MEDICAL X-RAYS AND LIFE-THREATENING ERRORS

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December 30, 2002

 

MEDICAL X-RAYS AND LIFE-THREATENING ERRORS

 

Concerns About The Accuracy Of X-Ray Readings

 

By Richard Altschuler

 

When you get a medical or dental X-ray, do you automatically believe what your

doctor, dentist, or radiologist tells you about what it reveals? I always have.

During my life, I’ve had X-rays taken of my foot, knee, back, chest, lungs,

finger, and, of course, teeth, on many occasions. And every time I have been

given results, I have accepted them as accurate, trustworthy, reliable, and

true, with nary more than a raised eyebrow when the finding was hard to accept,

based on my own feelings about my condition.

 

Then one day, about two weeks ago, I was having a casual chat on the phone with

a very close friend of mine -- a physician who has been a radiologist for about

30 years. He’s worked steadily in about five different radiology clinics – from

Philadelphia PA to Tucson AZ to Coral Gables FL – and has read tens of thousands

of X-rays, from what he’s told me. So given his authority and experience in the

discipline, what slipped out of his mouth during that call made me stop the

conversation cold to question him about what he was saying – and it will make me

always question the X-ray reports I receive from physicians and dentists, for

the rest of my life.

 

In essence, my friend casually mentioned that he and all radiologists sometimes

work with bleary eyes caused by fatigue, or under the influence of hangovers and

other sight-compromising states – and that these adverse ocular conditions

sometimes not only reduce the accuracy of the radiologists’ diagnoses but cause

outright errors that can and do result in the death of patients. My friend also

mentioned to me, in the same sentence, that radiology clinics – where millions

of X-rays each year are read – often compromise on the price of the bulbs they

buy, because the best bulbs, which allow one to see the X-rays the clearest, are

the most expensive. To cut costs, the clinics often buy bulbs with less

luminosity.

 

When I heard these comments, I stopped him from speaking and said something

like, " Wait a minute. What you are saying strikes me as really odd. I can see

where a radiologist might misdiagnose a patient’s condition because the X-ray is

difficult to interpret. " I was thinking of the subtle shadings of dark and light

that indicate, for example, a tumor. " But what you are saying, " I went on, " is

that radiologists sometimes work poorly, when they don’t have to, even though

patients’ lives may be at stake. " How can they come to work with hangovers? I

was thinking. How could they go ahead and read X-rays when they are so tired

that they are practically seeing " double? " And what right do radiology labs

(which pay their physician-drones handsomely to interpret films all day ) have

to buy less than the best bulbs, when they are dealing in life-and-death

decisions?

 

After I expressed my dismay, I settled down, as I quickly realized that

radiologists are, of course, people, too. They’re not always " perfect. " Who is?

They can’t always be well rested when they come to work, or have perfect

eyesight, or be wearing eyeglass with ideal prescriptions, or be sober when

reading film, can they? Nor can they always be sane, or in a state of emotional

equilibrium, or even in a good mood when diagnosing a film.

 

Under less than ideal conditions, who knows? I may or may not get an accurate

reading. I never thought that way before my conversation with my friend. I

always assumed that errors from X-ray readings could only possibly result

because of the difficulty of the diagnosis – not because of the incompetence of

the reader or the inferiority of the equipment. But that’s because I do not

usually think about such things.

 

After that conversation, I was curious to learn what the professional literature

had to say about this phenomenon. Here are some additional issues which have

only reinforced my newfound doubts about the accuracy of X-ray readings:

 

In America, in 15 states, the person who takes your X-ray in a doctor’s or

dentist’s office may be a qualified professional – but then again, your " X-ray

technologist " may be the receptionist. In 1981, Congress established minimum

training standards for people who administer radiation in doctors’ and dentists’

offices, but only 35 states have adopted these voluntary minimum standards. (One

exception: All mammography technologists must meet federal requirements.)

According to Ceela McElveny, a spokeswoman for the American Society of

Radiologic Technologists, about one-third of the people who take X-rays operate

the machines without credentials. An unskilled technologist might expose you to

excess radiation, which is a known health hazard. Potentially worse, his or her

sloppy work could produce a poor image. Before having an X- ray, ask if the

technologist is licensed and certified to do the job in your state.

A recent report by the Institute of Medicine documents that medical mistakes

are inherent in the practice of medicine. But pinning down the definition of a

medical mistake is complex. For example, if a physician is given a mislabeled

X-ray and makes decisions based on this film without checking, who is

responsible?

A University of Vermont study on the benefits of the double reading of

mammograms found that having a second radiologist review a mammogram resulted in

a nearly 8 percent increase in breast cancer detection. Out of 25,368 screening

mammograms reviewed in the study, a second reading identified 11 malignancies,

all early stage. The costs associated with double mammogram readings added only

$4.38 to each woman’s screen. Most women would probably be more than willing to

pay the additional cost to ensure a second reading. The study’s findings

prompted Fletcher Allen Health Care to change the way it double reads

mammograms, in order to reduce the need for and costs associated with additional

mammograms, ultrasounds, or biopsies. Now, if the interpretation of a mammogram

differs between the first and second reader, a third radiologist is called in to

review the case.

Computer checking of mammograms by systems programmed to detect subtle

patterns could increase breast cancer detection rates by 20%, reported Timothy

W. Freer, MD, Director of the Women’s Diagnostic & Breast Health Center, Piano,

Texas. Freer and associates oversaw the review of 12,860 screening mammograms –

by radiologists and by computer system. The computer alone discovered eight of

the 49 originally unsuspected cancers. All eight were in an early stage and were

retrospectively confirmed by a radiologist. Nine cases of breast cancer were

detected by a radiologist’s review alone and 32 by both the computer and a

radiologist. The recall rate was slightly increased by computer-assisted

detection; there was no change in the positive predictive value for biopsy.

In England, a former professor at Imperial College School of Medicine and

consultant radiologist at the Hammersmith Hospital in London, Peter Dawson, was

suspended from his job after raising concerns about patient safety related to

radiological readings. Professor Dawson, who resigned with a 120,000 pounds

sterling ($180, 000) settlement and now works for University College London

Hospitals, and a colleague, had raised concerns about on-call arrangements for

interventional radiology, which they felt were being provided by consultants who

were rusty or insufficiently trained in the field. They were also concerned

about the numbers of radiographs which were not reported or not reported within

a reasonable time.

Patient testimonies in the literature especially bring to life some of the

problems that result because of erroneous X-ray readings by professional

radiologists and lesser trained technicians. The following two anecdotes

illustrate the human travesties that have occurred.

 

* A patient was almost sent home with a fractured cheekbone late on a busy

Friday night. The Emergency Department was understaffed, and several graduate

trainees who were inexperienced in reading x-rays missed the fracture. The error

was caught by an experienced charge nurse who overheard them discussing the

case. Lack of knowledge on the part of the trainee contributed to the medical

errors, which had the potential for significant harm to the patient.

 

*A patient reported that after nine months of lumbar pain he was referred for an

X-ray investigation, but the investigating radiologist reported that no

abnormalities were found. The subsequent independent review, however, said that

his radiographs " clearly " showed that the lower third of the sacrum was missing

and that there was a " very obvious " mass arising from the terminal section of

the missing sacrum, extending anteriorily and displacing the bowel. The tumor

remained undiagnosed for a further seven months, allowing it to grow well up the

S2 vertebra, until it measured 10 cm in an anterior to posterior direction and

12 cm side to side. This necessitated an anterior and posterior approach to

remove the lower half of the sacrum, including the S2 and S3 nerve roots, and a

permanent colostomy. The patient now has to self-catheterize about five times a

day and suffers from hyperreflexia and bladder instability. He also has to live

with an increased chance of recurrence, and, indeed,

has already had four such instances. Given this situation, the patient asked,

Why did this tumor go undetected for seven months? He answered, First, the

radiologist failed to look at all the original films. In a letter of apology,

the hospital wrote to him of the " failure on the part of the consultant

radiologist to recognize a lesion of the sacrum which is clearly visible on one

of the views taken. We fully accept that it is the duty of a radiologist to look

at the whole film; this was a very unfortunate case of human error. "

 

Now that I realize the problems that can and do occur with X-ray readings, what

will I do, personally, the next time I have an X-ray taken? Or even before I

have an X-ray taken?

 

I’m not sure at this point, but perhaps I’ll bring a questionnaire with me, for

the " before " X-ray period, to learn about the qualifications, training and legal

record of the X-ray taker and reader (if they are different people). As for the

result, I may put more faith in my own personal opinion, and ask for a second

reader if the first reading seems to contradict my common-sense feelings about

what I believe is my problem. I also may research more closely in advance of

getting an X-ray where the best place to go might be, in terms of both personnel

and technology.

 

Ultimately, however, I know that I’ll always be the potential victim of some

professional radiologist’s hangover or jilted love affair that makes him or her

see " cockeyed " when it comes to reading my film. I suppose that bringing my own

breathalizer test kit to the X-ray room, along with a Rorschach test and

top-quality light bulb, would increase my chances of getting an accurate

reading. But I’d probably never get away with using them.

 

 

 

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