Step up to bat and practice dictating complex cases a residents guide to effective reporting
Step Up to Bat and Practice DictatingComplex Cases: A Residents Guide to Effective Reporting Mark D. Mamlouk, MD1 Eric vanSonnenberg, MD2,3 1University of California, Irvine 2Kern/UCLA Medical Center 3Arizona State University
INTRODUCTIONRadiology residencies provide little formal training in imagereporting. Studies have shown that residencies designate atmost one hour per year on dictation education. There is nostandard model or guide for residents to adhere to during theirtraining.Clinicians have expressed dissatisfaction with radiologyreports—41% of 432 clinical specialists feel that the radiologyreport is not valuable (Bosmans Radiology 2011). Cliniciansbelieve our reports are too vague.Our purpose is to highlight important and effective reportingguidelines and strategies using interesting image-based casesthat encompass all branches of radiology, thereby increasingresident education and clinician satisfaction.
EFFECTIVE REPORTING Clinical History: 47 F with Adequate, new onset memory loss billable history Findings: There is a 5 mm focus of Detailed, yet reduced diffusion in the concise findings left hippocampus. Impression: Findings compatible with Answers transient global amnesia. clinical question • Effective reports are straightforward • Report descriptions should be complete, but with a parsimony of words • Findings & Impression contain relevant points and are not redundant • Findings are for the radiologists and the Impression is for the clinicians • Reports are clinically oriented, i.e. attempt to make a clinical diagnosis rather than simply describing findings • Include prior comparisons, technique, contrast name and amount, radiation dose
FINDINGS IN THE REPORT PREFERRED DICTATION SUBOPTIMAL DICTATION• Findings should be organized Clinical History: 52 F with Clinical History: 52 F with hematuria• Use paragraphs hematuria Findings:• Include pertinent positives & The lung bases are well aerated. The Findings: Paragraphs The lung bases… make easier tonegatives liver and spleen are normal. There is read compression of the left renal vein by the• Be complete, even if aorta and SMA along with the presence There is compression of the left renal vein by the aorta and SMAnormal—50% of polled of a large left gonadal vein. There are along with the presence of a large left renal and pelvic varices. The adrenalclinicians believe if an glands, pancreas, and right kidney are left gonadal vein. There are leftorgan/structure is not renal and pelvic varices. normal. The bowel is nondilated andmentioned, the radiologist did there is no bowel obstruction. The Grouping The liver, spleen, adrenal osseous structures are normal. related findingsnot closely evaluate it glands…are normal. more logical Impression: Nutcracker syndrome Impression: Nutcracker syndrome
IMPRESSION IN THE REPORT• Single most important component of the radiology report• Should be concise, unambiguous, and not reiterate the findings• Should be separate from findings--94% of 703 polled clinicians believe that a radiologyreport greater than a few lines should have a separate conclusion (Bosmans Radiology 2011)• Should be numbered in decreasing importance; if a sole impression, don’t number• Should answer the clinical question! Findings: There is a nonenhancing mass extending from the right gonadal vein to the IVC to the right atrium. There is thrombus within the hepatic veins. The uterus is large and lobular with internal fibroids. Impression: Intravenous leiomyomatosis and secondary Budd-Chiari syndrome Findings: There are numerous perivascular spaces bilaterally that follow CSF signal. The sella is J-shaped. Impression: Findings suggestive of a mucopolysaccharidosis (Hurler disease, in this case)
ANSWER CLINICAL QUESTION SUBOPTIMAL PREFERRED DICTATION IMPRESSION Clinical History: Impression: 8 m/o M with lower GI bleeding—evaluate for High tracer uptake in the Meckel diverticulum. RLQ compatible with a Meckel diverticulum. Impression: High tracer uptake in RLQ.• Although obvious, answering the An easy, everyday case toclinical question is not always evaluate PICC placement SUBOPTIMAL PREFERRED DICTATION IMPRESSIONdone(these two cases) Findings: Clinical history: There is a new right-sided• Should be the first Impression Evaluate PICC PICC with the tip projecting placement over the mid SVC. The• Succinct and straightforward lungs are well aerated. The Findings/Impression: cardiomediastinal• Guides radiologist to commit to a There is a new PICC silhouette is not large.diagnosis identified. The lungs are clear. The Impression:• Will increase clinician’s satisfaction cardiomediastinal silhouette is stable. Satisfactory PICC position.
HANDLING NORMAL VARIANTS Clinical History: 37 F preoperative for pituitary tumor resection Impression: 1. Pituitary tumor unchanged (not shown). 2. Persistent trigeminal artery, a normal variant, that should be considered in surgical planning.• Significant normal variants should be mentioned in the Impression• Knowledge on when a normal variant can affect management is important• Trivial normal variants can be discussed solely in the Findings• If there is a rare normal variant that the clinician may not be aware of, mention “this is anormal variant” to not confuse with pathology
LIMIT COLLOQUIALISMS SUBOPTIMAL IMPRESSION PREFERRED DICTATION Clinical history: 2 y/o M with Impression: difficulty stooling Constellation of findings Findings: indicative of Currarino triad. There is a presacral cystic mass contiguous with the thecal sac. There is hypoplasia of the “Clinically correlate” sacrum and coccyx. A • Commonly used radiologist significant amount of stool is phrase seen in the rectum secondary • Does not add value to report to anal stenosis (not shown). • Clinicians satirize this Impression: expression Presacral cystic mass, skeletal • Does NOT save you from the anomalies, constipation. court room Clinically correlate. SUBOPTIMAL IMPRESSION Findings: There is a dissection flap extending from the ascending aorta across the aortic root and into the subvalvular left ventricular outflow tract (LVOT). There is a subtle dissection in the left main coronary artery ostium. Impression: Aortic dissection extending to the LVOT and left main coronary artery. If clinically indicated, MRI is recommended.
LIMIT COLLOQUIALISMS (Cont.)“If clinically indicated”• Before reporting this vague phrase, ask yourself what it means to you if youwere the clinician?• Clinicians may sometimes feel obligated to get additional imaging despite “ifclinically indicated”• Think about the implications of this statement before mentioning it (delayingcare [as in this case], clinician’s responsibility, cost, radiation, patient anxiety &stress)• While there are cases this statement may be said, consider clinical context &determine if relevant first• If radiologists want to be accepted as clinical colleagues, we must takeownership--this is our patient too! Do not rest everything on the clinician.
CLINICAL HISTORY PREFERRED DICTATION• The lack of a good clinical SUBOPTIMALhistory is the radiologist’s DICTATION Clinical History: 3 y/o M with ALL s/p bone marrowbane Clinical history: rule transplant with graft-versus-• In the age of EMRs out bowel obstruction host disease (GVHD) and abd painthough, a pertinent history Findings:is only a mouse click away There are fluid-filled Findings: loops of small bowel There are fluid-filled loopsfrom the radiologist that enhance, but are of small bowel with thin• Without an adequate not obstructed. central enhancement in the expected location of thehistory, you may not get Impression: mucosa.paid for the study...and 1. No bowel obstruction. Impression:possibly misinterpret the 2. Enteritis. Findings compatible withstudy (both shown here) GVHD.
REMEMBER YOUR PATIENTS SUBOPTIMAL IMPRESSION Findings: PREFERRED There is a mixed sclerotic DICTATION nidus within the superior aspect of the T12 vertebral Findings: body with surrounding … peripheral reactive sclerosis. Impression: Impression: Successful RF ablation Vertebral body Vertebral body lesion that osteoid osteoma may represent an osteoid osteoma, but a malignant tumor is not excluded.• When findings are classic (even in a rare location—first SUBOPTIMAL DICTATIONcase), commit to the diagnosis Impression:• Caveats & hedging can cause unnecessary patient concern Femoral stress fracture.• Suboptimal reports may lead to patient complications PREFERRED DICTATION(conservative treatment for supposed “stress fx” instead ofbisphosphonate fx may cause a displaced fx—2nd case) Impression: Femoral fracture related to• Patients are increasingly reading reports, thus radiologists bisphosphonate therapy.must keep this in mind
STRUCTURED REPORTINGClinical history: 33 M with left hip pain after traumaFindings: •Structured reporting is becoming more commonAlignment: Normal.Labrum: Normal. • Major advantages include uniformity & ensuring allCartilage: Normal. findings are included (e.g. soft tissue hematoma may beMuscles/tendons/entheses: Normal. easily missed in this case)Bones: Normal.Vessels/nerves: Normal. • May suit certain studies more than othersSoft tissues: There is a well-circumscribed mass inthe anterolateral left thigh that is isointense tomuscle on T1, primarily hyperintense on T2, andshows minimal peripheral enhancement.Impression: Morel-Lavallée lesion
MEDICOLEGAL SUBOPTIMAL DICTATION Does not mention Cyst in lateral kidney. possibility of Additional low-density neoplasm lesion in anterior kidney that may be a hemorrhagic Does not give cyst, but follow-up can be time interval done to ensure stability. for follow-upBerlin L. AJR 2002 3 years later—large RCC Clinical History: Elevated β-hCG SUBOPTIMAL IMPRESSION Findings: There is no IUP. There is an echogenic mass adjacent to right ovary. Does not document Impression: communication to Findings compatible with clinician ectopic pregnancy.
MEDICOLEGAL (Cont.)• Don’t assume clinicians will understand what you implyor may seem obvious. There is usually a different story inthe courtroom…• Be specific in your reports for thoroughness, but also forlitigation purposes• Communicate and document critical findings• Recommend additional studies/interventions whenappropriate (may vary on referring clinician, i.e. generalistvs specialist)• Remember that our ultimate duty is to our patients
TAKE-HOME POINTS1. Education on radiology reporting is essential fortrainees’ education.2. Radiology residents should understand the nuancesof dictating that will make them more effectiveradiologists.3. Structuring meaningful and clear reports benefitspatients, referring clinicians, and other radiologists,thereby improving patient care, streamlining diagnosisand treatment, and heightening radiologists’ role in costcontainment.