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Risk Focus: Failure to Communicate Mammography Findings |
Timely Communication of Exam Results Can Help Avert Losses
With their indemnity payouts now often reaching or exceeding $1 million, claims alleging delays in diagnosing and treating breast cancer are among the most frequent and costly sources of malpractice loss facing U.S. physicians. The delays are attributable to factors including but not limited to:
- failure to perform a breast examination,
- failure to detect an existing palpable lump,
- incorrectly diagnosing a tumor as benign and failing to recommend biopsy or removal,
- incorrectly diagnosing a tumor as a breast infection,
- failure to determine the cause of nipple discharge,
- failure to order a mammogram,
- misinterpreting mammogram findings,
- failure to react to mammogram findings, and
- failure to follow up with the patient.
Among the items listed, failures to react to mammography findings and to follow up with patients represent situations not only readily avoidable but also specifically addressed by the federal Mammography Quality Standards Act of 1992.
The typical case scenario begins when a patient visits a family practitioner or gynecologist because she thinks she has detected a lump in her breast. On examination, the physician identifies a small area of thickening, and he recommends a mammogram. Although the mammogram’s findings alone do not permit him to draw conclusions, they nonetheless lead to suspicions of possible malignancy. He consequently instructs his office staff to contact the patient, inform her of his suspicions, and recommend that she schedule herself for a biopsy.
However, three attempts to phone the patient fail, and she has left no instructions about forwarding the mammogram’s findings to another physician. No letter is sent, no other communication with the patient is initiated, and although the mammogram’s findings are filed in the chart, the three fruitless attempts to phone her are not documented. Assuming she would have been notified had the mammogram confirmed her fears of a lump, the patient neither contacts the physician nor takes any further immediate action. Nine months later, a biopsy performed by another doctor reveals breast cancer, and a chest X-ray and bone scan confirm bone metastases.
The patient’s subsequent lawsuit against the first physician alleges he failed to make a timely diagnosis of her cancer. The case ultimately is settled out of court for a large sum because the physician cannot prove he attempted to notify her of the mammogram’s results, and because it is difficult to convince a jury that a reasonable physician would allow a mass to remain in a patient’s breast.
Recommended Risk Management Tactics
Final rules for implementation of the Mammography Quality Standards Act (MQSA) of 1992 have been in effect since April 28, 1999. Among other things, the rules (excerpted below) specify the content of reports and methods for communicating exam results.
1. Mammography facilities must prepare a written report of the results of each mammography examination they perform. The report must include an overall final assessment that classifies the findings as one of the following:
| Classification | Definition |
| Negative | Nothing to comment on. If – despite the negative assessment – the interpreting physician is aware of clinical findings or symptoms, these must be explained to the patient |
| Benign | Also a negative assessment. |
| Probably benign | Findings have a high probability of being benign. |
| Suspicious | Findings without all the characteristic morphology of breast cancer but indicating a definite probability of malignancy. |
| Highly suggestive | Findings exhibit a high probability of malignancy |
2. Mammography facilities must maintain a system that ensures the results of each examination are communicated to the patient in a timely manner, as follows:
- If the assessment is "Suspicious" or Highly suggestive of malignancy," and the patient has not identified a physician to receive the report, the facility must send the report directly to the patient, along with written notification of the results expressed in lay terms.
- Every mammography facility that accepts patients who do not designate a physician to receive their mammographic examination report must maintain a system for referring such patients to a health care provider when clinically indicated.
As described in the MSQA’s final rules, an increasing number of mammography facilities are adopting the routine practice of reporting both normal and abnormal results directly to the patient – a sound risk management tactic that can help reduce the prospect of medicolegal complications for both the interpreting and referring physician.
For more detailed information on reporting requirements, visit the Federal Register’s Web site at http://www.access.gpo.gov/su_docs/aces/aces140.html and access the final rule on Quality Mammography Standards, published in the October 28th, 1997 edition. For additional assistance, contact ISMIE’s Risk Management Division at 1-800-782-4767 or 312-782-2749, or through e-mail at riskmanagement@ismie.com.