Radiologists create dictations with two audiences in mind, for the clinicians that read the report, and also for the lawyers that may interpret the record if the case turns sour. Depending on the radiologist, he might attune the report mostly toward the clinician or may create a dictation primarily for the attorneys. Every radiologist emphasizes one audience or another along a broad spectrum.
However, walking too far toward either extreme can become problematic. Forgetting about legal issues can lead to lawsuits. And, wholly concentrating on the attorney in your dictations can lead to angry clinicians.
In the situation of radiologists who write solely for the attorney, the report impact patients negatively. Why? They dilute the effect of our reports to care for our patients. Moreover, they send the wrong message to our trainees while neglecting the Hippocratic Oath. These radiologists are essentially saying that the legal importance of our reports trumps the clinical care of our patients.
Neither do I believe that we should ignore the legal aspect of our dictations entirely. That would be professional suicide.
So, we should think carefully about for whom we are writing and how it affects both the trainees and the clinicians. Therefore, today I am going to talk about how creating reports for clinicians or attorneys can impact your message. And, then I am going to give you some guidelines to compose a balanced dictation.
Problems Of Writing For The Attorneys
So, what happens if we create dictations with the attorney as the primary reader? First, it dilutes the message that we want to give to the clinician. These dictations tend to emphasize all possibilities for the diagnosis versus the most likely diagnosis. We overemphasize findings for our attorneys instead of the clinicians that read them. In the end, clinicians are less likely to pursue the correct avenue.
Next, our reports become wordier and harder to understand. When you write for the legal system, you tend to add more caveats. We use terms like cannot be excluded. I find these reports less straightforward and much longer to read.
And finally, when we write for the legal system, we tend to recommend additional tests to protect ourselves. Perhaps, that 22-year-old female with a probable hepatic hemangioma on ultrasound will receive a full workup that she does not need in the interest of protecting our hide.
Problems With Writing For Only Our Fellow Clinicians
On the other hand, what happens when we write only for the intended audience, the treating physician? Well, first we tend to de-emphasize the less likely diagnoses. So, if the clinician does not make the rare diagnosis, and it was not in your report, an attorney will more likely find fault with your dictation. Some of these “clinical dictations” may neglect the zebras entirely.
And, more importantly, by neglecting the attorneys we expose ourselves to the possibility of a lawsuit. By mentioning an appendicolith in a normal-appearing appendix and not talking about the rare outcome of early appendicitis, you may go down the proverbial tubes.
Striking A Balance
Like everything else in this world, the key to making something useful is to strike that perfect balance. To create a reasonable mean between the two extremes you can create dictations referencing the most likely diagnosis with some mention of the more uncommon etiologies, emphasizing the different probabilities.
Moreover, make the dictations easier to understand without using too many caveats. Wordiness does not necessarily protect you from having an attorney use your report against you in a lawsuit.
Finally, you should strive to recommend further workup for the most likely diagnoses that will significantly impact patient care without going overboard, using the clinical data to help make the decision.
The bottom line: We need to remember in every report that a patient’s medical care is at stake. And, that battle, for us radiologists, is worth the fight. So, think twice before you create your dictation for only the referring clinician or the attorney that might read your report!
