I find one button on Powerscribe more satisfying than almost any other. No, it’s not the sign button, although signing off a study feels quite rewarding. Indeed, it’s not the auto text button. However, I press that one all the time to make my templates. And it does shorten my dictation time. Instead, it is that button typically buried in the edit menu of Powerscribe, the lowly undo button. I can’t tell you how many times I clicked the wrong button to lose half my dictation. And then I clicked on the Undo button to restore it to how it was.
Most of you are aware of this undo function. It returns anything you did before to its previous state as long as it was a line of spoken text, a cut, or a paste. But imagine not knowing about its existence. Well, that was my world as an attending physician for a good year or two. Now, it is embarrassing to release this information to the masses. But I have to let it out. It is true. I spent eons trying to recreate what I had dictated before without knowing there was a simple way to retrieve the information. I was not aware of the existence of the undo button for way too long. Imagine that.
The Undo Button: A Symptom Of A Bigger Problem With Radiology And Technology
This point about the undo button brings me to one of the most significant technical radiology issues. We, as radiologists, don’t know about so many computer and technology functions that can potentially make our lives easier and shorten our days. Now, maybe this issue is somewhat magnified because I have reached middle age, but I don’t think that is the case.
I have seen younger physicians, like residents and early attendings, who need to learn how to link two studies together and compare them slice by slice. I have seen other attendings needing to be made aware of the simple functions of our software for calcium scoring, which would have saved them tons of time. And there are many other time-saving technology tools I am unaware of. If all the radiologists were to pool their technology know-how together, we would all shave off an extra hour of work every day. So, why do we not receive the technical training we need to make us more efficient at our job?
Radiologists Do Not Receive Formal Training Because We Are Expected To Learn On Our Own
Many radiologists jump headfirst into the world of dictation and PACS without receiving any formal training. Many of you who work for hospitals and imaging centers know what I am talking about. As a resident, I cannot remember any technology folks training the residents on using PACS. That same philosophy has continued throughout the years. Hospitals and imaging centers expect us to use our highly paid professional time to figure it all out independently.
Technology Trainers Don’t Know How To Train Radiologists
Several things happen when we get the “training” we need from the technology folks. First, they show you what you can do and allow you to play around with everything. And then they say you need to use it for a while to get accustomed to it. While that is undoubtedly true, we often miss out on multiple functions and knowledge that can increase our efficiency. The problem is that the technology experts training you are not radiologists. And they will never know the most important functions we need to use.
Lack Of Time/Money Dedicated Toward Training
Or, once in a while, you will get an excellent technology expert who will try to help you by creating hanging protocols, setting easy keys, and more. Some may become irritated when they realize they need to sit down with you for an extended period to make the technology precisely how you like. Or, the institution received a package deal that included limited training for the radiologists. The bottom line is that you may receive less education than you need.
Learning The Undo Button: A Simple Solution To Improve Workplace Efficiency
So, why do I bring up an entire blog about a simple undo button and the issues that go along with it? Well, it is a cry for good, down-to-earth technology instruction that every radiologist should have. We, as radiologists, hear about burnout and misery all the time. But, it is the little things that make radiologists happy. Radiologists are highly paid professionals who should become as efficient as possible to save time and money. Many excellent radiologists have left the field because of simple technology inefficiencies such as this one. Coming home 20 minutes earlier every day to be with our families should be a much bigger priority for radiology practices and hospitals. Improving radiologists’ technical and computer training is a simple and relatively inexpensive fix.
For those of you thinking about working in a radiology practice, working as a team is the key to survival. And part of that team effort is work ethic. If some radiologists have different work ethic levels than others, it becomes a nidus for discontent. I believe that this varying culture of employees/owners is one of the biggest downfalls of individual practices. For example, an owner interested in maximizing income will not mix very well with an employee who took the job for lifestyle. And vice versa. However, when starting, you need to assume more responsibility, not less, regardless of the practice culture. So, what does it take to improve your practice environment? It’s pretty simple. Be willing to take that extra case or dictate that study without a fuss at the end of the day. One additional dictation can make all the difference.
If you think this is a ridiculous statement with no relevance to you, take a look at your fellow residents or employees. Who are the folks that are the most successful at your level? It’s rarely the person that complains that he has too much work and cannot bear to read another study. And, it’s certainly not the person who always leaves over work for their colleagues. Instead, it’s that radiologist who completes that extra case at the end of the day to ensure that the next person is not swamped. So, what are the ways that dictating one additional study can make all the difference?
How Can One Additional Dictation Improve The Practice?
Builds Goodwill Among Fellow Physicians
If your colleagues notice that you are helping them out, they are much more likely to reciprocate for you. Therein begins the virtuous circle. And reading that one more case at the end of the day can start the whole process. It can have a snowball effect on the practice. You never know when you may have to leave in the middle of the day for an errand. Now, you have colleagues that are willing to cover and support you.
Builds Goodwill Among The Referrers
Sometimes that extra case can come at the end of the day. Most of you probably know of that 5 PM abdominal CT scan for abdominal pain. It may be the responsibility of the person on the next shift. But, by reading that case and calling the referrer, you have established a connection. That ordering physician will be much more likely to send future patients your way when they need a quick read.
Builds Goodwill Among Staff
Then, of course, most staff members hate to have extra cases lying around. Reading that additional case may allow them not to chase someone down to read the case later on that evening or the next day. Who wants the lead technologist to continually nag the radiologists to take care of that extra case? That employee will most likely put a positive word about you to your colleagues.
Increases Overall Revenue
The more cases that the practice reads promptly, the more revenue streams can come in quickly. It may sound silly that one dictation should make such a difference. But, rinse, wash, and repeat. Day after day, you can significantly prompt cash flow for the practice by reading that one extra case. That’s 365 cases per year if someone reads that case every day. Do the math and figure how much that is. That can only benefit you and your practice in the long run.
See, One Additional Dictation Can Make All The Difference!
I think you catch my drift. It’s not just about the one case itself. Instead, it is about the goodwill and economics that you bring to the practice over the long run by improving the work environment’s culture. Imagine if everyone does the same. That is called practice building, my friends. And it is the first step to creating an excellent environment to practice radiology!
Almost every time a governing body makes recommendations to institute a new reporting system, the amount of work multiplies. And, the advent of Thyroid Imaging Reporting And Data System (TI-RADS) is no different. Yes, I believe that the new reporting system has the potential to decrease unnecessary biopsies. And, new software dictation systems will eventually reduce the extra time that we spend on each case. But until that time, radiologists surrender their lives to increasing the verbiage and size of their thyroid dictations.
Imagine a patient with four significant thyroid nodules (not that uncommon). Then, tack on all the TI-RADS descriptors. (Check out the TI-RADS worksheet in this link from the ACR). Add on a final categorization and analysis of each thyroid nodule. Finally, compare the dictation size with the old dictation styles (in the past, you probably just measured the nodule size and consistency.) You are talking about an order of magnitude change in the radiologist’s time per dictation. And, yes, there are programs online that can calculate the scores for you. But, using these programs also takes additional clicks and time out of your day.
Big Deal Right?
No big deal. I mean, what is an extra 3-5 minutes per thyroid dictation, right? Well, multiply that number times 3, 5, or 10 depending on the number of thyroid ultrasounds you do in a day. That time racks up. It’s no longer that we are talking about 3-5 minutes more. Instead, we are tacking on 15 minutes to 50 minutes more per day. In an age where all the systems are trying to cut budgets, and radiologists need to increase efficiency to the nth degree. This increase in the workday doesn’t cut it.
Moreover, one of the most expensive links in the chain of an imaging center is the time of the radiologist. You are now increasing that time substantially. Fifteen minutes per day (on the low side) times five days per week times 40 weeks per year equals 3000 minutes of our time per year. Or, in other words, we are talking about 50 hours in a year. If you assume that a radiologist makes 300 dollars an hour, that small reporting change is instead costing 15,000 dollars per year per radiologist. Then, think about the costs to all radiologists (multiply that number by five or ten thousand). That’s not an insubstantial amount of dough!
What Is The Point Of This Exercise?
Well, let’s get to the bigger picture. I am trying to make the point that changing the requirements for radiologist reports is not just another inconsequential change. Instead, forcing us to modify the way we report cases for the good of society can substantially increase the costs to the system. So, we need to ask the governing bodies (like the ACR) to consider these points and take action to decrease the time and expense when they institute such a change.
How Can A New Reporting System Like TI-RADS Take Into Account The Radiologist’s Time?
There will be more reporting requirements to improve patient care. And, TI-RADS is only one requirement in a litany of many more to come. That’s fine. But, before initiating a new reporting system, organizations such as the American College of Radiology (ACR) should provide embedded software to compensate for the radiologist’s time. For instance, for those of us that use Powerscribe for dictation, when the ACR rolls out a new reporting system, provide the radiologist templates and artificial intelligence to simplify reporting.
So, in the case of TI-RADS, how can we restore the time of the radiologist? Well, take one of those TI-RADS calculators and embed it into the dictation software. And, create templates for thyroid ultrasound that will take the extra descriptive verbiage of a thyroid nodule and spit out a final assessment. Or, add a menu of options in a report-like configuration using the TI-RADS features to our dictation software to create a final report. These steps can decrease the costs and the radiologist’s time taken for the new reporting requirements by more than half.
Back To The Real World
Unfortunately, often, we, as radiologists, need to figure it all out on our own. We are left flailing about trying to work out how to decrease the time of reporting when these new change occur. It shouldn’t be this way. If we have to incorporate an entirely new type of report, and for a good clinical reason, the ACR should also take responsibility to help to restore the radiologist’s time. It’s not just decreasing radiologist’s leisure time with the family at stake. It’s also millions of dollars of cost to the system!
What are the most important differences between most resident and attending reports? Residents’ dictations tend to be one size fits all. On the other hand, the attending will usually look at the referrer’s name and specialty before starting with a dictation. Then, he integrates referrer psychology into the report. And finally, seasoned attendings will approach a dictation as a solution to the specific clinician’s problem.
Why is it important to address these differences? The primary reason for radiology’s existence is to provide solutions for our fellow physicians to come back for more. So, we must satisfy our referrers’ needs in our reports before anything else. And therefore, we need to individualize these solutions in every dictation we complete. For today, I aim to teach how residents and even junior radiologists can change their “one size fits all” reports into a report with a laser-like focus that answers the referrers’ questions. Let’s do just that!
Addressing Pertinent Positives And Negatives
Take a look at a great radiologist’s dictation. If the patient has a history of an abdominal aortic aneurysm, you will see statements about dissection, rupture, mural thickening, or ulceration. Or, if the patient has prostate cancer, the dictation will detail the sclerotic osseous lesions, iliac and inguinal nodes, liver lesions, the prostatic bed, and pulmonary nodules. You are much less likely to observe these relevant findings in the resident’s dictation. It is more likely to be a bland checklist. Addressing the pertinent information goes a long way to addressing the psychology of the ordering clinician.
Keep In Mind What The Referrer Wants To Know
Typically, the first paragraph of the findings should answer the clinician’s question. Logically, this makes sense. The clinician most likely analyzes only the first part of the findings and impression, if any. In addition, make sure to start with those items that contain the most critical information—then run down the findings in order of importance. For the clinician reading the report, the priority order clarifies what is most important. Dissimilar to the typical resident dictation, its goal remains clear, to answer the clinician’s question appropriately.
Give Some Leeway To The Referring Clinician
A clinician does not like to be hemmed in by the requirements of the report. So, make sure to give the clinician that leeway. Do not lock in on one diagnosis, forcing her to pursue that avenue. What do I mean by that? I will give you two examples.
First, give all the relevant likely diagnoses. If you start talking about something in-depth that is unlikely to be the cause of the patient’s illness, in essence, you may force the hand of the clinician to pursue the wrong diagnosis to the cost of poor patient care and expense to the system.
Second, you can legally bind the clinician to perform an unneeded procedure if you recommend a biopsy without an alternative. If for some reason, something goes awry and the doctor does not pursue that avenue, legal consequences can follow. So, be careful what you say!
Don’t Leave The Referrer Hanging
I like to call this waffling. Instead of giving many differentials, make sure to come down on those most likely to be the diagnosis. Always attempt to attach probabilities to the different possibilities. This process makes it much easier for the physician to provide appropriate testing and quality care.
Ask For More History
You may think the clinician will get annoyed if you ask him for more information. But, it is usually the opposite psychology. It shows you are taking the initiative. And, you are more likely to create a relevant report that will be helpful to the patient and the clinician. Rarely does a good history ruin a report!
Communicate The Results More Effectively
After you complete the report, check it over multiple times. Few things bother the referrer more than reports with incomplete, unintelligible sentences. Perhaps unwillingly, you leave out the word “no” somewhere in your dictation. Believe it or not, this can be crucial to the clinician’s treatment plan. Most of the time, the unnecessary phone calls I receive are for the occasional grammatical or incidental mistake in the dictation. It happens to everyone. But, try to minimize this effect by checking your work!
Summary On Addressing Referrer Psychology
To create a sound report that helps the clinician, you need to get into the mind of the ordering doctor. So, think like a clinician. Put all the relevant information into the dictation without the fluff, always keep in mind the goal of the ordering doctor, make sure to give some leeway to the physician, get an appropriate history, and make sure you look over your report so that it makes sense. Not only will the referrer appreciate your dictations more, but your patients will receive better care too!
Oh, the lowly addendum. Most physicians rarely give it a second thought. But, it can sometimes become the single most crucial part of the dictation. So, why do most of us ignore the addendum? And, yet how can it be one of the essential parts of our report simultaneously? Well, that is today’s topic!!! So let’s delve into the legal, medical, and ethical implications of the lowly addendum.
The Lowdown On The Lowly Addendum
OK. I will be the first to admit that the addendum is not the most exciting part of a dictation. Who wants to read that you discussed a case with physician x at time y on floor z? And, who cares that you had to add a correction to your dictation that seems so minor. But, there is so much more to the addendum. Let me show you below…
Addenda And The Legal World
First and foremost, the addendum is often the only part of the dictation that can protect us from a lawsuit. Many addenda incorporate a time, place, and person after we discuss a case with a clinician. Usually, we place it after the “final dictation.” Sometimes it is the only documentation in the chart that the radiologist took the time to give the caring physician the report results.
On the other hand, when the addendum is absent in the case of a serious diagnosis and the patient encounters severe morbidity, we leave ourselves open to the legal system. Who is to say that the clinician looked at the report results on your patient with appendicitis? It is only the supplement that documents this vital information.
When Absence Of An Addendum Is Legally Important
Ironically, the absence of an addendum can also protect the radiologist. If you write addenda on a routine basis every time you discuss a case with a clinician, then when you don’t write a supplement, a communication never occurred.
How is that important? Well, let me give you an example: You have just dictated a normal case on a pediatric chest film with a history of shortness of breath. And, the clinician states that they discussed the case with you. On the deposition, he claims that he told you about the possibility of child abuse on this patient and that you told them not to order a leg film to look for a fracture. Since the physician did not request the test at your hospital, it turns out the patient went to another hospital for additional imaging three days later with a positive study for a leg fracture. Perhaps, the fracture did not set correctly. Well, if you did not document the discussion with this clinician, it never happened (unless the other physician can prove otherwise). It is no longer your fault that the clinician did not order the correct test in your hospital!
Addenda And The Medical Record
Addenda can also be necessary for determining the order of events during a patient stay. At times, a nurse may poorly document the time of events crucial to determining a diagnosis for the patient. Documentation of communication in an addendum can help to clarify when events occurred. Theoretically, it can differentiate the cause of a disease/illness.
Alternatively, frequently we will issue a supplement as a correction to our dictation. Sometimes, we may see a finding we may not have documented in the “final report.” Placing an addendum, in this case, becomes medically essential. If a clinician looks back and does not see, for instance, a sclerotic bone lesion in your report, they may not know that it exists. The treatment can potentially change, leading to poor patient care. On the other hand, if you issue an addendum and communicate the results, you protect the patient (in addition to yourself!).
Or maybe, you made a typo in the history and said the patient had a history of breast cancer versus the true history of prostate cancer. Believe it or not, this can have significant implications for insurance companies reimbursing a patient for the imaging study. A lousy history can lead to a denial of care payment for a patient. An addendum as a correction can be a lifesaver for this patient. It is very frustrating to have to deal with denial of care payment issues when you are sick!!!
Ethical Obligations To The Addendum
We, as physicians, are ethically obliged to abide by our Hippocratic oath to do the best for our patients and do no harm. Based upon some of the examples above, we fulfill a moral and ethical imperative to improve patient care by creating addenda. So even though overlooked by our readers, we need to be vigilant about reporting addenda when necessary. Don’t forget about the lowly addendum!!!
Dictating is a rarely touched upon but vital tool in radiology. Over a radiologist’s 30-year career, they may dictate over 360,000 reports (assuming 12,000 cases per year for 30 years). In today’s world, the dictation usually spurs clinicians to act on their patients. In my experience, out of 100 cases, clinicians only act on a couple of them using other forms of communication such as conversations with a radiologist or interdisciplinary conferences. Moreover, just like a manufacturing company that creates automobiles, dictations form the end product of the radiologist’s service. We leave over only the dictation in the medical record after we are gone.
Learning dictating indeed has a “steep learning curve,” meaning that residents rapidly incorporate dictation techniques. And, they acquire a lot after the initial year of training. But it takes years and years of experience for a radiologist to fine-tune their dictations to the point of maximum utility for their readers.
Resident Versus Seasoned Dictating
So, how do a radiology resident/newly minted radiologist and seasoned radiology attendings’ dictating differ? Well, certainly every rule has its exception. But for the most part, when you look at a resident or new radiologist’s dictations, you see a more verbose conclusion and a comments section that contains more irrelevant findings. And that perfectly makes sense. Why? Because it takes time for new radiologists to get a sense of what is truly important for the clinician. Most seasoned radiologists already know this information innately from years of practice.
Residents Need More Formalized Guidelines To Learn Dictating
To top things off, many radiologists assume that their residents will know how to dictate appropriately after a short period. And, many believe that a radiology resident just learns to dictate by osmosis. But, in reality, if you want a resident to know the right way to dictate, we need to provide as much guidance as possible. So, that is my goal in this post. To do so, first, I am going to discuss a little about templates for dictating. Then, I will give you some guidelines for each part of the dictation: the history, the technique section, comparisons, comments, and the impression. And finally, I will talk about the use of structured and prose dictations.
Templates:
When I was a resident just starting, I remember we had a booklet of templates for all sorts of commonly used dictation types for residents. We would carry around this book during our first days of dictating. And then, we would dictate the information on tape recorders to the secretaries upstairs. Today most institutions use dictation/voice recognition software, but the template concept is similar. It is easier than ever to gather templates from other radiologists for dictation when you are starting.
In the beginning, numerous template choices can complicate how to decide on using a template for a dictation. So, I would recommend finding the best template for a given type of study. Then, stick to this one type of template when you are starting. Sure, some radiology attendings will insist you use their templates for a given report. That is fine. You should certainly abide by your attending’s wishes because, in the end, it is your faculty’s report. Overall, just try to be consistent. The more you use a given template, the more likely you will remember all the items you need to include in a dictation.
Even as a seasoned attending, templates are still handy. Why? They save time. In addition, you can use them as a checklist to make sure you have looked at all the different organs and physiological systems within a study. (As I often do!)
Important Pitfall
However, you will encounter a few pitfalls with templates. So, you need to be wary. The biggest problem: you may forget to take out the pertinent findings embedded in the template. I’ve seen many reports with the following statement in the comments section: The kidneys are normal because it is the embedded information in the template. However, when you see the beginning of the comments section and the impression, the dictation says there is a cystic mass in the kidney. These inconsistencies confound the clinician, leading to phone calls and medically ambiguous outcomes and lawsuits. So always make sure to check your work twice before the dictation is signed off/completed.
Histories/Priors:
Over time, requirements for histories have drastically changed. When I first began my radiology residency, attendings expected a history to be a one or two-word blurb about the patient’s condition. Now, with all the new regulations, accreditation bodies, and ICD-10 codes, the histories need to be comprehensive. Our billing managers recommend putting as much relevant data as possible in the history to ensure that the study is fully reimbursed.
One example: When I first started, the attendings frowned upon putting the patient’s age in the dictation history. Now, suppose I don’t add the patient’s age in my cardiac nuclear medicine dictations. In that case, the hospital cannot send the report to the accreditation body for our hospital nuclear medicine department to continue with cardiac nuclear medicine accreditation. So, try to put in as much relevant/appropriate data as possible in the history. In addition, more history can also sometimes help the clinician formulate a proper conclusion to the clinical question.
Finally, make sure to put relevant information from prior studies in this section. Often, instead, residents will add this information to the body of the report. The body of the report should not contain the history. Why? Because the clinician can confound the timing of the findings in your dictation, potentially changing management. Remember, you can refer to the history from the body, but the history does not belong in the body of the report.
Technique:
I consider the technique section the stepchild of the dictated report. The clinician and radiologist often ignore this section. But on occasion, it comes in very handy. Moreover, as a radiology resident, you should report it accurately. Why? For instance, you may say there is a 5 mm axial slice thickness on CT scan. Suppose you didn’t see a pulmonary nodule on that study, and the subsequent study has a slice thickness of 2 mm. In that case, the pulmonary nodule may have been on the prior study but not visualized because of the differences in technique. And, if you do not state the method accurately in the dication, it can confuse the clinician and the radiologist. So, do not ignore this section.
Also, don’t assume that the template technique is always correct. Many times residents and attendings alike will create a fantastic dictation. Then, I look back at the technique section. It is wrong. Of course, the resident did not change the standard technique template format. This dictating error happens more often than physicians realize. Make sure to pay attention!
Comparisons:
The site of placement of the comparison section varies from radiologist to radiologist. I will state comparison is made to the previous study dated blank at the beginning of the comments section. Others will make this into a distinct section. Regardless, it makes your comments and impression much easier to understand. The reader always knows which study you are referring to for comparison when you state something is worse, better, or improved.
Comments:
If you want to “go to town,” I recommend doing it in the comments section. Here you should place all the pertinent negatives and positives. Be detailed and specific, especially as a radiology resident. Describe the findings well. Make sure to put in locations, size, morphology, density, and so on. And, if you see an essential finding, make sure to put the slice number in the dictation. Over the years, I have found it much easier for the attending radiologist to pick out the abnormality you are reporting, especially when the finding is subtle.
One issue confounds the novice: should you put the differential in the comments section or only in the impression section? I recommend stating the relevant findings in the comments section and then giving the expanded differential in the comments section based on the relevant findings. You can also say the reasons why you think your final diagnosis is what it is. You can hone and tighten that information in the impression section later.
Again, I can’t repeat enough, be careful with using templates. As mentioned above, we often see inconsistencies in the report because standard template statements remain in the dictation. Make sure to erase the pre-populated statements in the comments section if you state a finding that differs from the standard normal template. Be very careful. Remember the report is a legal document. The attorneys can use it against you in a court of law!!!
Impressions:
The impression becomes the standard-bearer and the central representation of the quality of the report. To accomplish that, it should contain the information that most pertains to the clinical question. For instance, if the symptom says lymphadenopathy/possible sarcoidosis, you should place the relevant answer concisely in this section. Always think of the impression as the answer to the study; if you do that, your impressions will become relevant and valuable to the clinician readers.
In addition, clinicians will almost always read the impression. (If not, they should work in another field!) Many of them skip over the remainder of the report. So, I would like to say that the impression exists for the clinician. The rest of the report is for the radiologist. So, make sure to spend the most time on this section. Check this part repeatedly to make sure what you are dictating makes sense and you state it with brevity and relevance. Also, make sure to put your conclusions in this section of the dictation. And, don’t forget to put here anything else that you think the physician will need to know, such as management or follow-up.
Beware Of Technical Jargon
Don’t use technical jargon in this part of the report. What annoys radiologists the most? You got it… Getting phone calls for unimportant questions about technical terms within your dictation. It wastes lots of time and energy. I can assure you if you put terms in your report in this section that a clinician does not understand, you will get way too many silly phone calls!!!
Stick To The Answers
Finally, the impression should contain the most relevant conclusions in your dictation. So, for instance, if you describe the following in your comments section: Within the liver, there is a hypervascular well-circumscribed mass in segment VI measuring 2.5 x 3.0 cm on image #51 with some peripheral nodular enhancement. Delayed imaging does not show typical centripetal filling. The differential includes most likely atypical hemangioma. Other etiologies such as a hepatic adenoma or hypervascular metastatic lesion are within the differential diagnosis but are less likely.MRI is recommended for further characterization. Then the impression can say something like Hypervascular segment VI hepatic mass. Consider most likely hepatic hemangioma. Correlate with abdominal MRI for further characterization.
If you notice in the last paragraph, I have placed the most likely conclusion and the recommendation for further study in the impression section. You can leave the other information in the body of the report for further reading if necessary. This way, the clinician knows what you are thinking. Additionally, you have guided her on what to do next without the excess verbiage to potentially confuse the clinician.
What terms are most frowned upon in the impression?
Avoid the usage of cannot be excluded. This statement does not help the physician. Moreover, it does not provide any additional information to the reader. The sun can swallow the earth in the next hour. This event cannot be excluded!!!! If you enjoy angering your colleagues, this statement will work the best. Many clinicians will need to order additional unnecessary tests since she has to work up an improbable possibility.
But, I do like to give one exception to this rule (as always!) In a positive pregnancy test and a negative pelvic ultrasound setting, I will say ectopic pregnancy cannot be excluded because I always want the clinician to follow the patient for ectopic pregnancy with blood work/B-HCG levels regardless of the findings in my dictation. Otherwise, make sure not to use this phrase in the dictation.
Also, do not use the statement clinical correlation is recommended. We, as radiologists, need to correlate the radiological findings with the clinical findings. Clinicians consider this phrase to be a lazy, unhelpful statement almost all the time. Don’t make the radiologist look bad!!!
In addition, you will discover other terms that may irk some radiologists. Others may not care as much. I remember one attending who hated the phrase lung zone and the word infiltrates on a chest film. To this day, I do not use these phrases in my dictation because I do not think they are specific. However, I often come across these phrases in other radiologists’ reports. So, you still need to abide by the quirks and specificities of individual radiology attendings. In the end, it is their name at the end of the report!!!
Structured Reporting Dictating Versus Prose Dictating
Structured reporting itemizes the different findings in list form. Most structured reports are organ-based. And typically, you will create the report as a fill-in-the-blank or menu choice of items the radiologist needs to pick. Using structured reporting vs. prose dictation styles has become an area of controversy. Newly minted radiologists will more often apply the rules of structured reporting dictations, and seasoned radiologists tend to use a more flexible prose style. But, you will find a significant cross-pollination of both techniques at all points in the career of radiologists.
I found a great article from Radiology called Structured Reporting: Patient Care Enhancement or Productivity Nightmare. (1) In fact, I highly recommend you go to this URL if you are interested in learning the advantages and disadvantages of each style of dictation. However, I will summarize by saying that the key to a thorough and understandable dictation, regardless of the style, is to remember to create your mental checklist and stick to the same program each time you do a dictation. You may adopt either style, as both can be appropriate. Some departments, however, may have standardized dictations and may require the use of either of these styles. So, you need to abide by the rules of your department!
Dictating Tips: A Final Conclusion
You will learn the basic mechanics of dictation rapidly. However, learning to dictate concise, relevant, and valuable reports for the clinician takes four years of residency and beyond to hone your skills. I hope the guidelines above make your transition to a more professional dictation style a bit quicker and easier!
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. And, we need to communicate this information to our fellow clinicians reasonably. So, how do radiologists do this without infuriating our clinical colleagues? To investigate how, I will divide this post into multiple sections, each one with a meaningful discussion to help you 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 we cannot come up with a final diagnosis at times, it is important to say just that. Make sure not to put in too many caveats and extra words. 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 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. Suppose the possibility of a renal cell carcinoma is slight. In that case, you can say that the features arenot 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 actual probability of renal cell carcinoma. The phrase cannot be excluded often causes the unintended consequence of additional unnecessary workups related to your dictation.
Correlate Clinically
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 actual clinical history, the vital signs, or the accurate 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 stating 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.
Specify Probabilities
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 know how far to work up the patient for other possibilities. Giving a laundry list of diagnoses 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 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 proceed to the next step. By describing the findings well, you ensure that the physician will work up the patient appropriately.
Communicating Uncertainty Well!
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. Suppose you follow my advice about directly saying what you mean. In that case, 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.
Second-year radiology residents become overwhelmed and burdened by call. Third-year radiology residents feel exhausted from studying for their core radiology examination. And, the fourth-year radiology residents fret about all the things they need to know before starting their career. But, what about the plight of the first-year resident? Many non-radiology physicians and some long-practicing radiologists think that these residents have it easy since he does not have many responsibilities. He can merely sit and watch the radiology attending to learn the practice of radiology, right? However, in this post, I am going to dispel that notion. I will go through five reasons why I think the 1st year of radiology residency is usually the most difficult.
Little Medical School Background In Radiology
Unlike internal medicine, surgical, ob/GYN, and psychiatric residents, most beginning first radiology residents have had almost no experience in the mechanics of all things radiology. Sure, they take a few courses during medical school. However, they are usually surveys. Also, they do not provide the vast experiences needed to function as a full-fledged radiology resident.
On the other hand, internal medicine residents have worked up patients with histories during their medical school training. Ob/GYN residents have usually delivered a few babies in medical school before beginning. Surgical residents have assisted in multiple surgeries and have worked the floors before their first day of residency. And psychiatry residents have interacted with numerous patients before starting. These initiated residents can almost entirely function from day one.
Instead, new 1st-year radiology residents cannot dictate, review films to be read, or finish the procedures that we perform daily. Since a first-year radiology resident cannot complete most of the functions to be “of use” to the senior radiologist, many first residents feel inadequate until they can begin call as a second-year. At that point, they can function much more independently. However, the lack of training certainly can make for a problematic initial year.
Incredible Amounts of Reading For The First Year
More so than other specialties, radiology requires a boatload of reading during the first year. You need to understand internal medicine, surgery, obstetrics/gynecology, orthopedics, neurology, and more to become a respectable radiologist. Unlike other specialties, you cannot get away with little reading and learn only from your experience with others. If you do not read for hours every day, you will fall behind and not pass the core examination. Many residents do not know the requirements before starting and take a long time to adjust to the nightly reading regimen, a painful process.
Dictations- A Difficult Road
Imagine your frustration as you first start with never having held a Dictaphone. You click the wrong buttons and feel unsure of yourself as you talk into a stick!!! This routine is typical for the first year that starts to dictate. Not only does the first-year resident have to get the physical mechanics of learning dictation, but they also have to create a report that makes sense. This process often occurs with little instruction or regimentation. It becomes hard to put ourselves in the shoes of the first-year resident. However, as an associate residency director, I regularly recognize how hard it is to start from scratch what we routinely do as radiologists daily.
Frustrated Attendings Who Don’t Want First Years Around
Unlike more independent senior residents, radiologists typically have to take extra time out of their day to teach a first-year radiology resident. Given the increasing workloads of radiologists, many attendings see this as a burden. They would instead get home to their family on time in the evening. Additionally, the attending does not know the first-year resident well. Therefore, he cannot figure out how much responsibility to give. Other radiologists feel forced and have no desire to teach. The frustrations of many attending radiologists reflect in the personal interactions with the first-year resident. Often, the resident gets the sense that he/she is not wanted around. Depressing, huh…
Noon Conferences- A Foreign Language
Have you ever listened to a conversation in a language that you do not understand? That is the feeling that the first-year radiology resident often gets when he/she goes to the first noon conference. Attendings give noon conferences on topics such as ultrasound or MRI. Yet, these radiology residents have never seen these images. On top of that, they use language that is not common vernacular.
Moreover, the findings are incomprehensible to the uninitiated resident. Many attending radiologists do not recall what it is was like to attend these conferences. However, these esoteric conferences are standard for first-year residents.
The Final Upshot For The First Year Resident
Senior radiologists can easily dismiss and forget the challenges that first-year radiology residents face. However, please don’t discount the first-year radiology resident’s frustrations, experiences, and anxieties, as they are genuine. It takes an extended period of adjustment to acclimate to the daily work experienced by radiology residents and attendings. Give the lowly first-year radiology resident a chance!!!
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Join our mailing list for free to receive weekly articles and advice on how to succeed in radiology residency, the best ways to apply, how to have a successful radiology career, and more. Also, get a copy of the free ebook Called The New Attending Physician Guidebook: How To Search For The Right Job And What To Do Once You Start.
