October 30, 2013 -- To highlight common expressions that can mislead, misinform, or misdirect referring physicians, the radiology report needs to be re-examined, and it is vital to eliminate the lexicon of clichés that undermine a radiologist's work because of their vagueness, warns a respected global expert in a hard-hitting editorial.
The dictated report is probably more important today than ever before -- it reveals radiologists' interpretive expertise and has become central for the assessment of the value they aim to provide, noted Dr. Stephen R. Baker, professor and chair of the department of radiology at Rutgers New Jersey Medical School (NJMS), in Newark, U.S.
"The advent and dissemination of the electronic medical record (EMR) promises to make our dictations readily available, independent of the constraints of geography. Hence, persistent use of specific phrases understood only locally and radiology jargon in general may each not be comprehended or be comprehensible by distant, nonspecialist caregivers who receive our reports and then act on them," he wrote in an article published online by the European Journal of Radiology on 27 October.
In the era of team approaches to healthcare, a well-crafted, pertinent, and unambiguous narrative is essential to enhance radiologists' reputation and facilitate the successful interaction between them and their clinical colleagues, he added.
Baker, who is president of the Society of Chairmen of Academic Radiology Departments and editor-in-chief of Emergency Radiology, has identified the following eight terms that he regards as unhelpful and redundant, often because of their subjective qualities:
1. Cannot rule out, or cannot be excluded
These two phrases are identical in meaning, and often they are included in a report to avoid the retrospective insinuation that a less likely diagnostic possibility did not get a mention in the radiologist's narrative, he said. But each term is meaningless as a statement of the radiologist's ability to discern and clarify, and to include either term is in effect to offer a tautology, not an insight.
"What is needed instead is to provide the best diagnoses based on radiologic, historical, physical, and laboratory findings, not a flippant cover for everything even remotely likely. Referring physicians want the most compelling diagnosis described and explained," Baker stated.
This word often is used as a synonym for tiny or small, but it is not identical in connotation or denotation to either. Tiny and small are adjectives of comparison, and they are relative terms, whereas minimal implies a fixed boundary, a limit below which an abnormality of lesser length or volume cannot be discerned, he explained.
"Often a finding with dimensions less than what is ascribed as minimal could be observable. Instead of declaring something to be minimal, we as anatomists need not make such a claim. Instead we should measure the dimensions of the abnormality so that it could be compared with future depictions of the same finding and then estimates of enlargement or shrinkage could be determined," Baker wrote, adding this can help avoid the rhetorical trap that on a subsequent examination one could be compelled to admit that a radiodense or lucent lesion even smaller than its so-called minimal dimensions is recognizable.
Radiologists must understand the pathology and use the vocabulary familiar to each of the generalists and specialists they serve, and it is good practice and policy to label the implements and procedures whose images we observe with the appropriate terms, in precise and specific detail.
To call them collectively "hardware" should raise questions about whether our interpretations are merely pro forma exercises in irrelevancy instead of being a focused consultation relevant to the clinical issue at hand. The use of "hardware" serves to relegate the radiologist to the role of a mere observer, not an expert analyzer of a device's identity, position, and purpose, according to Baker.
4. May represent
Typically, this expression immediately precedes the listing of just two clinical choices that each correspond to the same radiographic pattern of abnormality, and it needlessly magnifies uncertainty, he argued.
"Either one is a legitimate possibility but other entities distinctly are not and are characteristically not mentioned by name. For instance, it may represent 'an infiltrate or edema in the lung.' But claiming that it may represent does not eliminate the plausible consideration that it could be a manifestation of some other entity," he wrote. "Customary use of this term is apt to eventually cast the radiologist as one who repeatedly seeks an 'out' when a more appropriate definiteness is required."
Vagueness is a trait that you do not need to display as a trademark of your reports, and the opinion you render should be a manifestation of your skills and your confidence about them, Baker advised.
"You should expunge 'questionable' from your list of acceptable words. For one thing 'questionable' does not relate to an estimation of your extent of uncertainty. And it also creates unnecessary confusion about the origin of that uncertainty."
By verbal and written communication, radiologists should reveal themselves to be vitally involved in the care of patients and yet measured in the articulation of judgments, and this requires offering diagnoses on the basis of sound, careful, unemotional assessment. Words like "suspicious" display subjective reactions that don't rely on the careful evaluation of evidence. The declaration of "suspicions" about the presence of an abnormality without the accompaniment of forthright reasoning is not reassuring to referring physicians, he stated.
7. Within normal limits
A chronic "malady" liable to affect all specialties of medicine is the "disease" of the insidious infiltration of jargon, and you must get rid of it from consultations, both oral and written. Often it takes the form of added words that gives a notion an air of heightened emphasis, seeming to impart a sense of augmented perspicacity to what could be false or silly, he explained.
Within normal limits is such a phrase when there are no agreed upon limits beyond or less than which a finding would be deemed abnormal. "If there are no measurable borders to ascribe or discern, the simple term 'normal' is more apt than 'within normal limits.' By so doing, you will not have to fumble around when a referrer asks you to describe to him or her what those limits are when there are, in fact, none."
8. Clinical correlation suggested or requested
This phrase does not protect a radiologist from being sued, with the exception of its stylized adaptation as part of the lingo of breast radiology diagnosis, Baker asserts. Referring physicians tend to regard its use as trivial and of no value, and may be offended by it. Moreover, with the advent of the EMR, the clinical characteristics of the patient's illness and knowledge of his or her medical history are now available to the radiologist with the click of a mouse, so use of the phrase "clinical correlation requested" is now not just a manifestation of a radiologist's heedlessness of its implications, and a mark of his or her laziness to acquire that clinical correlation. The phrase should be abandoned as a concluding sentence in a radiologist's report, he wrote.
The points covered in the editorial are part of the NJMS's policy for radiology reports, Baker concluded.