The Value of the Human Voice

"The single biggest problem in communication is the illusion that it has taken place." – George Bernard Shaw

Malpractice lawsuits against radiologists alleging failure of directly communicating actionable (urgent, critical or significant and unexpected) radiologic findings to referring physicians are increasing.  A recent study of adverse events occurring at a large medical center disclosed that 56% were due to communication errors, half of which were directly related to communication failure between radiologists and referring physicians.  The Joint Commission has found that 65% of sentinel events are due to communication errors.  Medical malpractice insurance data reveal that communication issues are present in the majority of lawsuits.

In a recent American College of Radiology (ACR) survey of radiologists, 23% responded that they have been sued at least once for failure to communicate. The ACR Practice Parameter on Communication states that radiologists should directly communicate (preferably either in person or by telephone) with the referring physician “non-routine” critical (urgent, or significant and unexpected) findings.  

Lawsuits alleging failed communication of urgent findings such as a brain hemorrhage or tension pneumothorax are extremely rare, for 97% of radiologists responded that they personally telephone the referring physicians with such findings. Unfortunately, only 24% of radiologists state that they telephone the referring physician for findings that are “merely” significant and unexpected, such as an incidental questionable lesion in the lung, kidney or other organ for which a follow-up CT or other imaging exam is suggested. Virtually all failed-communication malpractice lawsuits are filed against the other 76% of radiologists.

All radiologists—and especially the remaining 76%—lament that all too often it is extremely difficult to directly communicate with the referring physician. Either that physician is not available, or the radiologist is simply too busy to take the time to attempt to reach the physician. In an effort to diminish, if not altogether eliminate, failed radiologic-communication events, various researchers and radiology groups have turned to information technology (IT) and the development of red-orange-yellow computerized alert systems.

Various articles have appeared in the radiology literature reporting that the red-orange-yellow alert systems have shown considerable preliminary success in that almost 100% of radiology reports containing actionable findings have been sent to referring physicians; previously, many such reports, for inexplicable reasons, were never sent.  The same articles have reported that both radiologists and referring physicians seemed to be pleased with these systems.

Lost in cyberspace

Recent data, however, is not reassuring.  Surveys have shown that 15% of physicians admit that they do not read radiology reports, and the actual percentage may well be higher.  One published study revealed that physicians failed to acknowledge receipt of imaging results in 36% of outpatient reports transmitted to them by computer. 

A more recent study from a large academic center in Ireland found that 16% of clinicians failed to respond to radiology report alerts, 50% of which were issued because of findings suspicious for malignancy.  The researchers concluded that automated stand-alone systems are not sufficient to ensure that patients’ diagnoses will not be missed. 

The ACR practice parameter states that actionable findings suggesting the possibility of malignancy or other serious disease should be communicated to referring physicians by telephone or in person, i.e., by direct voice contact.  An American appeals court has defined communication as sharing knowledge, thoughts or opinions between two or more persons “encompassing the idea that knowledge is shared in a manner that is capable of bringing about a true communicative exchange.  True communication occurs only if knowledge, thoughts and opinions are successfully conveyed.”

Sending a computerized radiology report to a referring physician is metaphorically similar to a baseball batter getting on base by a hit or a walk.  Such action is indeed rewarding, but it is meaningless if the runner is stranded on base and does not score a run by crossing home plate.  Similarly, if the radiology report is stranded in cyberspace and not read by the referring physician, having simply sent it is meaningless. 

The worst that can happen in baseball is that a team loses a game.  In medicine, the worst that can happen is that a patient is severely harmed and/or dies.

Communication of radiologic findings entails the closing of the communication link between radiologist and referring physician. Legally and morally, communication is not complete until that transmission-receipt link is closed. The sole means of assuring that radiologist–referring physician communication is not an illusion, but rather has taken place, is the human voice.