A Cynic’s Guide to Radiological Severity

Sometime early in my residency training, I heard an attending telling another resident, who was falteringly dictating a report of some pathology, that it was OK and in fact a good idea to not just mention the presence of pathology but to be a little descriptive as to how bad it was -mild, moderate, severe, etc.

That was the sum-total of the attending’s wisdom at the moment; an impromptu lecture as to objective or reproducible criteria of what made one case mild and another severe did not follow. Certainly, no robust grading system was proffered for subsequent study.

What makes one case mild and the next moderate? It’s assumed that the radiologist has seen instances of similar pathology, remembers them well enough, and is able to place the new case somewhere in his recollected spectrum of disease.

It would also be nice to imagine that the rad’s experiences more or less match that of other diagnosticians, and that his “mild” is comparable to somebody else’s.

Hopeful suppositions, there. One might despair that there is any objective value at all in the bundle of verbiage being used in this venue. But let us not be hasty. Having reviewed more than a few reports and the cases to which they are attached, I believe there are oft-intended meanings to consider when seeing these terms. For instance:

Mild. I see the pathology, but I don’t expect a non-radiologist to. Maybe a relevant subspecialty clinician.

Moderate. I see it, and really anybody having anything to do with the patient should be able to see it without reading my report beforehand.

Severe. I see it, the technologist saw it, and even the medical student might have a clue as to what the images show. If he doesn’t, the guy mopping the floor in the hallway outside the reading room might feel charitable and give the student a hint.

These, of course, are far from the only severity terms one encounters in radiological reports. Some less-utilized variants:

Mild-to-moderate, moderate/severe, etc. I have such a crystal-clear recollection of the thousands upon thousands of similar cases I have previously seen that I have not only rigid criteria as to what mild, moderate, and severe are, but I have clearly defined ideas as to what belongs in-between them. Please see my forthcoming paper on the new terms “milderate” and “modervere.”

Extremely mild.(Substitute your favorite minimizing adverb for “extremely,” and/or “slight” or “subtle” for “mild.”) Wow, I am amazing for seeing this abnormality. Good thing I got this case rather than one of the cretins sharing my reading room. They’d blow right by it.

Possible, potential, questionable, equivocal. Even I don’t really see pathology, but strongly believe it’s there based on history provided or other things I know about the patient. Or I don’t suspect it at all, but I just know some hack will try to claim it was there during peer review and this is my preemptive defense. Go ahead, try to nail me down.

Massive, pronounced, critical, etc. Abnormality is so blatant that just saying “severe” doesn’t seem to cut it; I take no professional pride in reporting this thing that my cat could have diagnosed. So, here’s me impressing you with other ominous sounding words I have in my thesaurus. Whaddaya know, the voice-recognition software knew them, too.