariatric surgery with, with, uh, intake

28:01

or absorption of thymine.

28:03

It's, it's a common clinical history for thymine deficiency.

28:08

Um, so I had to testify actually for the, um,

28:11

for the plaintiff on this case.

28:14

Um, this is, um, uh, reference to a paper by,

28:19

um, the Emory Group.

28:22

And anything you see

28:23

with the co-author Elizabeth Repinski is great.

28:27

She is a fantastic, uh, researcher, PhD

28:30

researcher in perceptual

28:32

and cognitive errors in in radiology.

28:35

She does eye tracking studies.

28:37

She's a fantastic, uh, researcher.

28:39

And this one I highly recommend academic radiology 2019.

28:43

And it says that, you know, basically we have

28:46

to harness the electronic medical record

28:48

that will help us in the accuracy of our report, both

28:51

for detection errors as well as interpretation errors.

28:55

As you probably know, 80% of the errors

28:57

by radiologists are detection errors.

29:00

Where we miss something about 20% are interpretive errors.

29:05

Interestingly, interpretive errors

29:07

where you give the wrong diagnosis

29:08

or differential occur much more commonly in early in your

29:13

career when you don't have the experience

29:15

of having seen everything.

29:16

And different manifestations of common diseases

29:19

interpretation errors are very uncommon

29:22

for experienced radiologists 20 years out.

29:25

I don't make too many interpretive errors. I miss things.

29:29

Detection errors occur less commonly

29:33

in young radiologists

29:35

'cause they're like so scared about missing something.

29:37

They're looking at the study, you know, 10,

29:39

20 times all the different detection modes.

29:42

So anyway, um, electronic medical record will help you

29:45

with both detection and interpretation errors.

29:49

Okay? Part number six.

29:51

And this is, uh, for those people predominantly in academia,

29:55

and as when you are reviewing a trains report,

30:00

start with just reviewing it on your own without looking at

30:03

the trainees report and make a judgment of what you see.

30:07

Do not let the trainees report direct your attention,

30:10

because again, it sort

30:12

of satisfaction of search type of thing.

30:14

So beware, signing off on trainee reports.

30:17

Most of my errors, including that 2012 cervical spine

30:22

was an error where the, the,

30:24

a very reliable radiology resident missed the fracture

30:27

as well as myself, you know, signing off on it.

30:29

Um, you know, you don't, you know,

30:33

look at these cases independently,

30:34

it's like double reading, right?

30:36

So it's a good thing if you do that. So don't be complacent.

30:41

Um, when we looked at the rate of errors

30:44

with fellows versus the rate of errors with residents,

30:49

there really wasn't that much

30:50

of a statistically significant difference.

30:52

So you might say, oh, the fellows much better, you know,

30:55

completed a residency.

30:57

Um, I'm good with that. You know, pretty good, good report.

31:01

Like, no, even with that, look at the report.

31:04

So look at the case on your own.

31:06

So we looked at opportunities for targeted education,

31:09

critical neuroradiology findings, missed

31:11

or misinterpreted by residents or fellows,

31:13

and gives those numbers.

31:15

All of my clinic, all of my miss misses

31:19

were detection misses

31:20

and generally on cases I read with a trainee.

31:23

So we have, you know, pretty good peer review at Hopkins.

31:26

Um, but I do better reading the case

31:30

by myself than I do reading someone else's report

31:34

of someone who's previously reported it.

31:37

So sometimes the fellows will say, Dr.

31:39

youSo, you're stealing all the cases.

31:40

You know, you're reading the cases instead

31:42

of letting me read them.

31:44

That's because I'm worried

31:45

because most of my errors are when I read with a trainee

31:49

as opposed to just me reading it.

31:51

So, um, that's my personal experience.

31:57

Okay, case number, uh, point number seven,

32:01

interpretation misses.

32:02

Okay? So you've got a really good template.

32:05

You're not making detection misses, you know,

32:07

the template's kind of directing you to some of your, uh,

32:09

hidden spots or your pit potential

32:12

pitfalls or your blind spots.

32:14

So you're pretty good with that.

32:15

How do I improve my interpretation, Mrs.

32:18

Where I say it's a, you know, a brain tumor

32:22

and it's really tumor effective ms, how do you do that?

32:24

Well, that's gaining knowledge and gaining knowledge.

32:27

You know, it is like you don't see what you don't know.

32:31

So how do you improve your fund of knowledge?

32:33

I want to say this to the young radiologists in practice

32:38

as well as all the trainees.

32:40

Go to multidisciplinary conferences, find out

32:43

what they're asking the radiologist, find out what they need

32:46

to know, not, you know, whether

32:47

or not the patient has a lens implant, uh, you know,

32:51

on the CT scan, you know, those things are irrelevant.

32:55

What do the clinic clinicians need to know?

32:57

Go to path and learn about the pathology

33:00

of cases go to tumor board.

33:02

So important, particularly with head and neck in particular.

33:06

So important, uh, brain tumor to tumor board.

33:10

So important to know all the potential pseudoprogression

33:13

and pseudo response, uh, algorithms, for example.

33:17

So I'm gonna do my shameless plug to improve your fund

33:21

of knowledge, um, as a consultant for

33:25

MRI online modality, um, you know,

33:27

this is a good potential means.

33:29

Or if you person who likes to read books, the fifth edition

33:33

of neuroradiology, the requisites now called the

33:36

core requisites, is out.

33:38

And I give credit to Rohini Nagar

33:40

and Doris Lin, who are the primary, uh,

33:45

authors of the book, but lots

33:46

and lots of chapters by other people as well.

33:49

So you need to increase your fund of knowledge.

33:52

There's one source. So, um,

33:57

you know, I've been doing this for a long time,

33:59

and yet, um, I have gaps in my knowledge.

34:02

Uh, a lot of pediatric neuroradiology conditions.

34:05

I give credit to island ish

34:06

and Malika, um, who are are pediatric neuroradiologist

34:10

who teach us each time, um, at the society meetings.

34:15

I tend to go to the bizarre entity, um,

34:20

sessions to try to learn new things rather than, you know,

34:24

the latest stroke, uh, treatment,

34:26

um, interventional neuroradiologist.

34:28

I don't do it, but I need to know some of that stuff

34:31

for the relevant findings.

34:33

Um, anytime there's a clinician speaking

34:37

at an a radiology meeting, I try to attend that

34:40

because that's where you get, you know, relevant things

34:45

to be put into your reports.

34:47

You listen to the clinicians as far as what is

34:52

critical in the report that helps them diagnose

34:55

and or treat the patient.

34:56

So clinician's perspectives, I think, are the best parts

34:59

of our annual meetings.

35:02

So, um, for example, a couple months ago, um,

35:07

kudos to Francis De, who is one of our new faculty who's,

35:11

um, at Hopkins, uh, MGH Fellowship graduate,

35:15

a brilliant individual, great educator.

35:18

And, um, you know, we were looking at a case

35:22

that looked like small vessel ischemic disease routine kind

35:26

of, um, except

35:28

that on the CT scan there were these little

35:30

hyper, uh, dense areas.

35:32

This is not the case that we had, but it is from the thing.

35:35

And, and Francis showed this as a case of

35:39

CSF one R related leuk encephalopathy.

35:42

I said, I never even heard of that,

35:44

and he gave me a nice reference so I can read it up.

35:46

And it was a systematic review.

35:48

And, um, it's a related, it's a rare be fatal

35:53

Myopathy diagnosis is important to make

35:56

because, uh, there is treatment

35:59

that can prevent it from its, um, major, uh,

36:03

deficits, morbidity, and mortality.

36:05

So, uh, kudos to Francis. Um, never heard of it. He knew it.

36:10

And, um, you know, satin gja at

36:12

nor in neuroradiology at Hopkins, NAFI Agen,

36:15

formerly at neuroradiology at, I learned so much from them

36:18

because they are great readers of cases as well

36:23

as fund of knowledge and medical literature.

36:25

So, uh, Francis is in that boat too.

36:27

We've got lots and lots and lots of great people

36:30

in academia.

36:32

Um, but you've got, you know,

36:33

you've gotta read the journals.

36:37

Okay, tip number eight,

36:39

establish prospective peer review in your group.

36:42

Now, this is something that we have created at Hopkins,

36:46

and I think it is very helpful for avoiding suits,

36:50

and that is find the errors early.

36:52

I'm not, I never was a big fan of rad A CR Rad peer.

36:56

The reason for that is that

36:58

although you're reviewing a prior study,

37:00

that study may be six months ago,

37:02

and then you find an abnormality,

37:04

and the disease has progressed

37:06

and the disease is now no longer resectable.

37:10

When you look back on cases, what we created at Hopkins

37:15

and was subsequently sold to Phillips

37:17

was prospective peer review,

37:19

where you review each other's cases as they come out.

37:23

So you catch the error, the miss, the detection miss

37:27

within 24 to 48 hours of the completion of the report,

37:30

rather than seeing it a year later when, oh, yeah, now

37:34

that little lung, lung nodule

37:36

that was five millimeters is now 20 millimeters in size.

37:39

You don't wanna look back. You wanna catch

37:41

that five millimeter nodule

37:43

that was missed at the time it was missed.

37:45

And this, I give credit to my, um, brother Sam, um,

37:51

who, um, passed away in 2021,

37:55

but Sam created this at the University

37:58

of Pittsburgh Medical Center in pathology,

38:00

where a certain percentage of the pathology cases had

38:05

to be double reviewed before they were sent

38:07

to the electronic medical record.

38:09

Now, we don't do that at Hopkins, we don't, the reports go

38:12

to the electronic medical record,

38:13

but within 24 hours, a certain percentage

38:16

of them are double read as part

38:18

of peer review in the neuroradiology division.

38:20

So, and Sam was able to ratchet this up.

38:23

So for new pathology faculty,

38:27

he could have 15% of their, their reports we reviewed,

38:32

uh, before going out to the medical record.

38:34

And for people who are well established, you know,

38:36

in 20, 25 years experience, he could turn that down

38:39

to a 3% review rate.

38:41

So it was adjustable.

38:42

And we did this at, at Hopkins,

38:45

and subsequently, as I said, sold the product to, uh,

38:48

Phillips for prospective peer review rather than,

38:51

so we catch errors early rather than in retrospect

38:56

on rad peer months and months later.

38:58

So I think that's pretty important.

39:00

Now, I tend to be a little bit more critical

39:03

of my colleagues, um,

39:05

because when I ding somebody on an error, a detection,

39:10

error, interpretation, error, et cetera,

39:12

we separate 'em into clinically significant

39:14

or not clinically significant like rad p um,

39:17

but when you ding somebody, it increases their level

39:20

of dinging other people as well,

39:22

which is the bias in neurology, peer review, the impact

39:25

of a ding on dinging others.

39:26

So the, the likelihood that you're gonna ding someone else

39:28

when you've been dinged is higher, which is a good thing.

39:31

You want people to be critical of each other in

39:35

identifying blind spots or misses, et cetera.

39:38

So, um, in your practice, I highly recommend that

39:43

you convert to a prospective peer review

39:46

that catches the missed cancer, the missed breast nodule,

39:50

the missed lung nodule at 24

39:53

and 48 hours, rather than seeing it in retrospect,

39:57

six months later, one person's opinion.

40:01

Okay? Number nine, mitigate any damage. Okay?

40:03

So when you do have a miss, um, don't,

40:08

don't hide it, don't sweep it under the rug.

40:12

Take it seriously and address it.

40:14

So if you've missed something

40:16

and you see it in your retrospective study,

40:19

I call the clinician and say, you know, this patient has a,

40:22

uh, vesti schwannoma,

40:24

and I'm looking back at my prior report from six months ago,

40:27

and it was there and it hasn't grown or it has grown,

40:32

but I call the clinicians with my misses and,

40:35

and let them know and deal with it,

40:37

because I don't want to just put in a report

40:40

and have that report not be seen by the clinician

40:42

until six months later when the patient comes in for their,

40:45

for their outpatient, you know, visit.

40:48

And then that he reads the report, she reads the report,

40:51

and she says, oh, uh, by the way, six months ago on your MR

40:54

that we ordered, uh, there was a vestibular schwannoma

40:56

and uhoh, you know, has it grown in six months?

40:59

Uh, I'm on top of it. So mitigate the damage.

41:03

If you have an interventional, you know, a,

41:06

a patient who's got severe headaches

41:08

after a lumbar puncture, do the blood patch

41:10

and take care of the patient.

41:12

Um, if you are doing interventional procedures

41:15

and there's the embolus that occurs

41:17

because of a dissection of a vessel, go get it.

41:20

Mechanical thrombectomy, you know, you take care

41:22

of your errors prophylax your, the patients.

41:26

If they've got an allergy to iodine

41:28

and they're coming in for an MR

41:30

and they've had an anaphylactic shock for the,

41:33

from the iodine premedicate, I mean, what's the,

41:36

is there really much harm in putting the patient on steroids

41:38

for, you know, 24 hours?

41:41

Some patients, yes, but otherwise not.

41:44

So, uh, it's personal.

41:46

So here's a case, uh, where I was asked to do a, um,

41:51

uh, cervical myelo on a, um, a,

41:55

actually a complete myelo on a con plastic wharf

41:59

who had a pacemaker and it had surgery in the lumbar spine

42:03

and could not be approached from the lumbar spine.

42:06

Now, I've done a ton of C one two punctures for myography.

42:10

I love it. It's a lot of,

42:11

it's a high anxiety, but a lot of fun.

42:13

And, you know, I've written papers about the importance

42:16

of being able to do C one two punctures, uh, in patients

42:19

who have been operated previously.

42:21

So obviously these patients who are aplastic dwarfs have,

42:26

you know, stenosis, it's a challenge.

42:29

This patient came in with diminished sensation in their arms

42:33

and hyperreflexia as the clinical symptoms.

42:35

So myelopathy, right?

42:37

So I do a C one two puncture and I'm supervising the fellow.

42:41

And here was the fluoro image

42:46

that we had done, uh, maybe a little bit anterior,

42:50

but it looked like some of the contrast was trailing off,

42:53

but it wasn't really moving.

42:56

And, um, so I said, you know, let's stop,

43:00

let's just check, you know, let's do a ct.

43:04

Uh, I'm not sure where the, why this contrast is not moving.

43:07

So here it is on the CT scan of the, uh, cervical spine.

43:12

You notice it's a mixed injection.

43:14

We were coming from the left side of the patient

43:17

and there's contrast in the spinal cord.

43:19

Should I be there? You know, when you measure this,

43:23

this was about eight millimeters by three millimeters

43:29

by four millimeters.

43:31

And when you measure that in terms of CC of contrast,

43:35

it's about less than one cc.

43:38

One cc would've been one centimeter

43:40

by one centimeter by one centimeter.

43:41

This is eight millimeters by four millimeters

43:45

by three millimeters.

43:46

So, you know, it's a tiny amount of contrast

43:49

that was in the spinal cord,

43:50

but it was a cord injection, it was a mixed injection.

43:55

So immediately I call the clinician

43:59

and I say, we got put this patient on steroids,

44:02

and the patient was admitted, got IV steroids for 24 hours.

44:06

Why did this occur? You know, in retrospect,

44:09

this patient did not respond

44:10

to being dinged in the spinal cord with the needle.

44:15

And I'm wondering why is that?

44:16

Well, the patient had a myelopathy

44:18

and had decreased sensation in the upper extremities.

44:22

Normally you get a rare meat sign

44:23

and they go, God, you know, you hit my cord.

44:26

You know, this patient did not respond

44:28

because that was the pathology that they had.

44:31

Look at the spinal stenosis here in previous surgery.

44:34

So, um, we were a little bit complacent,

44:38

but we caught it just less than one CC in the court.

44:43

Patient got steroids and did not progress.

44:46

We did not get sued, not sure

44:48

that this would've been justified.

44:50

Sued. We did everything in the, under the typical, uh,

44:53

standard of care, but it happens.

44:56

This one not so much. Okay?

44:58

So again, a patient who's been operated on,

45:01

you're doing the C one two, this is not my case.

45:03

This is a case from, uh, another person.

45:06

Um, and you know, you're trying

45:09

to navigate the where the needle is going.

45:10

You've got so much hardware, patient's obviously not doing

45:15

so bigger amount in the spinal cord.

45:18

Again, take care of it yourself.

45:20

This patient, you know,

45:22

although it's not, it's empirical data,

45:24

it steroids will help decrease the inflammation associated

45:27

with having contrast in your spinal cord.

45:29

Take care of it. Um, again, you notice a lot

45:32

of these are in the post-op patients

45:33

who have less sensation in, in some ways.

45:37

This is patient of my mother's, of my mother's, oh my God,

45:40

this is a patient of my wife.

45:42

So my wife is a plaintiff malpractice lawyer,

45:45

and she had this case where a patient who had

45:49

a prior testicular cancer, um,

45:52

with retroperitoneal lymphadenectomy performed

45:56

complained post-op of having abdominal pain.

45:59

And the surgeon who took care of the patient said, yeah,

46:03

yeah, you know, you'll get better,

46:05

you'll get better months go by.

46:06

The patient's still complaining about pain in the

46:08

abdomen after the surgery.

46:10

And the surgeon, uh, orders the CT scan of the, um, abdomen,

46:16

gets the CT scan result,

46:17

and says to the patient, Hey, you know,

46:19

there's leftover lymph nodes there.

46:20

I have to go back in to remove more lymph nodes.

46:23

And the patient says, forget it, you know,

46:25

I'm in pain as it is.

46:26

I don't want any more surgery. No way.

46:29

20 years go by,

46:31

the patient has chronic abdominal pain

46:35

and 20 years later goes to the ED for one of these episodes

46:38

of chronic abdominal pain

46:39

and gets a plain film of the abdomen.

46:43

And what do they see? A 12 inch ribbon retractor

46:46

that was left in the abdomen

46:51

at the time of the initial surgery.

46:56

So my wife goes, can this be missed on a CT scan?

46:59

I said, of course not.

47:01

He said, she said she,

47:03

he got a CT scan three months after surgery.

47:06

I said, it would've been found,

47:08

and let me tell you, it's probably

47:09

in somebody's teaching file.

47:11

So she found the radiology group that did the, um,

47:15

that did the CT scan and found out who was on call that day.

47:19

They actually had the ca the call logs for that day.

47:23

And she found the radiologist and she calls the radiologist

47:27

and she says, you know, I have this case from Mr.

47:29

so-and-So, and, um, there was a ribbon retractor

47:32

that was left in the abdomen.

47:33

It's 14 inches long.

47:34

Do you remember the CT scan of that report?

47:37

He goes, oh yeah, I remember that.

47:39

He said, that was so amazing, this big ribbon retractor.

47:42

I called the surgeon and I said, Hey, you know,

47:45

there's a ribbon retractor left in the abdomen here.

47:48

Oh my God, I've never seen this before.

47:50

He said, I got it in my teaching file.

47:53

He told the surgeon, and the surgeon never told the patient

47:56

and swept it under the rug

47:58

and didn't deal with it, you know,

48:00

take care of your mistakes.

48:01

This, this patient wasn't in discomfort for 20 years.

48:05

Well, you can imagine how much money that made for my wife

48:08

who settled out court with the, uh, with the plaintiff.

48:12

Number 10, make sure you know the standards,

48:15

because at a medical legal case,

48:18

the lawyers are always going to bring up the standard

48:22

of care because the breach part of a suit, you know,

48:26

duty breach causation damages is, um, breach

48:30

of the standard of care.

48:32

And unfortunately, you have to be aware of the standard

48:34

of care in your institution as well

48:36

as within your specialty.

48:38

So your institutional rules, generally it's the local rules

48:43

that rule over national rules.

48:46

So if your hospital requires every patient coming into the

48:50

hospital to be tested for HIV

48:52

and one patient doesn't get an HIV test, you could be liable

48:57

because that's the standard at your institution.

49:00

It's not the national standard,

49:01

but it's the standard at your institution.

49:03

So all those book of standards and rules

49:05

and regulations in your institution,

49:07

you gotta know them, kind of, you know.

49:10

So, um, unfortunately there are a CR communication,

49:15

um, information here that,

49:18

and this is what's very cute, okay?

49:20

'cause the a CR used to put out practice standards.

49:24

And what happened was that lawyers would read those

49:28

standards and then quote them to plaintiff radiologists

49:32

and say, but the a CR standard says this.

49:35

So the a CR got a lot of negative feedback

49:37

and they changed the standard

49:39

because the standard is standard of care

49:41

and change it into guidelines.

49:43

So this, you know,

49:45

the lawyers still said the guidelines here say that you have

49:48

to contact the patient when you have a pne.

49:51

Uh, you have to contact a

49:52

clinician when you have a pneumothorax.

49:53

And again, the a CR got

49:56

negative feedback from its membership

49:58

because they were being sued based on the a CR guidelines

50:02

to now the a CR has called them practice parameters,

50:06

same exact text,

50:07

but they've gone from guidelines to standards

50:10

to now practice parameters.

50:11

And you have to know these fairly well.

50:14

So for example, at Hopkins, Elliot Fishman, who's our head

50:19

of, um, diagno was our head of diagnostics, um, radiology

50:23

for, you know, 35 years.

50:25

Brilliant man, you know, you probably know his CT is us.

50:28

He had a certain way of handling anaphylaxis prevention

50:32

that was born out of 35 years of practice

50:35

and a very good track record.

50:37

And this was the protocol, 40 milligrams, 24, 12,

50:40

and two hours prior to the CT scan.

50:42

Unfortunately, that's not what the a CR recommendations are,

50:46

which are 50 milligrams of prednisone 13 seven in one hour.

50:50

And there was a lot

50:51

of discussion about these subtle differences about whether

50:55

we should abide by the a CR standard

50:57

or the Fishman standard, given that he is

51:00

so well known in the field and is a noted expert.

51:04

Um, to suffice it to say

51:06

that in the neuroradiology division, we went

51:09

with the a CR guidelines because we didn't want,

51:11

or a CR practice standards, sorry, uh, practice parameters,

51:15

because we didn't want to have

51:17

that potential issue if a patient, for example,

51:20

had an actic reaction on the Hopkins protocol.

51:24

Same thing with communication.

51:25

This is the most, you know, I have seen a number of cases

51:28

where I've testified about the lack of communication,

51:31

about a significant finding by the radiologist.

51:34

And you know, you have to know what you need to do

51:37

with non-routine, uh,

51:40

communications when something is emergent

51:42

or non-routine clinical situation and the practice.

51:47

Um, the practice parameter talks about the things

51:50

that are needed for immediate or urgent reading.

51:52

Things like pneumothorax, pneumo, pneumoperitoneum,

51:55

or a misplaced line

51:56

or tube, um, discrepancies

51:59

with the preceding interpretation.

52:01

So if they said that the test x-ray was fine, and you look

52:05

and you find a small pneumothorax, the you have

52:08

to have discrepancy also with a preliminary report findings

52:12

that the physician believes are significant

52:13

and unexpected findings, like, you know, an aneurysm

52:16

and a patient who has a laryngeal cancer, et cetera,

52:19

you have to document it, et cetera.

52:21

All these things are in the a CR site,

52:23

and unfortunately,

52:25

it will be brought up at a medical legal case if you did not

52:29

expeditiously communicate with a clinician.

52:32

So we, um, we would ding people, um, if they didn't

52:38

notify patients, uh, clinicians about critical findings.

52:41

And after doing this, uh, study where we, uh,

52:44

looked at reports and consulted with the radiologist

52:48

and said, Hey, this was a critical finding that was not

52:51

communicated, um, we increased our rate of

52:55

appropriate communication significantly, um,

53:00

from 2.3% errors to 1.28% errors.

53:05

So here's my top 10 for you all to, uh, again,

53:09

serve a little bit humorous, but read fewer cases.

53:12

Get grant funding so you're only 50%, um, on clinical

53:16

or become the radiology chairman, where you may not have

53:19

to read cases at all.

53:21

Um, but know your limits

53:24

and potentially set a limit on

53:27

how many cases you read in a shift or in a long day.

53:30

Strategize for your detection misses.

53:31

That may be your detection template. Satisfaction of search.

53:35

Don't stop. You know, um, there may be five findings on

53:39

that Marfan's case.

53:41

Don't miss big things

53:43

and make sure that you're aware of of them.

53:47

Don't read tired, take a break, take a nap, take caffeine

53:52

and rest your eyes.

53:53

Go for a walk, et cetera. Look at the prior studies.

53:58

Look at the prior reports

53:59

and look in the EMR, particularly if you're,

54:03

you've made a finding

54:04

and it's not compatible with

54:06

what the clinic clinicians are saying,

54:07

or it doesn't really fit, go into the EMR, look at the labs.

54:12

You know, when I see a patient who has something

54:15

that looks like just degenerative nplate disease,

54:18

modic type one, and then I look

54:20

and see that thes rate's a hundred

54:21

and the CRP is, you know, 40

54:24

and the white blood count's 19, I may shift from saying

54:27

that's modic type one to potential dis osteomyelitis.

54:31

That's the value of even looking at the labs,

54:34

not just the, the re the notes.

54:37

Review other people's cases as if it was your,

54:39

your own case, as if it was a double read.

54:41

Don't read the report and then look at the, the case.

54:44

Improve your fund of knowledge. Lots of ways to do that.

54:48

Establish prospective peer review in your practice.

54:51

So you catch mistakes going out, not months

54:54

and months later, as in rad peer

54:58

mitigate any damage when you make a

54:59

mistake, call the clinician.

55:01

I, this was present three months ago.

55:04

Um, there is a lesion, you know, in the spinal cord

55:07

that could be from our, um, lumbar puncture

55:11

or cervical puncture.

55:13

Know the standards.

55:16

Um, one more thing about potentially avoiding being sued.

55:21

Uh, I have some bad news.

55:22

Our hospital's malpractice insurance forbids

55:24

us from treating lawyers.

55:26

So don't read any lawyer studies if you can identify that.

55:30

Um, I do want to again, uh, put in a plug for this, um,

55:35

article in academic radiology, um,

55:39

on perceptual interpret causes and potential solutions.

55:42

They have strategies

55:43

to reduce informational error mechanisms

55:46

to reduce cognitive error.

55:47

You can look those over

55:48

and strategies to mitigate perceptual errors worth reading.

55:52

Uh, a good article 2019 search under

55:56

the first author Nan.

56:00

So with that, I'm gonna look at some of the q and a.

56:03

Let me stop, uh, stop share and q

56:07

and A here, Q and a.

56:09

How many cases get read in an eight hour?

56:11

Shifting your institution? What advice do you have

56:13

for consistent high volume readers?

56:15

So, um, remember that we are in neuroradiology CT

56:19

and, um, MRI, uh, no plain films.

56:23

So in general,

56:26

I would say our average eight hour volume is about 50 cases.

56:30

And depending upon whether you're doing predominantly

56:34

teaching with the resident, you're reading on your own,

56:36

et cetera, it may flex lower or higher.

56:39

Um, but one of the things that I,

56:44

I'm opposed to,

56:46

but is in effect in our department is

56:48

that we get bonused based on higher RVs.

56:53

So depending upon whether you read more

56:55

and more cases each day,

56:57

you will get a higher quarterly bonus

56:59

of clinical productivity.

57:01

The negative of that is obviously, you know,

57:03

you may read it when you're tired,

57:04

you may read more quickly,

57:06

you're trying to get through more cases.

57:08

Um, I wish there was another way of incentivizing people

57:13

beyond, you know, this graded scale of read more cases.

57:18

Uh, first and last, oops, sorry.

57:21

Uh, first and last slice misses, agreed agree.

57:25

You know, um, look at every image

57:27

and you know, whether the, the study has 5,000 images

57:31

or 50 images.

57:33

My wife, the plaintiff malpractice lawyer will say to you,

57:36

you have to read every image.

57:37

And I don't care that it was only on one slice,

57:40

you should have missed it.

57:41

Are you saying that you're only responsible for 499

57:45

of the 500 images?

57:46

You're gonna get dinged on that.

57:48

So every slice is important.

57:51

Uh, use of short bevel needle

57:52

for C one two bug specific needle recommendations.

57:54

So we looked at the different numbers.

57:57

Um, you know, uh, when I was a trainee, we,

58:01

we used 25 gauge, uh, needles for cervical spine,

58:04

um, injections.

58:06

The problem is it's hard to see the contrast coming out

58:09

of a 25 gauge needle.

58:10

So we used, uh, 22 gauge needles.

58:13

We use, uh, the bevel

58:14

of the standard Becton Dickinson bevel cut.

58:16

We don't use the blunt needles.

58:18

Um, the blunt needles may be, uh, better for CSF leaks.

58:23

I'm not sure the literature is all over with that,

58:25

but, um, usually we're using a 22 gauge to do the injection.

58:31

Excellent presentation. Thank you. To online.

58:32

How do you select cases for peer review?

58:34

In our group, it's totally, um, random.

58:37

You get a, based on the number of cases that you have read

58:42

at baseline, you have to do peer review on 3%

58:47

of your volume, not on your own

58:49

cases when someone else's case.

58:50

So if I read 600 cases, I have to read

58:54

18 peer review cases of someone else.

58:58

Um, and it prioritizes

59:03

the recent 24 to 48 hour cases.

59:05

So that's how we, um, do it.

59:07

And there's just the list that's, you know,

59:09

18 cases are listed there

59:11

and I have to do them, um, for the, um, for the numbers.

59:15

This is monthly. Okay, next thoughts on using the, I go by,

59:19

by my, what I, I learned training not

59:22

with a CR practice parameters when in malpractice.

59:26

So, um, you have to refer to a standard

59:32

and, or a, um, a standard

59:36

of care within your practice or your institution

59:41

or your hospital or your specialty.

59:45

So, um, I would say

59:49

that you may be subject

59:50

unless you can identify what the training, you know,

59:54

you had the training manual or you have some slides from

59:57

your training that says this.

59:59

But if you are in a private practice setting,

60:02

and you were trained in a university setting, those

60:07

practice standards may be different.

60:10

In fact, I have to say this, when I'm a medical legal expert

60:14

and I, um, identify an error that was made by a radiologist,

60:18

um, I asked the, the, um, the lawyer,

60:23

was this person subspecialty trained in neuroradiology

60:26

Because in my opinion, the standard

60:29

of missing something like, for example,

60:31

that bariatric surgery case with thiamine deficiency,

60:34

I've done 10 thiamine deficiency cases

60:38

where I've been an expert witness.

60:41

And what I would say is that

60:43

I don't expect a general radiologist

60:46

who never did a neuroradiology fellowship in private

60:49

and is in private practice in blocks in Mississippi just

60:52

to make up a city, um, to be able

60:56

to detect thymine deficiency.

60:58

If the person has had a neuroradiology fellowship

61:00

or is reading neuroradiology

61:02

predominantly, I do expect them.

61:04

So the standard of care at that locale in the same setting,

61:09

I think is different when it's a general radiologist versus

61:12

a academic neuroradiologist.

61:14

WW should someone at, at, you know, Stanford, miss a,

61:18

a thymine deficiency case?

61:20

No. Should a private practice community radiologist

61:23

who does, who is doing it on the weekends doing

61:26

neuroradiology, miss it.

61:28

I, I think that that's different standard. Okay.

61:32

Um, let me see, uh,

61:37

thoughts on, I go by myself.

61:38

Do you have any resources for templates?

61:41

I do not use templates.

61:42

Um, I will refer you to Jen Hong at Hopkins,

61:47

who is our expert at templates and is a big advocate for it.

61:51

Um, Adam Flanders, also at Thomas Jefferson. Brilliant guy.

61:55

Funniest neuroradiologist.

61:57

I know also, I recommend him highly. He has templates.

62:00

Maybe you can ask them. Okay. Uh, where am I going?

62:04

Okay, Ray, talk.

62:05

Does the settlement agreement money get covered

62:07

by the own radiologist malpractice insurance?

62:12

Um, yes. Hopkins Self insurers, they paid the money.

62:18

Um, yes, the, the Plaintiff's malpractice insurance company

62:23

pays the money to settle a case,

62:26

not the radiologist themselves.

62:28

Next question. Thank you for great session sharing.

62:31

Will this lecture be posted on an M MRI one? Yes, it will.

62:33

I would like to show this to my residency program.

62:35

Priests do, um, short nap

62:39

between two shifts would help.

62:42

For those of you who don't know me personally,

62:45

um, glad to meet you.

62:47

Um, almost all of the, the people at Hopkins know

62:50

that from three to 4:00 PM Eastern time, I take a nap.

62:56

And then I am on shift generally from four 30

62:59

to 11:30 PM at night.

63:02

So I take a nap right before my shift.

63:05

Um, I am the evening reader, uh, during the weekend shifts.

63:09

When I'm at Bayview, generally from 7:00 AM to 9:00 PM at

63:14

around one or two o'clock, I just put my feet up

63:17

and snooze a little bit, get some coverage.

63:19

So I think naps are very important.

63:21

You have to get used to it.

63:23

It's part of my lifestyle that I nap every day.

63:26

So, um, some people when they wake up from a nap,

63:28

they're kind of groggy, not me.

63:30

All right. What is your opinion on too often using

63:32

non-specific white marrow disease

63:33

and hedging with, if clinically consider,

63:35

consider further evaluation with MRI?

63:37

So, um, my, my use

63:40

of the term not white matter disease

63:43

is usually couched in appropriate

63:45

or non appropriate for age.

63:47

So I will say, um, there is

63:50

bi bilateral per periventricular in injects the cortical

63:53

white matter, high signal intensity, foci in the brain,

63:56

most likely from chronic small vessel ischemic disease,

63:59

comma, greater than expected for age or appropriate for age.

64:03

That's my standard report.

64:05

As far as non-specific white matter in a 40

64:08

or 50-year-old, I go into the EMR.

64:11

If the patient's a migraineur

64:12

and it's just juxta cortical stuff, I say probably secondary

64:15

to the patient's migraine.

64:17

If it's, you know, patient who doesn't have any of that,

64:21

I will often say most likely from chronic small vessel

64:23

ischemic disease, uh, recommend correlation

64:26

with atherosclerotic risk factors.

64:28

If it looks like something other than just routine stuff,

64:31

then I'll add in, you know, um,

64:34

this could represent demyelinating disorder, recommend MRI

64:37

of the complete spine, et cetera, et cetera.

64:39

But, um, you know, give them the study

64:44

that will help them next.

64:46

That's my opinion. And it may be that you say, you know,

64:49

lumbar puncture for my own base protein

64:51

and AL bands, you can say these things,

64:54

how are the massive $100 million et cetera suits paid out?

64:58

Can those be career ending for ducks?

65:00

So according to my wife who is a, as I said,

65:02

a plaintiff malpractice lawyer, they don't want to sue

65:06

a person and get into their personal finances.

65:10

They usually will sue for malpractice limits.

65:13

So even if the damages are 5 million,

65:15

if you've only got 1 million in malpractice insurance,

65:18

they're not going for your personal, you know, to,

65:21

to make you bankrupt.

65:23

They will settle for prac, you know, the malpractice limits

65:28

and encourage the, the, the defense lawyer

65:33

to accept that because there is that risk of something more.

65:37

So most of the time you have a certain amount per case

65:41

and a certain amount per year.

65:43

So it may be you're up to 2 million per case

65:46

for 6 million a year.

65:48

If you get sued for 20 million, what happens?

65:50

Usually they, you don't get,

65:52

the plaintiff doesn't get that money.

65:54

They usually will settle for the practice limit.

65:56

Uh, thanks for a great presentation.

65:57

Is peer review only amongst peers in the strictest sense?

66:01

Are you peer reviewing, owning neuro cases? Yes.

66:03

Neuro is for neuro bodies, for body mammos,

66:05

for mammo ultrasound, ultrasound, nukes,

66:07

nukes PS, neuro cases.

66:09

Um, no we don't

66:13

peer review the peds neuro cases,

66:15

the peds neuro people peer review each other neuro IR cases.

66:18

Uh, spine we do because myelograms

66:22

and some biopsies in some, um, blocks, we do do residents,

66:26

fellows peer review attending cases.

66:27

No, thank you for explaining.

66:30

Do you use dictation system

66:31

and report in so many cases a day?

66:33

It seems six or more every hour.

66:34

So you have a system that goes so fast, like regional ology.

66:37

So I'm a, as you could tell just

66:38

by now, I talk very quickly.

66:39

So therefore I can get through a lot of cases very quickly.

66:42

Um, we, um, do use,

66:46

uh, PowerScribe.

66:48

So, and it's pretty darn good, I would say,

66:51

and I have no problem

66:52

with reading multiple cases in an hour.

66:57

And you know, obviously in academia you're also checking

67:00

your residents and your fellows cases.

67:03

So that may or may not be faster or slower.

67:05

For me, it's a little slower. Uh, I dictate very quickly

67:09

and, um, um, I I, I have to say this

67:12

and don't quote me.

67:14

Uh, I don't believe in templates.

67:16

I like to just look at the image

67:19

and just read what I'm seeing

67:20

and never have to look over at the dictation panel

67:24

to see the re what's happening in, in a template.

67:27

I'm just focused totally on the images

67:29

and just talking to the images.

67:31

In fact, two or three times a night I will look over

67:35

and I forgot to hit the button to record

67:37

and I'm like, oh man, I just dictated this long report.

67:40

And I never even looked over to see whether it was recording

67:43

'cause I was just focused on the images.

67:45

I am pretty fast in that way

67:46

because I don't have to scroll through templates

67:49

and look at things back and forth.

67:50

So that's just me. And is it hard to face the mistake

67:54

and communicate in a non-friendly environment?

67:55

Very smart people. There's people yelling at, so, you know,

67:59

as I said, it's a numbers game.

68:00

Dave Yousome has made tons

68:02

and tons of mistakes over the years.

68:04

And when you're reading 60 cases a day,

68:06

let's just say you're 99% accurate every two days you're

68:10

making an error and you have to get over it.

68:13

This is not about you, it's about the patient.

68:15

You know, I don't, if if you told me I'm 99% accurate,

68:20

I would slap you on the back and say, great job.

68:22

You're an awesome radiologist.

68:24

And then you tell me, well, and I read a hundred cases a

68:27

day, I would still slap you on the back

68:28

and say, you're a great radiologist.

68:30

You know, it's, it's ego

68:34

and you know, I'm gonna knock on wood here

68:36

because I'm um, been at this for 34 years

68:41

and I have not been sued.

68:43

I mean, I've made mistakes. You've heard the settlements

68:45

and everything and, and I've, you know, made big mistakes,

68:48

but I've never been sued.

68:51

You know, of course tomorrow's gonna be okay.

68:54

Do you recommend, do you recommend clinical correlation?

68:56

Yeah, I you use it judiciously.

68:59

I usually direct the clinical correlation.

69:01

You heard me say suggest clinical correlation

69:03

for atherosclerotic risk factors in a patient

69:06

who has small vessel ischemic disease

69:07

that is greater than expected for age.

69:10

So I do say that, um, I will say recommend lumbar puncture,

69:15

you know, on certain cases

69:17

where it's a little equivocal whether

69:18

or not there's meningitis or something like that.

69:21

Um, so I do use clinical correlation.

69:24

It's, you know, maybe one every 20

69:27

or 25 cases I'll suggest something,

69:30

but I do suggest additional imaging.

69:33

Do you include all your findings from the body of the report

69:35

and your impression or just hope

69:36

the clinician reads everything?

69:37

So my reports

69:39

because of the way I just dictate as I see things, my body

69:42

of the reports all over the place

69:44

because I dictate by sequence, be it non-contrast ct,

69:48

then contrast CT or flare T two susceptibility diffusion.

69:53

I bring it all together in an impression and yeah.

69:56

Um, for me, I assume

69:59

that the clinicians don't read the body.

70:01

I just assume it. So everything

70:03

that's important I'm putting in the impression.

70:06

And, um, so I bring it all together

70:08

that there's a 5.3 centimeter enhancing lesion in the left

70:11

temporal lobe, which has hyperperfusion restricted diffusion

70:16

suggestive of a high grade astrocytoma.

70:20

Um, and also I'll put in, uh, incidental node is made of,

70:25

you know, a arachnoid cyst posterior fossa causing mild

70:29

compression of the cerebellar hemisphere.

70:31

So I bring everything into the impression.

70:33

Have dictation errors ever been the cause

70:35

for major legal tissues issues?

70:38

Probably, um, yes,

70:41

because it reflects on,

70:44

my wife loves it when there's typos in reports

70:47

and it happens so frequently.

70:49

All, all of my reports probably have typos

70:51

'cause I don't read that carefully.

70:53

Um, because it reflects a carelessness

70:56

or a recklessness on the part of the radiologist.

70:59

You and I know that that's not the case,

71:01

but my wife will, as a plaintiff lawyer will say this, look,

71:05

look jury, there's five

71:09

syntax errors and grammatical mistakes

71:11

and spelling mistakes in this report.

71:13

How reliable is this radiologist?

71:16

So despite that,

71:19

I don't proofread my reports very carefully.

71:22

We probably should because if we are sued,

71:24

it will be used against us as a reflection on your,

71:28

uh, carefulness.

71:30

So, um, I think I've answered, let me go to the chat.

71:36

Um, so there's a lot of stuff from, uh,

71:39

what's with the goofy hat?

71:40

This is my favorite hat, hat, come on.

71:43

I always wear happy because I'm balding. Okay.

71:48

Do you include all your findings from the, okay, we answered

71:50

that awesome talk.

71:52

I learned a lot. Would a radiologist

71:53

ever have to pay out pocket?

71:55

The, that is not the goal

71:56

of the plaintiff route malpractice lawyer.

71:58

They will generally ask for limits of your practice,

72:03

of your malpractice, um, insurance plan.

72:07

All right. I think I've got 'em all. Yeah,

72:09

You, you got 'em all.

72:10

Dr. Husson, thank you so much for answering all of those

72:14

and thank you so much for your lecture today.

72:16

It was very informative

72:17

and I think a lot of people learned, uh,

72:19

they learned a lot today.

72:21

Alright, sorry I went over.

72:23

Oh, all good. And thanks to everyone for

72:26

participating in our noon conference

72:28

and asking great questions.

72:30

You can access the recording of today's conference

72:32

and all our previous noon conferences

72:34

by creating a free MRI online account.

72:36

We'll also email out a link to the replay later today.

72:41

Be sure to join us next week on Thursday,

72:43

August 8th at 12:00 PM Eastern, where Dr.

72:47

Ani Canelli will deliver a lecture entitled Imaging

72:51

for Sports Related Finger Injuries.

72:53

You can register it for at MRI online.com

72:56

and follow us on social media

72:58

for updates on future noon conferences.

73:00

Thanks again and have a great day.