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The pre-purchase examination – an image problem

We are seeing an increasing number of expensive claims associated with misinterpretation of radiographic images at the pre-purchase examination

07 December 2020, at 8:20am

The sale or purchase of a horse or pony can appear to be a simple business transaction and is, in the eyes of many prospective purchasers (and sellers). Often, considerable sums of money are involved and the purchase is surrounded by high emotion. It is important that we, as vets carrying out pre-purchase examinations (PPEs), do not promise too much of them. If for whatever reason disappointment follows or something goes wrong, the modern consumer society dictates that someone must be to blame, and most of the time the blame lands on the vet who carried out the PPE.

All veterinary surgeons who perform PPEs are at risk of a claim being brought against them. Reputation and experience do not provide immunity. Against this background, and considering the vast numbers of horses changing hands each year, it is a tribute to our profession that claims are not more frequent.

Radiography is not part of the routine PPE procedure but, given the rapid development in imaging technology, we are seeing an increasing number of expensive claims associated with misinterpretation of radiographic images at the PPE. This can either be the interpretation of radiographs taken at the time of the PPE or images having been taken by a third party some time previously. This typically involves an allegation that a feature such as a bone chip or other pathology was not detected and/or accurately reported on.

If radiographic evaluation is requested as an additional procedure by the prospective purchaser, it is a good idea to request precisely what images are required to form part of the PPE in writing. This avoids any confusion later. It is also prudent to only radiograph the structures requested. For example, if foot radiographic images are taken, ensure other structures such as the fetlock joint are not included.

We recognise that considerable pressure exists to report the PPE findings immediately, even when radiographs are included. This immediacy is enabled by the fact we are now in the digital age! However, this desire for immediacy coming from those involved in the PPE in whatever capacity must be resisted. No comment on the radiographs should be made whilst looking at a small screen by the side of the horse possibly with the seller and/or prospective purchaser peering over your shoulder. An agent being present is unlikely to ease the pressure but be strong – at most you should confirm that image quality appears satisfactory.
Then, once back in the comfort of your practice, you and a trusted colleague can chill out in a darkened room and care-fully commit to a final report on the images obtained.

Another potential pitfall looms when a prospective purchaser client asks you to “check” a number of radiographs sent by email from the seller. What does the word “check” even mean? Having completed a PPE, do not be drawn into evaluating a number of JPEG images on an archaic computer brought out to a brightly lit stable! In many cases, there is not even any proper identification on these images so there can be more than an element of doubt about their provenance. As for evaluating images on a phone: the less said the better. Not charging for this “check” affords no protection should a problem be detected down the line. In many cases, the missed features come to light when the purchaser decides to sell the horse on and the orthopaedic anomalies are clearly seen by the next vet involved when they view the images under optimal conditions without time pressure. In most cases the first vet involved can readily see the problems when the images are evaluated calmly and carefully in an appropriate room adding to the frustration all round. When the original DICOM images are tracked down the problems are typically even more apparent.

It is definitely a good idea to have practice systems in place to mitigate the risk and try to prevent, as far as possible, such events happening. Strict procedures should be in place for handling requests to interpret images at PPEs. If colleagues are presented with radiographic images taken by a third party, care should be taken to ensure the images are presented in the best format, are of appropriate quality and have adequate provenance and that all necessary views are available. Such images, and any obtained at the time of the PPE, are best evaluated carefully in the peace and quiet of the practice, for an additional fee of course, rather than providing an on-the-hoof interpretation at the yard. This allows time to assess them without distractions and, if necessary, to obtain a second opinion from a colleague before including the appropriate proviso and risk warning on the PPE certificate.