Check Your Alignment

Once, when free time was a thing (mostly pre-college), I spent a substantial chunk of the stuff playing RPGs. That’s Role-Playing Games, for you non-geeks-probably the most well-known being Dungeons and Dragons.

In such games, one’s “playing piece” is an imaginary character. One doesn’t necessarily act like one’s actual self; it’s a chance to assume a different personality. An otherwise-decent person might have a go at playing a villain, for instance. To keep track of what the character is supposed to be like (so the player doesn’t just alter his behavior at a whim), characters are given an “Alignment.” Good/evil, lawful/chaotic, etc.

Spend enough time on an activity in early years and it has a way of permeating your thoughts for long after. Thus, even though I haven’t played such games for a couple of decades, I still occasionally find myself contemplating the alignment of real-world folks based on their behavior.

In radiology, this most often happens to me as I’m reading reports from rads who interpreted prior studies on a case that’s gracing my workstation. I’ve come to feel that certain rads operate as agents of Order (another term for Lawful in the RPGs), while others foment Chaos.

An Orderly rad, lest it need saying, will produce reports that are organized and easily read. They lay out the information in a way that is useful to the report’s reader (such as the referring clinician). Even with free-form dictation, an Orderly rad’s usage of grammar and paragraphs tends to be as user-friendly as if a “structured report” template had been followed. The report’s Impression will be a nice, tidy summary of the important stuff, drawing whatever conclusions are relevant and suggesting next diagnostic or therapeutic steps if appropriate.

A Chaotic rad’s reports can be a bewildering mess, even if the rad is forced to use a template. Stuff might go in the wrong sections (the bowel gets mentioned in the liver’s section, for instance), there’s little if any effort at proofreading, and one wonders if the rad ever learned what the Impression section is for. There are some rads I’ve encountered whose Impressions are always “See above.” Literally no other words. Meanwhile, “above” is a tangled mess of a dozen paragraphs-if the rad bothered to make paragraphs at all.

Related article: Do You Learn Your Lessons?

If the Chaotic rad offers recommendations, invariably they’re about getting more imaging (other modalities or follow-up studies), or consultations from other subspecialists-the message being “I have no idea what’s going on here; maybe someone else will.” Diagnostic statements are rarely if ever declaratory, such as “This is the diagnosis,” or “Diagnosis X is ruled out.” Rather, any mention of a diagnosis is usually to say that it cannot be ruled out-without actually saying whether it’s particularly suspected.

Put another way, if a clinician requests diagnostic imaging because he or she’s a little lost in the wilderness and needs some guidance as to how to proceed (diagnostically or therapeutically), an Orderly rad will at least cut out some of the uncertainty for him or her and often provide a clear-cut answer. A Chaotic rad is more likely to muddy the waters further-even if the clinician had previously thought they understood the situation, the Chaos-rad will introduce uncertainty and doubt.

This is a spectrum, not a dichotomy. There are rads entirely capable of acting Orderly when the situation permits (a good clinical history, a high-quality imaging study) who will get more Chaotic at other times (a history of “R/O pain,” or a technically-imaged set of images). Some rads won’t exert much effort at making the bodies of their reports nice and tidy, but will take great pains with their Impressions.

Not every rad who acts Chaotic is worthy of condemnation. Some are just lacking experience and/or confidence (for instance, fresh out of residency and reading independently for the first time, or fellowship-trained in MSK but utilized primarily for mammo).

Similarly, not every Orderly rad is a paragon of diagnostic excellence. I know some folks out there are of the opinion that, right or wrong, we should always make a solid decision and offer it unequivocally. I disagree with that notion, and even wrote a column as to why, once upon a time: Referrers (and, indirectly, patients) are counting on us for our guidance-which should not only be what we think, but how confidently we think it. Exaggerating that confidence might be okay if one is in the business of selling used cars, but our reports need to be more intellectually honest than that.