Why the jury's still out on standardized reports

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So here we go again: that old chestnut, the standardized report. So logical and so sensible. Patients win, doctors win, and hospitals win, so all boats rise. Yet decades down the line -- despite numerous presentations, publications, and protestations -- we don't have buy in. Why ever not?

One problem is the "all or none," "my way or the highway" zeal that is common to believers and undermines the credibility of standardized reports. It seems to suggest that by not using standardized systems you are not just a bad radiologist, but also you are likely a bad person and a societal misfit. The answer simply cannot be black or white; the reality is gray because patients and their conditions will fill the space of fuzzy logic that defies -- and will continue to defy --textbooks, algorithms, and standard operating procedures.

Dr. Leo Lawler is a consultant radiologist at Mater Misericordiae University Hospital in Dublin.Dr. Leo Lawler is a consultant radiologist at Mater Misericordiae University Hospital in Dublin.
Dr. Leo Lawler is a consultant radiologist at Mater Misericordiae University Hospital in Dublin.

Of course a unified layout and content is absolutely logical for procedure-based imaging, necessary for limited data-point imaging (e.g., mammography, cardiac CT), and certainly desirable for aspects of multidata point imaging (e.g., body CT). So why the procrastination? What is contained within the narrative style that we are so reluctant to give up?

Let's start with individualism and the fact that lumpers don't like splitters. Many of my reports are recognizable at the hospital, perhaps for good and bad reasons. My style is dynamic and continues to evolve as I seek to respond to the needs of patients, carers, and my trainees. I don't think it is indulgent, but I do think it is a practical and utilitarian creative process that seeks to align my needs with the needs of the intended audience.

Your report is your individual testament. In radiology, a report is the final tangible embodiment of who you are as a professional and the application of your skill set. You will build your reputation upon it and you will be paid because of it. It is your part in the reciprocal duty of care that is communication of diagnostics. So yes, many of us are precious about it and do have a sense of ownership of how we do it.

Lean processing is vital, but extreme standardizing seeks to "commoditize" what I do. You would not dare ask surgical colleagues to standardize their ward consultations, though they can standardize select operative notes. I suggest we wish to summate our patient and imaging interface into a considered, individual, patient-centered dialogue bringing to bear all things unique to this patient's particular care episode. Many of these items will defy a standardized report layout.

Does the clinical report have to be universally and globally applicable? The reality is that the vast majority of radiology reports only need to be local, a small percentage need to be national, and very few indeed need to be international.

Let's not forget the target audience. The curt, succinct list of bullet points serves well those specialists in their area of interest, but is of less value to the nonspecialists and junior trainees who prefer the narrative, fuller explanatory style. The conceit of the former is such they rarely read the report and the humility of the latter means they usually do.

We do all share the fear of narrative reports by those who would seek to write laboriously vacuous novelettes of no use to man or beast. There are aspects of radiology well suited to standardized reporting and we should keenly seek these out and apply efficient, unified reporting wherever we can in a lean, processed system. However, there are many other aspects in this developing and complex field that require us to rise above a "one size fits all" approach and ask us to take the time and make the effort to sculpt the customized, personalized report to help our patients and their caregivers. The PACS, voice recognition, paper-less world allows us to design the macro-filled templates, but also liberates us from the analogue word count to add the narrative and the images and labels better suited to the personalized healthcare model.

I learn from trainees' needs and I hope they learn from mine in reporting styles. Standardized templates are easy to transfer and reproduce and aid checklists. However, narratives allow us to express subjective opinion and uncertainty and do not insist that square patients are put in round holes.

There are late adopters in standardized reporting, but it is not all ascribable to sloth. If one looks closely, there is good reason and unmet needs in the standardized report. The answer is standardized reporting that seeks to allow narrative input that respects the uniqueness of caregivers and their charges.

Dr. Leo Lawler is a consultant radiologist at Mater Misericordiae University Hospital in Dublin.

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