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The radiology report — Are we getting the message across?
Clinical Radiology 66 (2011) 1015e1022
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Clinical Radiology journal homepage: www.elsevierhealth.com/journals/crad
Review
The radiology report d Are we getting the message across? A. Wallis, P. McCoubrie* Southmead Hospital, North Bristol NHS Trust, Bristol, UK
art icl e i nformat ion Article history: Received 8 March 2011 Received in revised form 9 May 2011 Accepted 31 May 2011
The radiology report is the primary method of communication between radiologist and referrer. Despite this, radiologists receive very little formal training regarding the structure of the radiology report and also its importance as a medico-legal document. We present a review of radiology reporting, highlighting the importance of report structure and language with the purpose of helping radiologists improve the clarity, brevity, pertinence, and readability of reports. We encourage radiologists to avoid hedging and strive to improve communication with referring clinicians. Ó 2011 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
Introduction One of the principal measures of service delivery in radiology is the production of radiology reports. These should highlight to the referrer the clinical importance of radiological findings and answer clinical questions. Although there are forums for face-to-face discussion at multidisciplinary meetings, and the opportunity for discussion via e-mail and telephone, the radiology report remains the primary method of communication between radiologist and clinician. Indeed, in many cases it may be the only method and this is particularly pertinent with the widespread use of digital technology and picture archiving and communication systems (PACS) whereby there is ubiquitous access to images and fewer in-person consultations.1 The radiology report is the document containing the official interpretation of a single radiological examination or procedure.2 Whilst the radiology report must be accurate in content, it must be written in a style that is concise and pertinent, conveying the correct message to the referrer.
What the referrer concludes from a report has been shown to have important consequences in malpractice cases3 and the importance of the radiology report as a medico-legal document should not be overlooked. A great variety in the style, structure, and effectiveness of radiology reports exists. The clinical importance of a report can be lost if the report lacks structure and is incoherent, rambling, and verbose. Although the radiology report is a fundamental component of the way we function as clinical radiologists, very little training is given to radiology trainees regarding reporting style and technique. Similarly, reporting radiographers and sonographers also receive little, if any, formal training in reporting technique and style. In this current age where reports can be generated using voice-recognition in a matter of minutes, the written report is a little studied aspect of radiology. This article aims to emphasize the importance of the radiological report and provide some suggestions on style and content as well as pitfalls to avoid.
A historical perspective * Guarantor and correspondent: P. McCoubrie, Southmead Hospital, North Bristol NHS Trust, Bristol BS10 5HQ, UK. Tel.: þ44 1173236341; fax: þ44 1173235122. E-mail address: [email protected] (P. McCoubrie).
Preston Hickey was a pioneering American radiologist at the turn of the 19th century. As an early editor of the American Journal of Roentgenology, he was fundamental to
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the standardized naming of the roentgenogram as radiograph.4 He was also an early advocate of radiology reporting skills and noted as early as 1899 the necessity for a standardized approach to radiograph reporting. In 1904 he introduced the term “interpretation” of radiographs to define a process involving specialized knowledge wherein a differential diagnosis of the radiographic findings might lead to a conclusion based on probabilities.5 Despite this, in 1920 Hickey noted that the style of reporting remained erratic and even eccentric and described how many reports were worded such that it was impossible to form a diagnosis or relate findings to the clinical problem. In his survey of radiology departments and reports he describes how many reports simply stated “fracture” and one report stated that the examination was complete and “films are available for viewing in the x-ray room”!6 Hickey argued for the adoption of standardized nomenclature and a standardized report comparable to pathology reports. Gagliardi describes how he recommended to the American Roentgen Ray Society that all candidates for membership submit 100 x-ray reports for evaluation of their clarity and diagnostic value d if they did not meet diagnostic standards then admission would be denied.4 This parallels the modern trend towards competency-based assessment in postgraduate training and Hickey was ahead of his time in this respect. Another commentator on radiology reports in the 1920s, Charles Enfield, criticized the radiologist who “describes in detail [what] is seen in the film.but does not tell what he thinks about it, what conclusions he draws from it, and what it means to him”. He summarized that this kind of reporting “tells much, yet almost nothing”.7 The fundamental aim of reporting today is similar to that advocated by Hickey all those years ago and as clinical radiologists we must give an opinion on the clinical implications of the findings or stand accused of the same avoidance of clinical commitment as those described by Enfield.
The radiology report as a medico-legal document A malpractice claim is difficult to defend in the absence of good documentation and in the case of radiology often the only documentation available is the radiology report. Poor communication has been found to be a causative factor in up to 80% of malpractice lawsuits involving radiologists.8 It cannot be emphasized enough that the radiology report is an important medico-legal document, and this fact alone should encourage us all to review our reporting standards. A review of cases by Berlin highlights the danger of the vague radiology report.3 All were bound by a common thread d a vague radiology report. Each involved a delayed diagnosis of malignancy leading to medical malpractice litigation. Whilst the reports were not wholly inaccurate, in no case did the referring physician take action that would have led to a prompt diagnosis. As a cautionary tale each of the referring physicians testified that if the radiologists had been stronger in their reports they would have acted much
sooner. It is important for radiologists to communicate effectively to the referring clinician and try to think what the referring clinician will interpret from a report. The distinction between error and malpractice is blurred. Medico-legal researchers have instructed juries to consider during their deliberation of malpractice lawsuits that there is an unavoidable “human factor” in radiology reporting, and that, therefore, not all “misses” mean that malpractice has been committed. Therefore, attention will be on issues including proof of competence (evidence that the radiologist is competent in daily practice) and habits of practice (the radiologist demonstrates safe working habits).9 Defensive practice only encourages hedging, but the point emphasizes the importance for radiologists to ensure that every report is of a high standard.
Is there a problem with today’s radiology reports? Having established that the radiology report is an important means of communication and a medico-legal document, are the radiology reports of today still suffering from the problems noted by Hickey all those years ago? Recent surveys have asked clinicians to rate the quality of radiological reports that they receive out of 10. General practitioners (GPs) gave 7.8 for clarity and 8 for content.10 Hospital clinicians gave 7 for content and 6.7 for clarity.11 Most reports were clear with helpful advice; however, some did not answer the clinical question, and gave measurements without their significance being given. GPs disliked the use of abbreviations with which they were unfamiliar. A survey of Australian oncologists noted that the majority (97.6%) were very satisfied or satisfied with radiology services and this correlated closely with promptness of reporting.12 One study of radiology reports used a commercial writing evaluation program to determine their readability.13 Those containing lengthy, complex sentences (with a high readability index) were viewed negatively by clinicians, possibly impeding effective communication between radiologist and clinician. Personal preference and previous experience influence a radiologist’s reporting structure and variation in linguistic complexity. This was reflected by the variation in mean readability index among radiologists d some used lengthy complex sentences more frequently than others. The readability index was also higher for more complex modality reports such as MRI due to the greater technical and anatomical information conveyed. There was a strong negative correlation between readability index, average clarity, and average certainty; the use of long sentences reduces the clarity of a report and may convey an impression of diagnostic uncertainty to the clinician and a sense of unreliability. The quality of radiology reports has been assessed by several other authors. Some have found that most (>90% of reports) met the minimum standard when scored for spelling errors, medical terminology, readability, relevance to the clinician, and conclusion.14 It is difficult to develop a truly objective scoring system but one study using
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a system based on the clinical impact of the radiology report determined that 14% did not meet the standard required.15 A retrospective audit of 272 radiology reports noted that only 18% had a separate opinion.16 If a comparison study was used, the date was mentioned in only 46%; pertinent negatives were discussed in 36%; clinical information recorded in 27%. The audit clearly highlighted several deficiencies in radiology reporting.
What are the essential components of the radiology report? Ideally the radiology report should aim to address the needs of the referring clinician. Hospital-based clinicians are able to visit radiology departments to discuss reports and can attend meetings, whereas those based in a primary care setting do not generally have this benefit. What is clear to a specialist may need to be highlighted to a nonspecialist. Ultimately if end-users of the report are dissatisfied with the quality of reports this can mean that services are redirected. For example, GPs could source alternative providers for their imaging needs.10 Historical surveys of clinicians generally agree on several principles regarding the components of a radiology report. LaFortune et al. identified that they appreciated a radiology report with a description of radiological findings followed by a conclusion.17 The report should answer the clinical question if one is given. This latter point is central to the aim of the report and is supported by other authors.18 As radiologists we owe patients the interpretation of radiological studies in a manner that is meaningful to the referring clinician,19 and should ask what the referring clinician is intended to conclude from the report. There is a lack of clear evidence regarding reporting guidelines and much of the literature is based on personal judgement and individual opinion. There is no standardized structure of reporting in practice in general radiology in the UK, though in the US the Breast Imaging Reporting and Data Systems (BI-RADS) provides a level of standardization using a lexicon of terms and definitions. Obstetric ultrasound also has a more structured format, although this consists of many more measurements than are generally provided in day-to-day reports. The typical radiology report follows the logical and inductive structure of a description of the findings followed by a discussion of the differential diagnosis and a conclusion. This is similar to the structure of scientific reports and supports the notion that the radiologic study is a scientific test.20 The American College of Radiology handbook for residents divides the radiology report into six sections: examination, history/indication, technique, comparison, findings, and impression.21 Not all of these will be applicable to all reports but it is a useful framework. A logical structure is advocated by many authors16,22e24 and provides a sound foundation upon which to produce a clear and concise radiology report. GPs10 and hospital clinicians11 appreciate a well structured report. Table 1 illustrates the key components of a radiology report.
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Table 1 Radiology report format. Title of examination History/indication Technique Comparison Findings Conclusion
We will now focus on the history, findings, and conclusion to discuss some important aspects of the radiology report and recommendations for improving their quality.
History When available the clinical question should be identified and recorded,10,15,24 to facilitate the answering of the question. The referring clinician will acknowledge that the radiologist has noted the question and perhaps gain more from the report than one in which they are left wondering whether the radiologist even read the request. The clinical history is often incorporated automatically into the report on computer-generated systems. If no pertinent history is provided then stating this in the report may help convey any diagnostic uncertainty.25 Consider mentioning the technical quality of the examination, specifically if sub-optimal.17 However, if the study is slightly suboptimal but not to the extent that it reduces diagnostic capability, then why burden the clinician with this fact? Statements such as “there is movement artefact but no perfusion defect is seen” are unqualified, ambiguous, and best avoided.26 Radiologists should not use examination quality as an excuse to hedge. Hedging is discussed in more detail later but refers to the use of ambiguous statements that avoid commitment on the part of the radiologist. In general, detailed descriptions of the technical aspects of a study are not required, and GPs find this detail unnecessary.10 This depends on the examination/procedure and is more pertinent for interventional techniques and perhaps magnetic resonance imaging (MRI). Common practice is to state the date and type of any comparative study at the beginning of the report.27 The use of appropriate comparative imaging is of considerable importance, particularly in oncological imaging. However, Hall disagrees that the comparison study should be listed at the top of the report and finds it disconcerting as the reader does not yet know which findings are being compared and there is repetition when the comparison is finally made.24 As with most recommendations, the preference for the exact manner of describing comparisons with previous imaging will be at the discretion of the radiologist. Table 2 is a summary of these guidelines concerning the history.
Findings When describing the findings, try to use terminology that is clear and in common use. Unfortunately, even the terms proximal and distal can cause some confusion.28
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Table 2 Guidelines for the history. Clinical question identified and recorded. Consider need for technical details. Technical quality should be mentioned particularly if suboptimal. State the date and type of any comparative study.
Therefore, it is of upmost importance to ensure the meaning of the report is correct and avoid the use of ambiguous terms that could lead to medical error and patient harm. The description should not be confused with the impression.24 Terms such as consolidation and vascular congestion are descriptive whereas pneumonia and congestive cardiac failure are not. Whilst this component generally forms the greatest part of a report, brevity (discussed below) is key, and a verbose description of the findings, which may unwittingly convey the impression of uncertainty to the reader,13 is to be avoided. The present tense is advocated when describing what is seen on a radiograph and the past tense for describing what was done at the time of an examination.20,22,24 The observations should be described in a logical manner,22,29 and it is usually pertinent to put the major finding first and describe findings in order of importance22,24,29 such that they are not overlooked. Freidman developed the hierarchy of terms as a concept to aid radiological reporting some years ago but it remains a useful framework on which to structure the report.30 The basic description of an image is a pattern of light and dark. Anatomical structures comprise the second level, pathological description the next, and the final level is the diagnosis. This helps the radiologist keep to basic principles of describe the findings before moving on to interpretation and finally diagnosis. Findings should be quantified where possible with measurements and those that cannot be directly measured (e.g., ascites or involutional change) with graduated modifiers such as mild, moderate, and severe,23,29 although these are unavoidably subjective. Quantification should be tailored to the referring clinician. GPs do not appreciate measurements of normal structures (e.g., kidneys or common bile duct).10 If measurements are used their significance should be stated. Measurements are of utmost importance in oncological imaging and comparison with previous studies must be accurate. There is limited use of criteria such as the Response Evaluation Criteria in Solid Tumours Group (RECIST) for evaluation of tumour response.12 A long list of incidental findings is best avoided27 and negatives should be mentioned only if pertinent.17 This will help prevent key findings from being overlooked. Medical terminology should be correct13,24,31 and generally abbreviations are best avoided, particularly if these are likely to be unfamiliar with the referring clinician.10,27 When used abbreviations should be accurate22 and in common usage, e.g., “PE” is acceptable for “pulmonary embolism”, whereas “cancer” is preferable to “CA”.27 Table 3 is a summary of these guidelines concerning the findings.
Table 3 Guidelines for the findings. Use clear descriptive terminology avoiding impressions until the conclusion. Use the present tense and organize the findings in a logical manner with the most important first. Quantify important findings where possible. Mention only pertinent negatives and avoid lists of incidental findings. Use correct medical terminology and generally avoid abbreviations.
Conclusion The conclusion is the most important component of the radiology report. It should contain summary statements that include conclusions about the radiological findings and suggestions for further management. The exact location of the conclusion is unlikely to have any significant impact on the clarity of the report, and it may be termed a summary or impression. Whatever the case, a concise conclusion is vital in enabling the report to be communicated effectively to the referrer.17,18,24,29,31 A survey of the attitudes of referring clinicians has shown that it may be the only part of the report that is read.18 Only 38% read the entire report and 18% read it only if the conclusion was unclear; 43% read only the conclusion if the report was longer than one page. Thirty-two percent preferred the summary statement at the beginning of the report, whilst 38% had no preference. There are some exceptions. It is generally considered acceptable that brief reports do not require conclusions and some advocate that the report should contain a conclusion if more than four lines long.22 Reports in which the conclusion is longer than the description are best avoided d this has been coined as “avoiding report inversion” by Wilcox,20 who also advocates the use of numbers in the conclusion to help the reader understand how the radiologist ranks the importance of the points made. The report should answer the clinical question, demonstrating to the reader that the radiologist has understood the main clinical concern.22 This should be addressed in the conclusion. If the clinical information given is “cough and pyrexia” then it is appropriate to state whether there are findings consistent with pneumonia.20 Referrers prefer that the report answers their question rather than simply states “normal”.17 The conclusion is where the radiologist can use clinical judgement, taking time and thought to separate the important from the incidental and answer the clinical question. However, the degree of certainty should also be mentioned in the conclusion22 as this will clarify whether the diagnosis is definite, possible, suspected, or equivocal. It should help to avoid the radiological hedge. Using the first person in cases where there is equivocation can add a personal touch, for example, “I would be happy to discuss this” or “I am unsure as to the significance of this”. GPs may appreciate a longer list of differential diagnoses,17 though differential diagnoses should be clear and not rambling as this can give the impression of diagnostic uncertainty.23 GPs also appreciate more detailed advice on further investigation and a recent survey regarding the
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content of a report showed that recommendations for further non-radiological investigation were listed as the item they would most like to see in a report (97%), followed by recommendations for further radiological investigation (96%).10 Further investigations should be recommended when appropriate. Ridley advises considering whether the findings of the current test require further clarification and whether the test will improve patient management.29 This should be balanced against the potential implication that the referrer will request the test simply because of concerns about legal implications of not doing so. Hall notes that radiologists make too many recommendations, particularly in patients in whom there is very little history and they may be unhelpful or even wrong.24 He advises also that when the recommendation is obvious it may be resented and supports the view of Ridley that clinicians may feel medico-legal pressure to act on suggestions of further imaging. Recommendations should be tailored to the referrer; the more specialized the referrer the less appreciated they are. However, responsibility to the patient is paramount. The reason for further imaging should always be mentioned. Terms along the lines of “clinical correlation advised” should be avoided where possible as they are overused and may be seen as reflecting defensive posturing and hedging by the radiologist.29 They should never be used as a substitute for offering a diagnostic opinion.27 Consider whether there is a need for the report to be acted upon with a degree of urgency; in which case the report should ideally be verbally communicated to the referring clinician. If findings were conveyed then it is generally advocated that this is recorded in the report.13,32,33 If a preliminary report undergoes substantive change before finalization this should also be mentioned34 and communicated to the referring clinician.35 Table 4 is a summary of these guidelines concerning the conclusion of the radiology report.
Notes on reporting style The radiology report is influenced by the personal preferences and experiences of the radiologist; consequently, there is a large individual stylistic component. Brevity and clarity are important stylistic elements to bear in mind when producing a radiology report. Grammar and English should be correct. When choosing words the radiologist should also try to consider any hidden meaning and avoid ambiguity. By stating Table 4 Guidelines for the conclusion. Brief reports may not require a conclusion; avoid “report inversion”. Answer the clinical question. Try to give a diagnostic opinion and avoid hedging. Where there is equivocation try using the first person to add a personal touch. Tailor the list of differential diagnoses and further investigations to the referring clinician. If findings are conveyed to the referring clinicians this should always be recorded.
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“no active lung lesion”, is there an inactive one? Similarly for “no acute lung pathology”, is there chronic pathology? Therefore, the language of the radiology report is all important. An inherent error of radiological terminology is the many different ways there are to describe any one pathological entity. Pneumonia could be described as pneumonitis, infiltrate, and consolidation, and until a standardized lexicon is developed this is unavoidable.1 Chest radiology does have a lexicon in terms of the Fleischner society guidelines.36 Radiologists should strive to be consistent in the terminologies they use so that at least individual consistency is maintained. A second point regarding language is that we should speak the simple truth and not hide behind technical parameters and obscure information. Radiologists have reinvented the English language, “interrogating” the lungs on lung windows, being “concerned” about malignancy.37 We should not use obscure language as a protective element of our specialization; rather we should speak our minds and use meaningful language.38 It may be unavoidable to conclude a report stating that “This is of uncertain importance/aetiology”, as long as it is an honest statement pointing to our lack of an answer based on what we are seeing and not a radiological hedge. As discussed, the length of a radiology report may be seen as reflecting diagnostic uncertainty of the radiologist by the referring clinician.13 Brevity is the ability to express much in few words and is the soul of wit. Shorter pieces take longer to write, and as the French polymath Blaise Pascal put it “I would have written a shorter letter, but I did not have the time”.39 Brevity is an important element of reporting style, though the descriptive detail expected by clinicians in radiology reports depends on the clinical circumstances. There is a greater desire for more descriptive detail when there are abnormal radiological findings or relevant symptoms.23 Unnecessary (redundant) words should be removed29 and in particular avoid starting strings of sentences with “There is.”, “There are..”.27 Hall provides an extensive review of terminology that is worth reviewing.24 There is a balance to be struck and even Hickey noted that some reports masked their uncertainty by being brief, presumably on the assumption that “what you don’t say can’t hurt you”.4 There are variations of preference of reporting style amongst referrers, and whilst surgeons prefer brevity, some physicians may prefer reports more respectful of grammar with complete sentences.17 We should strive to educate ourselves as radiologists on the information and format the clinicians prefer from our reports23 and remind ourselves that the clinician requesting the expert opinion of a radiologist expects a professionally written response.17 Clarity is a strongly valued aspect of a radiological report amongst referring clinicians.17 The phrase “evidence of” is overused and is best reserved for findings that can be inferred and not directly visualized.27 Care should also be taken using the term “significant” as for example when referring to lymphadenopathy there is no such thing as “insignificant lymphadenopathy”. Some structural elements contributing
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to clarity have been discussed d a logical layout and ordering of findings. Clarity of thought and perception are more clearly conveyed to the referrer if there is also ordering of paragraphs20 and the sentences within each paragraph. This will allow clear organization of ideas29 and will help make it easier to avoid sitting on the fence. Tips for style guidance are set out in Table 5. With continued advances in radiological information systems and the increasing use of voice-recognition software, it will become easier for radiologists to produce standardized tabulated reports. These have been shown to be favoured over prose reports by GPs,10 hospital clinicians,11 Canadian clinicians,16 and Australian oncologists.12 Sistrom also demonstrated a strong preference amongst clinicians for structured reports, whereby radiologists complete data fields in a computer-generated report proforma to improve organization and consistency of reports.31 Structured and prose reports were equally effective and accurate for transmitting case-specific interpretative content to the referrer. Other authors advocate novel methods such as annotation over key images, shifting away from the printed word to image-centred content, although this has yet to be validated or supported by clinicians.1
person adding a personal touch and demonstrating thought. The radiological hedge can have deleterious effects. In the aforementioned medico-legal cases, if the radiologist had been stronger in their opinion and climbed off the hedge the legal culpability attributed to this would not exist.3 The use of the word “appear” is particularly widespread as a hedge term. Levine calls this “spy stuff” as it is the language a CIA operative might use in a memorandum to protect himself.37 “There appears to be a nodule” could be considered as hedging as if there is no nodule at least the radiologist never said there was, merely it appeared that there was. Perhaps a better way of phrasing uncertainty is to state “I think there is a possible nodule”; as previously discussed, using the first person in equivocation adds a personal touch and suggests thought rather than hedging. “No evidence of pneumothorax” is a clever term as we can not be culpable if there is one as we never said there was. Think about the language used in your reports and avoid giving the report described by Enfield that “tells much, yet almost nothing”.7 Examples of hedging are shown in Table 7.
The importance of proofreading
A word on “hedging” The radiological hedge has been called the “tree of our specialty”.40 Hall describes the hedge as “an evasive statement to avoid the risk of commitment”24 and gives a rule of thumb of using not more than one hedge per sentence quoting “no obvious pneumonia identified”. The hedge is an ambiguous statement, and it is important “not to let the fear of being wrong rob you of the joy of being right”.41 Examples of hedge vocabulary are demonstrated in Table 6. If the main body of the report text states “thrombus in IVC”, do not hedge in the discussion by stating “likely thrombus in the IVC”. Stick to your guns! To state diagnosis at the end of a report encourages radiologists to hedge and so it is best to use terms such as conclusion, summary or impression.24 Consequently, if there is over 90% certainty that the diagnosis is correct then this should be the impression and hedging with terms such as “no fracture identified” suggesting one might have been “missed”, avoided. If there is diagnostic uncertainty then this should be stated and any unnecessary hedging avoided.3,22 As discussed, equivocal findings can be put in the first
The radiologist should always fully proofread the report before verifying it, whilst reviewing the images being reported, in order to minimize clinical risk from error.42 This will avoid errors in transcription (for example, carpal menari, an as yet unknown condition of the carpal bones, inadvertently transcribed instead of cor pulmonale) or with voicerecognition software. Words such as “asymmetric” can easily be mistyped as “symmetric” and so on.29 Errors such as these can dramatically influence the report. LaFortune et al. argued that a court could easily find the radiologist responsible for harm done to a patient as a result of a careless unchecked report and adds that the use of phrases such as “dictated but not checked” and other phrases to limit responsibility also reduce the reliability of a report.17 Although voice recognition is a viable method of reporting for experienced users, with a quicker overall report time, this comes at the price of an increase in the radiologists’ time and a tendency to more errors for inexperienced users.43 Other errors (such as grammatical or spelling errors) can also make the radiologist look rather careless, as demonstrated in Table 8, which are all excerpts from verified radiology reports.
Table 5 Style guidance. Style guidance
Before
After
Avoid “there is”, “there are” Avoid words with hidden meanings Avoid “no evidence of” to describe the absence of findings that can be directly visualized Remove redundant words Overuse of “significant” Brevity
There is consolidation in the middle lobe No active lung lesion No evidence of pleural effusion
Middle lobe consolidation No lung lesion No pleural effusion
The lung fields are normal No significant lymphadenopathy There is right hydronephrosis. The right ureter is dilated to the right vesicoureteric junction. There is a stone at this site.
Normal lungs No lymphadenopathy Right hydroureteronephrosis due to a stone at the right vesicoureteric junction.
A. Wallis, P. McCoubrie / Clinical Radiology 66 (2011) 1015e1022 Table 6 Examples of hedge vocabulary. Density or opacity Apparent Appears Possible/possibly Borderline Doubtful/uncertain/unlikely Suspected Indeterminate Identified Seen No definite/gross/obvious/overt/evidence of No significant Possible Probable Suggested Suspected Suspicious Vague Clinical correlation needed If clinically indicated Equivocal May represent
Teaching radiology reporting skills to tomorrow’s radiologists In a discussion regarding the readiness of today’s radiology trainees to become tomorrow’s diagnostic radiologists, the need for teaching how to dictate effective reports was highlighted.44 Trainees need to appreciate the importance of radiology reporting skills yet an American study in 2004 noted that radiology residents received no more than 1 h of didactic instruction in radiology reporting per year.45 The figure in the UK is unlikely to be any higher. The ability to write clearly is a skill, not an art, and is learned by practise.46 Didactic instruction, supervised practice, and the rigorous evaluation of reporting skills are necessary in any comprehensive radiology programme to improve radiology reporting.2 Radiology trainees generally glean information about reporting style and technique from their consultant colleagues through informal reporting sessions. Varieties of reporting style and phraseology are assimilated and from these the trainees own reporting style will arise. The Royal College of Radiologists (RCR) has recently updated the curriculum for radiologists in training to complement the introduction of an e-portfolio. This introduces a new era of competency-based training and workplace-based assessments. Progression is mapped to a defined curriculum and demonstrated by the achievement of core competencies. The curriculum can be accessed via the e-portfolio47 and describes (in the generic content under the heading of written records) the competencies required that Table 7 Examples of hedging from verified reports. The lungs appear clear No definite bone destruction is seen though this may be better assessed by MRI if required No evidence of pneumothorax No definite evidence of pulmonary embolism Appearances suggest a malignancy in the right lung
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Table 8 Voice recognition errors from verified reports. No adds renal pathology seen. Marked hydronephrosis of the renal pelvis with loss of renal para time is suggesting this stent is no functional. There is slight increases size of a number of nodes. Low attenuation adjacent to the later ventricle. Multiple low density lesions or nerve root on the liver, unchanged the previously noted a para-aortic or and the coeliac are lymph nodes have significantly reduced in size. The actual a tumour itself is cir slightly less then scan in the previous scan.
pertain to the radiology report. The trainee should “demonstrate appropriate contents of reports”, although what is deemed appropriate is not elaborated further and remains at the discretion of the consultant trainer. The trainee should “produce concise and accurate reports with clear conclusions and other written correspondence tailored to the referrer”. Table 9 demonstrates the competencies a trainee is expected to achieve in the knowledge, skills, and behaviour learning domains as set out in the new curriculum. Other curricula provide little further details regarding specific content of radiology reports. Describing general competencies in radiology resident training, Collins et al. go further and state that residents should “provide a clear and informative written radiological report, including a precise diagnosis whenever possible, a differential diagnosis when appropriate, and recommended follow-up or additional studies when appropriate”.33 The routine editing of trainee-generated reports for style has been shown to result in a small but measurable improvement in perceived report quality.48 Reports were evaluated for clarity, brevity, readability, and quality of impression using a five-point scale. Editing improved the scores given by both radiologist and physician. This raises the importance of emphasizing the stylistic aspects of reporting during the training of radiologists. Workplace-based assessment tools have been incorporated into the new e-portfolio for assessment of radiology trainees and their application in radiology has been discussed.49 We propose that an additional workplace-based assessment tool of radiology reporting skills is required alongside those currently used as part of the RCR e-portfolio. The Bristol Table 9 Written records competencies adapted from the RCR Clinical Radiology 2010 curriculum. Knowledge Demonstrate appropriate content of reports. Understand the relevance of data protection pertaining to patient confidentiality. Skills Produce concise and accurate reports with clear conclusions and other written correspondence tailored to the referrer. Behaviours Appreciate the importance of timely dictation, cost-effective use of medical secretaries and the use of electronic communication. Contact clinical colleagues appropriately dependent upon clinical scenarios.
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Radiology Reporting Assessment Tool (BRRAT) is undergoing local piloting and aims to provide summative and formative feedback to trainees to improve radiology reporting skills.50 In many respects this harks back to the plea by Hickey for reports to be evaluated for clarity and diagnostic value.
Summary Radiology reports are the primary form of communication between radiologist and clinician, and they must be structured in such a way to allow easy transfer of information. They are important medico-legal documents and whilst accuracy of reports is vital, clinical radiologists must avoid the urge to hedge unless absolutely necessary. When a clinician requests a radiological examination they are requesting the opinion of a radiologist, and this should be clearly conveyed in the report. The radiological report should be conceived as a method of communicating the expertise and clinical judgement of the radiologist and not a means of hiding behind obscure and ambiguous language. We present guidelines on reporting style and structure. We urge all clinical radiologists in practice and in training to strive to produce accurate and well-formatted reports that answer the clinical question and give pertinent advice regarding further management and follow-up. Referrers appreciate prompt reports, but despite onerous workloads, we should always take care to proofread reports, eliminating unnecessary errors and confirming that the correct message is communicated to the referrer. Close collaboration with our clinical colleagues will enable us to produce reports that meet their needs.
References 1. Reiner B, Siegel E. Radiology reporting: returning to our image-centric roots. AJR Am J Roentgenol 2006;187:1151e5. 2. Sistrom CL, Langlotz CP. A framework for improving radiology reporting. J Am Coll Radiol 2005;2:159e67. 3. Berlin L. Pitfalls of the vague radiology report. AJR Am J Roentgenol 2000;174:1511e8. 4. Gagliardi RA. The evolution of the x-ray report. AJR Am J Roentgenol 1995;164:501e2. 5. Hickey PM. The interpretation of radiographs. J Mich Med Soc. 1904;3: 496e9. 6. Hickey PM. Standardisation of roentgen-ray reports. AJR Am J Roentgenol 1922;9:422e5. 7. Enfield CD. The scope of the roentgenologist’s report. JAMA 1923;80:999e1001. 8. Levinson W. Physicianepatient communication: a key to malpractice prevention. JAMA 1994;272:1619e20. 9. Berlin L. Radiologic errors and malpractice: a blurry distinction. AJR Am J Roentgenol 2007;189:517e22. 10. Grieve FM, Plumb AA, Khan SH. Radiology reporting: a general practitioner’s perspective. Br J Radiol 2010;83:17e22. 11. Plumb AA, Grieve FM, Khan SH. Survey of hospital clinicians’ preferences regarding the format of radiology reports. Clin Radiol 2009;64:386e94. 12. Koczwara B, Tie M, Esterman A. Are radiologists meeting the needs of Australian medical oncologists? Results of a national survey. Aust Radiol 2003;47:268e73. 13. Sierra AE, Bisesi MA, Rosenbaum TL, et al. Readability of the radiologic report. Invest Radiol 1992;27:236e9. 14. Stavern K, Foss T, Botnmark O, et al. Inter-observer agreement in audit of quality of radiology requests and reports. Clin Radiol 2004;59:1018e24.
15. Robert L, Cohen MD, Jennings GS. A new method of evaluating the quality of radiology reports. Acad Radiol 2006;13:241e8. 16. Naik S, Hanbidge A, Wilson SR. Radiology reports: examining radiologist and clinician preferences regarding style and content. AJR Am J Roentgenol 2001;176:591e8. 17. LaFortune M, Breton G, Baudouin JL. The radiological report: what is useful for the referring physician? J Can Assoc Radiol 1988;39:140e2. 18. Clinger NJ, Hunter TB, Hillman BJ. Radiology reporting: attitudes of referring physicians. Radiology 1988;169:825e6. 19. Berlin L. Equal rights for all d except for doctors. AJR Am J Roentgenol 1998;170:1395. 20. Wilcox JR. The written radiology report. Appl Radiol 2006;35:33e7. 21. ACR Handbook for residents. ACR, http://rfs.acr.org/pdf/GettingStarted_ Handbook.pdf; 2009 [accessed 02.03.11]. 22. DeLacey G. Radiology reports. Rule 8 does not always like normal. RCR Newsletter. 76:10. 23. McLoughlin RF, So CB, Gray RR, et al. Radiology reports: how much descriptive detail is enough? AJR Am J Roentgenol 1995;165:803e6. 24. Hall F. Language of the radiology report: primer for residents and wayward radiologists. AJR Am J Roentgenol 2000;175:1239e42. 25. Hall FM. Clinical history, radiographic reporting and defensive radiological practice. Radiology 1989;170:575e6. 26. Bury B. Commentary on: survey of hospital clinicians’ preferences regarding the format of radiology reports. Clin Radiol 2009;64:395e6. 27. Coakley FV, Liberman L, Panicek DM. Style guidelines for radiology reporting: a manner of speaking. AJR Am J Roentgenol 2003;180:327e9. 28. Skillicorn CJ. Do the terms "proximal" and "distal" cause confusion amongst radiologists and other clinicians? Clin Radiol 2009;64:397e402. 29. Ridley LJ. Guide to the radiology report. Aust Radiol 2002;46:366e9. 30. Friedman PJ. Radiology reporting: the hierarchy of terms. AJR Am J Roentgenol 1983;140:402e3. 31. Sistrom CL, Honeyman-Buck J. Free text versus structured format: information transfer efficiency of radiology reports. AJR Am J Roentgenol 2005;185:804e12. 32. ACR standard for communication: diagnostic radiology. In: Standards. Reston, VA: American College of Radiology; 2000. p. 1e3. 33. Collins J, Christenson MR, Gray L, et al. General competencies in radiology residency training: definitions, skills, education and assessment. Acad Radiol 2002;9:721e6. 34. Holman BL, Aliabadi P, Silverman SG, et al. Medical impact of unedited preliminary radiology reports. Radiology 1994;191:519e21. 35. Raskin MM. Communication and malpractice. Appl Radiol 2004;33:7. 36. Hansell DM, Bankier AA, MacMahon H, et al. Fleischner Society: glossary of terms for thoracic imaging. Radiology 2008;246:697e722. 37. Levine MS. It’s all in the words. Appl Radiol 2007;36:8e9. 38. Phillips CD. Rethinking the language of obscurity. Appl Radiol 2004;33:7. 39. Blaise Pascal, Provincial Letters: Letter XVI, 1657: Full text is available at http://oregonstate.edu/instruct/phl302/texts/pascal/letters-c. html#LETTER%20 XVI [accessed 1 July 2011]. 40. Hall FM, Movson JS. The radiologic hedge. AJR Am J Roentgenol 1990;154:903e4. 41. Rogers LF. Personal communication in: Berlin L. Pitfalls of the vague radiology report. AJR Am J Roentgenol 2000;174:1511e8. 42. Royal College of Radiologists. Risk management in clinical radiology. London: Royal College of Radiologists; 2002. 43. Rana DS, Hurst G, Shepstone L, et al. Voice recognition for radiology reporting: is it good enough? Clin Radiol 2005;60:1205e12. 44. Vydareny KH. Radiology 1998: Are today’s resident’s ready for (tomorrow’s) practice? AJR Am J Roentgenol 1999;173:537e8. 45. Sistrom C. Reporting instruction for radiology residents. Acad Radiol 2004;11:76e84. 46. Goodman NW, Edwards MB. Medical writing: a prescription for clarity. New York: Cambridge University Press; 1991. 47. The RCR e-portfolio. www.nhseportfolios.org [accessed on 14.02.11]. 48. Coakley FV, Heinze SB, Shadbolt CL, et al. Routine editing of trainee-generated radiology reports: effect on style quality. Acad Radiol 2003;10:289e94. 49. Augustine K, McCoubrie P, Wilkinson JR, et al. Workplace-based assessment in radiology d where to now? Clin Radiol 2010;65:325e32. 50. Wallis AG, Isaac A, McCoubrie P. The Bristol Radiology Report Assessment Tool (BRRAT): developing a workplace based assessment tool for radiology reporting skills. BJR Congress Series; 2009:106.
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Clinical Radiology journal homepage: www.elsevierhealth.com/journals/crad
Review
The radiology report d Are we getting the message across? A. Wallis, P. McCoubrie* Southmead Hospital, North Bristol NHS Trust, Bristol, UK
art icl e i nformat ion Article history: Received 8 March 2011 Received in revised form 9 May 2011 Accepted 31 May 2011
The radiology report is the primary method of communication between radiologist and referrer. Despite this, radiologists receive very little formal training regarding the structure of the radiology report and also its importance as a medico-legal document. We present a review of radiology reporting, highlighting the importance of report structure and language with the purpose of helping radiologists improve the clarity, brevity, pertinence, and readability of reports. We encourage radiologists to avoid hedging and strive to improve communication with referring clinicians. Ó 2011 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
Introduction One of the principal measures of service delivery in radiology is the production of radiology reports. These should highlight to the referrer the clinical importance of radiological findings and answer clinical questions. Although there are forums for face-to-face discussion at multidisciplinary meetings, and the opportunity for discussion via e-mail and telephone, the radiology report remains the primary method of communication between radiologist and clinician. Indeed, in many cases it may be the only method and this is particularly pertinent with the widespread use of digital technology and picture archiving and communication systems (PACS) whereby there is ubiquitous access to images and fewer in-person consultations.1 The radiology report is the document containing the official interpretation of a single radiological examination or procedure.2 Whilst the radiology report must be accurate in content, it must be written in a style that is concise and pertinent, conveying the correct message to the referrer.
What the referrer concludes from a report has been shown to have important consequences in malpractice cases3 and the importance of the radiology report as a medico-legal document should not be overlooked. A great variety in the style, structure, and effectiveness of radiology reports exists. The clinical importance of a report can be lost if the report lacks structure and is incoherent, rambling, and verbose. Although the radiology report is a fundamental component of the way we function as clinical radiologists, very little training is given to radiology trainees regarding reporting style and technique. Similarly, reporting radiographers and sonographers also receive little, if any, formal training in reporting technique and style. In this current age where reports can be generated using voice-recognition in a matter of minutes, the written report is a little studied aspect of radiology. This article aims to emphasize the importance of the radiological report and provide some suggestions on style and content as well as pitfalls to avoid.
A historical perspective * Guarantor and correspondent: P. McCoubrie, Southmead Hospital, North Bristol NHS Trust, Bristol BS10 5HQ, UK. Tel.: þ44 1173236341; fax: þ44 1173235122. E-mail address: [email protected] (P. McCoubrie).
Preston Hickey was a pioneering American radiologist at the turn of the 19th century. As an early editor of the American Journal of Roentgenology, he was fundamental to
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the standardized naming of the roentgenogram as radiograph.4 He was also an early advocate of radiology reporting skills and noted as early as 1899 the necessity for a standardized approach to radiograph reporting. In 1904 he introduced the term “interpretation” of radiographs to define a process involving specialized knowledge wherein a differential diagnosis of the radiographic findings might lead to a conclusion based on probabilities.5 Despite this, in 1920 Hickey noted that the style of reporting remained erratic and even eccentric and described how many reports were worded such that it was impossible to form a diagnosis or relate findings to the clinical problem. In his survey of radiology departments and reports he describes how many reports simply stated “fracture” and one report stated that the examination was complete and “films are available for viewing in the x-ray room”!6 Hickey argued for the adoption of standardized nomenclature and a standardized report comparable to pathology reports. Gagliardi describes how he recommended to the American Roentgen Ray Society that all candidates for membership submit 100 x-ray reports for evaluation of their clarity and diagnostic value d if they did not meet diagnostic standards then admission would be denied.4 This parallels the modern trend towards competency-based assessment in postgraduate training and Hickey was ahead of his time in this respect. Another commentator on radiology reports in the 1920s, Charles Enfield, criticized the radiologist who “describes in detail [what] is seen in the film.but does not tell what he thinks about it, what conclusions he draws from it, and what it means to him”. He summarized that this kind of reporting “tells much, yet almost nothing”.7 The fundamental aim of reporting today is similar to that advocated by Hickey all those years ago and as clinical radiologists we must give an opinion on the clinical implications of the findings or stand accused of the same avoidance of clinical commitment as those described by Enfield.
The radiology report as a medico-legal document A malpractice claim is difficult to defend in the absence of good documentation and in the case of radiology often the only documentation available is the radiology report. Poor communication has been found to be a causative factor in up to 80% of malpractice lawsuits involving radiologists.8 It cannot be emphasized enough that the radiology report is an important medico-legal document, and this fact alone should encourage us all to review our reporting standards. A review of cases by Berlin highlights the danger of the vague radiology report.3 All were bound by a common thread d a vague radiology report. Each involved a delayed diagnosis of malignancy leading to medical malpractice litigation. Whilst the reports were not wholly inaccurate, in no case did the referring physician take action that would have led to a prompt diagnosis. As a cautionary tale each of the referring physicians testified that if the radiologists had been stronger in their reports they would have acted much
sooner. It is important for radiologists to communicate effectively to the referring clinician and try to think what the referring clinician will interpret from a report. The distinction between error and malpractice is blurred. Medico-legal researchers have instructed juries to consider during their deliberation of malpractice lawsuits that there is an unavoidable “human factor” in radiology reporting, and that, therefore, not all “misses” mean that malpractice has been committed. Therefore, attention will be on issues including proof of competence (evidence that the radiologist is competent in daily practice) and habits of practice (the radiologist demonstrates safe working habits).9 Defensive practice only encourages hedging, but the point emphasizes the importance for radiologists to ensure that every report is of a high standard.
Is there a problem with today’s radiology reports? Having established that the radiology report is an important means of communication and a medico-legal document, are the radiology reports of today still suffering from the problems noted by Hickey all those years ago? Recent surveys have asked clinicians to rate the quality of radiological reports that they receive out of 10. General practitioners (GPs) gave 7.8 for clarity and 8 for content.10 Hospital clinicians gave 7 for content and 6.7 for clarity.11 Most reports were clear with helpful advice; however, some did not answer the clinical question, and gave measurements without their significance being given. GPs disliked the use of abbreviations with which they were unfamiliar. A survey of Australian oncologists noted that the majority (97.6%) were very satisfied or satisfied with radiology services and this correlated closely with promptness of reporting.12 One study of radiology reports used a commercial writing evaluation program to determine their readability.13 Those containing lengthy, complex sentences (with a high readability index) were viewed negatively by clinicians, possibly impeding effective communication between radiologist and clinician. Personal preference and previous experience influence a radiologist’s reporting structure and variation in linguistic complexity. This was reflected by the variation in mean readability index among radiologists d some used lengthy complex sentences more frequently than others. The readability index was also higher for more complex modality reports such as MRI due to the greater technical and anatomical information conveyed. There was a strong negative correlation between readability index, average clarity, and average certainty; the use of long sentences reduces the clarity of a report and may convey an impression of diagnostic uncertainty to the clinician and a sense of unreliability. The quality of radiology reports has been assessed by several other authors. Some have found that most (>90% of reports) met the minimum standard when scored for spelling errors, medical terminology, readability, relevance to the clinician, and conclusion.14 It is difficult to develop a truly objective scoring system but one study using
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a system based on the clinical impact of the radiology report determined that 14% did not meet the standard required.15 A retrospective audit of 272 radiology reports noted that only 18% had a separate opinion.16 If a comparison study was used, the date was mentioned in only 46%; pertinent negatives were discussed in 36%; clinical information recorded in 27%. The audit clearly highlighted several deficiencies in radiology reporting.
What are the essential components of the radiology report? Ideally the radiology report should aim to address the needs of the referring clinician. Hospital-based clinicians are able to visit radiology departments to discuss reports and can attend meetings, whereas those based in a primary care setting do not generally have this benefit. What is clear to a specialist may need to be highlighted to a nonspecialist. Ultimately if end-users of the report are dissatisfied with the quality of reports this can mean that services are redirected. For example, GPs could source alternative providers for their imaging needs.10 Historical surveys of clinicians generally agree on several principles regarding the components of a radiology report. LaFortune et al. identified that they appreciated a radiology report with a description of radiological findings followed by a conclusion.17 The report should answer the clinical question if one is given. This latter point is central to the aim of the report and is supported by other authors.18 As radiologists we owe patients the interpretation of radiological studies in a manner that is meaningful to the referring clinician,19 and should ask what the referring clinician is intended to conclude from the report. There is a lack of clear evidence regarding reporting guidelines and much of the literature is based on personal judgement and individual opinion. There is no standardized structure of reporting in practice in general radiology in the UK, though in the US the Breast Imaging Reporting and Data Systems (BI-RADS) provides a level of standardization using a lexicon of terms and definitions. Obstetric ultrasound also has a more structured format, although this consists of many more measurements than are generally provided in day-to-day reports. The typical radiology report follows the logical and inductive structure of a description of the findings followed by a discussion of the differential diagnosis and a conclusion. This is similar to the structure of scientific reports and supports the notion that the radiologic study is a scientific test.20 The American College of Radiology handbook for residents divides the radiology report into six sections: examination, history/indication, technique, comparison, findings, and impression.21 Not all of these will be applicable to all reports but it is a useful framework. A logical structure is advocated by many authors16,22e24 and provides a sound foundation upon which to produce a clear and concise radiology report. GPs10 and hospital clinicians11 appreciate a well structured report. Table 1 illustrates the key components of a radiology report.
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Table 1 Radiology report format. Title of examination History/indication Technique Comparison Findings Conclusion
We will now focus on the history, findings, and conclusion to discuss some important aspects of the radiology report and recommendations for improving their quality.
History When available the clinical question should be identified and recorded,10,15,24 to facilitate the answering of the question. The referring clinician will acknowledge that the radiologist has noted the question and perhaps gain more from the report than one in which they are left wondering whether the radiologist even read the request. The clinical history is often incorporated automatically into the report on computer-generated systems. If no pertinent history is provided then stating this in the report may help convey any diagnostic uncertainty.25 Consider mentioning the technical quality of the examination, specifically if sub-optimal.17 However, if the study is slightly suboptimal but not to the extent that it reduces diagnostic capability, then why burden the clinician with this fact? Statements such as “there is movement artefact but no perfusion defect is seen” are unqualified, ambiguous, and best avoided.26 Radiologists should not use examination quality as an excuse to hedge. Hedging is discussed in more detail later but refers to the use of ambiguous statements that avoid commitment on the part of the radiologist. In general, detailed descriptions of the technical aspects of a study are not required, and GPs find this detail unnecessary.10 This depends on the examination/procedure and is more pertinent for interventional techniques and perhaps magnetic resonance imaging (MRI). Common practice is to state the date and type of any comparative study at the beginning of the report.27 The use of appropriate comparative imaging is of considerable importance, particularly in oncological imaging. However, Hall disagrees that the comparison study should be listed at the top of the report and finds it disconcerting as the reader does not yet know which findings are being compared and there is repetition when the comparison is finally made.24 As with most recommendations, the preference for the exact manner of describing comparisons with previous imaging will be at the discretion of the radiologist. Table 2 is a summary of these guidelines concerning the history.
Findings When describing the findings, try to use terminology that is clear and in common use. Unfortunately, even the terms proximal and distal can cause some confusion.28
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Table 2 Guidelines for the history. Clinical question identified and recorded. Consider need for technical details. Technical quality should be mentioned particularly if suboptimal. State the date and type of any comparative study.
Therefore, it is of upmost importance to ensure the meaning of the report is correct and avoid the use of ambiguous terms that could lead to medical error and patient harm. The description should not be confused with the impression.24 Terms such as consolidation and vascular congestion are descriptive whereas pneumonia and congestive cardiac failure are not. Whilst this component generally forms the greatest part of a report, brevity (discussed below) is key, and a verbose description of the findings, which may unwittingly convey the impression of uncertainty to the reader,13 is to be avoided. The present tense is advocated when describing what is seen on a radiograph and the past tense for describing what was done at the time of an examination.20,22,24 The observations should be described in a logical manner,22,29 and it is usually pertinent to put the major finding first and describe findings in order of importance22,24,29 such that they are not overlooked. Freidman developed the hierarchy of terms as a concept to aid radiological reporting some years ago but it remains a useful framework on which to structure the report.30 The basic description of an image is a pattern of light and dark. Anatomical structures comprise the second level, pathological description the next, and the final level is the diagnosis. This helps the radiologist keep to basic principles of describe the findings before moving on to interpretation and finally diagnosis. Findings should be quantified where possible with measurements and those that cannot be directly measured (e.g., ascites or involutional change) with graduated modifiers such as mild, moderate, and severe,23,29 although these are unavoidably subjective. Quantification should be tailored to the referring clinician. GPs do not appreciate measurements of normal structures (e.g., kidneys or common bile duct).10 If measurements are used their significance should be stated. Measurements are of utmost importance in oncological imaging and comparison with previous studies must be accurate. There is limited use of criteria such as the Response Evaluation Criteria in Solid Tumours Group (RECIST) for evaluation of tumour response.12 A long list of incidental findings is best avoided27 and negatives should be mentioned only if pertinent.17 This will help prevent key findings from being overlooked. Medical terminology should be correct13,24,31 and generally abbreviations are best avoided, particularly if these are likely to be unfamiliar with the referring clinician.10,27 When used abbreviations should be accurate22 and in common usage, e.g., “PE” is acceptable for “pulmonary embolism”, whereas “cancer” is preferable to “CA”.27 Table 3 is a summary of these guidelines concerning the findings.
Table 3 Guidelines for the findings. Use clear descriptive terminology avoiding impressions until the conclusion. Use the present tense and organize the findings in a logical manner with the most important first. Quantify important findings where possible. Mention only pertinent negatives and avoid lists of incidental findings. Use correct medical terminology and generally avoid abbreviations.
Conclusion The conclusion is the most important component of the radiology report. It should contain summary statements that include conclusions about the radiological findings and suggestions for further management. The exact location of the conclusion is unlikely to have any significant impact on the clarity of the report, and it may be termed a summary or impression. Whatever the case, a concise conclusion is vital in enabling the report to be communicated effectively to the referrer.17,18,24,29,31 A survey of the attitudes of referring clinicians has shown that it may be the only part of the report that is read.18 Only 38% read the entire report and 18% read it only if the conclusion was unclear; 43% read only the conclusion if the report was longer than one page. Thirty-two percent preferred the summary statement at the beginning of the report, whilst 38% had no preference. There are some exceptions. It is generally considered acceptable that brief reports do not require conclusions and some advocate that the report should contain a conclusion if more than four lines long.22 Reports in which the conclusion is longer than the description are best avoided d this has been coined as “avoiding report inversion” by Wilcox,20 who also advocates the use of numbers in the conclusion to help the reader understand how the radiologist ranks the importance of the points made. The report should answer the clinical question, demonstrating to the reader that the radiologist has understood the main clinical concern.22 This should be addressed in the conclusion. If the clinical information given is “cough and pyrexia” then it is appropriate to state whether there are findings consistent with pneumonia.20 Referrers prefer that the report answers their question rather than simply states “normal”.17 The conclusion is where the radiologist can use clinical judgement, taking time and thought to separate the important from the incidental and answer the clinical question. However, the degree of certainty should also be mentioned in the conclusion22 as this will clarify whether the diagnosis is definite, possible, suspected, or equivocal. It should help to avoid the radiological hedge. Using the first person in cases where there is equivocation can add a personal touch, for example, “I would be happy to discuss this” or “I am unsure as to the significance of this”. GPs may appreciate a longer list of differential diagnoses,17 though differential diagnoses should be clear and not rambling as this can give the impression of diagnostic uncertainty.23 GPs also appreciate more detailed advice on further investigation and a recent survey regarding the
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content of a report showed that recommendations for further non-radiological investigation were listed as the item they would most like to see in a report (97%), followed by recommendations for further radiological investigation (96%).10 Further investigations should be recommended when appropriate. Ridley advises considering whether the findings of the current test require further clarification and whether the test will improve patient management.29 This should be balanced against the potential implication that the referrer will request the test simply because of concerns about legal implications of not doing so. Hall notes that radiologists make too many recommendations, particularly in patients in whom there is very little history and they may be unhelpful or even wrong.24 He advises also that when the recommendation is obvious it may be resented and supports the view of Ridley that clinicians may feel medico-legal pressure to act on suggestions of further imaging. Recommendations should be tailored to the referrer; the more specialized the referrer the less appreciated they are. However, responsibility to the patient is paramount. The reason for further imaging should always be mentioned. Terms along the lines of “clinical correlation advised” should be avoided where possible as they are overused and may be seen as reflecting defensive posturing and hedging by the radiologist.29 They should never be used as a substitute for offering a diagnostic opinion.27 Consider whether there is a need for the report to be acted upon with a degree of urgency; in which case the report should ideally be verbally communicated to the referring clinician. If findings were conveyed then it is generally advocated that this is recorded in the report.13,32,33 If a preliminary report undergoes substantive change before finalization this should also be mentioned34 and communicated to the referring clinician.35 Table 4 is a summary of these guidelines concerning the conclusion of the radiology report.
Notes on reporting style The radiology report is influenced by the personal preferences and experiences of the radiologist; consequently, there is a large individual stylistic component. Brevity and clarity are important stylistic elements to bear in mind when producing a radiology report. Grammar and English should be correct. When choosing words the radiologist should also try to consider any hidden meaning and avoid ambiguity. By stating Table 4 Guidelines for the conclusion. Brief reports may not require a conclusion; avoid “report inversion”. Answer the clinical question. Try to give a diagnostic opinion and avoid hedging. Where there is equivocation try using the first person to add a personal touch. Tailor the list of differential diagnoses and further investigations to the referring clinician. If findings are conveyed to the referring clinicians this should always be recorded.
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“no active lung lesion”, is there an inactive one? Similarly for “no acute lung pathology”, is there chronic pathology? Therefore, the language of the radiology report is all important. An inherent error of radiological terminology is the many different ways there are to describe any one pathological entity. Pneumonia could be described as pneumonitis, infiltrate, and consolidation, and until a standardized lexicon is developed this is unavoidable.1 Chest radiology does have a lexicon in terms of the Fleischner society guidelines.36 Radiologists should strive to be consistent in the terminologies they use so that at least individual consistency is maintained. A second point regarding language is that we should speak the simple truth and not hide behind technical parameters and obscure information. Radiologists have reinvented the English language, “interrogating” the lungs on lung windows, being “concerned” about malignancy.37 We should not use obscure language as a protective element of our specialization; rather we should speak our minds and use meaningful language.38 It may be unavoidable to conclude a report stating that “This is of uncertain importance/aetiology”, as long as it is an honest statement pointing to our lack of an answer based on what we are seeing and not a radiological hedge. As discussed, the length of a radiology report may be seen as reflecting diagnostic uncertainty of the radiologist by the referring clinician.13 Brevity is the ability to express much in few words and is the soul of wit. Shorter pieces take longer to write, and as the French polymath Blaise Pascal put it “I would have written a shorter letter, but I did not have the time”.39 Brevity is an important element of reporting style, though the descriptive detail expected by clinicians in radiology reports depends on the clinical circumstances. There is a greater desire for more descriptive detail when there are abnormal radiological findings or relevant symptoms.23 Unnecessary (redundant) words should be removed29 and in particular avoid starting strings of sentences with “There is.”, “There are..”.27 Hall provides an extensive review of terminology that is worth reviewing.24 There is a balance to be struck and even Hickey noted that some reports masked their uncertainty by being brief, presumably on the assumption that “what you don’t say can’t hurt you”.4 There are variations of preference of reporting style amongst referrers, and whilst surgeons prefer brevity, some physicians may prefer reports more respectful of grammar with complete sentences.17 We should strive to educate ourselves as radiologists on the information and format the clinicians prefer from our reports23 and remind ourselves that the clinician requesting the expert opinion of a radiologist expects a professionally written response.17 Clarity is a strongly valued aspect of a radiological report amongst referring clinicians.17 The phrase “evidence of” is overused and is best reserved for findings that can be inferred and not directly visualized.27 Care should also be taken using the term “significant” as for example when referring to lymphadenopathy there is no such thing as “insignificant lymphadenopathy”. Some structural elements contributing
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to clarity have been discussed d a logical layout and ordering of findings. Clarity of thought and perception are more clearly conveyed to the referrer if there is also ordering of paragraphs20 and the sentences within each paragraph. This will allow clear organization of ideas29 and will help make it easier to avoid sitting on the fence. Tips for style guidance are set out in Table 5. With continued advances in radiological information systems and the increasing use of voice-recognition software, it will become easier for radiologists to produce standardized tabulated reports. These have been shown to be favoured over prose reports by GPs,10 hospital clinicians,11 Canadian clinicians,16 and Australian oncologists.12 Sistrom also demonstrated a strong preference amongst clinicians for structured reports, whereby radiologists complete data fields in a computer-generated report proforma to improve organization and consistency of reports.31 Structured and prose reports were equally effective and accurate for transmitting case-specific interpretative content to the referrer. Other authors advocate novel methods such as annotation over key images, shifting away from the printed word to image-centred content, although this has yet to be validated or supported by clinicians.1
person adding a personal touch and demonstrating thought. The radiological hedge can have deleterious effects. In the aforementioned medico-legal cases, if the radiologist had been stronger in their opinion and climbed off the hedge the legal culpability attributed to this would not exist.3 The use of the word “appear” is particularly widespread as a hedge term. Levine calls this “spy stuff” as it is the language a CIA operative might use in a memorandum to protect himself.37 “There appears to be a nodule” could be considered as hedging as if there is no nodule at least the radiologist never said there was, merely it appeared that there was. Perhaps a better way of phrasing uncertainty is to state “I think there is a possible nodule”; as previously discussed, using the first person in equivocation adds a personal touch and suggests thought rather than hedging. “No evidence of pneumothorax” is a clever term as we can not be culpable if there is one as we never said there was. Think about the language used in your reports and avoid giving the report described by Enfield that “tells much, yet almost nothing”.7 Examples of hedging are shown in Table 7.
The importance of proofreading
A word on “hedging” The radiological hedge has been called the “tree of our specialty”.40 Hall describes the hedge as “an evasive statement to avoid the risk of commitment”24 and gives a rule of thumb of using not more than one hedge per sentence quoting “no obvious pneumonia identified”. The hedge is an ambiguous statement, and it is important “not to let the fear of being wrong rob you of the joy of being right”.41 Examples of hedge vocabulary are demonstrated in Table 6. If the main body of the report text states “thrombus in IVC”, do not hedge in the discussion by stating “likely thrombus in the IVC”. Stick to your guns! To state diagnosis at the end of a report encourages radiologists to hedge and so it is best to use terms such as conclusion, summary or impression.24 Consequently, if there is over 90% certainty that the diagnosis is correct then this should be the impression and hedging with terms such as “no fracture identified” suggesting one might have been “missed”, avoided. If there is diagnostic uncertainty then this should be stated and any unnecessary hedging avoided.3,22 As discussed, equivocal findings can be put in the first
The radiologist should always fully proofread the report before verifying it, whilst reviewing the images being reported, in order to minimize clinical risk from error.42 This will avoid errors in transcription (for example, carpal menari, an as yet unknown condition of the carpal bones, inadvertently transcribed instead of cor pulmonale) or with voicerecognition software. Words such as “asymmetric” can easily be mistyped as “symmetric” and so on.29 Errors such as these can dramatically influence the report. LaFortune et al. argued that a court could easily find the radiologist responsible for harm done to a patient as a result of a careless unchecked report and adds that the use of phrases such as “dictated but not checked” and other phrases to limit responsibility also reduce the reliability of a report.17 Although voice recognition is a viable method of reporting for experienced users, with a quicker overall report time, this comes at the price of an increase in the radiologists’ time and a tendency to more errors for inexperienced users.43 Other errors (such as grammatical or spelling errors) can also make the radiologist look rather careless, as demonstrated in Table 8, which are all excerpts from verified radiology reports.
Table 5 Style guidance. Style guidance
Before
After
Avoid “there is”, “there are” Avoid words with hidden meanings Avoid “no evidence of” to describe the absence of findings that can be directly visualized Remove redundant words Overuse of “significant” Brevity
There is consolidation in the middle lobe No active lung lesion No evidence of pleural effusion
Middle lobe consolidation No lung lesion No pleural effusion
The lung fields are normal No significant lymphadenopathy There is right hydronephrosis. The right ureter is dilated to the right vesicoureteric junction. There is a stone at this site.
Normal lungs No lymphadenopathy Right hydroureteronephrosis due to a stone at the right vesicoureteric junction.
A. Wallis, P. McCoubrie / Clinical Radiology 66 (2011) 1015e1022 Table 6 Examples of hedge vocabulary. Density or opacity Apparent Appears Possible/possibly Borderline Doubtful/uncertain/unlikely Suspected Indeterminate Identified Seen No definite/gross/obvious/overt/evidence of No significant Possible Probable Suggested Suspected Suspicious Vague Clinical correlation needed If clinically indicated Equivocal May represent
Teaching radiology reporting skills to tomorrow’s radiologists In a discussion regarding the readiness of today’s radiology trainees to become tomorrow’s diagnostic radiologists, the need for teaching how to dictate effective reports was highlighted.44 Trainees need to appreciate the importance of radiology reporting skills yet an American study in 2004 noted that radiology residents received no more than 1 h of didactic instruction in radiology reporting per year.45 The figure in the UK is unlikely to be any higher. The ability to write clearly is a skill, not an art, and is learned by practise.46 Didactic instruction, supervised practice, and the rigorous evaluation of reporting skills are necessary in any comprehensive radiology programme to improve radiology reporting.2 Radiology trainees generally glean information about reporting style and technique from their consultant colleagues through informal reporting sessions. Varieties of reporting style and phraseology are assimilated and from these the trainees own reporting style will arise. The Royal College of Radiologists (RCR) has recently updated the curriculum for radiologists in training to complement the introduction of an e-portfolio. This introduces a new era of competency-based training and workplace-based assessments. Progression is mapped to a defined curriculum and demonstrated by the achievement of core competencies. The curriculum can be accessed via the e-portfolio47 and describes (in the generic content under the heading of written records) the competencies required that Table 7 Examples of hedging from verified reports. The lungs appear clear No definite bone destruction is seen though this may be better assessed by MRI if required No evidence of pneumothorax No definite evidence of pulmonary embolism Appearances suggest a malignancy in the right lung
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Table 8 Voice recognition errors from verified reports. No adds renal pathology seen. Marked hydronephrosis of the renal pelvis with loss of renal para time is suggesting this stent is no functional. There is slight increases size of a number of nodes. Low attenuation adjacent to the later ventricle. Multiple low density lesions or nerve root on the liver, unchanged the previously noted a para-aortic or and the coeliac are lymph nodes have significantly reduced in size. The actual a tumour itself is cir slightly less then scan in the previous scan.
pertain to the radiology report. The trainee should “demonstrate appropriate contents of reports”, although what is deemed appropriate is not elaborated further and remains at the discretion of the consultant trainer. The trainee should “produce concise and accurate reports with clear conclusions and other written correspondence tailored to the referrer”. Table 9 demonstrates the competencies a trainee is expected to achieve in the knowledge, skills, and behaviour learning domains as set out in the new curriculum. Other curricula provide little further details regarding specific content of radiology reports. Describing general competencies in radiology resident training, Collins et al. go further and state that residents should “provide a clear and informative written radiological report, including a precise diagnosis whenever possible, a differential diagnosis when appropriate, and recommended follow-up or additional studies when appropriate”.33 The routine editing of trainee-generated reports for style has been shown to result in a small but measurable improvement in perceived report quality.48 Reports were evaluated for clarity, brevity, readability, and quality of impression using a five-point scale. Editing improved the scores given by both radiologist and physician. This raises the importance of emphasizing the stylistic aspects of reporting during the training of radiologists. Workplace-based assessment tools have been incorporated into the new e-portfolio for assessment of radiology trainees and their application in radiology has been discussed.49 We propose that an additional workplace-based assessment tool of radiology reporting skills is required alongside those currently used as part of the RCR e-portfolio. The Bristol Table 9 Written records competencies adapted from the RCR Clinical Radiology 2010 curriculum. Knowledge Demonstrate appropriate content of reports. Understand the relevance of data protection pertaining to patient confidentiality. Skills Produce concise and accurate reports with clear conclusions and other written correspondence tailored to the referrer. Behaviours Appreciate the importance of timely dictation, cost-effective use of medical secretaries and the use of electronic communication. Contact clinical colleagues appropriately dependent upon clinical scenarios.
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A. Wallis, P. McCoubrie / Clinical Radiology 66 (2011) 1015e1022
Radiology Reporting Assessment Tool (BRRAT) is undergoing local piloting and aims to provide summative and formative feedback to trainees to improve radiology reporting skills.50 In many respects this harks back to the plea by Hickey for reports to be evaluated for clarity and diagnostic value.
Summary Radiology reports are the primary form of communication between radiologist and clinician, and they must be structured in such a way to allow easy transfer of information. They are important medico-legal documents and whilst accuracy of reports is vital, clinical radiologists must avoid the urge to hedge unless absolutely necessary. When a clinician requests a radiological examination they are requesting the opinion of a radiologist, and this should be clearly conveyed in the report. The radiological report should be conceived as a method of communicating the expertise and clinical judgement of the radiologist and not a means of hiding behind obscure and ambiguous language. We present guidelines on reporting style and structure. We urge all clinical radiologists in practice and in training to strive to produce accurate and well-formatted reports that answer the clinical question and give pertinent advice regarding further management and follow-up. Referrers appreciate prompt reports, but despite onerous workloads, we should always take care to proofread reports, eliminating unnecessary errors and confirming that the correct message is communicated to the referrer. Close collaboration with our clinical colleagues will enable us to produce reports that meet their needs.
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