In order to deliver value-added care, we must take pause to not only identify the salient findings but craft our reports in a manner that allow our referring providers to understand the relative significance of those findings. In an era of diminishing face-to-face communication between radiologists and primary care-physicians the wording of our reports is more important than ever.
Many of you may be familiar with this song and its memorable line, “Potato, potahto, Tomato, tomahto, Let's call the whole thing off.” I’ve heard it a few times but my favorite rendition is by Christoper Walken on Saturday Night Live. While the subtle differences in these words are trivial, the words we choose to use in our radiology reports impact the actions taken by our referring providers, and ultimately, the care delivered to our patients.
Mr. Peterson, a 61-year-old man, finally gave in to his wife’s repeated requests to visit his physician after two weeks of complaining of severe left hip pain. After a battery of tests, Mr. Peterson’s doctor ordered an X-ray of the hips that demonstrated lucency in the left acetabulum. The impression of the radiology report included both infection and metastatic deposit in the differential and recommended a CT scan of the abdomen and pelvis for further evaluation.
Mr. Peterson’s images were forwarded to MGH and my section collectively reviewed his CT scan during our daily abdominal imaging conference. The case was presented by one of my colleagues whose training also includes a three-year stint as an orthopedic resident. Many abnormal findings on the scan were noted, including multiple ill-defined calcifications in the liver as well as pelvic and retroperitoneal lymphadenopathy.
Mr. Peterson’s left hip, however, demonstrated the most dramatic abnormality. The CT confirmed the lucency noted on the plain film and revealed destruction of the joint and a rim enhancing fluid collection around the joint. My colleague was quick to point out that a septic joint can have this appearance and went on to add that destruction of bone on both sides of the joint space was a relatively specific finding for a joint infection.
During this discussion, one of our more experienced attendings asked how the final impression was worded. Impression number one read, “Findings in the left hip are suspicious for infection. The adjacent fluid collection is amenable to percutaneous aspiration and drainage.” My attending was stunned and asked about the liver findings. “Indeterminate calcifications are present within the liver. An MRI may provide further characterization of occult liver lesions.”
A vibrant discussion ensued. The more experienced radiologists began to piece together Mr. Peterson’s medical condition. The calcified liver lesions likely represented metastatic deposits from a mucinous adenocarcinoma and the left hip findings indicated an additional metastatic deposit with super infection.
While my colleague correctly identified all the findings on the images, the group ultimately decided that the phrasing and ordering of the initial impression was potentially misleading. Rather than an immediate work up by Oncology, Mr. Peterson may have been referred by his primary-care doctor to Infectious Disease and Orthopedics, delaying his necessary cancer work up.
Mr. Peterson’s report was changed to emphasize suspicion of cancer and a subsequent workup revealed a colonic malignancy with metastatic involvement of the liver and osseous structures including the left hip.
Mr. Peterson’s case highlights the importance of the radiology report and its affect on the care our patients receive. A recent article in the British Journal of Radiology found that primary-care doctors “value the radiologist's opinion outside the remit of imaging when suggesting further patient management.”1 Given that our reports are the final product of our work, it is critical for radiologists to understand the subtle implications of our impressions especially for our colleagues in primary care for whom our sole communication may be through our dictated reports.
Imaging has become as critical a diagnostic tool in medicine as the stethoscope. But while a stethoscope provides objective information, our dictation of imaging studies are filled with subjective assessments based on our experience and expertise. In order to deliver value-added care, we must take pause, as in Mr. Peterson’s case, to not only identify the salient findings but craft our reports in a manner that allow our referring providers to understand the relative significance of those findings. In an era of diminishing face-to-face communication between radiologists and primary care-physicians the wording of our reports is more important than ever.
1 Grieve FM, Plumb AA, Khan SH. Radiology reporting: a general practitioner's perspective. Br J Radiol. 2010 Jan;83(985):17-22. Epub 2009 May 26.