Observing, interpreting and reporting

For radiology trainees

This short essay reflects my personal approach to radiologic practice, the aim of which is always to help the referring clinician diagnose and treat our patient’s condition effectively.

Some examinations, such as a radiograph of a simple fracture in a long bone, can be appreciated immediately and accurately. Others, especially those involving complex anatomic structures such as the hand, wrist, foot and most cross sectional examinations require a structured approach to ensure that all elements of the study have been reviewed. In reality, most radiologists and other observers use a combination of immediate recognition, or “gestalt” and a mental checklist, and the mix changes with experience. It is much easier to recognize an important finding if one has seen it before, preferably many times before.

Appreciating the significance of an imaging finding is as important as its recognition, and “normality” on a radiograph is a function of many factors including age, body habitus and composition, radiograph or CT quality, and position. Experience and practice leads to both sensitivity in detecting subtle abnormalities and an understanding of whether a finding is truly pathologic.

The imaging report is the the radiologist’s work product. It consists of a written description of all observations that support the diagnostic impression, and a summary that contains one or several diagnoses and any necessary discussion or recommendations. The format of the report may vary depending on the type of study, and the preferences of the radiologist or their institution, but generally includes the following:

Body part imaged

Technique

Indication and relevant history

Comparison studies (if any)

Findings

Impression

It is important to present one’s findings and conclusions in a clear, organized and succinct manner. Unfortunately, many reports are hobbled by wordiness, jargon, and redundancy.

“Say what you see…. Say what you think it means,” is a good mantra for reporting. I try to honor necessity and sufficiency, by including whatever I think needs to be said and then stopping. This keeps the signal to noise ratio in a report high and gets a clear message across without distracting the reader. While every radiologist will develop their own personal style, usually by emulating teachers and colleagues, application of some basic principles will result in reports distinguished by clarity, brevity, and meaning. Here are a few of my own pet peeves.

Present findings anatomically, especially when reporting studies of anatomically complex regions, such as the neck and abdomen. Within this context, try to address the findings relevant to the clinical question early in the report, and note incidental findings later.

If many findings—multiple facial fractures, intracranial metastases, or enlarged lymph nodes—need to be accounted for on a single report, list each one on a separate line rather than in a densely packed paragraph. Summarize the pattern or condition in the report’s impression.

Avoid using “there is” before each finding. “No pneumothorax,” for example, delivers the same information as “There is no pneumothorax.”

Avoid “is seen,” “is noted,” “is demonstrated,” and the like. These are the equivalent of putting “there is” in front of each finding. Simply state the finding.

Avoid “of the.” It is usually possible (and preferred) to put an adjective in front of the noun it modifies. “The base of the skull” is better described as “the skull base.”

Avoid abbreviations and jargon. You do not know who will be reading your report. It is best to spell out most words and use conventional anatomic terminology: “The first carpometacarpal joint,” for example, is understood by anyone who knows basic anatomy. Its synonym, “the basal joint,” is known to hand surgeons, but not necessarily to psychiatrists or internists, who may be caring for the patient.

While eponyms make for useful shorthand, they should be used in addition to, rather than in place of, a clear anatomic description: “A transverse, extra-articular, fifth metatarsal fracture, one centimeter from the base (Jones fracture)” is preferable to “fifth metatarsal Jones fracture.”

Finally, if a word or phrase doesn’t add to the meaning of the report, delete it. Radiologists are not meant to create a mood, develop a complex story line, or vividly paint a character. Our aim is to efficiently and effectively interpret the visual evidence presented in order to support an accurate clinical diagnosis and help direct treatment.