TCS Daily

My Asbestos Patients

By Sydney Smith - August 10, 2004 12:00 AM

Asbestos has had a troubled history. A natural, fibrous blend of iron and magnesium, it's been recognized since the Stone Age for its strength, wearability, and heat resistance. It became an essential material for the construction, auto, and ship-building industries after the Industrial Revolution. Alas, for asbestos, it is also a potentially deadly material. A lifetime of inhaling the fibers can leave a worker with scarred, inflexible lungs (a condition called asbestosis), or worse -- cancer. The danger is greatest for those who mine it from the earth, and for those who directly handle it during manufacturing processes. It poses no danger to those with only casual contact with it through the environment. The dangers of constant exposure to asbestos became apparent by the early twentieth century, and by the late 1980's, the EPA had banned most of its uses.

That should have been the end of the story, but in many ways it was only the beginning. Enter the personal injury attorneys, who launched suits against companies that used asbestos. Their clients include not only those who handled asbestos, but those who worked in any plant that once used it. Fortunes of many a trial a lawyer have been made and those of many companies lost in the ensuing battle. A recent Rand study reports that $54 billion have been spent on asbestos settlements. Eighty companies have had to file for bankruptcy, and 60,000 people have lost their jobs as a result.

As of this writing there are over 600,000 asbestos claimants in the United States. There is good reason to believe that few of them actually have asbestosis. Typically, these claimants are gathered by personal injury attorneys through union lists. The attorneys offer free chest x-ray screenings to determine if they've been injured by asbestos in the workplace. These x-rays are then read by radiologists employed by the attorneys, who pay them a fee per chest x-ray. In the medical world, the diagnosis of asbestosis is not made by chest x-ray alone. It also requires knowledge of the patient's health history, subjective complaints, physical exams, and measurable lung function. But in the legal world, all that's required is an abnormal chest x-ray. And so, most of the 600,000 asbestos claimants have been diagnosed with asbestosis not by their doctors, but by radiologists they've never met. Radiologists, it bears repeating, who are employed by personal injury lawyers.

A recent study by researchers at Johns Hopkins suggests that the radiologists making these diagnoses may be gaming the system. To be an expert in the interpretation of chest xrays for asbestos damage, a radiologist has to have what's known as "B-certification", which means that he's been schooled in the radiological changes accepted by the International Labor Organization as defining asbestos damage in the lungs. The researchers took 492 chest x-rays that had been given the diagnosis of asbestosis by radiologists in the employ of attorneys, and gave them to independent B-certified radiologists to interpret. The differences in interpretation were stunning. The independent radiologists were 159 times more likely than the attorney's radiologists to read the x-rays as normal. Statistically, there was no agreement between the interpretations of independent radiologists and the attorney's radiologists.

But that's not the worst of it. When B-certified radiologists look for asbestos damage in an x-ray, they use a standardized form to help guide their interpretation. They're asked to rate the size and density of the shadows on the film from a scale of 0/1 (normal) to 3/3 (very abnormal). To qualify for asbestosis compensation, the worker's x-ray must have opaque shadows that rate at least a 1/0 or higher. And this is where the biggest difference in film interpretation was found. The attorneys' radiologists rated 96% of the 492 films as having abnormalities of 1/0 or higher. The independent radiologists put just 4.5% of the films in that category. To put it another way, if a radiologist is being paid by a personal injury lawyer to interpret a film, he's 2,227 times more likely to discover signs of asbestosis than a financially independent radiologist is.

To be sure, interpreting x-rays is far from a perfect science, especially when the changes being interpreted are as subtle as those involving early asbestosis. Ten percent of the time, if given the same film two days in a row, the same radiologist will come up with two interpretations. Such is the fuzzy nature of x-rays. That's why other occupational disease programs -- such as that in place for coal miners, which use chest xrays to confirm a diagnosis -- rely on two or more radiologists' interpretations instead of just one. But radiologists are usually able to agree with one another at least seventy percent of the time. A disagreement rate like that seen in the Johns Hopkins study is unheard of. As an accompanying editorial put it, something's rotten here.

Evidence abounds that that "something" is the personal injury industry that produces these "cases." Plaintiff's attorneys are not only known to shop around for clients, they also shop around for favorable x-ray interpretations. As an added incentive, they often pay their radiologists twice as much for a 1/0 rating than they do for a normal reading. The system is in obvious need of reform, or at the very least, regulation.

Of those 600,000 asbestos claimants, 34,000 are in Cleveland, Ohio. Some of those are my patients. Some worked on the assembly line at auto plants, some only in the cafeteria. None of them has any clinical evidence of asbestosis. But all of them are eagerly awaiting the day their check comes in.

I did once have a patient who certainly suffered from asbestos exposure. He handled it all of his adult life, first in the shipyards of Norway, then later in an automotive factory here in the States. He died of mesothelioma, a rare form of cancer that's known to be associated with asbestos exposure. His widow has been trying to get compensation, but so far has been unsuccessful. The lawyers say they can't prove which was responsible for his health problems -- the shipyards or the auto plant. Whatever that is, it isn't justice.

Sydney Smith is a family physician who has been in private practice since 1991. She is board certified by the American Board of Family Practice, and is a Fellow of the American Academy of Family Practice. She is the publisher of MedPundit and a TCS columnist.


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