Several states require reports include breast density information. What’s next? Why rely on physician judgment when you can have a one-size-fits-all policy?
It has been observed that, for most non-interventional radiology, the signed report on an imaging study is our final product. We do well to make sure it accurately represents the work we have done. Careful proofreading can mean the difference between a polished, well-formatted piece and a typo-ridden mess full of spelling and grammatical errors, each one of which detracts from the appearance of a professional document.
I can understand the logistical pressures which might make one forsake careful proofing in the name of churning out 10 percent more studies per day. Still, many of us take this stuff seriously, whether out of a sense of pride in what we do or an embarrassing recollection of a past incident when we let stuff slide and it came back to haunt us.
No surprise, then, that when some outsider comes along and starts telling us what to put in our reports, what not to say, or what to say differently, we can get a wee bit defensive.
Our would-be censors always think they have a good reason, and sometimes they’re right. I wasn’t reading mammos in the pre-BIRADS era, so I can only go by what I’ve been told, but it seems that before it was standard to conclude reports with an official diagnostic category, breast imaging was something of a Wild West.
One gives an inch, however, and a mile is taken. I have seen non-physician inspectors, supposedly present to evaluate mammo equipment and reading environments, issue citations for phraseology utilized by radiologists in their reports. Nitpicky stuff that adds nothing to quality and can actually detract.
For instance, I once had a clipboard-wielding visitor to my office insist that all Category 0 mammo reports mention a need for prior comparison-studies - even if I actually HAD all prior studies and was dictating a zero on the basis of a need for additional imaging. (I wanted to protest the issue, but was overruled for fear that the clipboarder might be peeved at being challenged, and find ways to make life difficult for us in the future.)
If an appointee can wield such power over what we say in our reports, it goes without saying that elected politicians already do. I believe there are now four states with legal requirements that mammo reports include verbiage about the hazards of dense breast tissue. Again, the reasoning behind such rules is hard to argue against, without seeming petulant over our diminishing professional autonomy.
Other avenues of resistance against such incursion include weak anecdotal or hypothetical tales of incidents when adherence to the rules means value detracted rather than added. For instance, a BIRAD-0 case following the inspection mentioned above, when the clinician phoned to ask why my report expressed a need for prior comparison films when I had clearly stated earlier in the report that I had all films on file. (Yes, that actually happened.)
Another protest against this involvement of the public good is the slippery slope approach. That is, what CAN’T be forced into our reports? Shall we be required to start reporting on all patients who appear obese? After all, the health hazards of their excess poundage have been proven time and time again. Maybe it’s not enough that we include a one-liner like “Patient is visibly obese.” Maybe we should have to include specific commentary on risk for diabetes, hypertension, stroke, diminished quality of life, etc. How about including a pamphlet on the subject with each report we issue?
On the other hand, maybe some politico wants to posture some other way, and patient habitus should become verboten for us to mention as per, say, the ADA (lest we mention obesity and it lead to discrimination against the patient in the future).
Even better, let’s have rules simultaneously requiring and prohibiting us to comment; it certainly wouldn’t be the first time governmental agencies issued conflicting edicts and left citizens to fight their way out of the paradoxical mess. Would make it easier to punish a wayward doc if the Powers That Be ever feel like taking him down a few pegs.
By all means, let’s make formal rules for everything. Let it be a legal matter every time a physician fails to give three-dimensional measurements for lesions, specify how many cc’s of contrast were administered, or give dates, times, and names for each instance of reporting results, big or small, to clinicians. Why rely on the judgment of individual physicians, each holding about a decade’s worth of education and training (and mandated dozens of hours of CME per subsequent year), when you can have a one-size-fits-all policy to ride herd on them?