The Art and Science of Reporting

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This is complete compilation of my 6 blog articles for series "The Art and Science of Reporting", written for www.iradix.in

I hope it might be of some use for the Radiologists, especially from India.

The Art and Science of Reporting

  1. 1. THE ART AND SCIENCE OF REPORTING
  2. 2. My Mistakes Every science touches art at some points, every art has its scientific side; the worst man of science is he who is never an artist, and the worst artist is he who is never a man of science. In early times, medicine was an art, which took its place at the side of poetry and painting; today they try to make a science of it, placing it beside mathematics, astronomy, and physics." - Armand Trousseau. During my radiology residency, we used to write reports of plain radiographs on a sheet of yellow paper which used to come with the x-ray film. We used to write NRA (No Radiological abnormality), OA (osteoarthritis), #neck femur, CCF (congestive cardiac failure), Morquio's syndrome (of course without any description) etc. We used to have a printed ultrasound report template where we used to fill in the gaps with pen. During senior residency, we already had computers in the we hardly had any training department, and the reports were typed in Microsoft Word. in writing a good and Hence, we used to have templates for virtually everything, sensible report, we hardly from chest radiograph to CT petrous. Only thing we were read anything about art of asked to do was to change couple of lines here and there. If reporting. a CT scan of a lady is normal, we used to print template of "normal CT Abdopel female", by changing the name and age of the patient. A normal CT report of abdopelvis used to run in 2 pages (something like this)! Example: CT abdomen and pelvis: Oral contrast was given. I.V contrast was given. Liver: Liver is normal in size, attenuation and enhancement. The hepatic and portal veins appear normal. There is no intra or extrahepatic biliary dilatation. There is no focal lesion. Gall bladder: Gall bladder is distended normally. Wall is thin and smooth. No pericholecystic collection. So on and so forth for pancreas, adrenals, spleen, small bowel, large bowel, right kidney, left kidney, urinary bladder, lung bases and bones! Then, at the end,
  3. 3. Impression: Normal CT examination of abdomen and pelvis. These templates did cause lots of problems. A patient who had undergone cholecystectomy had "a normal gall bladder" in his CT report, and he wanted to sue the surgeon for not performing cholecystectomy! For one of the female patients, the ultrasound report mentioned "Normal sized prostate", because the secretary chose the wrong template. No wonder, the patients who had hysterectomies, used to have normal uterus in their ultrasound reports!! Plain films used to have shortest reports, ultrasounds used to have slightly longer reports, and MRs used to have longest reports. The more expensive the investigation, the longer should be the report! Whether clinically relevant or not, the conclusion used to have 5 to 10 bullets (something like this): Conclusion (or impression): 1. Right hilar spiculated mass - highly suggestive of bronchogenic carcinoma (most likely SCC) with pleural effusion 2. Right hilar and mediastinal lymphadenopathy 3. Metastasis right lobe of liver with simple cyst left lobe of liver 4. Right adrenal metastasis 5. Vertebral metastasis We have all been taught the science and art of radiology through volumes of text books, innumerable journals, excellent teachers and enthusiastic seniors. We are trained to ignore the normals and normal variants, we are trained to pick up all the abnormalities, we are trained to put all the abnormalities together to come to give the differentials in order, and we are trained to correlate the radiological findings in appropriate clinical context to come to a sensible conclusion. But we hardly had any training in writing a good and sensible report, we hardly read anything about art of reporting. We learnt what are the imaging findings in Osler-Rendu-Weber syndrome, but we did not know how to write a sensible report of a chest x-ray with a clinical question of tuberculosis. It took a lot of time to change the style of my reporting. I came across with great teachers and colleagues, who taught me the art and science of reporting. I am still learning the art and science of reporting, and I will share what I have been learning in next few series of articles.
  4. 4. Translation of images to words "An actor in his 60s, 61/2 tall, well built with a French beard, has a voice of loin. Did you get him?" No guess work here, you all are right, he is Amitabh Bachan. A few appropriate words are more than enough to give the picture in words. Now imagine the same sentence is given to a man, who does not know Bollywood and does not watch Indian television. Even if you describe Amitabh Bachan in 200 pages, he cannot make out whom you are talking about, unless you tell in the beginning that you are talking about Amitabh Bachan, a Bollywood actor. This is problem of communicating a picture in words. It is Radiology is not about extremely easy to describe a Dalmatian dog to a man who writing the list of has seen German Shepherd, but how can you describe an differentials, it is about elephant to a man who has never seen any animal in his life? guiding the referring I think the job of a radiologist is somewhere between the clinician in right direction. two. Radiology is not about picking up all the abnormalities, it is about giving right names to the abnormalities. Radiology is not about listing all the abnormalities, it is about prioritising clinically relevant abnormalities. Radiology is not about writing the list of differentials, it is about guiding the referring clinician in right direction. Radiologist is a consultant's consultant in true sense. Unfortunately, Radiology training puts immense emphasis on radiological knowledge (You should know everything written in Danhert), developing all the necessary skills, but it fails to address the art and science of reporting. Hence even a good radiologist finds it difficult to record an observation in brief and plain language. A good radiology report is one, if you close your eyes and listen to the report, you should get the full picture of the imaging. It also suggests a diagnosis, or a small list of differentials (not as given in Danhert, or Chapman) and next appropriate management. A good report is accurate, concise, relevant to the clinical question and clear. A good report is very important as it is not only the only means (often) of communication with clinician, but also it is a Medicolegal document. Reports should be clear, correct, concise, complete, consistent, and have a high confidence level. We shall explore how to achieve this in future posts.
  5. 5. Structure of Report We have seen what to avoid in reporting. Before I proceed to few more tips in reporting, let us look in depth about the structure of radiological report. The radiological report can be divided into 4 parts: 1. Heading/Type of examination 2. Technique/Protocol 3. Description/Main report/Findings 4. Conclusion/Summary/Comment 1. Heading: The heading should clearly reflect what radiological examination is performed. Examples: 1. "Right shoulder AP, axial and Y-views" would be better heading than "Shoulder Radiographs". 2. Rather than writing "CT whole body", we should be more specific, as "CT chest, abdomen and pelvis". 3. "CTPA" would be better heading than "CT thorax", when CT chest is performed for pulmonary embolism. 4. "MRI of the brain and IAM" makes more sense than "MRI brain" when the referral has come from an ENT surgeon to exclude acoustic schwannoma. Do not use unfamiliar or ambiguous short forms in headings, such as "TVS pelvis"; for few this may be "transvesical sonography" and for others, "transvaginal sonography". 2. Technique: Most of us do not bother to mention the technique in the report. Plain radiograph: In plain radiograph a good heading, such as, "Right knee lateral and weight bearing AP views" gives sufficient information about the technique also. If the chest radiograph is rotated, or underexposed or appears to be expiration, mention it in the report. If the film is taken on a trolley in an unconscious patient in expiration, we cannot pick-up pneumothorax; hence I would put my heading as "Chest AP supine trolley film", which clearly desribes the technique and its lmitations. Ultrasound:
  6. 6. It is a good practice to mention the frequency and type of the probe used in the examination, unless your establishment has got all the types of probes available in the market. If the procedure involves intimate contact, such as endovaginal scan, mention "verbal/written consent was taken" in the report. CT and MRI: Most of the departments follow fixed protocols for CT scanners. Mentioning the protocol would be enough most of the time. Example: "CTPA protocol" is sufficient when the CT chest is done for pulmonary embolism. I personally feel it is worth mentioning the MR sequences in the report. Interventions: It is very important to document the technique (i.e. procedure) in the report. This includes drug and dosage (10ml lignocaine 1% as local anaesthetic), type of the catheter (10G pig-tail catheter), description of the proceudure, and after-care notes. 3. Description (Main body of the report): "KISS" approach: Keep It Short and Simple (KISS). One of my educational tutors used to say, "long report is wrong report". The description should be clear, concise, accurate and relevant to the clinical question with a high confidence level. There are few things which we should try to avoid, about which I have discussed in my previous blogs. I will further discuss few more tips about writing radiological description (main body of the report) in my next post and hopefully conclude this series with tips on writing summary.
  7. 7. What to avoid in radiology reports? Avoid long descriptions for normal findings. Example: "The kidneys appear normal" is enough, there is no need to say "Both kidneys appear normal in size and echotexture. The corticomedullary differentiation is maintained. The margins are smooth. There is no evidence of calculus or hydronephrosis". Avoid unnecessary words. Example: "The Kidneys appear normal" rather than "Both kidneys appear normal", or "The kidneys appear normal bilaterally" Avoid repetitions. Example: "Comparison is made with the CT dated 12/08/07. The low attenuation lesion in segment 7 of the liver is seen again, and has not changed in size since the previous study." Instead, just say, "Compared with the CT dated 12/08/07, there is no significant interval change." Avoid abbreviations. Example: "The features are suggestive of MS". You might be thinking of Multiple Sclerosis when you dictated the report, but the cardiologist who is reading the report starts worrying about Mitral Stenosis. Avoid giving measurements of normal things and incidental findings. Example: "The right kidney measures 12.5 cm in bipolar length and the left 13.0 cm. The spleen measures 10.5 cm. The liver span is 13.5 cm. The right ovary measures 38 x 18 mm and the left ovary measures 26 x 20 mm. There is simple cyst in the upper pole of the right kidney measuring 25 mm in diameter. Another simple cyst is seen in the lower pole of the right kidney measuring 15 x 12 mm. Uterus is anteverted and measures 8.0 x 4.5 x 5.2 cm." Are we tailors to measure each and everything? Avoid mentioning in which window you reviewed the images. Example: "On review of the images in bone window, no metastases are seen". As a radiologist, we are supposed to view the images in various window settings before we issue the reports. "No bone metastases are seen" implies that I did look all the images in bone windows. Avoid "lymphadenopathy". Lymphadenopathy means pathology in the lymph nodes, and even 4 mm nodes can be metastatic. It is better to use the term "enlarged lymph nodes based on CT/MR size criteria" than "lymphadenopathy". Try not to begin too many sentences with, "there is a ....". Example: "There is a large spiculated mass lesion in the right lower lobe of the lung. There is
  8. 8. obstruction of the right lower lobe bronchus. There is complete collapse of the right lower lobe". All these can be put together, "A large spiculated mass is shown obstructing the right lower lobe bronchus, leading to right lower lobe collapse." Avoid words with different meaning to different people. The words are same, but the meaning is different. Swastik is auspicious for Hindus and Jains, but it is symbol of Hitler in rest of the world. Example: "Collection" means abscess to surgeons; hence "use fluid attenuation lesion" when you are not suspecting abscess. Avoid double negatives. Using double negatives is not good English. Example: "The findings are suggestive of pneumonic consolidation, but a bronchoalevolar carcinoma cannot be excluded." Say, "Although the features are suggestive of pneumonia, bronchoalevolar carcinoma should also be considered in the differential." Avoid highlighting the mistakes of previous report. Example: Don't mention "The spiculated lesion in the left lower lobe of the lung was clearly seen in the previous CT as 8 mm density, but was not mentioned". It might be your turn tomorrow. Downplay the misses, something like "On retrospective look, the left lobe spiculated lesion is seen as 8 mm density" Avoid repetitions in conclusion (impression or comment). Do not repeat what you have already described in 2 pages in your "conclusion" also.
  9. 9. Few more tips in writing the report • Start with the main abnormality and add supporting radiological abnormalities centered around it. Example: Instead of writing, "Significant hydronephrosis is seen in the left kidney. The right kidney is normal. The left ureter is also dilated...." and somewhere in next paragraph, "There is a large soft tissue mass in the retroperitoneum encasing the aorta and left ureter", it is better to say, "A large retroperitoneal soft tissue attenuation mass is shown encasing the aorta and left ureter, leading to moderate left hydronephrosis." • Include important negative findings in the report, depending on the clinical information and imaging findings. Example: If there is a speculated mass in the left lung, mention negative findings, such as “there are no enlarged lymph nodes in the mediastinum. No other lung lesion, no focal liver or adrenal lesion to suggest metastasis. No lytic bone lesions”. • Mention, but do not highlight, the incidental findings: Example: If you think the abnormality is clinically not significant (for example, multiple gall stones in a patient with known breast cancer showing multiple lung and brain deposits), mention it as "note is made of multiple gall stones", rather than highlighting it as one of the abnormalities related to breast cancer. Don’t mention these unrelated clinically not relevant abnormalities in the “conclusion”. • If you think the radiological finding is equivocal or indeterminant, do not hesitate to mention it in the report. Example: If you are unable to come to conclusion whether the appearance in the caecum is secondary to a mass or secondary to faecal loading, do not hesitate to mention it. At the same time, suggest the next step (colonoscopy or CT colonogram) to clarify the doubt. • Use standard abbreviations (please read this in conjunction with “avoid abbreviations” in one of my previous posts). Example: Do not write, "It was difficult to compare computed tomography images with the magnetic resonance imaging dated First of February 2008". It is easily understood if it is written as "it is difficult to compare CT images with MR images dated 1/2/2008."
  10. 10. • Quantitative assessment is essential. The report may read "there is large mass." But how large is large? A 2 cm lesion appears large in orbit, where as a 5 cm lesion appears small in the thigh. It takes a bit of more time, but it is worth mentioning approximate measurements, at least in the longest axis (please read this in conjunction with one of my previous posts, where I mentioned there is no need to measure normal structures). • Use proper terms when subjectively quantifying. When quantitative assessment is not possible, for example, as in pleural effusion, use subjective grading. Use proper terms in quantifying the abnormality using grading. Example: There is no “mild pleural effusion”, there is “small pleural effusion”; there is no “severe ascities”, there is “large ascites”. • Use "clinical correlation might be useful" or "further clinical correlation is suggested", only if clinical correlation is going to make the difference to radiological finding. Use "....is suggested, if clinically indicated" sparingly. Example: For a left hilar mass seen on CT, you cannot say "bronchoscopy is suggested, if clinically indicated" as bronchoscopy is necessary in this case, whether clinically indicated or not. • Whenever possible compare the images with previous imaging, even if the modality is different. Make a note of the date of the previous imaging which you are comparing. It is worth comparing previous 2 images, especially in the follow-up of cancer patients, even if different modalities are used.
  11. 11. How to conclude the report? What do you call it? Call it “Summary”, “Impression”, “Conclusion”, “Opinion”, or “Comment” (I call it “Summary” in this discussion), but avoid "Diagnosis", because diagnosis is more specific, and is a combination of clinical, radiological, biochemical, microbiological, and histopathological factors. Summary is not mandatory. Not all reports should have a summary. If the main report itself is short and precise, there is no need to repeat the same thing again in summary. Summary needs to be short and precise. It is a medicolegal requirement on the part of the clinician to read the whole report. Despite, most of the clinicians rely on summary only. Hence, summary should be short and precise, should answer the clinical questions, and/or shows an unexpected clinically relevant finding. There is no need to repeat the whole episode of the main report in the summary too (just like some of the TV serials' "recaps", which are as long as 10 minutes!). Some of the orthopaedicians and neurosurgeons do not bother to read the report which is all together a different issue. Summary addresses the clinical question, contains clinical relevant conclusion, and ignores irrelevant positive incidental findings. Example: if the request asks for pulmonary mass, the summary should specifically state whether mass present or not. Example: CT chest, abdomen and pelvis with a history of colonic cancer has following findings (from top to bottom): 2 thyroid nodules in a retrosternal thyroid, abberent right subclavian artery, pulmonary emboli, multiple lung metastasis, multiple liver metastasis, multiple gall stones, ascites, degenerative lumbosacral spine, and haemangioma in L3 vertebral body. I would put my “summary” as follows: “In a known case of colonic carcinoma, there are multiple liver and lung metastases with generalised ascites, which is also likely to be malignant. Bilateral pulmonary emboli in the lobar branches need urgent clinical attention.” I would not put other findings in my “conclusion”; they are there in the “main report”. More importantly, I would pick up the phone and ring the relevant team to tell about the pulmonary embolism which needs urgent anticoagulation, and I would also document the communication in my report. Commit, even if your opinion may turn wrong. Everyone make mistakes. Radiological report is a small part of clinical investigations. A wise clinician knows how much weight to attach to a radiology report, when he/she is making the complete diagnosis.
  12. 12. Summary is for clinicians. Summarise in words which clinicians understand. The main report is always better understood by fellow radiologists, and is very useful for the radiologist who is comparing the previous images. Example: If a CT shows focal fluid attenuation area with thick wall enhancement, then summarise it as “abscess” rather than “fluid attenuation cystic lesion. Do not make too many recommendations, especially the non-radiological ones. If another radiological investigation is capable of answering the radiological dilemma of the current investigation, and can give more definitive answer, then do not hesitate to recommend it. It not only helps the clinician to take next relevant step in establishing the diagnosis, but also safeguards you medicolegally. Example: Illdefined low attenuation area in the left centrum semiovale may be a white matter infarct, but in a 30 year old lady, do not hesitate to recommend MRI to look for demyelination. If another radiological investigation might help to clarify the doubt of current investigation, but clinically not going to change the management, then one can suggest it in summary. Example: A few rounded low attenuation lesions in the liver are most likely to represent “simple cysts”, but suggesting ultrasound would be useful, if the patient is known to have a malignancy. When recommending a non-radiolgical investigation, be extra cautious or your ignorance may exposed. Use “clinical correlation is needed” sparingly. The terms like "further clinical correlation is suggested" and "CT is suggested, if clinically indicated" are too defensive way of practicing radiology, and should avaoided as much as possible. These kind of sentences should be reserved if you think clinical correlation makes a difference in reducing differential diagnosis. Whenever you feel like writing “further clinical correlation is suggested”, be specific about “what further clinical correlation is needed” Example: In reporting a HRCT of an interstitial lung disease, “further correlation with occupational history is suggested” sounds better than “further clinical correlation is suggested”. Add a personal touch. Adding personal touch is a great way of building a good rapport with the referring clinician. It also makes you sound you are an experienced radiologist. Examples: "I think this is unlikely to be any clinical significance". “In my opinion, this is tuberculosis, unless proven otherwise”. “I would suggest MRI of the brain”. “I explained the risks and benefits to the gentleman and took a written consent for ultrasound guided biopsy”. Keep your report open-ended.
  13. 13. When a radiological investigation is performed and reported, do not presume the patient no longer belongs to you, and leave everything back into the hands of the referring clinician. Hence, do not shut the door of the report, keep it open. Open-ended summaries not only increase the rapport with the referring clinician, but also can, to some extent, can safeguard against medico-legal issues. Examples: “I am more than happy to review the findings if you can provide the previous CT imaging". I wish to thank one and all for the encouraging words while writing this series of “reporting in radiology”. I am indebted to the below mentioned articles to articulate my thoughts and have taken liberty to take a few ideas from these articles. On a lighter note, I sign of this series with these 2 radiological reports which I came across in the UK. REPORT 1: Clinical information: ? Fracture neck of Radius Report: Yes. REPORT 2: Clinical information: cough - ? cause Chest X-Ray: Merry Christmas (to the referring doctor)! The lungs are clear and your patient can have a good Christmas this year. References: 1. Radiology reports: How much descriptive detail is enough?, McLoughlin RF et al. AJR 165, 803-805 2. Language of the radiology report: primer for residents and wayward radiologists. AJR 175, 1239-1242 3. Style guidelines for radiology reporting: a manner of speaking, AJR 180, 327- 328

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