Medical disciplinary jurisprudence in alleged malpractice in radiology: 10-year Dutch experience.

Purpose To systematically investigate the frequency and types of allegations related to radiology practice handled by the Dutch Medical Disciplinary Court in the past 10 years. Methods The Dutch Medical Disciplinary Court database was searched for verdicts concerning radiology practice between 2010 and 2019. The association between the number of verdicts and time (years) was assessed by Spearman’s rho. Other data were summarized using descriptive statistics. Results There were 48 verdicts (mean 4.8 per year). There was no significant association between the number of verdicts and time (Spearman’s rho < 0.001, p = 0.99). Most allegations were in breast imaging and musculoskeletal radiology (each 18.8%), followed by interventional radiology, head and neck imaging, and abdominal imaging (each 12.5%), neuroradiology and vascular imaging (each 10.4%), and chest imaging (4.2%). There were 46 allegations against radiologists (95.8%) and 2 against residents (4.2%). The most common allegation (37.5%) was error in diagnosis. In 20.8% of verdicts, the allegation was judged (partially) founded; disciplinary measures were warnings (n = 8) and reprimands (n = 2). An appeal was submitted by the patient in 11 cases and by the radiologist in 3 cases. All appeals by patients were rejected, whereas 2 of the 3 appeals by radiologists were granted and previously imposed disciplinary measures were reversed. Conclusion Allegations against radiologists at the Dutch Medical Disciplinary Court are relatively few, their number has remained stable over the past 10 years, and a minority were judged to be (partially) founded. We can learn from the cases presented in this article, which may improve patient care. Key Points • The frequency of allegations against radiologists at the Dutch Medical Disciplinary Court is relatively low and has not exhibited any temporal change over the past 10 years. • These allegations reflect patient dissatisfaction, but this infrequently equals malpractice. • Knowledge of the circumstances under which these allegations have arisen may improve patient care.


Introduction
Radiology is one of the medical specialties with the highest number of malpractice suits in the USA [1]. The likelihood of a radiologist in the USA being the defendant in at least one suit is 50% by age 60 [2]. It can be expected that the number of malpractice suits will further increase [3,4]. Data from the USA show that diagnostic errors are by far the most common cause of malpractice suits, whereas failure to communicate and failure to recommend additional testing are both uncommon reasons for initiating a suit [1,5]. There are relatively few published data regarding malpractice suits against radiologists in Europe [6,7] compared with those against radiologists in the USA [1,2,5,[8][9][10][11][12][13][14][15][16][17]. The medical disciplinary law system in The Netherlands is unique and essentially different from a medical malpractice claim system, because its main objective is to maintain and improve the quality of healthcare rather than punishing healthcare professionals and/or financially compensating patients [18,19]. In addition, patients can allege healthcare professionals without proceeding to civil court or insurance claims. To our knowledge, verdicts by the Dutch Medical Disciplinary Court related to radiology practice have not been systematically investigated yet. In addition, it is still unknown if the frequency of patient allegations has remained stable or if it has changed over the years. This information may be helpful to radiologists to improve the care they provide to their patients, and to prevent patient dissatisfaction and allegations. Furthermore, this experience may be valuable to governmental bodies and healthcare policy makers in other countries who wish to reform their medical disciplinary law system from a malpractice claim system into a system akin the Dutch. Therefore, the objective of our study was to systematically investigate the frequency and types of allegations related to radiology practice handled by the Dutch Medical Disciplinary Court in the past 10 years.

Methods
The online database of the Dutch Medical Disciplinary Court is publicly available and all data are anonymized. Therefore, ethics committee approval was not applicable for this study.

Data collection
The database of the Dutch Medical Disciplinary Court (https:// tuchtrecht.overheid.nl/nieuw/gezondheidszorg) was searched for verdicts published in the past 10 years (2010-2019). All cases handled by this institute (which consists of independent medical and legal experts) are published in detail online 1 day after the verdict. Only verdicts concerning allegations against radiologists or radiology residents were selected and included in the present study. Verdicts concerning allegations which were not directly related to radiology practice (such as private affairs or non-radiological work) were excluded.

Data extraction and analysis
The following data were extracted for each verdict: radiological subspecialty, whether a radiologist or resident was alleged, number of days between date of filing the allegation and date of the verdict, the type of allegation, the verdict, the type of disciplinary measure (Table 1), if the allegation was judged to be (partially) founded, and whether there was an appeal against the verdict. In order to determine whether the number of verdicts has either increased or remained stable over time, we calculated Spearman's rho between the number of verdicts and time (years). Other data were summarized using descriptive statistics. In cases in which the allegation was judged (partially) founded, we determined (potential) causes that have led to error/malpractice [20,21].

Results
There were 52 verdicts. Four verdicts were excluded, because they were not directly related to radiology practice. Eventually, 48 verdicts were included (Table 2).There was no significant association between the number of verdicts and time (Spearman's rho < 0.001, p = 0.99) (Fig. 1a). Most allegations were in breast imaging and musculoskeletal radiology (each 18.8%), followed by interventional radiology, head and neck imaging, and abdominal imaging (each 12.5%), neuroradiology and vascular imaging (each 10.4%), and chest imaging (4.2%) (Fig. 1b). There were 46 allegations against radiologists (95.8%) and 2 allegations against residents (4.2%) (Fig. 1c). The most common allegation was error in diagnosis (19/48 cases, 39.6%). In 10/48 verdicts (20.8%), the allegation was judged (partially) founded; disciplinary measures were warnings (n = 8) and reprimands (n = 2) (Fig.  1d). All 11 appeals by patients were rejected, whereas 2 of 3 appeals by radiologists were granted and the previously imposed disciplinary measures were reversed. (Potential) causes leading to error/malpractice in cases in which the allegation was judged (partially) founded are displayed in Table 3.

Discussion
The results of our study show that the Dutch Medical Disciplinary Court handles a mean of 4.8 allegations against Monetary fine up to a maximum of 4.500 € 4. Suspension for a maximum of 1 year 5. Partial prohibition to practice 6. Total prohibition to practice *A warning represents the lightest measure: it is a reproof for misconduct (but not for culpable negligence) and has no direct consequences to the healthcare professional. A warning is neither published in the publicly available Dutch registry for healthcare professionals nor in a local newspaper # A reprimand represents a more severe measure: it is a reproof for culpable negligence. A reprimand is published in the Dutch registry for healthcare professionals and will be available for 5 years. Furthermore, a reprimand may be published in a local newspaper, if decided upon by the Dutch Medical Disciplinary Court . Therefore, the relatively low number of allegations may also indicate an overall high quality of radiology practice in The Netherlands. Accordingly, The Netherlands is frequently ranked as having one of the best healthcare systems in Europe [27]. A minority of allegations were judged to be (partially) founded. The Dutch Medical Disciplinary Court imposed 8 warnings and 2 reprimands to radiologists in the past 10 years (of which two were rejected after appeal). These disciplinary measures are the lowest penalties which can be imposed by the Dutch Medical Disciplinary Court. However, the impact of the disciplinary process and the measures itself should not be underestimated. Alleged healthcare professionals describe feelings of misery and insecurity both during the process as in its aftermath, and they fear receiving new complaints and provide care more cautiously after the imposed measure [28,29]. This in turn may lead to defensive medicine, which is an important contributor to healthcare costs without adding any benefit to patients [30][31][32][33].
Error in diagnosis was the most common allegation (39.6%) filed at the Dutch Medical Disciplinary Court and most allegations were in the subspecialties breast imaging and musculoskeletal radiology. These findings are in accordance with previous studies on medical malpractice suits in the USA [1,34], the UK [6], and Italy [7]. Errors are common, with an estimated day-to-day rate of 3-5% of radiology studies reported [35]. Radiologist reporting performance cannot be perfect, and some errors are inevitable [35]. However, there are strategies to avoid error and malpractice and we can learn from our mistakes (see Table 3). We also refer to the informative medicolegal series by L. Berlin, which have been published in the American Journal of Roentgenology in the past years [36]. We further note that radiologists should think about the consequences of error and malpractice in the context of the trend of using artificial intelligence. However, the question of "who is responsible for the diagnosis" when using artificial intelligence (being it either data scientists, manufacturers, and/or radiologists) remains to be answered [37].
Our study has some limitations. First, because our study included only data from The Netherlands, it is not sure whether our results are generalizable to other (European) countries, which have different law systems. Notably, a study which was published in 2010 showed a much higher risk of medical malpractice litigation for Italian radiologists, which was comparable to that for radiologists in the USA [7].
Italy, however, may be an exception among European countries [38]. Second, we only included data from the Dutch Medical Disciplinary Court. Because patients may also proceed to the civil court where they can file an allegation in parallel or separately from the Dutch Medical Disciplinary Court, the number of all official allegations may be underestimated. However, it was not possible to perform an unbiased research of civil court data, because only a selected part of civil court verdicts are publicly published [39]. Furthermore, the Dutch Medical Disciplinary Court essentially differs from civil court in that its main objective is to maintain and improve the quality of healthcare rather than punishing healthcare professionals. In two cases (cases 6 and 34), the appeal against the initial verdict was granted and the previously imposed disciplinary measures were reversed; these two cases are not included in this table # Largely adopted from references [20] and [21] Third, we did not investigate the amount of time and attorney costs (83.3% used an attorney during the court session) spent by defendants. Fourth, we did not investigate the psychological impact of disciplinary measures on radiologists and whether these disciplinary measures achieved their primary goal: to maintain and improve the quality of healthcare. The systematic presentation of cases in this article may further contribute to the quality of radiology practice in general.
In conclusion, allegations against radiologist at the Dutch Medical Disciplinary Court are relatively few, their number has remained stable over the past 10 years, and a minority were judged to be (partially) founded. We can learn from the cases presented in this article, which may improve patient care.
Funding information The authors state that this work has not received any funding.

Compliance with ethical standards
Guarantor The scientific guarantor of this publication is Robert M. Kwee.

Conflict of interest
The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and biometry
No complex statistical methods were necessary for this paper.
Informed consent Informed consent was not applicable for this study.
Ethical approval Ethics committee approval was not applicable for this study.

• Retrospective • Observational • Multicenter study
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