How To Artfully Communicate Uncertainty
Many of you know the oldest radiology joke in the book: What is the national plant of radiology? The Hedge! In truth, we as radiologists have to face more uncertainty in our profession than most. Diagnoses of 100 percent certainty are rare, to say the least. And, we need to reasonably communicate this information to our fellow clinicians. So, how do radiologists do this without infuriating our clinical colleagues? In order to investigate the question of how, I am going to divide this post into multiple sections, each one with an important discussion to help you to decrease uncertainty for the clinician. Welcome to my world!!!
Don’t Beat Around The Bush
Say what you mean and mean what you say. Don’t hem and haw about your insecurities. Even though at times we cannot come up with a final diagnosis, it is important to say just that. Make sure not to put in too many caveats and extra words. So, if you see a liver lesion and it could be an atypical hemangioma or hypervascular metastases don’t use flowery language or multiple qualifiers like the words: however, compelling, of course, and so on. Just simply say the differential diagnosis includes hemangioma or hypervascular metastasis.
Excommunicate Cannot Be Excluded
One of my most hated phrases in radiology is (drum roll please…) “cannot be excluded”. But, it is not just my least favorite phrase; it is also the clinicians’. Why? It has the potential to force a clinician to investigate further an unlikely diagnosis. If you think that a renal lesion is most likely a hemorrhagic cyst, you should say the renal lesion is most likely a hemorrhagic cyst. If the possibility of a renal cell carcinoma is small, you can say that the features are not characteristic for a renal cell carcinoma and the likelihood of the lesion to be a renal cell carcinoma is exceedingly rare. On the other hand, if you use the term renal cell carcinoma cannot be excluded; you give the clinician no sense of the true probability of renal cell carcinoma. The phrase cannot be excluded often causes the unintended consequence of additional unnecessary workups related to your dictation.
Another way to reduce uncertainty is to find additional clinical information on the patient. If you are not sure, look up the laboratories, the prior studies, the real clinical history, the vital signs, or the real ER report to add more certainty to your report. Think of it this way. You have one report that says: chest film shows right lower lobe pulmonary parenchyma disease, possibly pneumonia, atelectasis, or pulmonary edema. On the other hand, you have another report that states the following: Given the elevated white count of 20 and the patient’s elevated temperature of 106 degrees, the right lower lobe pulmonary parenchymal air space disease is most likely pneumonia. You can see that the increased certainty of diagnosis in the second report is significantly more helpful to the clinician that ordered the study.
If you are not sure of the diagnosis, why not just say the probability of the diagnosis? At least, this will help the physician on the other end of the report to know how far to work up the patient for other possibilities. Giving a laundry list of diagnosis x versus y versus z helps no one. But, if you know the chance of x is much greater than y, which is greater than z, that opens up a whole new way for the clinician to proceed next with the patient.
Describe The Findings Well
Finally, if you are unsure of the final disposition, make sure you describe the findings really well. For instance, if you see bulky adenopathy in the right hilum, make sure to say the size and shape, whether it narrows the mainstem bronchus, and if it causes post-obstructive atelectasis or pneumonia. You may not know the diagnosis. But, the clinician can now decide whether they can get to the abnormal lymph node by bronchoscopy or how to proceed to the next step. By describing the findings well, you ensure that the patient will be worked up appropriately by the physician.
Our specialty is fraught with uncertainty. That is OK. It’s just the way it is. More importantly, good skills to communicate uncertainty can save your reputation and the reputation of the specialty. If you follow my advice about directly saying what you mean, avoiding cannot be excluded, looking up clinical information while incorporating it into your report, specifying probabilities, and describing the findings well, you can at least drive the clinical physician to the appropriate next step. See… uncertainty is not that bad!!! Just like always, it is all about good quality communication.