alleged patient injury due to failure to use nonionics. TABLE 3: Radiology-Related Malpractice Lawsuits, Cook County, IL, 1975-1 994: Miscellaneous Lawsuits Yr Multiple-Defendant Cases Communication Issues 1975-1979 10 4 1980-1984 57 11 1985-1989 33 15 1990-1994 10 3 Failure to Order Radiologic Examinations As can be seen in Table 1 and Figure 2, the number of malpractice suits classified as failure to order has constituted a substantial portion of radiologic malpractice litigation throughout the 20-year span of this study. Ranging from a low of 17% during 1980-1984 to a high of 30% in the period ending in 1994, the percentage of failure-to-order cases has averaged 22%. The total number of these lawsuits has been rising, and the specific nature of the allegations has been changing (Table 4). Lawsuits charging patient injury due to failure to order mammograms numbered only four each during the S-year periods from 1975 through 1979 and 1980 through 1984 but grew to 12 during the 5-year period from 1985 through 1 989 and doubled to 24 during the period from 1990 through 1994. This finding is not surprising, because enormous publicity has been generated by such organizations as the American Cancer Society, the American College of Obstetrics and Gynecology, and the American College of Radiology to promote mammographic examinations. Nonnadiologic physicians who fail to adhere to breast radiographic screening guidelines have been placed in a similarly growing medicolegal jeopardy over the 20-year period. Conclusive scientific proof is lacking that massive screening programs and earlier diagnosis of breast lesions have actually reduced mortality from breast cancer. Yet general agreement exists that a delay in either detection or treatment of breast cancer will be viewed as inappropriate by the patient and the legal system and will thus cause malpractice litigation against the nonordening physician. The monetary awards resulting are quite likely to be high [1 6-1 9]. In a review of breast cancer malpractice cases in New York oven a recent 6-year period, Mitnick et al. [20] found that two of the largest awards in the study were given to patients who had as little as a S-month delay in diagnosis. Table 4 details how malpractice litigation reflects contemponary radiologic practice. As might be expected, the number of lawsuits alleging failure to order angiognaphy, MR imaging, and CT has risen dramatically oven the past 20 years, while sonognaphy claims have risen only moderately. On the other hand, failure-to-order suits involving bone radiography have steadily decreased, and those alleging failure to order myelography have dropped markedly, none having been filed since 1989. Lawsuits referring to X-ray pelvimetry have disappeaned, the last one having been filed in 1985. Figure 3 illustrates the rise in the number of suits alleging failure to order mammograms and cross-sectional imaging, along with the simultaneous decrease in those alleging failure to order skeletal nadiognaphs. In December 1994, 17 failure-to-order malpractice cases were recorded, the largest single monthly total in the entire 20-year period. Included was the first lawsuit claiming injury by failing to order a cone biopsy of a breast lesion. Cleanly, activity in the legal arena is keeping up with radiologic advances. Controversy exists oven the degree to which the fear of getting sued influences the ordering of radiologic examinations. A recent government study concluded that fewer than 8% of all diagnostic tests are ordered primarily because of concern about malpractice and that the fear of getting sued is only minor for most doctors [21]. Others, however, have disagreed. For example, Murphy [22], writing in JAMA, stated that unless physicians order tests and X-rays, patients are “likely to perDownloaded from www.ajronline.org by 2600:1700:3c30:a3d0:f906:a606:b80b:7d98 on 07/20/22 from IP address 2600:1700:3c30:a3d0:f906:a606:b80b:7d98. Copyright ARRS. For personal use only; all rights reserved Fig. 3.-Trends In failure to order cross-sectional imaging (CT, MR im- aging, sonography), skeletal radiographs, and mammograms, Cook County, IL, 1975-1994. AJR:165, October 1995 MALPRACTICE AND RADIOLOGISTS 785 TABLE 4: RadIology-Related Malpractice Lawsuits, Cook County, IL, 1975-1994: Failure to Order Radiologic Exams 5-Yr Period Angiography Myelography Sonography MR Imaging Mammogram CT Skeletaceive our care as substandard and a malpractice lawyer can make a physician seem utterly careless if he doesn’t order a simple test or a chest x-ray.” The group of malpractice lawsuits falling under the failureto-order category assumes even greater importance with the advent of the managed care era. As managed cane enrollment increases markedly throughout the nation, and with the impetus among radiologists to form networks and to engage in capitated contracts with insurers and other payers, radiologists will be placed more and more in a gatekeeping function [23]. Whereas until now the potential liability for failing to order a radiologic examination has fallen on the referring physician, current and future developments may well shift this liability to radiologists themselves. Because cancer is the