Many doctors lack skill reading mammograms, study says

By MICHAEL MOSS New York Times

Thursday, June 27, 2002

Ten years after the federal government set out to clean up a mammography industry awash in scandal, many women are still getting inaccurate examinations at clinics bearing the federal seal of approval.

The federal mammography standards have eliminated many of the most egregious abuses and have made the breast X-rays much easier to read. But an examination by The New York Times has found that they have largely failed to remedy what many experts say is the biggest problem of all: the skill of the doctors who interpret those X-ray films.

A growing body of research is revealing that radiologists are missing far more tumors than previously assumed. Many of them simply lack the ability to discern the elusive signs of breast cancer in the shadows and swirls of a mammogram.

Interpreting mammograms is widely regarded as the hardest task in all of radiology. Yet the government, by its own admission, holds the doctors to only minimum standards. Little specialized training is required. While studies indicate that doctors need to read at least 2,500 films each year to stay sharp, the government mandates a mere 480, a number many experts say is so low as to be virtually meaningless.

Most important, the government does not monitor the doctors' performances. In fact, the doctors themselves rarely know with any precision whether they are doing a good job.

And the women are often left to fend for themselves.

"It's what I call radiologist roulette," says Trisha Edgerton, a physicist who used to run the mammography oversight program in California.

In a sense, that is simply the way most of medicine works. Except for the clearest cases of criminality or gross incompetence, doctors have always pretty much policed themselves. But mammography was supposed to be different; it was, after all, the great public-health hope of the politically charged war on breast cancer.

And so, in the early 1990s, the government embarked on an extraordinary experiment: a system of national standards to ensure accurate screening for the more than 30 million women who had mammograms each year. At a time of rising furor about doctor competency and medical errors, many people believed it might become a template for other precincts of medicine as well.

Today, at government-certified clinics all over the country, women can pick up official pamphlets assuring them that "your mammogram will be safe and of high quality." Congress is about to extend the program for five more years.

But the inside story of that regulatory experiment -- based on hundreds of interviews with doctors, experts and regulators over the course of a year -- is a chronicle of opportunities lost. Far from ensuring high-quality mammography for all, many experts acknowledge, the system has promoted mediocre care for all but an elite, or just plain lucky, few.

Women have long been told that mammography is an imperfect tool, that even the best doctors, under ideal conditions, will miss as many as one in 10 potentially visible cancers. But new studies in North Carolina and New Hampshire have found that doctors' skills vary widely; some clinics miss nearly four tumors in 10. In New York, health officials analyzing data from a government program for poor women stumbled across a Bronx radiologist, fully qualified under federal rules, who they say missed 25 cancers over two years while catching only seven.

A television segment based on this investigation will be broadcast on the program "Now with Bill Moyers" Friday night on PBS.

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