Guest Editorial: What we got here is failure to communicate

Dr. Raskin is an Associate Professor of Radiology at the University of Miami School of Medicine, and a Neuroradiologist at the University Hospital and Medical Center, Tamarac, FL. He is a member of the editorial board of this journal.

“What we got here is … failure to communicate,¹” is a famous line from the film Cool Hand Luke. It is the opening of a warning speech given by the Captain, played by Strother Martin, who goes on to say, “Some men you just can’t reach.” Well, it’s also true that some physicians you just can’t reach!

Failure to communicate is one of the greatest problems facing radiologists today. It is a causal factor in 80% of all lawsuits, although not the primary factor. Your communication must be timely, appropriate and should be documented. The courts have consistently held that timely communication may be as important as the diagnosis itself. As machines and employees handle more of our responsibilities, we risk becoming more isolated in our work.

The American College of Radiology’s (ACR) Practice Guideline on Communication is designed to help radiologists understand that certain situations require more than just an accurate written report. These situations require nonroutine communication. Foremost are findings that suggest the need for immediate or urgent intervention. Even the slightest delay may compromise patient safety. Almost as important are findings that are discrepant with a preceding interpretation when a failure to act may adversely affect the patient’s health. Most problematic are findings that are unexpected by the referring physician but that the radiologist reasonably believes could seriously adversely affect the patient’s health. In all instances, radiologists face liability for inadequate communications apart from the practice guidelines and the liability is determined by case law. In this issue, my colleague Leonard Berlin, MD, explains the circumstances and outcomes of several malpractice cases involving failed radiologic communication (pages 17–23).

There is an increasing onus being placed on the radiologist to ensure that reports are communicated to the ordering clinician, especially when there are urgent or unexpected findings. Virtually all state appeals courts have held that even if a report is faxed to the ordering physician, the radiologist is liable for any patient injury that results if the ordering physician claims that he or she never received the report. The referring and treating physicians share the responsibility of obtaining results of imaging studies. However, this provision will not let radiologists off the hook. It merely spreads the blame and adds another deep pocket. If you are in doubt about receipt of the findings, it should be handled as a nonroutine communication. This is where radiologists have the greatest problem.

What is clear here is that there are a series of cases, several of which are described by Dr. Berlin, in which the holding against the radiologist have been adverse. The decision is made regardless of the superseding or intervening errors that occurred at the hands of other physicians if the radiologist was the first on the chain of events that resulted in the harmful outcome. Since the radiologist is often the first to make the diagnosis, this squarely places the responsibility on the radiologist to not only communicate the unexpected finding, but to also ensure that it was properly received by the intended recipient.

National studies show that as many as 20% of radiology practices do not have an established policy on communication of findings. Insurance companies have documented that the referring physician is not contacted on urgent or significant findings in up to 60% of malpractice cases. Over half of these lawsuits are related to issues regarding communication and follow-up of important findings. The emphasis should be placed on the timely receipt of the reports instead of focusing on the method of delivery. Communication that is clear, comprehensive and directed to the appropriate receiver is the key to quality patient care. If one leaves this critical part of care to nurses, clerks or other persons who are not directly responsible for the care of the patient, then the communication will potentially leave out or omit essential information.

We can use information technology (IT) to help us. It is almost inconceivable that any teenager can reach any one of dozens of their friends almost instantly with the click of a key but a radiologist cannot reach the ordering physician with urgent or unexpected findings. We need to do better with the IT available to us. If you think it would be too time consuming to directly contact the ordering physician, think of how time consuming and mentally anguishing it would be to spend weeks in a courtroom!

At the end of the movie, when surrounded by police after escaping to a church, Luke mocks the Captain with the famous line, “Whatwe got here is a failure to communicate.” He is tragically shot in the throat and silenced forever. The handwriting is on the wall: it is the radiologist who is ultimately responsible for conveying unexpected or adverse findings to the ordering physician and, in some situations, to the patient.

The courts are increasingly expecting the radiologist, as well as all treating physicians, to be part of the team providing care to the patient. Failure to communicate is one of the greatest challenges facing radiologists today. You should develop a policy on communication of urgent and unexpected findings and it is imperative that you consistently follow this policy. This is the one area where you can make a positive change to reduce your risk of being sued and losing. Don’t be like Luke!

REFERENCES

1. Cool Hand Luke. 1967. Directed by Stuart Rosenberg. Distributed by Warner Brothers/Seven Arts.