Q&A: Writing the Book on Radiology Reports

November 9, 2015

Langlotz’s new book describes the urgent need for improvement of radiology reports.

For radiology and radiologists, their most significant work product is the radiology report. It provides guidance to referring physicians and plays an integral role in the design of a patient’s treatment plan. However, providers haven’t had much guidance on how to optimize the reports they produce in recent decades.

To change that and offer more clarity, Curtis Langlotz, MD, PhD, professor of radiology and medicine at Stanford University Medical Center, wrote The Radiology Report: A Guide to Thoughtful Communication for Radiologists and Other Medical Professionals, which was released last week.

Diagnostic Imaging spoke with him about why the book was necessary, the information he provides, and the impact he hopes the publication will make.

What was the impetus behind writing this book?

Considered as a whole, radiology reports are awful. Plenty of data in the literature backs up that claim: there is an appalling rate of clinically significant errors, reports that don’t answer the clinical question, dissatisfied clinicians, unnecessary hedging, and just a general lack of clarity. I wanted to help radiologists get better.

Most of my career has been focused on the radiology report in one way or another, and I found myself often lamenting the sorry state of affairs. One of the biggest problems was the lack of a comprehensive resource for radiologists, which leads to poor training and limited skills.

Then around 2005, it finally dawned on me that nobody else was going to write the book, so I probably should. I started collecting relevant literature, reporting pitfalls, and speech bloopers, and began thinking about how to organize the material. Writing doesn’t come easily to me, and style guides can be pretty dry, but it became a fun challenge to make the material interesting.  That was easier for some parts of the book than for others. I will leave it to the reader to judge whether that worked out. 

How important is the radiology report today? Has this importance changed in recent years, and, if so, how?

The radiology report continues to be a radiologist’s most important work product. Despite the understandable drive toward patient engagement, the radiology report still is our primary means of patient care. And strictly speaking, it’s what we’re paid for. [[{"type":"media","view_mode":"media_crop","fid":"43098","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_1581181229900","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4692","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 200px; width: 200px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Curtis Langlotz, MD, PhD","typeof":"foaf:Image"}}]]

Radiology reports today aren’t much different than reports produced over a century ago, but the need for better reports is more crucial now than ever before. As payment models change, we need to convey clear and clinically meaningful information that patients, providers, and insurance companies are willing to pay for.

What type of information or guidance are you providing in the book?

The radiology reporting literature is full of well-reasoned editorials and impassioned letters to the editor arguing for or against the use of a given word or phrase. And over the years, a number of brief guides to radiology reporting have been written. I wanted to collect and organize all that material as a comprehensive practical guide. When I couldn’t find any literature on a particular issue, or there were conflicting views, I presented the evidence and offered my opinion, in hopes of generating discussion and perhaps consensus. So most of the book serves as a resource for radiologists who want to get better.

The book also details the history of radiology reporting dating back to the late 19th century and helps readers understand some of the theory behind the radiology report and the reporting tools we use today. For example, later chapters cover the basics of reasoning under uncertainty and talk about how to master the use of speech recognition systems.

Why is this guidance important, and what do you hope will develop from it?

When I went through radiology training I received a grand total of about 15 minutes of instruction on how to report, all in one sitting from a single attending radiologist-a story I tell in the book. And today’s residents don’t get much more. My primary goal was to produce a resource that radiology residents could use to learn good habits, but I hope the book will be of some interest to any radiologist who wants to improve.

You mention the radiology report in 2025 – how will this book work toward or fashion that?

Quite frankly, most of the book is focused on practical tips to improve today’s reports, because that is the urgent need, and because good reporting practices today will pay dividends in the future, regardless of how reports may change. But the book’s final chapter does make some predictions. I think new payment models will revolutionize radiology reporting. When we no longer need to produce a full report for each study, a more flexible paradigm will open up. For example, imagine a two-word full report for daily ICU chest radiographs: “no change,” unless there are clinically-significant changes or other findings. An analogous approach could apply to many of our frequent exams. You could call it the extinction of the radiology report.    

What do you hope the take-away message will be for radiologists?

A few simple changes can vastly improve your reports. It is easier than you think to produce reports that clinicians appreciate.

In researching this book, what surprised you the most?

That’s an easy one: The rich history of radiology reporting. One of my hobbies is genealogy, and researching the history of the radiology report was a very similar pursuit. It’s amazing how much information you can find if you keep digging. One of my favorite treasures is an 1896 letter proposing a discounted fee for an abdominal radiograph because no abnormality was found. In 1965, Emanuel Grigg, MD, compiled a delightful tome on the history of radiology called “The Trail of Invisible Light,” containing numerous old cartoons, advertisements, and photographs from the early 20th century. It’s a riot. And, of course, I relied on the seminal historical research of Ronald Eisenberg, MD. Sprinkled throughout the book are vignettes of the early pioneers of radiology reporting and portraits of some of the scientists whose theories underlie imaging information. Their stories are priceless.

What was your process for writing this book?

I really didn’t have time to write this book during work hours, so it became sort of a hobby over the last 10 years or so. Typically, I would be watching a baseball game with my laptop open, tinkering away. Incidentally, an earlier draft of the book contained a number of baseball analogies. But, one of my colleagues who reviewed the draft rightly pointed out that baseball would completely mystify most non-U.S. readers, so I substituted other illustrative stories.

During one particularly busy time, I didn’t look at the manuscript for 18 months. I, initially, worried about the slow pace, but, then, I realized that no one had written such a book over the previous 100 years, so I was unlikely to be scooped now. 

What has the reaction been so far?

Since the book became available for pre-order a couple of months ago the response has been tremendous. For a time, the pre-order version was Amazon’s No. 1 ranked e-book for radiology.  Radiology reporting, like any form of narrative, is ultimately personal. So I think the topic strikes a chord with radiologists.

What is the best way to learn more about the book?

The full table of contents and an excerpt are available on the companion web site. I will use that site to update material over time. The book is now available on Amazon in paperback and as an e-book.