Monday, March 09, 1998

Ms. Judith Nolte, Editor-in-Chief
American Baby Magazine
c/o PRIMEDIA, Inc.
249 West 17^th Street
New York, NY 10011

Dear Editor,

I read with interest your article titled "Can You Read Me?" which appeared in the medical update section of the March issue of American Baby. Although I believe it to be a good faith attempt to elucidate a real problem in diagnostic ultrasound, in my opinion, the thrust and conclusions of the article miss the real point. I did notice that you do not have a "Letters to the Editor" feature, yet it is my hope that this letter will be read by you and your editorial staff.

As a radiologist whose practice is limited entirely to diagnostic ultrasound, and who personally performs all of his examinations, I believe it is important to shed a light on the reality of ultrasound technician - performed examinations. You suggested in your article that "ultrasound procedures are ordered and interpreted by your doctor." Even in the best of circumstances, this is not entirely the case. The physician is unaware of the content of the entire examination and bases his or her diagnosis only upon the few images presented to him or her by the technician. A close analogy is surmising the content of a whole movie based upon a half dozen still frames from the film. Even worse is the all too common situation in which the physician frankly asks the tech, "Well, what did you find?"

(In the complete universe of tech-performed ultrasound exams there are several other flavors (variations), each as unsavory as the ones mentioned in the paragraph above. For example, in some centers techs provide the physician with images and a worksheet they fill out for each study; or, techs discuss the findings with the physician in the absence of the patient, etc. Each is a different variation of medical "hearsay" as the physician is not present with the patient during the examination.)

Of the three groups of errors which your magazine cited none were the direct fault of the technicians. Each resulted from the abdication of responsibility by the physicians who were interpreting the studies. In the first group, where the sonogram failed to pick up an abnormality that was later confirmed, the fact that the physician did not perform the examination may have been the cause. In the second group, where the ultrasound report failed to accurately document suspicious anomalies, that is the fault of the interpreting physician. He or she should have known what a "suspicious" finding looked like. And in the third group, where image quality was an issue, the physician interpreting the examination should have noted the poor technical quality of the study and requested a repeat examination.

The fact is, ethically, practically, morally, medically and legally, the physician is the captain of the ship and the gatekeeper of the quality of the examination that is interpreted. Whether the initials following your name are MD, DO or RDMS, you can still perform a lousy ultrasound examination that is technically poor. It is the responsibility of the physician interpreting the examination to request that a technically adequate study be performed or acknowledge in his or her report that due to uncorrectable patient or technical factors an adequate study was not obtainable. It is also the obligation of the physician to know what constitutes a "suspicious" finding. Similarly, if physicians assume the responsibility of interpreting work they did not perform, it is their responsibility if findings are missed. If the physician cared enough, he or she would have performed the examination him- or herself.

In conclusion, based upon the content of your article, the credentials of the technician performing the ultrasound examination appear to be of dubious significance, as all the errors you cite are the responsibility of the interpreting physician and therefore bring into question the skills and qualifications of the physicians, not the technologists.

Sincerely,

Michael Applebaum, MD, JD, FCLM