— Radiology reports should be hosted to greater standards, says Saurabh Jha, MD

through Saurabh Jha MD in march 10, 2016


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""Normal" is among the most powerful words a radiologist deserve to use."

– Curtis P. Langlotz, professor of radiology, Stanford University

After I offered "clinically correlate" thrice in a heat in my report, the attending radiologist asked, "How would certainly you feel if the referring clinician stated on the requisition because that the research "correlate v images"? once you ask them to clinically correlate, you"re reminding castle to carry out their job."


I had been a radiology resident because that 6 months -- too soon to master radiology however not too shortly to understand radiology"s bad habits. Ns had gained several behavior -- tics, to it is in precise. These tics contained saying "seminal vesicles room unremarkable," i m sorry I stated remorselessly ~ above the CT that the abdomen in males, even if the clinical concern was portal vein thrombosis, sending, i suspect, several young males to existential despair. Yet the tic the really acquired under my attending"s skin was "cannot exclude." The attending to be Curtis P. Langlotz, the writer of "The Radiology Report," a book around writing efficient radiology reports.

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Ubiquitous in clinical care, and also sometimes parody, radiology reports space enigmatic. What"s most striking about radiology reports is your variability. Reports vary in length, tone, precision and also frequency that disclaimers. Reports differ in strength of recommendations for additional imaging.

One radiologist may say "small pancreatic cyst, recommend MRI to exclude neoplasm." Another, conscious that the patient might cross St. Peter"s gate sooner quite than later, may bury the result in the bowels of the report, hope the clinician will spot its irrelevancy. However another, eager to it is in nonjudgmental, could say "small pancreatic cyst, likely benign, yet MRI may be taken into consideration if clinically indicated," which, Langlotz notes, is vacuous because with pancreatic cysts there"s nothing clinically the clinician can anchor that reference on.


Radiologists, conscripted come ail skepticism in diagnostic medicine, have responded by presenting their very own uncertainty. We remind medical professionals that "CT does no exclude ligamentous injury" ~ above CT the the cervical spine i beg your pardon is negative for fracture. The pedagogic value of this disclaimer is shed by the 2nd time the is read.

Why do we mention metaphysical truisms such as "subsegmental pulmonary embolism is not entirely excluded v absolute certainty?" This is component honesty and component disingenuity. Skepticism is a reality of life. Yet radiologists understand that clinicians recognize that no pathology can be excluded with absolute certainty. Stating this truism throw the ball earlier in their court, legally. The radiology report is a legit document.


"The Radiology Report" has actually been written in the method Langlotz hopes his colleagues compose their reports. The book is short, readable, ~ above point, and, importantly, the author takes a stand. The doesn"t hedge. Langlotz supporters standardized reporting, unapologetically. One may argue with the stand, and he knows the I regularly do (I argue v everything). But here is the point. Since Langlotz bring away a stand, the conversation moves. The was standing anchors the narrative.


Medical decision making is comparable -- you have to take a stand. While the is vital to it is in right, that is better to be wrong 보다 vague. Because when you"re wrong around a diagnosis, at the very least the clinicians understand which diagnoses space wrong so that they can move come the next. By being vague, no one knows what have to not be suspected. Together I remind radiology residents before their call, "make a decision."

Langlotz"s prescription because that useless radiology reports is simple. Hedgeless, it is in consistent and also say "normal." like a date too polite to decline the 2nd date, radiologists do all sorts of excuses for "normal." Such as "liver is unremarkable." Or, "no CT proof of abscess," leave one wondering even if it is they have to wait for the non-CT evidence of abscess. Or, "no identify pulmonary embolism is seen" so that we"re every clear -- radiologists don"t hear identify pulmonary emboli, let alone unknown emboli.


Perhaps the most mysterious word in radiologist"s lexicon is "prominent" such together "pulmonary arteries are rather prominent." Not even radiologists understand what "prominent" really means. Is it the the pulmonary arteries room seen? Famous? Loud? Is Donald trump card "prominent?" Or is the structure big and we"re also gentlemanly come say so? Or is it another word that shows our discomfort the normal and abnormal overlap?

Many radiology reports are baroque, clunky, and also literal interpretations the the idiom, "a photo says a thousands words." This is not just habit, yet culture. I"ve seen many equate pith through laziness and also verbiage with work ethic. Thus, "the liver displayed a regular size and contour, undamaged vasculature, and is devoid of a focal mass" has actually replaced "the liver is normal." Bones room "osseous structures" quite than "bones." "Osseous structures expose mild degenerative disease in the lumbar spine" leave one shellacked -- what a revelation. Why was it concealed?


If pith is underused, pith is also under appreciated. I as soon as read a CT in a middle-age guy with abdominal pain. I claimed "no abnormalities in the solid viscera, hollow organs, bones or vessels." I thought all bases to be covered. Minutes later on the referring clinician called. "You claimed the hard viscera were normal, however you didn"t to speak anything around the pancreas. We"re suspecting pancreatitis." ns amended the report: "I have actually looked at the pancreas and seminal vesicles, and also they are unremarkable."

Radiologists view far an ext on cross-sectional imaging, such as CT, 보다 projectional 2-D imaging, such as chest radiographs. Thus, radiologists have end up being the chroniclers of age, and the finders of pathology. Everyone with a university degree, and almost everyone there is no one, has "mild degenerative an illness of the lumbar spine." present me a nonagenarian that doesn"t have "perivascular hypodensities suggestive of small vessel ischemia" and I"ll present you an erroneously labelled CT head. And then over there is the "somewhat atrophic uterus" -- a finding which reassures the leader that the radiologist has a functioning intuitive cortex.


The greatest resource of variability in radiology reports is agreeing around which of the epidemic of clinically insignificant findings must be discussed in the report. I veer towards relevance. I"m happy to make a judgment call. Part veer towards completeness.

Langlotz doesn"t ask radiologists to rid disclaimers altogether. He identify many situations where honesty around the imprecision is apt. Because that example, as soon as a fracture is dubious, not slam dunk, ~ above a radiograph, the is reasonable asking that findings be correlated with tenderness in ~ the site. Paper definition maketh a radiology report.

"The Radiology Report" covers much more than smart reporting. There"s a nifty section about probabilities. And a hilarious chapter about speech acknowledgment errors, my favourite -- "right interior jugular coitus" as soon as the radiologist stated "right inner jugular cordis," giving the erroneous impression the radiologists room watching Fifty Shades of Grey whilst dictating.

Langlotz has actually done one E.B. White because that radiology. I advise radiology inhabitants to review "The Radiology Report" in their very first year and also after overnight call. Nonradiologists must read this book, too, and also hold reports to the requirements he describes.


I credit Langlotz for my visceral dislike that "cannot exclude." I additionally no much longer say "seminal vesicles are unremarkable." If you have actually nothing nice to say about someone"s seminal vesicles, say nothing at all.

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Saurabh Jha is a radiologist and can be reached on Twitter
RogueRad. This post originally showed up in the
Health care Blog, and additionally appeared in KevinMD.com.