Size Matters

May 15, 2018

Is it really so bad to have some of one’s impressions outsizing one’s findings?

One of the earliest things one learns in postgraduate training for radiology, if not earlier, is the format one will be using to report on imaging-studies. There are some variations in style, but typically one will be dictating two major sections: A detailed, blow-by-blow description of everything on the study (sometimes termed the “body” of the report, or “findings”), and a summary called something like “impression” or “conclusion.”

It makes sense that the latter would be the more concise of the two…after all, that’s the definition of “summary.” Sometimes, that’s easier said than done, especially for newbies who are just getting accustomed to the rad-world, and/or those uncomfortably aware of how commonly clinicians make a habit of just glancing at the Impression without reading the rest of the report. Knowing that your findings are liable to be ignored, you might feel more inclined to repeat them in the Impression.

So it’s often a teaching-attending’s task to browbeat-ah, encourage-trainees to trim down those impression sections to something manageable. Not just for style, but because clinicians reading the reports will find them more helpful. (Although it has occurred to me that this might engender some of the findings-skipping behavior mentioned above-a nice, bite-sized Impression might lure eyeballs away from heftier paragraphs nearby.)

A typical radiologist’s report will thus have a certain form to it, with the impression, whether it’s at the top or on the bottom, visibly smaller than the findings. And, on occasions when the Impression gets a bit bigger or the findings smaller, it can start looking a bit weird to the radiologist. To the point that some of the more stylistically meticulous might feel uncomfortable at seeing the disproportion of their verbiage…like a neatnik forced to sit at a messy desk.

The problem is that circumstances do arise which make this style difficult or impossible (with the exception of a couple of cheap tricks I’ll get to below). Sometimes, it just takes fewer words to describe what’s on the images than it does to talk about what they mean, let alone what should be done about them. And that’s increasingly the case as various authorities require us to put extra verbiage in our Impressions: BIRADS categorization, for instance, or follow-up recommendations for pulmonary nodules.

Some rads just shrug it off, and are willing to have reports sporting impressions bigger than their findings sections. Others start to squirm when they see what’s brewing on their dictation-screens, and try to make adjustments.

One maneuver I’ve seen is to start taking things out of the impression section and put them back in the findings. Again, a potential problem if the intended audience is not going to actually read the findings. I’ve known a couple of rads who made use of this; having to give lip-service to findings that they knew were of no import, they’d “bury it in the body of the report.”

Some rads do a modified version of this, putting impression-worthy stuff in the findings section, and then referencing it in the impression with something like “Please note other findings in the body of this report.” In other words, I didn’t just dictate this whole report for you to ignore most of it. I wonder how many of those rads think that saying such a thing will cause any of the clinicians to read a single sentence more than they otherwise would have.

Another trick that I’ve seen less commonly (because it requires additional investment of time without real benefit for anyone involved) is to puff up the findings section until it is once again fatter than the Impression. Just keep on adding statements about various abnormalities that aren’t there; why just say the urinary tract is normal when you can go on for a whole paragraph about the kidneys, the ureters, and the bladder? How there are no stones, hydronephrosis, mass lesions, etc.

One mechanism I’ve wondered at, most often used for x-rays where the findings section can be particularly slim, is to simply do away with the pretense of a separate impression. The report just has one “findings/impression” block. This makes perfect sense to me, but I could have sworn I once heard that one or more authorities (insurance companies, CMS, etc.) discourage and/or punish such behavior-withheld payments or other, harsher sanctions. Thus, I’ve never had the bravery to try it. I’d love to hear from someone who has, as to whether they’ve ever experienced blowback as a result.

Now and then, I find myself wondering if it’s really so bad to have some of one’s impressions outsizing one’s findings. We are, after all, not just reading studies, but interpreting them. Saying what we see on images is all well and good, but we’re also supposedly the ones best suited to say what they mean. If it takes a few more sentences to share all of the insight we have to offer, is that such a bad thing?