Let me begin by expressing my understanding of how difficult it is to dictate radiographic reports. My experience indicates that success in the preclinical years of medical school helps to prepare you for success in the clinical years. Success in the clinical years improves your likelihood of success as a clinical intern. However, nothing in my previous experience prepared me for the first few months of my radiology residency. The responsibility for interpretation of images was daunting enough. Even more unforgettable was the literally painful exercise of trying to dictate a small stack of chest radiographs for the first time. I remember sitting with dictaphone in hand, struggling to put into words what needed to be said.

There are two times when it is particularly important to consider the information content of your radiographic reports: when you first start dictating and all the time after that. It is helpful to remember that the referring clinician reading your report may not have images to view at the time the report is read. You should try to put yourself into that clinician’s place, making sure the descriptions you provide will be meaningful even to someone not looking at the radiograph.

In addition, be sure your report says what you intend. We conduct a very instructive teaching conference with our residents from time to time. One resident is positioned in a far corner of the room, unable to view the radiographs being presented. A second resident has to describe the findings on the radiographs so that the first resident is able to make a correct diagnosis. It is eye-opening to the residents to see what erroneous diagnoses their initial descriptors evoke and just as instructive to find out how easily many diagnoses can
be made with a few well-chosen phrases. Dictators of radiographic reports should be sure they are choosing phrases in this fashion.

Here are a few questions to consider. Have you made it clear what is abnormal (if there is an abnormality)? Does your description indicate where the abnormality resides? If there is a possible abnormality, have you indicated your degree of certainty that the finding is abnormal? If there is uncertainty, have you suggested how it can be resolved?

I do not mean to imply that a definitive diagnosis can always be made. I also suspect that the more difficult cases for diagnosis are also often the more difficult cases for dictation. A good radiographic report is not always a report that gives the answer; sometimes it is simply a report that clarifies what further questions need to be addressed. However, clarity is an important feature of a good report. When a clinician finishes reading a good radiographic report, there ought to be a sense of understanding about whether the radiograph is normal, abnormal, or possibly abnormal; about what the abnormality does or might represent; and about how remaining uncertainties can be addressed (1).

To coin a phrase, “Brevity is the soul of wit.” Brief accurate reports are far more helpful to clinicians than long accurate reports. Brief reports are far more likely to be read in their entirety. Residents sometimes like to run through long lists of pertinent negatives in their reports as proof that they have looked at a variety of structures in the chest. My advice is to keep the search pattern but do not feel compelled to mention everything you have looked at. Truly pertinent negatives are great (if the clinical history is rule out pneumothorax, it is advisable to say “no pneumothorax”). Otherwise, my personal favorite report is “normal.”

There are a number of ways to organize reports. Some radiologists like to dictate findings and then separately to dictate conclusions. This is certainly an acceptable way to organize a report, but there is a huge pitfall to avoid. A frequent outcome of this reporting style is as follows:

The problem is that the “impression” is seldom an impression; it is more often a rehash of what has already been said. This style works well if the report above is redone as follows:

My current preference is to avoid redundancy by dictating only impressions. To encourage brevity I do not adhere to strict grammatical correctness, instead using phrases. The report described above might look like this:

Some of my colleagues prefer to dictate findings and impressions for computed tomography (CT) reports because there are usually more findings. I adhere to the impressions-only style for CT, although I add a technique section that describes what area was scanned, what sort of contrast was administered, and what field of view was used (so it can be used again for follow-up studies). A typical example of such a technique section would be as follows:

My favorite CT report is the same as my favorite chest x-ray report (as noted above, it is “normal”).

Whatever I am dictating, I try to maintain a balance between appropriate modesty and inappropriate uncertainty. In other words, I am quick to acknowledge that I do not know what every finding represents or what its significance may be in a particular patient (in one memorable dictation, at least to me, I included the phrase, “I have no idea what this is”). Nevertheless, I hate to see uncertainty creep into every report. Referring clinicians already complain (and joke) about the tendency of radiologists to hedge (i.e., to couch their interpretations in so many layers of doubt that they can never be pinned down to a specific diagnosis). Why add unnecessary fuel to this fire?

In particular, I seldom refer to pacemaker lead tips, for example, as being “projected over the right ventricle,” even when I only have a frontal radiograph to evaluate. I believe that for most vascular catheters, we know where the tips are because the catheters are following the course of the vascular tree, just as they have in the other 22,000 catheter placements we previously reviewed. In almost every instance, that course could only be duplicated by a catheter taped to the skin surface, a highly unlikely alternative. I only allow uncertainty to enter my report if the catheter follows an atypical course or if there has been interval development of a potential complication that could indicate catheter malposition (such as mediastinal widening). The same applies to enteric and endotracheal tube placements. I make no similar claims for chest tubes; because the tube is not in a conducting structure like the vascular tree or the gastrointestinal tract, I do not know if it is in the pleura, lung, chest wall, or somewhere else.

With regard to style, I encourage you to find your own voice. I do not believe my personal style is the only acceptable one; it is simply the best one. Still, I do not require all reports dictated by residents under my supervision to be in my personal style. I try to encourage diverse styles as long as they do not include words, phrases, or errors that are anathema to me.

We must keep in mind the ultimate purpose of having radiologists to interpret various imaging studies. It is not merely to have highly trained and capable interpreters of those images. We move closer to our true purpose when we better understand the nature of the examinations being ordered and their impact on patient care. The key question for any study is “how will this advance the care of this particular patient?” Although I do not advocate sorting through the chest radiographic requisitions for a particular day to decide which ones should and should not be done, I believe that mindset is important and perfectly appropriate for studies such as chest CT and magnetic resonance imaging (MR). My objective is not to refuse to do examinations so that my life will be easier; it is to recognize that our tests are not always completely benign, and even tests that do not endanger the patient may still have significant costs to the patient, especially financial costs. The bottom line is that there must be communication to the radiologist about the motive behind a proposed study, and communication back to the referring clinician is sometimes essential (and surprisingly welcomed by our clinical colleagues) when there is a better way to approach the given problem.

We get closer still to our ultimate purpose when we understand that communication does not end there. The report itself is a critical element in communicating with the clinicians, especially if it is structured properly. Even if your report is brief, accurate, and to the point, consider these questions:

Although the finely crafted radiologic report often suffices to convey what we want it to, that still may not be enough. I try to call reports to referring clinicians at least 5 to 10 times a day. It is obvious enough that this needs to be done with emergent life-threatening findings (such as tension pneumothorax) and equally obvious that it should be our practice for unexpected potentially ominous findings (preoperative chest for hernia repair showing a noncalcified lung mass). There are many times during the course of a radiologist’s day when it is unclear if a report needs to be called or not. My advice is that if you are not sure, call. I call most times when I detect pneumonia in an outpatient. I call most times when a patient with an extrathoracic neoplasm has what I believe is the first evidence of intrathoracic metastases. I call most times when a catheter or tube placement goes astray or may have caused a complication. I call most times when an immunocompromised host has potential evidence of an opportunistic infection.

Ultimately, we need to realize that although many of us no longer do physical examinations or prescribe routine patient medications or discuss findings and prognosis with patients, our real job is to take care of patients. Communication is a critical part of that job. Some of our communication should be with the patient, especially with the patient who is ill and frightened and in pain. We can reduce patient distress by explaining the more invasive procedures that we do (such as percutaneous biopsies) in sympathetic tones and by making sure that we medicate patients appropriately to limit suffering.