The Expert: Dr. Carl Capelouto: A Georgia-based urologist testifying as to the standard of care in urological treatment when imaging is performed.
Testifying as an expert for the defense in a Georgia state court trial in which a fatal renal tumor went undetected, urology expert Dr. Carl Capelouto defines the standard of care for a urologist reacting to radiologic interpretations.
As a clinician, Capelouto says he only looks at perhaps half of the CT scans that he orders. Reasonable urologists, he explains, may not even look at the images that they have ordered, though they must look at the radiologists’ interpretation of those images. This custom within the medical community is not well understood by patients or laymen in general, but it is within the standard of care.
It is reasonable for a urologist to look at the films they have ordered themselves and try to interpret the findings, but it is not required since there is a medical specialist who is better trained and more knowledgeable about the technology and expected variations. That specialist, the radiologist, will ultimately give the definitive interpretive report.
Capelouto discusses the initial films that he was supplied with, and prior to having full knowledge of the case, he interpreted these films as investigating a kidney stone complication. He says he could see the cysts in question, but felt that they would not require any further investigation, unless the radiologist provided different guidance. Once the testifying expert was supplied with documentation and official radiologic interpretation, he did not see wording that would have indicated a need for more extensive workup of the cysts than had already been performed.
Capelouto goes on to state he believes that the defendant actually went “above and beyond” reasonable expectations by acting quickly to obtain a CT scan in this case, instead of opting to treat the patient’s condition with further antibiotics and observation since there was no objective evidence of tumor in initial screening tests. The doctor calls upon his experience in his own practice to express his belief that, given the fact that the patient’s symptoms abated after passage of a kidney stone, this patient may, with another doctor, never have had a CT scan to evaluate this problem. He testifies reassuringly, “that’s happened numerous times in my practice.”
Pointing to the images on the CT scan in front of the jury, the expert addresses the separate variations seen on the films. In each case he states that these findings do not call for a repeat of the CT scan with contrast imaging. He also is questioned about specific wording within the radiologist’s report and whether that wording signals the need for further investigation. For example, the doctor explains that the term “lobulation,” used in the report, can describe normal structures seen on these films. Wording that would be of concern would be “septations, calcifications, or thickening of cyst walls,” creating complex cysts. “Lobulation,” by contrast, does not imply that a cyst is complex or that it requires further workup. Dr. Capelouto speaks earnestly when he says that he has seen simple cysts like this on X-ray as well as in the operating room, and that these usually present no problem to the patients that have them.
Delving further into the radiology report, the expert points out that there is nothing in the description of these cysts that indicates to him that more workup must be done. It is not necessary, he explains, to describe a cyst as a “simple cyst” in a radiology report, as that is customarily what the unqualified word “cyst” implies to the clinician. As well, there is nothing in the report to imply that the urologist that ordered the report needs to look at the film. Indeed, radiologists are is considered the true experts in the interpretation of radiologic findings and their opinions will be the ultimate determinant of whether a diagnosis can be made from the films, or further workup is indicated.
Capelouto concludes that, given the radiologic findings and urine analysis, once the kidney stone was passed and the patient’s symptoms were alleviated, the standard of care did not demand any further workup or even follow up by the defendant. In the end, Capelouto tells the jury that, “This is not even a close call,” when considering the standard of care for urologists under these circumstances.
The jury agreed, clearing the defendant urologist.
Gary Gansar, MD, is residency-trained in general surgery. He served as Chief of Surgery and Staff at Elmwood Medical Center and on the Medical Executive Committee at Touro Infirmary and Mercy Hospital in New Orleans, LA. Dr. Gansar was Board Certified in general surgery while in active practice. He joined AMFS in 2015 as a Physician Medical Director.
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