legal Archives - RadsResident

Posted on March 22, 2020 by Barry Julius

Is There A Deadline For A Final Radiologist Interpretation?

Ever notice that there is always at least one or two cases that stick around on the worklist day after day? Perhaps, it was a complicated case for which someone is waiting for a consult. Or, maybe the technologist took the wrong MRI sequence and needed to bring the patient back. Regardless, you will see this all-too-familiar case on the worklist for what seems like eons at a time. But, at what point does the case become a hazard to the patient, institution, or radiologist? Is there a formal deadline for a final interpretation? Can radiologists even get paid for these ancient cases? And, at what point, do we need to bite the bullet and dictate the darn thing?

Believe it or not, this deadline for radiology case interpretation is a complex issue. It is not quite like the “best by” date on a package of bread. (although that date can be a little confusing as well!) And, like most complex issues in this world, the answer to how long you can sit on a case depends. Furthermore, I would go as far as to say that each case has several different shelf lives depending on the eye of the beholder. Each time is more relevant to a specific entity within the health care system. Let’s categorize them into the standard institutional time limit for the institution, the deadline for excellent patient care by the radiologist, the legal time limit for the attorneys, and the expiration time for reimbursement by the billers. So, let’s go into through what each of these means.

Hospital Statistical Deadline

Many of you have probably heard of the time to transcription. Well, that is an example of a statistic that many hospitals, practices, and institutions monitor closely. In some centers, if there is a case that goes past that typical time, the institution may flag it or call the doctor to let them know. Each institution has its numbers based on the type and the place performed. For instance, an ER x-ray may have a mean time to transcription of a few hours. And, a non-emergent MRI may have a typical time to transcription of 24 hours. We can consider those cases that significantly surpass these time limits to exceed the standards of the hospital or the credentialing societies. And, sometimes, this may be at a detriment to patient care. Other times, not as much. (depending on the case!) All this brings us to the next limit.

Quality Patient Care Deadline

OK. So, you’ve run past the “hospital statistical deadline.” But all is not lost. Depending on the situation, you may be well within the expiration date for quality patient care. Sometimes, it pays to wait past the hospital’s statistical expiration time. Let’s take, for example, an oncological CT scan that sits waiting for comparison. If you were to dictate it right off the bat, you would have a meaningless report. Why? The oncologist most likely wants to know if the lung cancer metastatic disease is better, worse, or unchanged. In this situation, you cannot provide that answer with only a single time point. So, the hospital statistical expiration time often does not necessarily match up with the time it takes for quality patient care.

Legal Deadline

Simply put, this time is when the radiologist or institution becomes legally responsible for any findings missed because of a lack of interpretation. This time frame is a little bit more shadowy and vague. To understand this expiration time, think about the nighttime floor film that has a pneumothorax. If you do not read this case in a reasonable amount of time, and the findings go unnoticed, you and your group can be in for some trouble. But, this legal time limit can vary depending on the situation. Indeed, if the clinician notifies a radiologist to read the film immediately, and the radiologist does not, that could be a cause for immediate liability. On the other hand, if the clinician ordered a study without any priority notification, the timing for radiologist liability can become a lot longer. Additionally, in any given case, the time of delay in interpretation that can cause radiologist liability can vary widely depending on the situation, location, and jury (if the case goes to trial!)

Reimbursement Deadline

And then finally, we have the reimbursement expiration time. Believe it or not, this was difficult information to find on the web. In my opinion, it is because insurers do not want to advertise these dates. But, Scott Raley, the client service manager from Zotec Partners, gave me a few benchmark dates to remember. He stated that the reimbursement expiration time for Medicare cases is one year, and Medicaid is 180 days. For private insurers, this time can vary depending on the contract negotiated. But it typically ranges from 90-180 days. So, these times vary widely.

The Deadline For Final Radiology Interpretation- More Than Meets The Eye

Whew. So, there you have it. The shelf life of a radiology case can vary depending on the eye of the beholder. For the hospital, it’s one time. For the radiologist, it’s another. And if you are a lawyer or a biller, you will worry about other times of expiration. The bottom line is that you should be aware of all the consequences of those films that lag on the list forever. So, if you see one of these cases on the worklist, don’t just let sit. See if you can figure out why it’s there and follow it through to its conclusion. The patient, hospital, and radiologist will benefit immensely!

Posted on December 24, 2017June 22, 2022 by Barry Julius

Texting- A Minefield For The Radiologist

Formerly as a student, you could get away with texting anything you wanted on your smartphone or computer. Unless you bullied your colleagues or significantly abused the technology, the consequences remained minimal. On the other hand, an “insignificant” text from a medical professional, including a medical student, radiology trainee, or radiologist, can lead to dire results. Between the potential for HIPAA violations, unforeseen job losses, and discoverability of texts for evidence in legal cases, poorly thought out texting can severely damage your career. So today, we will delve into the dark side of an important technology that we all use, the unencrypted electronic text/message. And, you will see why radiologists need to use this particular communication tool so carefully. We will go through five different situations in more detail.

Patient Information Texting Taboos

Sending patient information over an unencrypted text message can lead to a disaster. HIPAA has its tentacles everywhere. God forbid… If a third party discovers this message containing sensitive private patient information without authorization, the federal government can severely fine and even incarcerate you! And, we are not just talking about a few hundred dollars. Millions can be on the line! (1) Not only that, but the patient can sue you for breaching their confidentiality. It is a lose-lose-lose situation!

Sending The Wrong Information To The Wrong Person

Have you ever texted a friend only to realize that two seconds after clicking send, it went to the wrong person or group? I suspect a majority of you, at one point or another, have encountered this problem. Usually, it is something benign. But occasionally, it can damage your reputation. Imagine sending a text to a friend saying, “I find Harry annoying.” And instead, it travels to the head of the department, and Harry is her fiance. These damaging texts happen all the time. But no longer may you lose just a friend. Instead, you may also lose your job or damage your reputation.

Poorly Communicated Intentions

Did you notice that most texts come off abruptly without context or emotion? We often misinterpret information that we intend to communicate by text as an offensive slight to colleagues or ourselves. A simple, seemingly insignificant text message to a technologist such as why didn’t you complete the study? can be interpreted in many different ways. Think about it. The technologist recipient may think that you blame him for never finishing his studies. Or perhaps, he can interpret this message as the radiologist believes that the technologist has a personal vendetta, which is why he thinks the technologist does not want to complete studies. On the other hand, it may just mean what it says: you need to complete the study and nothing more. Simple oral communication would have translated the initial intention more accurately with the appropriate accompanying facial expression and emotion.

Helping Out The Dark Side

Did you know that any text you send is potentially discoverable evidence for a lawsuit? You text your colleague, “I missed the pulmonary nodule on patient MR#123456”. Now that the text is in cyberspace and on your friend’s phone. The lawyers can recover that text from the cloud or your friend’s phone if the patient decides to sue you. All bets are off whether that text will incriminate you in a court of law!

Unintended Slip-Ups

And then, there is the essential unintended slip-up. Perhaps, the word correction software on your iPhone changed a word to something more sinister. Think about it. We see it happening all the time. I’ve seen the shift in expression from “see to sex” or “person to pee.” And unknowingly, you send the message out to the program director. (He may not be as forgiving as me!) In the wrong context, especially with the recent spout of sexual harassment charges, that message containing these words can be devastating!

Beware The Simple Text

In the modern era, avoiding texting our friends, colleagues, and loved ones is next to impossible. And, I am not saying that we should never text each other. However, based on these hazards, we should proceed cautiously and read over every text we create many times. An ounce of caution today can prevent a lifetime of work trying to recover from a poorly thought-out text!

(1) https://www.truevault.com/blog/what-is-the-penalty-for-a-hipaa-violation.html

Posted on June 4, 2017June 11, 2023 by Barry Julius

Should I Sell Out To The Legal Profession?

Often radiologists deliberately take advantage of the opportunity to do legal consultation work for a fee. These services include expert witness work and legal brief consultations. Their colleagues deride some of these radiologists. Other physicians call this “selling out” to the lawyers. But is it? Today I will discuss why I think that radiologists who perform legal work provide some benefit not only to their financial well-being but also contribute to their own clinical and professional skills as a radiologist.

Better Understanding Of Radiology Malpractice

Nowadays, in the United States, radiologists encounter so many pitfalls that can potentially envelop them in a lawsuit. Sometimes the only way to avoid one is to observe others’ mistakes. Participating in legal work provides this window to see other radiologists’ errors and to understand how to prevent these hazards. We are only a hair’s width away from being involved in a lawsuit for our actions and vocabulary daily. Why not work to distance yourself from being the next lawsuit victim?

Improved Reports

Contrary to popular belief, involving oneself in legal work improves the readability of most radiologists’ reports instead of detracting from them. Those who do legal work are much less likely to leave grammar errors, typos, and other blunders in their reports. They tend to take the radiology report’s structure and final appearance much more seriously. Since they understand the ramifications of an unclear dictation, they are much less likely to confound their fellow clinicians with poor dictation.

Physicians participating in legal work are also more likely to know the jargon to not place in a report. Sometimes the wrong word choice can increase the chance of a lawsuit. Why not decrease the likelihood of it happening to you?

In addition, these radiologists tend to create differentials that consider the clinical situation because they know that subtleties can vastly change the outcomes of the patient’s management based on the malpractice outcomes of other radiologists. The final impression is more likely to consider these clinical issues, providing more benefit to the ordering clinicians.

Improved Communication With Fellow Physicians

Knowing what has happened in other malpractice situations also forces us to be more careful to communicate the results of a report on the phone or “in person” with other clinicians. Those that have completed malpractice work have a much lower threshold to trigger a phone call to their colleagues so that the report and the patient do not “slip through the cracks.” This understanding is only to the final benefit of patient care.

Is Legal Work Selling Out?

Based upon these tangible benefits of malpractice work, I think I make a case that participating in legal consultation is not “selling out.” Of course, some physicians abuse the legal system to make a quick buck and never learn from the mistakes of other radiologists. However, most radiologists that work with attorneys genuinely want to help their radiology colleagues and improve their clinical and professional skills as a radiologist. Maybe we should all consider doing some malpractice work at one time or another!

Posted on February 5, 2017February 5, 2017 by Barry Julius

The Presidential Executive Order And Foreign National Radiology Residents- Will Life Ever Be The Same?

In a medical resident’s life, he or she is so busy that politics rarely influences day to day work and living circumstances in the United States. But, this is no ordinary year and we are not in ordinary times. A new presidential executive order has been issued. No longer can residents from the following countries: Iran, Iraq, Libya, Somalia, Sudan, Syria, and Yemen travel to the United States without the appropriate documentation. But, it turns out that the implications of the executive order run much deeper than just the inability to return to the United States. Resident physicians lives may be altered for many years to come.

On the surface, the executive order makes some sense. Prevent the bad guys from coming into the country by halting travel for all citizens of the designated countries, countries where there have been incidences of terrorist activities. Dig deeper and you realize that most of the foreign born nationals have already been in the United States for years legally, either with a green card or certain visas. A majority of these residents are not terrorists and are in fact, good people, hard working, and excellent physicians. Additionally, many other countries with histories of harboring terrorists were not included in the executive order.

Effects of the Travel Ban On Residency

So what are the potential effects of this executive order if you happen to have been away in another country? Since some of these residents are already abroad and cannot return to the United States, these physicians in training will have their training delayed by at least 90 days since they need to stay in their country of destination. On the surface, that does not sound so bad. But, it can have profound implications. Training will have to be delayed by over 3 months. This means that the resident cannot graduate from the radiology residency program on time at the end of the 4 years. And, he/she will potentially have a difficulty either beginning their chosen fellowship on time if they are scheduled to start at the end of residency. Others will have to delay finding a fellowship potentially for over a year.

Furthermore, many foreign medical students from these targeted countries have recently interviewed for residency positions. Program directors are either ranking these medical students lower on their rank lists or are being placed in the “do not rank” category due to the uncertainty that these prospective residents may not be able to start at their residency on time or perhaps not at all. This year’s residency selection is already being affected by the executive order. In the fact, the NRMP has already submitted a statement on the executive order recognizing these challenges. (NRMP Statement on Immigration Executive Order)

Also, on top of the general work related issues, these residents can no longer visit their relatives abroad, for the risk of not being able to return to the country, giving them less of a support system during the time of their residency. Residency is time a time of significant emotional and intellectual stresses. It is also possible that the international travel ban can last longer than has already been stated, potentially making the stressors even greater. So, although well intended, the executive order is severely flawed.

What Needs To Be Done To Make The Executive Order More Effective And Reasonable?

First of all, the current blanket executive order needs to be made more targeted. Most of these foreign residents have already had their green cards for many years and have been working in the United States as productive employees for most of that time. If need be, these residents can be reinterviewed by the government, but should not be banned from travel abroad or from returning to the United States during this period of “vetting”. Why prevent these legal workers from contributing to the United States workforce and potentially causing shortage of labor in residency programs? We are only harming ourselves.

Second, those countries chosen by the executive order to be targeted is a random selection of “terrorist harboring” countries. Other countries that have traditionally harbored many of the terrorists were not included. So, if you are going to make an executive order to restrict travel and reinterview these residents, it does not make sense to only target a few of those countries.

And finally, vetting should be more individualized and reason based. If in fact, the vetting that was done was not so thorough upon the initial interviews when these foreign born residents came into the country, then by all means go ahead and do the appropriate procedures to make sure that they are in the United States legitimately. But, make sure to do it in a reasonable manner instead of targeting everyone without cause.

What Should You Do If You Are Specifically Affected By The Executive Order?

There are two groups of residents and resident applicants affected by the executive order: applicants who are already in the country and those who are abroad. For those residents that are in the country, I would recommend to avoid travel abroad until the situation clears- you may have difficulty getting back into the country if you make this decision.

For both groups of residents, I would also pay close attention to posts on the ACGME website if you are a resident and the NRMP if you are a applicant for residency. They are scheduled to have frequent updates with relevant information. Also, make sure to stay in close contact with the hospital, residency program, and program directors to receive any relevant updates or other helpful practical and legal advice.

Unfortunately, if you happen to be abroad since the executive order, depending on whether you have permanent resident status or not, you may or may not be able to return to the United States. I would recommend seeking the help of an immigration attorney to help with the issue of returning to the country.

Difficult Times For Foreign Nationals From the Targeted Countries

It is unfortunate how the executive order was issued without regard to the specific circumstances of the individuals affected. Regrettably, many excellent well trained and talented foreign national residents and applicants may be at least temporarily prevented from completing their training due to no fault of their own. However, I believe that once the flaws of the executive order have been worked out, order will be restored to the medical training process, most qualified residents will be able to return to their positions, and medical students will be able to reapply. Although it is only 90 days until a more logical system can be sorted out, these residents may be affected for a much longer time due to the unintended consequences of the order. Continued patience and perseverance is in order for these residents. Hopefully, this situation will eventually pass.

Posted on February 2, 2017July 1, 2021 by Barry Julius

Can I Be Sued As A Radiology Resident?

As radiology medical school applicants, radiology residents, and full-fledged radiologists, we all dread the possibility of a lawsuit when we begin to practice radiology. Very rarely discussed, however, is the possibility of being sued during radiology residency. The good news: it is very unusual! One article stated that there were only 15 legal cases and 10 law review papers that addressed physicians in training and standards of care on two large legal databases. And, these cases were not necessarily radiology residency specific. The bad news is that although a remote possibility, it has happened several times in the past.

So, this makes for a relevant topic that is not frequently addressed but is certainly a possibility. In this article, I analyze a few different sources on the web and literature to understand the conditions you need to meet for a patient to sue a radiology resident. More specifically, we will analyze what standards of care a resident needs to breach. Also, we will go through several ways radiology residents can prevent lawsuits in the future.

The Grounds for a Lawsuit

For a lawsuit to be successful against any physician in general, three requirements need to be satisfied. According to a recent article in Diagnostic Imaging, these are breach, causation, and damages. Breach implies that the physician did not satisfy the requirement of the standard of care. Causation means that the breach of duty caused the malpractice. And, damages indicate that the event produced significant harm.

In today’s article, I will explicitly discuss the issue of breach without discussing causation and damages. Why? Because the concept of breach makes a malpractice case performed by a resident different from a fully trained attending.

Resident Breach For A Successful Lawsuit

Due to the standard of care being different for a resident, the definition of breach for a resident involved in a malpractice event becomes a little more complicated. In fact, over time, the standards of what breach means for the radiology resident have become blurred. I will discuss several cases with different definitions of what the legal system considers “standard of care,” specifically for a resident in training.

Breach For The Intern

Some cases have involved the medical intern. There was one case where an intern failed to identify retained glass fragments and sewed a wound shut. In this case, the court concluded that the criteria for the standard of care should be based upon the standards for the typical intern’s skills. Subsequent lawsuits have demonstrated that the first-year resident needs to fail to do something that a “physician or surgeon of ordinary skill, care and diligence” would typically do to breach the standard of care rule. In other words, the legal system can require a first-year resident without a full license to meet the standards of a general practitioner physician in terms of standard of care.

Breach For The Subspecialist Trainee

For residents in a subspecialty level training program, breach of the standard of care is even more confusing. Some cases imply that the sub-specialized resident should meet the obligations of a general practitioner. Other instances suggest that residents should meet the demands of a more specialized physician. Adding more confusion to the issue, one relevant article’s author reported a radiology resident-specific case of a misread MRI of a newborn. In this case, the court was unable to determine a specific resident standard of care and ruled in favor of the defendant. So, this case did help to define the “standard of care” for this radiology/specialist. (1)

In another case with a radiology resident, an AJR article discussed an incident during radiology moonlighting. The patient sued the resident for missing an abscess and instead called it a bladder diverticulum on a CT scan. The parties eventually settled the lawsuit, but the court determined that the jury would decide the liability before the settlement. This settlement implies that a standard of care was breached at the level of an attending subspecialist/radiologist.

The Main Source of Confusion About Breach

So, according to the literature, the law sometimes considers residents to have lower than the typical standard of care for attendings. Other times they are considered to be at the standard of care of a general practitioner, and at other times the resident has to meet the standard of the attending in his subspecialty. Confusing, huh?

What Does This All Mean?/Primary Take-home Messages to Reduce Liability For A Lawsuit

So, now that all this information confuses you, what does this mean?

Precept 1: Regardless of the definition of breach for the radiology resident, make sure to get help if you are unsure, and the case can lead to patient morbidity. Getting help can reduce the odds of getting sued for a questionable interpretation and allows your fellow attending to take responsibility for the case.

Precept 2: If moonlighting, make sure you have malpractice insurance. Misses do happen, and the courts may treat you as a fully trained radiologist. So, don’t catch yourself off guard without proper insurance. You need to make sure that your insurance will specifically cover you for moonlighting mishaps.

Finally, Precept 3: Although it is infrequent, lawsuits do happen to radiology residents, and you are certainly not immune from the ravages of the legal system. So, treat each case as if you are the responsible party and always provide your best effort to make the correct findings, diagnosis, and management.

Lawsuits And Residents

Although unlikely, patients can still sue residents for malpractice. Don’t leave yourself susceptible to the possibility of a lawsuit as a resident!

References

Clin Orthop Relat Res. 2012 May; 470(5): 1379–1385.

Published online 2012 Jan 26.

Medical Liability of the Physician in Training

Brian Wegman, MD, James P. Stannard, MD, and B. Sonny Bal, MD, JD, MBAcorresponding author

Radiologists, Expect to Get Sued Mar 03, 2016 | RSNA 2015, Practice Management

By Liza Haar

AJR1998;171:565 Malpractice Issues in Radiology: Liability of the Moonlighting Resident By Leonard Berlin

Tag: legal