Applied Radiology

 Dr. Mirvis is the Editor-in-Chief of this journal and a Professor of Radiology, Diagnostic Imaging Department, University of Maryland School of Medicine, Baltimore, MD.

Two months ago I received a call from a young professional in another state who had a variety of symptoms persisting a year after a motor vehicle collision. She was experiencing a great deal of back pain and had undergone a total spine magnetic resonance imaging (MRI) exam that was interpreted as normal. She came across my name in association with imaging spinal trauma and asked me to review her study to determine if I believed the MRI was indeed negative. She sounded like a very reasonable and well-spoken person with a real problem. I was in a quandary as to how to proceed. Should I kindly refuse her request, as I am not her physician? If I give my opinion, do I establish a formal doctor-patient relationship that could perhaps come back to haunt me?¹ Should I just review the case and offer my opinion?

A month ago a former resident and friend called me at home to ask me to review a computed tomography (CT) scan of a trauma victim at an outside hospital. The patient had sustained a severe head injury in a vehicular collision and was in a coma. A CT scan of the head showed significant brainstem damage. The patient’s spouse was consulted by the hospital physicians regarding discontinuation of life support given what they believed was a hopeless prognosis. This radiologist, now in practice for a few years, was asked by the spouse, a friend, for advice on this excruciatingly difficult decision. I was consulted to support or perhaps oppose his opinion concerning the prognostic implications of the CT, having had a great deal of experience evaluating such injuries.

Two weeks ago my wife’s aunt, a lovely person, was hospitalized with a saddle pulmonary embolism. That diagnosis was established and treated without any involvement on my part, except for a hospital visit as family and quite a fan of hers. Despite feeling lousy and appropriately concerned over her condition, she was upbeat, laughing at my stupid jokes, and being her usual charming self. That evening after our visit she was transferred to a rehabilitation facility. The next morning she called our home terribly upset and crying. The first reason was that due to her fibromyalgia, she had severe pain in her arm when a blood pressure cuff was used. This was attempted multiple times in one hour, but she could not cooperate. When a staff physician saw her she was crying over this situation. He asked if she was unhappy being in the facility and she not surprisingly said, “I’d rather be at home.” So antidepressants were prescribed. This was the other cause for her to be upset. My wife, her niece, called the facility asking about this and was promptly given over to the physician, rather than the nurse she expected. Apparently, you can only get to speak to the doctor when you don’t want to.

She explained her aunt’s problems with fibromyalgia, but was not getting very far. She then, as I expected, asked me to speak to the physician. I explained that this was the happiest lady I had ever known and had been joking with us last evening. He asked me if I was a psychiatrist, to which I responded in the negative and informed him I was a radiologist. I could almost see his smirk and feel his incredulity over the phone. At that point, he commented that he had no reason to talk to us about her condition since her daughter was the only contact for medical matters. I agreed with him and the conversation was abruptly ended. She wasn’t put on antidepressants.

Finally, yesterday a co-worker, an excellent nurse, asked me to read a report of her friend’s chest radiograph taken for a prolonged cough. There was a 2-mm ground glass nodule described and follow-up was recommended in the report. She wanted advice on what her friend should do.

Having people asking you for medical advice in a nonprofessional situation is probably nothing new to most of us. You may be the only doctor in the family or just the one known and trusted by friends. Perhaps a national reputation and lots of hits on the Internet or Medline brings questions to you from far afield.

Most of us have been at parties and mentioned during a conversation to a group of strangers that we were physicians. People often then ask about your specialty. Even after knowing you’re a radiologist, folks seem to have no problem asking all sorts of medical questions. A doctor ….is a doctor…. is a doctor. I’m sure lawyers and some other professionals occasionally get questions in their fields too. The worst encounters are those who want to show me disgusting rashes. I am fully prepared for this and quickly mention how I missed almost my entire medical school dermatology rotation having been stuck at home in a blizzard (better than being stuck in the hospital). I also mention I get severely nauseated looking at diseased skin. Usually this drives them off without my direct refusal to offer my opinion.

Are we being helpful by giving free medical advice when we know almost nothing about the medical details, have no professional relationship with the person requesting your advice, and when we are perhaps not as knowledgeable about the subject as we may think? Most of us have fairly strong egos and are unlikely to say we know nothing of a medical subject, even one that we barely remember from medical school and never see in our practices. However, we assume that in the land of the blind (like at a party), the one-eyed man is king. As one of my college roommates, a pre-law major, opined, you really only get at most as much as you pay for. I think that adage should apply to casual professional advice. I’m not suggesting you charge for your offhand opinions, but I advise caution.

I do not know the potential medical legal consequences of offering well-meaning advice that leads to a terrible clinical outcome. The lack of a written record of such a communication will probably not offer much protection. This is the ultimate in curbside consults.² Even advice to friends can get you sued if things go awry. It is certainly appropriate to decline to offer an opinion for one of a large variety of reasons. If you recommend a physician for the person to consult professionally and things go wrong, are you in danger of second-hand malpractice?

References

1. Smith JJ, Berlin L. E-mail consultation. AJR Am J Roentgenol. 2002;17;179:1133-1136.
2. Berlin L. Curbstone Consultation. AJR Am J Roentgenol. 2002;178: 1353-1359.