— Radiology reports need to be organized to greater standards, argues Saurabh Jha, MD

by Saurabh Jha MD march 10, 2016


""Normal" is just one of the most powerful words a radiologist can use."

– Curtis P. Langlotz, professor the radiology, Stanford University

After I offered "clinically correlate" thrice in a heat in my report, the attending radiologist asked, "How would certainly you feel if the referring clinician stated on the requisition because that the research "correlate through images"? once you questioning them to clinically correlate, you"re reminding them to carry out their job."

I had actually been a radiology resident for 6 month -- too shortly to understand radiology however not too soon to grasp radiology"s negative habits. Ns had acquired several habits -- tics, to it is in precise. These tics consisted of saying "seminal vesicles space unremarkable," i m sorry I proclaimed remorselessly ~ above the CT of the abdomen in males, also if the clinical concern was portal vein thrombosis, sending, ns suspect, number of young guys to existential despair. But the tic that really obtained under mine attending"s skin was "cannot exclude." The attending to be Curtis P. Langlotz, the author of "The Radiology Report," a book around writing efficient radiology reports.

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Ubiquitous in clinical care, and also sometimes parody, radiology reports room enigmatic. What"s many striking about radiology reports is your variability. Reports vary in length, tone, precision and frequency that disclaimers. Reports differ in stamin of referrals for more imaging.

One radiologist may say "small pancreatic cyst, introduce MRI come exclude neoplasm." Another, conscious that the patient may cross St. Peter"s gate sooner rather than later, might bury the findings in the bowels the the report, hoping the clinician will spot its irrelevancy. Yet another, passionate to it is in nonjudgmental, could say "small pancreatic cyst, most likely benign, but MRI might be thought about if clinically indicated," which, Langlotz notes, is vacuous due to the fact that with pancreatic cysts there"s nothing clinically the clinician have the right to anchor that reference on.

Radiologists, conscripted to ail hesitation in diagnostic medicine, have actually responded by introducing their very own uncertainty. We remind doctors that "CT does no exclude ligamentous injury" top top CT of the cervical spine i beg your pardon is an adverse for fracture. The pedagogic worth of this disclaimer is shed by the second time that is read.

Why carry out we point out metaphysical truisms such as "subsegmental pulmonary embolism is not entirely excluded v absolute certainty?" This is part honesty and part disingenuity. Suspicion is a truth of life. However radiologists recognize that clinicians understand that no pathology can be excluded with absolute certainty. Stating this truism throw the ball back in your court, legally. The radiology report is a legit document.

"The Radiology Report" has actually been composed in the method Langlotz hopes his colleagues compose their reports. The book is short, readable, ~ above point, and, importantly, the author takes a stand. He doesn"t hedge. Langlotz advocates standardized reporting, unapologetically. One might argue v the stand, and he knows the I frequently do (I argue with everything). However here is the point. Due to the fact that Langlotz takes a stand, the conversation moves. The was standing anchors the narrative.

Medical decision do is similar -- you have to take a stand. While the is crucial to it is in right, that is better to it is in wrong 보다 vague. Because when you"re wrong around a diagnosis, at least the clinicians know which diagnoses are wrong so the they can move to the next. By gift vague, no one knows what need to not it is in suspected. Together I repeat radiology residents before their call, "make a decision."

Langlotz"s prescription because that useless radiology reports is simple. Hedgeless, be consistent and also say "normal." prefer a day too polite to decline the 2nd date, radiologists make all sorts of excuses because that "normal." Such as "liver is unremarkable." Or, "no CT proof of abscess," leave one wondering whether they need to wait for the non-CT evidence of abscess. Or, "no identify pulmonary embolism is seen" so the we"re all clear -- radiologists don"t hear definite pulmonary emboli, allow alone unknown emboli.

Perhaps the many mysterious word in radiologist"s lexicon is "prominent" such together "pulmonary arteries are somewhat prominent." Not even radiologists recognize what "prominent" yes, really means. Is it that the pulmonary arteries are seen? Famous? Loud? Is Donald trumped "prominent?" Or is the structure huge and we"re too gentlemanly to say so? Or is it another word that reflects our discomfort that normal and abnormal overlap?

Many radiology reports room baroque, clunky, and also literal interpretations that the idiom, "a photo says a thousand words." This is not simply habit, however culture. I"ve seen numerous equate pith with laziness and also verbiage with work ethic. Thus, "the liver displayed a regular size and also contour, undamaged vasculature, and also is devoid of a focal distance mass" has actually replaced "the liver is normal." Bones space "osseous structures" rather than "bones." "Osseous structures expose mild degenerative an illness in the lumbar spine" leave one shellacked -- what a revelation. Why was it concealed?

If pith is underused, pith is likewise under appreciated. I when read a CT in a middle-age guy with abdominal muscle pain. I said "no abnormalities in the hard viscera, hole organs, skeleton or vessels." I believed all bases to be covered. Minutes later on the introduce clinician called. "You said the solid viscera were normal, but you didn"t speak anything around the pancreas. We"re suspecting pancreatitis." ns amended the report: "I have looked at the pancreas and also seminal vesicles, and also they are unremarkable."

Radiologists watch far an ext on cross-sectional imaging, such as CT, than projectional 2-D imaging, such as chest radiographs. Thus, radiologists have come to be the chroniclers that age, as well as the finders of pathology. Everyone through a college degree, and practically everyone without one, has actually "mild degenerative condition of the lumbar spine." display me a nonagenarian that doesn"t have "perivascular hypodensities suggestive of little vessel ischemia" and I"ll show you an wrongly labelled CT head. And then over there is the "somewhat atrophic uterus" -- a finding i m sorry reassures the reader that the radiologist has a functioning visual cortex.

The greatest resource of variability in radiology reports is agreeing about which of the epidemic of clinically insignificant findings should be pointed out in the report. I veer in the direction of relevance. I"m happy to do a judgment call. Some veer towards completeness.

Langlotz doesn"t asking radiologists come rid disclaimers altogether. He identify many cases where honesty around the imprecision is apt. Because that example, when a fracture is dubious, not slam dunk, top top a radiograph, that is reasonable asking that findings be correlated with tenderness at the site. Paper definition maketh a radiology report.

"The Radiology Report" covers much more than clever reporting. There"s a nifty section around probabilities. And a hilarious chapter around speech acknowledgment errors, my favourite -- "right inner jugular coitus" once the radiologist stated "right internal jugular cordis," providing the erroneous impression that radiologists are watching Fifty Shades that Grey whilst dictating.

Langlotz has actually done one E.B. White because that radiology. I advise radiology occupants to read "The Radiology Report" in their very first year and after overnight call. Nonradiologists have to read this book, too, and hold reports come the criter he describes.

I credit transaction Langlotz for my visceral dislike of "cannot exclude." I additionally no much longer say "seminal vesicles space unremarkable." If you have nothing nice to say about someone"s seminal vesicles, say nothing in ~ all.

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Saurabh Jha is a radiologist and also can be got to on Twitter
RogueRad. This post originally appeared in the
Health treatment Blog, and also appeared in KevinMD.com.