Dr. Raskin is a practicing diagnostic radiologist in the
subspecialty of neuroradiology in Fort Lauderdale, FL and is
the Internal Legal Counsel to the Florida Radiological Society.
He is also a member of the Editorial Board of this
Signing a radiology colleague's interpretive report becomes
problematic if that colleague is sued for malpractice, as you will
almost certainly be sued as well. Substituting your signature for
the radiologist who actually did the interpretation is an
invitation to the plaintiff's attorney to name another physician in
the lawsuit. Some have called this a proxy signature, but a proxy
is an authorization by one person to another so that the second
person can act for the first. A proxy binds the first person by the
act of the second person. A substituted signature can bind you
both. Whatever we wish to call it, substituting your signature for
a colleague's signature may place you in their shoes in the eyes of
Why do we bother to sign reports in the first place? According
to the Health Care Financing Administration (HCFA), the radiologist
who performs the service must sign the interpretive report.
In addition, the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) mandates that the interpretive report have
the author identified.
It is not clear that JCAHO requires the author of the report to
actually sign the report. However, it is quite clear that HCFA
fully intends that the author actually sign the report. The
Standard Guide for Electronic Authentication of Health Care
Information indicates that the signature is the act of taking
responsibility for a document and the purpose of the signature is
to determine accountability.
How does this work in practice?
Most reports are signed by the interpreting radiologist.
However, there is a "gray area" when the author of the interpretive
report is not available in a timely matter and the report is signed
by a colleague in order to expedite delivery of the report. The
timeliness of reporting any radiologic examination varies with the
nature and urgency of the clinical problem. When a colleague's
signature is substituted for the author of the interpretive report,
that colleague may or may not have read the report. The American
College of Radiology (ACR) Standard for Communication indicates
that the final report should be proofread to minimize typographical
errors, deleted words, and confusing or conflicting statements.
However, most reports are produced using word processing software
that checks spelling and even grammar. Any "deleted words and
confusing or conflicting statements" may not be recognized by
anyone other than the author. Rarely will a colleague review the
actual films of a report rendered by someone else, which further
compounds the problem.
When named as a defendant in a lawsuit, the radiologist who
substituted his or her signature for the author of the interpretive
report will rarely ever claim that they actually looked at the
films but will claim that they proofread the report. They will
often claim that they signed the report to expedite timely delivery
to the referring physician. However, bear in mind that if a
significant error has occurred in the written report, expediting
this erroneous report only further compounds the initial error.
Radiologists are often reluctant to come in to sign reports when
they are off for the weekend. The radiologist on call usually winds
up signing all the reports that were generated by those who are off
duty. We learned in kindergarten (unfortunately, some never
learned) that we clean up our own mess. If you dictated it, you
should sign it and not expose a colleague as another "deep pocket"
because they signed your report.
Consequences of signing a report
Regardless of any disclaimers you may include on the report, if
you sign it, you will most likely be held responsible for the
content of the report. Although no Appellate Court decisions have
been heard regarding the substituted signature of a radiologist,
the New Jersey Appellate Court concluded that by signing a report,
a physician attests to the accuracy of the information that the
This is an important holding as it does not matter what disclaimers
the physician may put before or after the signature. Even a juror
knows that you "don't sign something unless you have read it and
agreed to it." To afford a physician anything less would let them
off the hook for what every juror knows is "common knowledge."
Report of a case
A 55-year-old woman was referred to a surgeon for complaints of
a persistent dripping and running nose. The surgeon ordered a
cysternogram, and a CT scan of the ethmoid sinus. Based upon the
results, the patient was told that the left side of her dripping
and running nose was due to cerebral spinal fluid leaking as a
result of sinus disease and a defect in her left cribriform plate.
The patient was told that the easiest and fastest approach to seal
the defect in the cribriform plate was to undergo an operative
procedure through her nose, internasal endoscopy, because of
decreased anesthesia time.
During the course of the surgical procedure, the surgeon entered
the ethmoid sinus and found a mass present. A biopsy was taken and
sent for analysis, which was indeterminate as to cell origin due to
hemorrhage, although the pathologist thought it might be neural
tissue on frozen examination. The surgeon continued to remove the
mass from the roof of the ethmoid. The defect in the cribriform
plate was visualized, and a fat graft and flap closure was
performed. The patient failed to awaken following surgery, and an
emergency CT scan showed subarachnoid and interventricular
hemorrhage. A ventriculostomy was performed, and the patient
remained comatose until her death approximately 1 week later. The
pathology report confirmed normal brain tissue.
The cisternogram showed a leak from the left cribriform plate.
The CT scan was interpreted as showing "lytic erosive changes" of
the left cribriform plate, "likely representing a CHF leak or
inflammatory changes." In deposition, the radiologist testified
that she considered that this might represent an encephalocele but
since an encephalocele was so rare, and she had never seen one
before, she did not include it in her report.
As you might imagine, the case was settled by the surgeon and
the radiologist without even deposing the expert witness
radiologist for the plaintiff. However, the story doesn't end here.
The author of the report had been out of the office the day after
dictating it, and one of her colleagues readily signed the report.
Despite his protestation that he was merely signing the report for
"content and expedience," and not attesting to its accuracy, his
attorney wisely advised him to settle as well. The "content"
defense fell short when the radiologist had to admit, in
deposition, that "CHF" stood for congestive heart failure and not
cerebral spinal fluid, considerably changing the content of the
report. Expedience matters little when the report is patently
What to do?
* No one signs the report. This is not really possible or
feasible since HCFA requires that the radiologist who interprets
the study must sign his or her own report.
* Sign your colleague's report. If you do this, do it with the
understanding that this will result in legal exposure to you and
you may be held liable for the report. Therefore, it would be
prudent in those cases in which there is no alternative except to
sign a colleague's report for you to review the actual films and
correlate them with the report.
* Have the author of the report authenticate the report. This is
what we are actually trying to accomplish, but it may become
burdensome when the author of the report is not available or may be
away. In today's high-technology world, there is little excuse for
not being in touch and not being able to communicate. Reports are
routinely faxed to referring physicians. The report can be sent to
the author of the report by fax or e-mail. These devices are
readily available virtually all over the world, in airport lounges,
and on cruise ships.
In January 2001, Air Canada began offering e-mail and Internet
access on their North American flights. In April 2001, Singapore
Airlines began offering e-mail on all of their international
flights. Virgin Atlantic and Cathay Pacific soon followed.
Boeing will be introducing a broadband e-mail and Internet system
that can deliver e-mail at speeds about 25 times faster than
Soon all passengers will be able to send and receive e-mail no
matter where they are flying. So there will be no place you can
hide and not get your report.
HCFA allows authentication to include signature, written
initials, or computer entry. In this way, the author of the report
can authenticate his or her own report. Some radiology departments
have started the process of installing software on their home
computers that will avoid the necessity of a radiologist signing a
colleague's report (L. Berlin, personal communication, May 29,
2001). In the rare situation in which the films must be correlated
with a report, a colleague could then review the films. Sending
reports electronically to the author of the report will minimize
the need for a radiologist to sign a colleague's report.
If the author of the report will not be available within 24
hours after dictating the report, a system should be in place to
either fax or electronically transmit the reports to the author.
The author can then provide authentication by signature, written
initials, or computer entry. By using presently available
technology, it should be rare that the author of a report cannot
authenticate it within 24 hours. In these rare situations, the
radiologist who substitutes his or her signature for the author
should review the films and make corrections to the report, if
necessary, with the full understanding that he or she will most
likely be held responsible for the contents of the report.