Mock Jury Trial, Part 2
Demetrio continues to grill Berlin on hospital policy as it relates to the reading of ED x-rays and communication of those findings. Demetrio establishes that the ED is about twenty feet from the radiology department at Berlin's hospital. "Normally the way it works is that if the x-ray was taken in the ED, those x-rays go to the radiology department for final review," says Berlin. (Is it me, or is he sounding awfully defensive for a mock defendant?) Now Demetrio is stressing that Berlin knew that both the patient and the ED referring physician were not in the ED anymore at the time he faxed the report. Berlin says he considers the ED physician to be the one ultimately responsible for the patient in this case, and stresses that a printed fax confirmation let him know that the ED had received his report. Demetrio is asking if Berlin thinks early detection of cancer is "critical"; an objection from the defense is sustained. Demetrio's back to reading from the ACR guidelines, asking whether Berlin agrees with certain phrases and paragraphs. It's clear that he's attempting to establish that these findings represented "critical" results, while Berlin feels they represented a possible situation, not a strictly "critical" issue. I want to note here that Demetrio's tone is very aggressive and critical. He's clearly attempting to frustrate Berlin, break him down -- and either these guys are excellent actors or he's doing a wonderful job in spite of the fact that this trial is just a simulation. Now they're onto the issue of whether Berlin was aware that there was a discrepancy between his report and the preliminary findings by the ED doc. Berlin says that he didn't have the preliminary report and didn't attempt to track it down because he felt it was more important to read his x-rays in a timely manner. "A patient sometimes is referred to you directly by his or her physician," Demetrio says, "Regardless of the source of the referral, the diagnostic imager has an ethical responsibility to ensure communication of unexpected or serious findings to the patient. Would you agree?" "Not in every case," Berlin says, but Demetrio insists -- "Agree or disagree?" Berlin attempts to explain that it depends on the type of radiology being practiced. He's right, but I wonder how it sounds to a jury. Nickels is up now. "During your ten years as a radiologist, how often do you have direct communication with the patient?" he asks. "Almost never," Berlin says. As they move into the specifics of the case, you can sense how much more relaxed Berlin is now that Demetrio has taken his seat. Nickels establishes that it is not standard for the radiologist to see the ED preliminary report, then shows Berlin's report as an exhibit. The report states that he saw "normal chest except for a poorly defined small opacity in the right upper lung which may be simply a superimposition of normal lung markings, but a CT of the chest should be considered if clinically warranted to rule out a tumor." Now we're looking at the x-ray itself, and Berlin is walking the jury and audience through what they're seeing, including the cardiac silhouette, the air within the lungs, the ribs and the clavicle. He points out the poorly defined density -- I'd never have been able to pick it out, not that I have a radiologist's eye. Berlin then recounts how he faxed the report to the referring ED doc, and received the confirmation that the fax had been sent. With Demetrio back at the podium, we've moved on to debating whether a fax is the safest possible way to communicate a suspicious finding. I have to admit, as much as I'm on Berlin's side, when Demetrio asks him whether he had the ED doc's phone number and he says yes, I feel awful for Mrs. Rowley and her family -- and I'm guessing the jury does too. Here comes Heidi Rowley, the daughter of the deceased patient, to the witness stand. She's in her second year of medical school at Harvard; her younger sister is in her second year of premed at Yale. Both girls are going to school to become radiologists -- "because of this case," Heidi says, drawing laughter from the crowd and a call for order from the judge. Heidi is already crying recounting the day she talked to her mom about going to the ED. "She woke up in the middle of the night with her heart pounding and went to have it checked out," she says before bursting into tears. (This is lifelike!) "I talked to her the next day and she said she felt good, the doctor told her she was okay, so we didn't think anything of it." Twenty months later, Mrs. Rowley returned to the ED, where she was diagnosed with lung cancer. A year later she died. "Did she put up a strong fight?" Demetrio asks. "Yes," Heidi sobs. Then Demetrio displays a number of pictures of Mrs. Rowley -- hard to see how they're pertinent to the details of the case, but they're tugging at my heartstrings, and I know what I'm seeing is fake. If those in the room were hoping to learn what they'd be up against in a potential malpractice case, now they definitely know. "Tell us what you can about your mom," Demetrio says, and Heidi replies, "We went on a lot of different trips. She wanted to make sure we understood that the world wasn't just here. That was when we could spend time as a family. It was hard for her because my father died when we were so young. She paid for us to go to college. She always wanted us to be as successful and full of integrity as she was. We volunteered a lot." Jeez. Give a young radiologist a chance! Perhaps wisely, Nickels keeps his cross-ex to a minimum, merely establishing that Heidi was not present when her mother went to the ED in 2005. Next up is the plaintiff's expert witness, Richard Chesbrough, MD. Demetrio establishes his credentials, then gets right to the point: "What is the obligation of the radiologist when there's a discrepancy?" he asks. Chesbrough says that it is standard for a radiologist to get the preliminary reading before issuing his or her report, the better to notify the referrer if there's an issue. "If an ED physician concludes all is normal, is a radiologist then a failsafe part of the team, a backup in case there is a mistake?" "Yes," Chesbrough answers, "and they have to know what that preliminary report said." Chesbrough says that in his opinion, the case at hand represents a breach in the standard of care, and that Mrs. Rowley's death was a direct result of the failure in communication on Dr. Berlin's part. Stay tuned for part three!