Me, Myself, and Undersigned

August 14, 2015
Eric Postal, MD

Radiology reporting in first person.

Once upon a time, I was absolutely certain I was going to med school to become a psychiatrist. I was fortunate to be able to work summers during college at a local psychiatric clinic, and it was there that I was introduced to the joys of writing progress notes and other entries into patients’ medical records.

The folks supervising and instructing me, mostly social workers and an occasional clinical psychologist, were good about showing me the ropes. One of the points of instruction was that the writer did not refer to himself in the first person. Sometimes it took considerable verbal contortion to avoid. For instance, one should not write “I saw patient X trying to set the clinic on fire,” but, rather, “Undersigned” witnessed the attempted arson.

As with so many other things, there wasn’t much of a reason offered for this practice, or if there was it wasn’t intellectually engaging enough for me to remember. The best I can recall is that it supposedly made the notes sound more “professional.” Far more importantly, simply everybody did it this way, it wasn’t a matter of style, but practically etched into the rules of engagement for health care.

So, being eager to learn/please and having no reason to rebel, I took this as the gospel truth, and had no occasion to question it for the next few years. Maybe, once in a great while, I encountered an entry in a patient’s chart during med school or internship wherein the author deviated, but if/when I did it was probably with a superior smirk on my face while I patted myself on the back for being wiser and more experienced than the perpetrator.

And then, sometime during residency, I started noticing some radiologists who thusly transgressed in their reports. A very small minority, but they were around, and they were not exactly the dim bulbs of the department. Indeed, some of them were the sorts of rad I hoped to become one day. Instead of dictating “The appendix is not identified,” they might say “I do not see the appendix.”

Which got me wondering if I had been wrongly indoctrinated. If these intelligent, capable folks saw fit to do this, maybe there was a good reason for it.

The problem was that, at this advanced stage of my training, there was no way to get a firm verdict from other radiologists as to which was the proper way to dictate a report. Yes, some attendings were more seasoned or erudite than others, but at their level, nobody was going to opine that his colleague was dictating the wrong way. At most, I might elicit a vague comment that it was a matter of personal style.

So, for no reason other than this was the way most of my mentors were doing it and pure peer pressure, I kept avoiding first person phrasing in my own reports. And yet, I have to admit, to this very day, when I pull up a report of a prior comparison study and see the interpreting radiologist is one of the few who feels at liberty to use first person phrasing, I feel a twinge of curiosity and even envy.

Why do they choose to dictate this way? Is it indeed just a matter of style, or do they feel it strengthens their reports? Are they constantly feeling pressure from their colleagues to knock it off? If so, how impressively resilient and confident they must be to persist in what they feel to be right or simply comfortable.

If readers out there have thoughts on the matter, I’d be very interested to see some comment here. Hopefully (perhaps with the cloak of internet anonymity), we could get some pros and cons laid out on both sides.