Banned: Top 8 words or phrases to avoid in radiology reports

By Philip Ward, AuntMinnieEurope.com staff writer

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.

2. Minimal
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.

3. Hardware
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."

5. Questionable
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."

6. Suspicious
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.

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Last Updated rm 10/29/2013 12:39:18 PM

7 comments so far ...
10/31/2013 12:32:12 PM
PedRad123
I find it interesting that the official BI-RADS lexicon word "suspicious" is among the top 8 banned words. Also the word minimal is frequently used not as an indicator of size but an indicator of severity, to mean less than mild.

11/2/2013 4:09:51 AM
F.Stahl
I find that the terms "suspicious" and "not suspicous" very useful in radiology reports, whem the patologhy in question has no definitive imaging criteria. I also find helpfull to the referring physian adding levels of suspicion as high or low. 

11/4/2013 6:04:46 AM
Philip W
[Dr. Paul McCoubrie, a regular columnist on AuntMinnieEurope.com and consultant radiologist at Southmead Hospital in Bristol, U.K., asked me to post the message below. Regards. Philip Ward, Editor in Chief, AuntMinnieEurope.com]
 
As Adam Wallis and I found when we published our 2011 review (Clin Rad 66(11) 1015), there is nothing like implied criticism of other people’s reports to get them stirred up. The tone of this is a little more strident that that we used – difficult where there is no hard empirical evidence, just opinion. I happen to agree with the points made but when you analyse several of them (e.g. 4-7), many fall under the collective heading of ‘hedging’, where the fundamental fault of the report is being much vaguer than is strictly necessary. Radiology is not black or white, investigational results are not binary normal/abnormal; uncertainty is intrinsic to our speciality. Our advice is summarized as ‘Get off the fence or at least explain why you are on it’
 
Point 3 is pedantic; I fail to see the clinical benefit of this. I’m all for accuracy and precision but there is a balance to be drawn with clinical utility. The more lengthy and technical description may not translate into additional benefit and may impair readability. For example, there are more than 60 different hip prostheses made by 19 different manufacturers. What degree of detail is truly necessary over and above “No prosthetic or periprosthetic abnormality”?”
 
Dr. Paul McCoubrie
 

11/5/2013 1:57:00 AM
Philip W
[Dr. Annie Paterson, consultant pediatric radiologist, Royal Belfast Hospital for Sick Children, Belfast, U.K. and editorial adviser on AuntMinnieEurope.com, asked me to post the message below. Regards. Philip Ward, Editor in Chief, AuntMinnieEurope.com]

Whilst I agree that reports should be well structured, succinct and clear, it is not always possible (here in the National Health Service) to follow the guidelines to the letter. At the present time, not all PACS are linked to those from other (neighbouring) institutions, and so access to prior imaging, whilst the ideal, is not always possible. Similarly, whilst it would be wonderful if radiologists had access electronically to patient notes and lab results, this is not always the case, and even if we could have instantaneous access to notes, there is not always a readily available contemporaneous clinic letter to assist – our colleagues here in the NHS are overburdened too, and their dictation may be days or even weeks behind. Time is an issue.
For NHS radiologists, the reporting workload does not always allow the leisure to check all the clinical notes and lab results for all patients. It would be a luxury if we could, but realistically that’s not going to happen. In my own practice, if I have suspicions about a child’s radiology studies, it is more helpful to phone the relevant clinician or call into their clinic, and review the images with them directly or ask direct clinical questions to help with the interpretation. Regular multidisciplinary team meetings also assist greatly with the sharing of clinical information.
Finally (and most importantly), the accuracy and detail of any radiology report are heavily dependent upon the clinical information provided on the request form. If clinicians scribble the bare minimum of information on a request form to comply with Ionising Radiation (Medical Exposure) Regulations and get the study approved/performed, that does not mean they have given sufficient information to help with image interpretation. “An emergency department patient who is short of breath – huge clinical and radiological differential diagnosis”: this is likely to get my “paracetamol” type report (i.e., a generic report that points out the radiological abnormality/pattern type, but says the differential diagnosis is wide; I give the top 3-ish for a child of the relevant age, and tell them to correlate with their clinical information or come and talk to me). However, if the clinician adds that symptoms have developed over days, the child has a temp of 39.5 ºC and a cough with green spit – and tells me there are coarse creps in the left lower lobe, then I will give “panadol” in my report, and just tell them that the air space disease in the left lower lobe is a pneumonia!
To sum up, there are ideals, and then there is real life. We always strive to the ideals, but as we work in teams, we can only be as good as our colleagues let us be.
Dr. Annie Paterson
 

11/14/2013 10:13:38 AM
Philip W
[Comment by Dr. Christiane M. Nyhsen, consultant radiologist, Sunderland, U.K.]

Firstly I think it is very good for any radiologist/radiology department to take time to reflect on wording used in radiology reports and I commend the authors on “stirring up” that discussion.

However, wording used will always be subjective. As previous comments already indicated, the word “minimal” is (at least here in the UK) often used as “not significant” rather than meaning “small”.

The clinicians reading the report will also be used to a particular reporting style and will have learnt over the years to understand it. I personally think that radiology reports should be as clear as possible, but that it is also important to indicate the level of uncertainty when appearances are
equivocal. To add to every report that “malignancy cannot be ruled out” is clearly not helpful, but there are many scans which are not black or white.

I also agree with Dr. Annie Paterson that when the clinicians fail to provide a complete clinical history then giving out a clear report will not always be possible. Maybe Prof. Baker has a perfect IT system available in his hospital, but where I work you can click your mouse 25 times and still not get a single up to date hospital letter. I do try on various occasions, but often simply give up in the end.
 
Lastly, the paragraph “hardware” is not entirely clear to me. If clinicians do not provide detailed information which surgery has been performed exactly (in particular complex multiple surgeries), how can I be sure? And I would also like to challenge which orthopaedic surgeon would ask a radiologist on the exact prosthesis used. But maybe I misunderstand …

Anyway, thank you Prof Baker for this editorial and for getting me thinking. I don’t agree with all of it but I shall reflect more on how to phrase my reports in the future - to the best of my humble abilities!