A shortage of qualified radiologists in breast imaging in the United States could diminish the ability to provide women with their recommended regular screening mammograms. Fears of the medicolegal risks of breast imaging may be an important influence on whether radiologists decide to interpret mammograms [6
]. Our study found that radiologists' perceptions of the risk of malpractice lawsuits related to breast imaging were significantly higher than their actual reported experience of being sued, and these perceptions remained high over a 5-year period. Interestingly, those radiologists who found uncertainty in clinical medicine more troubling reported higher estimates for their likelihood of being sued.
Our data show that the average perceived risk for a lawsuit related to mammography is about four times higher than the reported rate of malpractice claims: 41% average perceived risk from the first survey for the time period from 2001 to 2005 versus 10% actual risk reported from the follow-up survey in 2006. This overestimation is higher than that shown in a study by Lawthers et al. [11
] in which high-risk specialists, including neurosurgeons and general surgeons, only overestimated their risk of being sued by a factor of 1.6, whereas low-risk specialists such as internists overestimated their risk by a factor of 1.3. However, the data were gathered by Lawthers et al. more than 15 years ago, which may explain the lower perceived risk in their study.
The radiologists' 5-year estimates for the likelihood of being sued varied enormously, with 19% estimating their risk at 10% or lower and 25% estimating their risk at 70% or higher. This variation suggests a considerable need for education to help radiologists better understand their actual risk of being sued. Radiologists responding to the 2002 survey with the highest estimates for the likelihood of being sued were those who had previously been sued or knew colleagues who had been sued. Although physicians with prior claims may have an increased likelihood of experiencing a future claim [18
], there is no known relationship between knowing a colleague who has been sued and actually being sued. Yet seeing a colleague experience the trauma of being sued may lead radiologists to mistakenly conclude that their own risk of being sued is higher by association, as might be anticipated. In addition, physicians are generally advised by risk managers not to discuss malpractice lawsuits that have been filed against them with colleagues because of concern that the colleague could be subpoenaed to testify in the case [19
]. Thus, the information physicians may learn about lawsuits against colleagues may be incomplete or inaccurate, leading physicians to mistakenly inflate their chances of being sued.
Radiologists' malpractice risk perceptions remained high over the 5 years between the two surveys despite the fact that only 10% were actually sued during this time period, suggesting that understanding the sources of radiologists' malpractice risk perceptions will be important in bridging the gap between these risk perceptions and reality. For example, radiologists whose survey responses showed greater discomfort with uncertainty in clinical settings also perceived that the risk of being sued was higher—an association that persisted when adjusted for clinical and sociodemographic characteristics. Being sued for malpractice is fraught with uncertainty, including which clinical events will initially lead to lawsuits, whether a lawsuit will proceed to trial, and the outcome of that trial [20
In a malpractice situation, this uncertainty is deeply unsettling for physicians—a successful lawsuit can dramatically increase insurance premiums or, occasionally, render a physician uninsurable [22
]. One study of Swiss physicians has shown that stress due to clinical uncertainty is associated with lower work-related satisfaction; this is an especially important issue in breast imaging, given the workforce strain in mammography [23
]. Radiologists' discomfort with clinical uncertainty is also associated with higher recall rates, lower specificity, and lower positive predictive value when interpreting diagnostic mammograms [9
]. Thus, developing interventions to reduce radiologists' discomfort with uncertainty could reduce their fears of malpractice and enhance the quality of mammographic interpretations.
Many other sources likely contribute to physicians' elevated perception of the risk of litigation. The mass media actively report errors in medicine and often emphasize breast cancer cases [24
], potentially heightening radiologists' awareness and anxiety regarding malpractice issues. Many medical societies and other physician interest groups have vigorously publicized the challenges in the current malpractice environment in hopes of encouraging tort reform [26
]. The medical community should strive to help physicians better understand their actual risk of litigation by providing malpractice education that is accurate and balanced. Radiologists may also be less anxious about malpractice if they know that many lawsuits are dropped or never go to trial and that plaintiffs prevail in only a small fraction of cases that do proceed to trial [27
Interventions, such as the use of CAD programs, did not influence physicians' perceptions of the risk of being sued. The practice of having a second set of human eyes looking at each examination may provide more reassurance that cancers are less likely to be missed. Radiologists may not have the same sense of trust in the second reading by a CAD program [32
]. Considerable legal uncertainty exists regarding the impact of new technologies, such as CAD, on malpractice litigation. In one recent lawsuit, an appellate court upheld negative CAD results as reliable supportive evidence in the radiologist's defense [10
]. It is also possible that CAD markings on a lesion that radiologists decided not to recall could be used to assist a plaintiff. However, positive CAD marks may be less helpful to plaintiffs in light of the low reliability of a CAD mark given the large number of false-positive findings [33
]. Thus, the actual impact of these technologies on radiologists' risks of being sued for malpractice and the outcomes of these lawsuits remain uncertain.
This study addresses an urgent topic given that delay in breast cancer diagnosis remains the leading reason for medical malpractice claims in the United States and an important factor for declining interest in specializing in the field of breast imaging. The strength of this study is inclusion of community radiologists from three regions across the country. The participating radiologists from the state of Colorado might have lower perceptions of malpractice risk compared with other U.S. radiologists because these physicians are self-insured, and there are caps on malpractice lawsuits in Colorado. Limitations of this study include the reliance on self-reported data about malpractice litigation and experience. It is not known if these data are relevant to fields other than breast imaging. Radiologists who work part time and full time were asked to provide risk estimates for full-time practice in mammography; the risk estimates were similar for those whose practice at the time of the survey was part-time compared with the full-time radiologists. Although we had an unusually high response rate to mailed surveys for physicians (> 70%), we do not know if there was a bias induced by the type of radiologists who responded to our survey. The interpretive performance of responders to the 2002 survey was similar to that of the nonresponders, which is reassuring [34
Recruiting and maintaining radiologists in breast imaging has become problematic due in part to malpractice litigation threats and resulting fear of litigation [4
]. Our study is the first to evaluate trends over a 5-year period in malpractice lawsuit experience and perception of risk among radiologists who interpret breast imaging. Our study is different from prior studies in that we compared perception of malpractice lawsuit risk not only to physician demographics and experience but also to practice characteristics (such as double reading and use of CAD) and physicians' reactions to uncertainty in clinical situations. Our data allow radiologists to review their peers' experience with malpractice litigation in breast imaging. Developing an accurate perception of malpractice lawsuit risk and understanding the characteristics of individual radiologists that are associated with an increased concern may help to lessen anxiety. Ultimately, radiologists who can put malpractice lawsuit risks in a realistic context may be more likely to choose the field of breast imaging and maintain their interest in remaining in the field. Given potential manpower shortages in breast imaging, maintaining radiologists in this field is an essential goal.