Obstetrical cases represent a large percentage of medical malpractice claims in the U.S. As the number of cases continues to grow, radiologists who scan such patients have good reason to fear being sued.
But with a better understanding of the legal landscape and some specifics related to the practice of ultrasound, ultrasound specialists may be able to prevent most malpractice claims, according to Dr. Peter Callen, professor of radiology, obstetrics, gynecology, and reproductive science at the University of California, San Francisco.
Callen provided his own legal overview with specific examples from malpractice cases in a session entitled, "Avoiding the malpractice crisis in obstetrics and gynecology," at the 2002 San Francisco-based Society of Radiologists in Ultrasound meeting.
One major change from the past stems from the development of obstetrical ultrasound practice guidelines; one set issued by the American College of Radiology (ACR) and American Institute of Ultrasound in Medicine (AIUM) in 1986 and another by the American College of Obstetrics and Gynecology (ACOG) in 1988. Now, instead of comparing an alleged malpractice to the standard of care in a given community, the legal system looks to these as national standards of care, Callen said.
"All obstetrical sonographic examinations, except for specialized emergency examinations, should conform to guidelines based upon the AIUM/ACR and ACOG guidelines," Callen stated. He also suggested that it wasn’t enough to simply note an inability to meet one of the guidelines, as was done in a report he excerpted citing a "technically suboptimal" sonogram of fetal kidneys. "If you can’t see the renal region with your ultrasound equipment, you perhaps shouldn’t be performing obstetrical ultrasound examinations."
Sonologists should also meet the legal requirements of informed consent by disclosing an adequate amount of information and making sure that the patient understands the information and voluntarily decides to proceed. Informed consent should also disabuse patients from unrealistic expectations, Callen suggested.
For obstetrical exams in particular, "physicians should explain that congenital malformations occur in approximately 3% of live-born infants and that ultrasound is one of several diagnostic tests used in their detection," Callen said. "And patients should understand that some anomalies may be detected fortuitously during a routine examination; however, many anomalies may not be detected without an a priori risk."
The obstetrical ultrasound scenarios that can lead to medical malpractice claims include misdiagnosis or failure to suggest an ectopic pregnancy, placenta previa, fetal anomalies, or multiple fetuses, Callen said. Another pitfall is overestimation or underestimation of gestational age, he said, adding that "ultrasounds done in the third trimester should never be done to establish dates."
Callen also cautioned against the use of examination checklists, citing one case where a sonologist failed to check the section confirming a fetal heartbeat. "The plaintiff’s attorney basically proved to the jury that this guy was a nincompoop," Callen said. "How could he possibly find something as very insignificant as what they were suing for if he couldn’t even get this stuff right?"
Choice of words in dictation can also be critical, Callen noted, citing another example from an actual malpractice case. A radiologist’s report that he was unable to visualize cranial anatomy because the fetal head was "engaged within the maternal pelvis" inappropriately used a term of art in obstetrics that ultimately led to the termination of a healthy pregnancy.
Relying solely on the report of a trusted sonographer can also bring problems, since physicians ultimately bear the legal responsibility for the "agents" whose work they are supposed to be supervising, Callen said.
In general, sonologists can avoid or mitigate malpractice claims by practicing within their competence, using consultants in especially difficult cases, communicating results without delay, and using a standard routine for all examinations, Callen concluded.
By Tracie L. ThompsonAuntMinnie.com contributing writer
December 10, 2002
Related Reading
Imaging by non-radiologists drives up healthcare costs, November 25, 2002
Turf Wars in Radiology IV: Radiologists, ob/gyns sound off on fetal imaging, September 26, 2002
Obstetricians face problems finding insurance, and close their offices, July 8, 2002
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