An Abundance of Words in Radiology Reports: Much Said, Less Communicated

For those not keeping score, I have been writing this blog for approximately 15 years. I worked on a few publications before that. Stringing words together to create meaning and/or entertainment has always resonated with me.

It is not an effortless affair. As I have honed my skills, I have discovered new challenges to go with them. A biggie, first learned from a high-school teacher, was brevity. One day, I was introduced to the concept of essays specifying a maximum count of words rather than previous assignments specifying minimums.

I found it a lot harder. Previously, I could just go on until I had written out all I wanted to say. Suddenly I was working in a confined space with words being a finite resource. If I couldn’t trim sufficient verbiage to make all five points I thought important, I might have to sacrifice one and make do with four.

It was a worthy exercise. In real life, babbling on until you feel like stopping doesn’t serve you well. Sooner or later, your audience tunes out, even if they pretend to still be paying attention. That is particularly true when speaking, but not exclusive to it. Try writing a beefy email to someone about everything you want him or her to get done in the next week and see what happens.

At the heart of this is the limited short-term memory our wetware provides us. You might have heard of the “magic number” of 7 +/-2, referring to how many items we can reliably hold in mind at once. Someone reading your document is, at best, going to recall only that many points from it, and those will swiftly be displaced by whatever else comes to the reader’s attention.

Unfortunately, sometimes everything you have got to communicate is of potential importance. Leaving some of it out risks later wishing you hadn’t. You may even be taken to task by your audience for not having addressed some item or other. Meanwhile, if you had included it, it might have been item 7(g) on a 12-point list, and nobody would have noticed or remembered anyway.

Radiology reports are a prime example. Everything we put in them is because:

• we consider it diagnostically relevant;

• we were trained to regard it as important (even if we don’t personally agree); • we know we will be asked to make an addendum if we don’t include it; or

• we are required to do so by some regulator or payor.

Feel free to Include med mal ambulance chasers in that last bit if you like.

We wind up with this wall of text, and it’s a bad because its true joke that nobody reliably reads it all. What is the solution: an “Impression” section that summarizes the important points.

This propagates the issue by practically inviting the reader to ignore everything else that was said. Some rads make a feeble gesture to the contrary, ending every one of their impressions with something like “please see above for other findings.” Other rads generate bulky impressions that aren’t any handier than the bodies of their reports and, to be fair, some studies are just complex messes that don’t allow for better.

Even putting aside those messes, many other exams don’t allow one-line impressions like “No acute disease,” or “Appendicitis without complication.” We have got stuff to convey that might exceed the reliable attention span of whoever is reading our reports, and we would like to maximize the chances that they will come away with a proper appreciation of what we thought was important.

Formatting can help. One popular approach is to make a tidy, numbered or bullet-point list that makes each item of interest its own bite-sized tidbit.

Kissing cousins with that is making the entire body of the report more itemized with each sentence getting its own line. Another alternative comes in the form of “structured” reports, in which we try to organize things under headings like “Liver,” “Kidneys,” etc. There are drawbacks to that, but I have written about those before.

Another contrivance is verbally conveyed findings, whether from our own lips or those of ancillary staff. If our impressions are the important stuff that we have sifted from the bodies of our reports, the spoken bits are the extra important stuff. This maneuver has gotten to be such an expectation that plenty of rads get in medicolegal hot water for not doing it.

The fact of the matter remains, however, that from one perspective or another, everything in our reports is supposed to be important. Otherwise, we would have left it out. The more we call attention to this or that being the “really” important stuff, the likelier the other stuff will fall by the wayside.

That can be intentional. I recall hearing rads advise to “bury that in the body of the report” way back in my residency. Yes, you kind of have to say X, but you know it’s not likely to matter, so you make it extra easy for folks skimming your report to ignore.

We beat ourselves (and occasionally our fellow rads) up about how we can more effectively communicate findings. Let us make it as unlikely as possible that clinicians fail to see and understand everything we have said. Yet as one rad I saw on social media this past week bluntly put it, they bear responsibility in this too.

Ultimately, no matter how much fault one might find with the style in which a rad laid out his or her diagnostic report, if the information is there, it is there. If a referrer failed to notice something, read it incorrectly, or otherwise came to a wrong conclusion that other readers would not have, that referrer doesn’t automatically get to shrug and blame it on the rad.