When Good News Is
Misinterpreted as Bad News
Who Is to Blame When a Misunderstanding Ends a Life?
The days when radiologists would personally discuss find- ings with ordering physicians who in turn would discuss them with patients are fading into history. Patient portals
and other electronic communications are rapidly becoming the
exclusive means of conveying information, which is amplified
by the fact that everyone wants news immediately! So how does
this impact the radiologist who is saddled with a heavy workload and under pressure to quickly finalize reports?
“Whether the news is good or bad, radiologists should make
every effort to avoid medical jargon and use language that patients will understand and accept with equanimity,” said Leonard
Berlin, professor of radiology at Rush University and University
of Illinois in Chicago.
In a commentary published in the February 2017 edition of the
American Journal of Roentgenology, Berlin illustrates the importance
of clear communications between physicians and patients by describing two lawsuits that ended badly for the medical professionals.
In both cases, the patients committed suicide after misunderstanding written correspondences containing medical language accoding
to the commentary titled, “Radiologist Found Liable for Malpractice
in Israel for Causing a Patient's Suicide by Sending a ‘Bad News’
Report: Can This Happen in the United States?”
The Case in Israel
The first lawsuit involved a 51-year-old man living in Haifa, Israel,
whose condition was diagnosed as lung carcinoma. He underwent
thoracotomy with resection of the upper lobe of the right lung and
several mediastinal lymph nodes. He later had a PET/CT examination that revealed focal uptake in the mediastinum but no evidence or
suggestion of metastatic disease. Following radiation treatment, the
patient experienced clinically significant deterioration of his mental
status and was treated by a psychiatrist, who prescribed antidepressant medication. A follow-up PET/CT revealed improvement in that
the pathologic update in the mediastinum had decreased markedly.
The patient received follow-up correspondence by mail which
read: “Pathologic uptake in mediastinal lymph node, less prominent
than before.” Misunderstanding the message, the patient was
apparently distressed and ended his life. The patient’s wife filed a
malpractice lawsuit alleging that because the radiologist and
oncologist were aware that the patient had been undergoing
psychiatric treatment for depression, they acted negligently by
sending the radiology report directly to the patient at his home. In
2015, the family was awarded 1. 5 million Israeli Shekels
Berlin agreed with the plaintiff’s claim that the defendant had
the means to apply simple safety measures in order to prevent
the suicide. The defendant could have sent the results directly to
the referring physician, or by instructing the deceased to open
the envelope containing the report only in the presence of the
referring physician who would be able to explain the clinical im-
plications of the results of the report.
Berlin’s commentary discusses the various definitions and in-
terpretations of “bad news,” and accepts the allegation that inas-
much as no one could have predicted that the report of the
outcome of the final PET examination was ambiguous, it was
more appropriate for the physicians to adopt a more cautious way
of discussing the outcome.
After studying the Israeli lawsuit, Berlin commenced a search
of U.S. cases to find out if anything similar had occurred here.
He found a case from 1984 that involved a 67-year-old Missouri
woman diagnosed with lung cancer.
U.S. Case Also Ends in Suicide
During the staging process before treatment of the lung cancer, the patient underwent a brain CT study that a neurologist
interpreted as normal. There being no evidence of metastatic
disease, the patient underwent thoracotomy and soon thereafter
was discharged from the hospital. The neurologist’s clerical staff
completed a Medicare claim form and submitted it to the regional Medicare fiscal intermediary. In a box titled “diagnosis or nature of illness or injury,” the neurologist wrote the words “brain
tumor.” This was done because the intermediary prohibited the
use of a rule-out diagnosis when payment was requested for a C T
study. Therefore, the neurologist claimed that he was forced to
use a provisional diagnosis, which in this case was brain tumor.
When the patient received her copy of the bill and noticed that
the form included the words “brain tumor,” she became depressed and went to bed early. The next morning she was found
dead due to an apparent suicide.
The husband filed a lawsuit against the neurologist, contending
that the neurologist negligently inserted the words “brain tumor” on
the claim form and that this negligence caused the patient’s death.
The jury awarded the plaintiff’s family $200,000.
The Million Dollar Question
Would a radiologist in the United States in 2017 be found similarly negligent if a patient were to commit suicide after reading
a report issued by a radiologist and perceiving it as bad? The
short answer is—yes.
“We have to be careful to review every report and correspondence with patients because the information can be misunderstood or taken the wrong way,” said Berlin. “Ten to 15 years ago,
plaintiffs would only get remuneration for physical injury, now they
can claim psychological or mental injury without physical injury.”
In January 2016, the Obama administration issued guidelines
requiring physicians and hospitals to provide copies of medical
Misinterpretation continues on p. 16