Discord between the interpretations of compensated physicians providing legal testimony and blinded radiologists reviewing the same study highlights flaws in the medicolegal system, according to a study published in the August edition of American Journal of Roentgenology.

The specter of medical malpractice leads to defensive medical practices, exposes patients to unnecessary harm, may lead to provider shortages in subspecialties such as mammography and affects clinical decision making, explained Richard C. Semelka, MD, of the department of radiology at the University of North Carolina at Chapel Hill. Required paid legal testimony “may be subjective and biased by knowledge of the clinical outcome and by financial compensation,” he noted.

Researchers recruited 31 radiologists with an average of eight years of experience to review six CT studies including one case pertaining to a settled lawsuit. A second case of major trauma and similar history, fractures and soft-tissue injury was clinically matched to the medicolegal case. The cases simulated a typical emergency department caseload, and all secondary reviewers read CTs of the chest, abdomen and pelvis at their host institutions.

Radiologists were not informed that any case was a medicolegal case, and they were instructed to spend the appropriate amount of time reviewing each study. Physicians participating in the study received $100 compensation and were asked in a follow-up email if the amount was adequate for court-mandated interpretation.

Although 30 of the 31 secondary readers identified all findings in the CT study clinically matched to the medicolegal CT study, none observed the finding critical to the litigation in the medicolegal case. “None of the secondary readers reported any findings to suggest spinal instability, which was the inference made by the medical expert witnesses who found [1-mm] facet widening and was the basis for legal action,” wrote Semelka.

Other findings in the medicolegal case proved similarly subtle. None of the secondary readers identified the fracture of the T3 vertebra, one of the standard of care findings reported by the four medical expert witnesses, and nineteen of the 31 noted the T10 fracture in the legal case.

On the question of compensation, 10 of the 31 radiologists considered the $100 adequate for court-mandated interpretation, noted Semelka.

“Our pilot data … show our method may be useful in determining standard of care in medical-legal cases,” wrote Semelka, who argued that the method minimized bias. Blinding reviewers to the medicolegal case; submitting multiple cases to simulate clinical practice; and including a control case, randomly assigned cases and a matched case curbed bias. The short but reasonable timeline for reviewing cases and $100 compensation helped ensure that readers would read the studies.

Semelka proposed using the method to acquire expert opinions to determine standard of care independently of plaintiff and defense compensation and answer two main questions: Should the litigation proceed and does the finding confirm or suggest the diagnosis.

The inability of blinded radiologists to confirm expert witness interpretation of subtle findings “illustrates an intrinsic flaw in the current medicolegal system that specifically affects radiologists,” concluded Semelka.