Who is to blame when a patient suffers a fatal adverse reaction to a diagnostic test—the urologist who ordered it or the radiologist who carried it out?

The case involved a 41-year-old man, Mr. E, who was admitted to the emergency department (ED) of the local community hospital. Mr. E had been suffering from severe pain in the right flank that had persisted for more than an hour. A urinalysis revealed microscopic hematuria. An abdominal x-ray showed moderate intestinal obstruction, but overlying bowel gas made it impossible to determine if a kidney stone was present.

The ED physician called the consulting urologist, Dr. R, 70, who recommended that excretory urography be performed to confirm the presence of the stone, locate the point of urinary obstruction, and evaluate the degree of dilation of the proximal ureter and renal collecting system. The ED physician conveyed the request for the urography to the radiologist, who immediately called Dr. R on the phone.

Procedural differences

“It's the policy of the radiology department to use an unenhanced CT scan of the pelvis in this sort of case rather than a urogram,” the radiologist said. “It's preferable because CT will provide more clinical information than urography and won't subject the patient to the risk of a reaction from the IV contrast.”

“I've been ordering excretory urograms on patients with suspected stones for 40 years with satisfactory results,” Dr. R replied. “I see no need to change that practice now.”

The radiologist tried again: “The CT has really become the standard of care now,” he said. “Why subject the patient to unnecessary risk?”

“Which one of us is going to be ultimately treating this patient,” the urologist replied, “you, or me?”

The radiologist, faced with what he perceived to be an unyielding attitude on the part of Dr. R and fearing the loss of future referrals, reluctantly agreed.

The patient was taken to the radiology department where the radiologist administered an IV of the contrast solution. Within five minutes, Mr. E went into anaphylactic shock. Attempts to revive him failed, and Mr. E was pronounced dead a half hour later.

Four months later, the family of the patient filed a medical malpractice lawsuit naming as co-defendants the ED physician, the urologist, the radiologist, and the hospital. The lawsuit alleged that the defendants had acted with gross negligence in performing an excretory urography that required the use of contrast solution, “known to be associated with a high incidence of serious reactions including death, rather than the superior, risk-free alternative diagnostic test known as helical CT scanning.”

Each physician was assigned a defense attorney and the discovery process began. During depositions, the plaintiff's attorney brought in a radiologist as expert witness. He testified that unenhanced CT had completely replaced excretory urography in assessing patients with suspected urinary tract stones because of the diagnostic superiority and absence of risk of adverse reactions. The expert further testified that the use of contrast solution was associated with a small but definite risk of bodily harm and death. The expert then went on the criticize the defendant radiologist's actions, stating that he was a board-certified professional who was responsible for making independent judgments that would provide the best care for his patient. He should not have functioned a mere “technologist,” doing what he was ordered.

The defense attorney for the radiologist on call, introduced an older, semiretired radiologist who testified that he had used excretory urography for years in similar situations without any complications. He was, however, unable to refute the argument that unenhanced CT had essentially replaced excretory urography in most situations. The defense expert did say, though, that having been “ordered” by the urologist, the radiologist essentially had been coerced, and that the urologist should bear ultimate responsibility for the outcome to the patient.

The ED physician testified that he had very limited knowledge of the various imaging modalities and would always defer to the “superior knowledge of the radiologist.”

Dr. R, the urologist, testified that although he had requested that the radiologist obtain a urogram, he nonetheless would have gone along with the radiologist's recommendations for a CT scan had the radiologist explained why it was important.

The attorney for the plaintiff was unable to provide testimony to support the charges of negligence against the ED physician or the hospital, but did call a urology expert who was critical of Dr. R, but who acknowledged that the radiologist ultimately had final say in determining which imaging tool was used was clearly .

The defense—realizing that chances of winning in court were slim—entered into settlement discussions with the plaintiff's attorneys. The case was settled for $1 million, 90% of which was paid by the radiologist's insurance company and 10% of which was attributed to the urologist.

Legal background

The purpose of discovery, which involves deposition and the exchange of evidence such as medical records and notes, is to allow each side to assess the strength of the case and gather evidence. Quite often, this process reveals that one party isn't likely to prevail at trial, and this spurs settlement negotiations between the parties, and often (as in this case) representatives of the malpractice liability provider. Settlements are often worked out that take into consideration the limits of the parties' malpractice insurance.

Protecting yourself

Dr. R could have protected himself in this case by listening to the advice of the radiologist, who is an expert in the field of imaging modalities. While Dr. R may have been older and more experienced generally, his hard line attitude about taking advice from the radiologist is what caused the death of the patient and brought him into court. 

Likewise, the radiologist should have insisted that the urography decision go on record as being Dr. R's—under strong protest from him. The radiologist should have documented all conversations with Dr. R and had a third party witness sign off on the diagnostic treatment options discussed. Furthermore, Dr. R was not completely honest under oath when he let the radiologist take the blame for his catastrophic decision. By being intractable and pulling rank, Dr. R not only destroyed a life, but he significantly damaged the radiologist's career.

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