Patients-not just Images

The Language in the Radiology Report :

The said, the unsaid and the unnecessarily said

Ravi Ramakantan

Sounds familiar?

So, here goes...

Referring Physician : Do we need to biopsy this lung mass?

Radiologist: These findings are probably suggestive of a benign lesion; however, the remote possibility of the presence of malignancy cannot confidently be ruled out. Suggest…clinical correlation. A CT guided biopsy may be done.

Now, watch your step - the next part gets a little tricky!

No 'obvious' English language writing is seen within the red box on the image above.

No 'gross' difference between the color of the box and the lettering within it is seen.

No 'significant' reference to a Greek letter is made in the image above.

There 'appear' to be two different fonts in the writing within the box.

The 'probability' of this box being a captcha is unlikely.

Just because you use 'hedging qualifiers', you will not be protected from 'expected quality of care' law suits... you ought to have seen the box and the stuff within it carefully and known about what it is..

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These are but a few examples of how - a full world of special radiology reporting language lies hidden within us - a language that speaks a lot ... but says very little.

What is worse, we pass this culture on to the next generation which seems to imbibe this without as much as a simple "why?"

And so, I have now taken upon myself, the task of moderating this ubiquitous radiology reporting tradition with:

Ravi Ramakantan's Radiology Reporting Rules.

How pompous can one get!

1. Do not use the words .... Appears to be, gross, significant, apparent, may be, possible, probable, unremarkable, obvious and such others flippantly.

Instead, use 'is' whenever you can.

2. As far as possible, avoid the passive voice .. here are some examples:

Previously seen right gangliocapsular hematoma has resolved with gliosis. Significant decrease in the mass effect on the right lateral ventricle is seen. No hydrocephalus is seen. Brainstem and cerebellum appears unremarkable.

Instead..

The right gangliocapsular hematoma seen previously has resolved with gliosis. There is significant reduction in the mass effect on the right lateral ventricle. There is no hydrocephalus. The brainstem and cerebellum are normal.

There is presence of a Schmorl's node noted along the superior plate of L1.

Instead...

There is a Schmorl's node along the superior end plate of L1

And, the extreme example I have seen of the usage of the passive voice is this one:

"There is seen a soft tissue mass.. "

Instead..

There is a soft-tissue mass.

3. In radiologic reporting, there is NO SCOPE for visualising - only for seeing.

Standing on the seashore, watching the sunrise, you SEE the sunrise.

And, when you describe the same scene - even in the most colourful words - to your colleague, he VISUALISES (imagines it). Therefore , if you visualise and report you must be day-dreaming and reporting! Needless to say, that's not in the best interest of patient care!

Thus, no report of yours should have the word 'visualise' - instead, use the plain, simple word 'seen'.

4. NEVER use the phrase - Clinical correlation.

This is the one that gets my goat. For, except perhaps in case of plain radiographs, the patient is with you long enough for you to obtain a history or, for that matter, even to do a physical examination. By letting go off this opportunity, you are 'degrading' yourself from being a physician to an image reader.

In any case, how would you feel if you got a request like this : "CT Scan of the brain: Plain + Contrast : Look at all images from both series carefully and then report".

In a similar vein, do not use the word "Advice" but, rather - 'Suggest' or 'Recommend'.

5. NEVER EVER : Clinico-pathological correlation. For, on such a comment, the referring physician will come calling :

"Hey, you! What do you think you are being paid for?"

6. Do not suggest non-radiological investigations for further management. After all, you are not an expert, for example, in laboratory investigations.

7. Tense : It is best to use the present tense throughout the report - though purists would give long-winded arguments as to why it should be otherwise. This applies even to fluroscopic findings that have happened in the 'past'. In any case, do not make a 'bhelpuri' of the past and present tense in one report.

8. Avoid repetition. Do not repeat the description of a pathology that is in the body of the report - again in the Impression.

For example: Body of the report: . I saw a huge, 8 foot tall, gray skinned animal with four pillar-like legs with a long trunk, small eyes and white tusks ambling slowly across the road - swinging its small tail from side to side.

Impression: I saw an elephant on the road..

While on repetition, here is an afterthought : Avoid Tautology : For example : round in shape, blue in color, 3 cm. in size, 30 mL in volume,... and the best of all... 'past history'. All this is pretty stupid, but, we keep doing this all the time and I am no exception.

9. Know when to say 'evidence of' ... and when not to.

When you see a gall stone on a CT, you say "There is a gall stone...".; but, when you see surgical clips in the gall bladder fossa , you say "there is evidence of surgery in the gall bladder fossa"

10. And, never forget that you can always pick up the phone & talk to the referring physician.

Did somebody say: "The Ten Commandments"?

I always like to remember that when I dictate a report, I report on a patient’s illness and not just on abnormal findings on an imaging study; and that, the main aim of the words in my report is not to protect me from a malpractice suit but contribute in instituting the right treatment or in directing further imaging - if required.

I am always conscious of the patient behind the film. After all, Radiology is about: Patients - not just images!

And finally, do I follow my own rules above ? Surely, not always. But, I am trying my best to get there..To.... Break Patterns, and Create Change.

After 40 years of Radiology practice, I hope one day soon, I will garner enough courage to say:

"I do not know the nature and significance of this lesion" rather than "The nature and significance of this lesion is not apparent".

I truly look forward to that day.

Below are a few images to illustrate the words I have said above.

This essay is based of my own thinking on this matter over very many years. But, I would like to acknowledge that the following resources have inspired me to convert those thoughts into 'keyboard strokes'!

1. The Radiology Report: A Guide to Thoughtful Communication for Radiologists and Other medical Professionals by Curtis P. Langlotz

2. The Story Behind the Image : Richard B. Gunderman, MD, PhD Radiology 2013; 268:312–314 : Link

3. Language of the Radiology Report : Primer for Residents and Wayward Radiologists : Ferris M. Hall .

American Journal of Roentgenology. 2000;175: 1239-1242. : Link.

4. For those really interested in digging deeper and especially for the language buff, a whole repository of interesting information, from the Journal of the American College of Radiology, is available at this link.

And, to add some spice to the thoughts above:

5. Bhelpuri : A favourite Indian snack Link

Throughout this essay, I have used dramatic photographs and words to illustrate what would appear to be the obvious. In doing so, I do not mean to insult the intelligence of the reader. If I appear to be doing so, I am sorry. It is just that I see these 'mistakes' ever so often that I felt that some 'drama' is necessary to change well- entrenched traditions and habits.

Copyright

This essay has NO copyright

You can reproduce this essay in any form, anywhere, anytime. as long as the intention behind this writing is not changed. I seek no attribution!

Postscript

I have received close to 200 comments on this essay - from people far and near; known and unknown.

Thank you all for taking this effort to let me know what you thought.

I have reproduced below ONLY those comments that, in some way, disagree with what I have said.

So, there we have, more fodder to ruminate on.

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The language skills of many residents is much to be desired, with due respects and apologies. I hammer almost all the points you described, to my residents every day, but comprehension is essential before articulation.

Of course it is now the era of computer based ' Structured report ' concept where our language skills do not really matter.

Agreed we need to be more brave. But I would never write I do not know the significance of the lesion. Coz when common man read it they think ok "this radiologist doesn't know then why pay money", instead of "my body has a tricky lesion most radiologist s would find difficult to diagnose".. And visualise has 2 meaning 1. To imagine 2. To make visible to human eyes and our machines do that they make the inner organs visible to our eyes. Hence we are not seeing the lesion we are visualising it through the grey images produced by the machines

Agree with most of the points. Only thing is often we may not have adequate clinical details and we may not have access to them. For ex. “Pain abd “ is a common indication for CT. But the fact that lipase is high is not given. The patient can’t tell you that either. In that situation clinical or lab correlation may need to be mentioned or else the report cannot be issued without this value coming in. Same thing “rule out ectopic “ comes the urgent request. But the UPT or BHCG is unavailable. Patient won’t know either. How do we tackle these things without hedging on adjectives? But just as highlighted i'm trying where possible to avoid “noted, evidence”.

Very well written sir. But work all due respect, no radiologist has time to interview every patient. There's reason radiological form has to be filled and relevant details given. Thus onus lied in both referring clinician and radiologist to act together in best interests of every patient. Everybody cannot be taught English during radiology residency and thus emphasis on tense, literary meanings are of farcical importance rather than answering the clinical question for which imaging study was done. I believe that in future they'll be no reports but columns having clinical indication, relevant findings and other incidental findings with their interpretation for patient care as the main topics with additional footnote for further investigations if required.

Lawsuits in America are based on not meeting the vague “standard of care”! What if needed to avoid these ‘greek’ reports is base the lawsuits on ‘gross negligence’

…I believe that the real meanings of the common words(appear, visualise etc) used in our formats are not understood either by practising Radiologists or residents. I do not mean to downgrade vernacular languages ( I myself went to a Gujarati medium school way back in 50s) but currently many of our students who come from smaller towns are poor in basic English languages skill and proficiency in spoken English is a far cry. They also insisting on conversing in vernacular language with senior Radiologists, not realising that the 2-3 yrs they are in the Dept is also an opportunity to improve English language skills leading to their improved performance in the exams.

….. Now reason to tell this story was it took 20 -30 min for a single case. Following and discussing with clinician explaining to him another 20-30 min. I get 400 for usg.Clinician gets 900 for first consultation, and 700_ 800 two three consults during next admission and follow up charge.I am helping pt, clinician.I am not helping myself.I loose two three usg patients - patients don't wait. Next time clinician does not bother to inform about clinical features assumes i will ask pt.If some clinical point is overlooked radiologist, it becomes his fault he tells the patient radiologist at fault 2. We get clinically biased, tunnel vision specially usg pt comes with rt upper quad pain,raised counts cholecystitis, liver abscess, there is mild wall thickening gb, labelled cholecystitis pt may be having congestive hepatomegaly and raised counts due to infection with copd."

1. Not clear to me who will be reading this (to whom is indirected?). Its department website but is it directed at other radiologists? Patients? Referring, Physicians, Students-Residents. That makes a big difference. I assume it may be for radiology residents altho you mention that you are now working at private hospital and perhaps haver fewer, or no, residents. 2. Big change in radiology reporting in last has been years are structure reports rather than the free text I wrote about years ago (not sure this has permeated India as much as USA but its coming). The exact wording of templates etc ("evidence of") will primarily be determined by the individual departmental members. However, its clear to me that the future will be more and more structured reports and that fits in well with our increasing use of artificial intelligence.