Dr. Sir William Osler was a famous doctor who lived between 1849 and 1919. He said, “Errors in judgment must occur in the practice of an art which consists largely in balancing probabilities.”
Medicine remains an art which is rapidly and transforming into a science. However, when human judgment enters into the diagnosis, mistakes will occur. As every physician has probably once stated, “ As god as my witness, I have seen things on subsequent viewings that I initially did not.”
A Risky Business
Orthopedic surgery and radiology are two of the highest specialties sued in malpractice suits. Orthopedists, radiologists, and emergency room physicians, are usually at the center of liability due to fractures and subsequent complications.
Yet, the highest sought after residency is orthopedic surgery. Orthopedic surgeons are among the highest individuals in academic standing in their medical school classes. They certainly are the best of the best and are very well trained.
Reputation often does not reflect a surgeon’s level of competence.
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Preventing diagnostic Errors
Most early diagnostic errors occur in emergency rooms. Unfortunately, emergency room physicians are very busy and are not experts in all aspects of medicine. Subtle fractures are often not seen by emergency room physicians. It is the radiologist who usually sees these findings and informs the emergency room of the problem.
Evaluation of emergency room exams demonstrates that the average miss rate for all fractures is 3.7%. The highest rate of common fracture errors in interpretation is usually in the foot. These errors are at a rate of about 7.6% and errors in readings at the knee is at 6.3%. The lowest percentage of fracture misses in an emergency room setting is usually at the tibia and fibula and is at a 4% miss rate.
However. when accounting for specific location, tibial plateau fracture is missed 16% of the time and radial head fracture 14%. These statistics do not include the more difficult to evaluate insufficiency fractures of the sacrum, knee, or spine. These fractures have a much lower probability rate for a correct diagnosis initially. These fractures are either sorted out by the follow-up from CT or MRI.
As a practicing radiologist, these numbers seem greater than expected. The miss rate is too high, especially if you are the individual with the fracture.
Most missed fractures are very subtle and are usually not clinically significant long-term. Some fractures, however, have long-term dire consequences when not seen initially. As an example, the lisfranc fracture can result in long-term disability of the midfoot.
Correlating diagnostic results with symptoms
One of the most helpful hints for diagnosis is to correlate the degree of physical findings and symptoms related to the findings on x-ray or other imaging.
Orthopedic surgeons make few clinical diagnostic errors and are excellent at clinical diagnosis even without imaging. They may be misled by diagnostic imaging reports or by verbal reports. They also have a much greater malpractice risk due to the fact that they perform surgical procedures.
Any surgical procedure has inherent risks, especially in an aging population with poor healing and multiple health problems. Most surgical procedures proceed appropriately without complication. Higher risk patients needing more complicated types of surgery produces greater complications. These patients include the elderly, the obese, osteoporotic patients, diabetic individuals, and smokers.
Even though arthroscopy is a much less complicated procedure, it can result in infection or chronic pain. In addition, inadvertent complications from surgery do occur. Many Orthopedic surgeons will not operate on smokers due to the decreased healing ability and increased complication rate these people.
The medical profession is composed of humans who do make mistakes. The complications are usually not due to incompetence and constantly learning about common misreadings such as Supracondylar fracture of the elbow. Unfortunately, surgical procedures do not always go as planned. Most physicians are highly trained and always work in your best interest.
Nevertheless, a radiologist is trained in reading exams. An Orthopedic surgeon is trained in surgery and should leave the radiology work to the specialists in that area.