Sunday, March 14, 2010

Top medical professionals dispute extent of x-ray crisis

‘It was like a media tsunami," said consultant radiologist Dr Risteárd O’Laoide about reaction to the news that thousands of x-rays had not been reviewed by radiologists at Tallaght Hospital.

O’Laoide, dean of the faculty of radiologists at the Royal College of Surgeons in Ireland, expressed concern about the ‘‘sensationalist’’ portrayal of the facts.

He said the media coverage and public debate had left the public confused and misinformed, with many people left with the mistaken impression that thousands of x-rays had not been examined by any doctors.

The comments come despite the fact that management at Tallaght Hospital acknowledged that it was a serious issue that had to be rectified.

‘‘To describe it as a national catastrophe was completely over the top. There is also no evidence whatsoever to suggest that this is a misdiagnosis scandal," said O’Laoide.

His views were echoed by the HSE’s national director of clinical care, Dr Barry White.

‘‘As a practice the unopened GP referrals was a more serious issue than the x-rays. That cannot be defended, but the unopened letters was an imperfect response to significant pressure on outpatient waiting lists at the hospital," he said.

Tallaght Hospital chief executive Kevin Conlon said last week that Tallaght Hospital had reviewed 34,752 x-rays of some 57,921 adult x-rays that had not already been reviewed by a consultant radiologist.

Two cancer patients received a delayed diagnosis as a result of the failure to have their x-rays reviewed by radiologists at the hospital. One of these patients has since died, while the other is being treated at the hospital.

‘‘It is very unfortunate that they had a delayed diagnosis. That is extremely difficult for them and their families, but it does not necessarily mean the same thing as a misdiagnosis," O’Laoide said.

The difference between a delayed diagnosis and a misdiagnosis is fairly immaterial to a patient with cancer whose tumour was not spotted at the outset, however.

‘‘In a properly functioning department chest x-rays should always be reviewed by radiologists," O’Laoide said.

It is understood that most of the 57,000-plus x-rays which were not reported on by consultant radiologists at the hospital between 2005 and 2009 related to orthopaedic work, but it remains unclear how chest x-rays slipped through the net.

‘‘I suspect that what happened in Tallaght was that they did some degree of risk stratification and decided that, because of the heavy work load, they would leave orthopaedic x-rays with the orthopaedic consultants at the hospital," said O’Laoide.

He said it was not uncommon for this to happen in hospitals.

‘‘This issue is not unique to Tallaght. Some hospitals have radiologists report everything.

Others do not," he said.

Orthopaedic consultants, for their part, maintained they were well equipped to read the vast majority of orthopaedic x-rays.

David Moore, a consultant orthopaedic surgeon at Tallaght Hospital, said orthopaedic surgeons were more than capable of reading x-rays in 95 per cent of cases.

‘‘We spend a good deal of our time studying x-rays. An opinion from a consultant radiologist [for orthopaedic patients] is necessary only in a small number of difficult cases," he said.

‘‘There are no absolute rules," said another doctor. Neurologists, for example, are adept at interpreting CT and MRI scans of the brain. Intensive care specialists often interpret their own xrays. Respiratory physicians interpret their patients’ x-rays.

Dr Tony Holohan, chief medical officer at the Department of Health said: " In situations where there is a clear agreement policy in place between radiologists and other consultants, it is perfectly appropriate for those consultants to review x-rays."

However, it is unclear whether there was a clear agreement at Tallaght. While it is understood that a significant number of the controversial x rays were of orthopaedic patients, that was not the case for all of them. It may well emerge that a significant number of x rays in that 58,000 should have been read by a radiologist.

Tallaght Hospital did not respond to numerous requests from this newspaper for clarification regarding the cohorts of patients involved.

The fact that there were no national guidelines or protocols to dictate best practice has confused the public and muddied the waters, but national protocols are being established by a group which had just been set up by the Health Service Executive.

‘‘The Faculty of Radiologists is leading a new National Quality Assurance programme in conjunction with the National Cancer Control Programme and the Royal College of Physicians of Ireland.

This will hopefully help to reassure patients, radiologists themselves and the wider public," O’Laoide said. Many jurisdictions have different protocols in place to dictate best practice.

‘‘There is a shortage of radiologists in England. One of the ways they decided to tackle it was to introduce a protocol under which orthopaedic films can be reviewed by orthopaedic consultants. In the United States, they say every x-ray should be reported by a radiologist," said O’Laoide.

Some observers have criticised the workload of radiologists at Tallaght Hospital.

Donal Duffy, assistant general secretary of the Irish Hospital Consultants Association, said he had spoken to radiologists at Tallaght who said the hospital did not have enough consultant radiologists to cover the workload. The hospital is now recruiting more staff.

‘‘What happened at Tallaght is a symptom of a wider problem - resources," Duffy said.

While there is a shortage of radiologists in Ireland, O’Laoide said the failure to deploy radiologists to areas of most demand was of greater concern. He said there was a high concentration of radiologists in the breast area, but a shortage of neuro-radiologists.

He said the workloads of radiologists had increased greatly in recent years, due to more advanced imaging and the time devoted to multidisciplinary team meetings in the cancer arena.

It may well emerge that a significant number of x-rays within the 58,000 x-rays at Tallaght should have been interpreted by a radiologist.

A number of those patients may well have been referred for x ray by GPs. Mistakes were undoubtedly made, but the real scale of the problem and the number of x-rays that fell into that category has yet to become clear.

While it maybe of little comfort to patients and families involved, there is an accepted level of error in radiology. To put it in perspective, the British Institute of Radiology recently held a meeting entitled ‘‘How much error is acceptable in radiology?"

According to O’Laoide, an error incidence of 2 per cent is deemed acceptable.

‘‘People miss cases. I do. Am I alone? No. Everyone does. It can be very difficult to convey that to the media at times like this. The debate is often brought down to individual patients and it is very emotive. It is impossible to advance a good debate on the back of that," he said.

‘‘If the miss rate at Tallaght is two out of some 34,752 x-rays it can only be described as remarkably low. That said, all chest x-rays should be reported by radiologists and that did not happen."

No comments:

Post a Comment