Defensive Dictation in Radiology: A How-to Guide

April 19, 2013

The harder you make it for others to read your radiology reports, the less readily they'll persevere to find fault with you. Here are some tips.

Following an older column of mine regarding how we radiologists sometimes take defensive medicine to a new level, it occurred to me that reactions might differ. Some might regard vague, can't-pin-me-down reporting as a shirking of our professional responsibility, and consider it a dangerous way to diminish our value to clinical colleagues.

Others, perhaps besieged by one too many meritless lawsuits or bad peer-review stats, might wish for more ways to Teflon-ize their reports against disparagement.

Much as when I offered ways to cherry-pick easy cases while dumping the toughies, or repel reading-room visitors bearing unwanted distractions, I'm here to help. The harder you make it for others to read your reports, the less readily they'll persevere to find fault with you:

Don't proofread so much. I'm not saying to have complete faith in your voice-rec software or transcriptionists - blatant discrepancies between what you meant to say and what got signed will come back to haunt you. But a steady stream of "errors" in grammar and punctuation will confuse or at least slow down and annoy any poor sap trying to wade through your words. It also increases your ability to claim that any important mistakes were just typos. Try doing that when the report surrounding your alleged misdiagnosis is spotless.

Weasel-words are your friends. Remember those lectures you attended and articles you read about all of the hedging words and phrases that you should avoid? Priceless sources of material to add to your lexicon! Peppering your dictations with stuff like "possible," "potential," "could be," and "cannot be excluded" lets you include all sorts of nifty pathological entities without actually having to commit to anything. Even when you're pretty sure of your diagnosis, don't just say it - say you "suspect" it, or at most you have a "strong suspicion" for it. If anybody later contradicts you (like those annoying surgeons or pathologists who actually made a definitive diagnosis), you didn't fully commit yourself.

Clinical history is your enemy. Your days of cursing clinicians for telling you to "R/O pathology" without actually supplying any information specific to the patient are gone. This absence of information is now your golden ticket to offer only the broadest, most superficial differentials…or even abandon them entirely. Politicians and businessmen call this "plausible deniability." And for heaven's sake, don't go looking for trouble, like calling up the clinician and asking for more info. You'll not only waste valuable RVU-generating time, but you'll be on the record as gaining details that would have allowed you to make a diagnosis. (It will then be your fault if you do not.)

Volume, volume, volume. "Anything you say can and will be held against you," so be concise? Forget it. Churn out reams of verbiage for even the simplest study, so that good and bad information alike are hopelessly buried. Make healthy usage of macros to ensure that you don't waste valuable time actually dictating the fluff. Go into painful, eye-glazing detail about how and when the exam was done, reported findings from previous exams - anything that doesn't actually involve your personal interpretation of things. Anybody who actually proceeds to dig through your paragraphs in a search for your theoretical wrongdoing, with any luck, will be lulled into a sort of hypnotic trance by the abundance of transcribed "white noise."

(And anybody making a crack about the volume of this blog and its similarity to white noise loses points for picking the low-hanging fruit.)