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Dealing with Obligatory Disclaimers in Radiology Reporting
“I hate to say this but …” prefacing criticisms with tired disclaimers is an all-too common, albeit necessary, practice in radiology.
While chugging through my worklist last week, I encountered a scenario I face on a regular basis. I see an unimportant imaging finding, which I am obligated to comment on, but I know my statement has a vanishingly small chance of making any clinical difference. If I leave it out, however, my inner perfectionist will be aggravated with a possible QA-ding for a “minor miss,” and, God forbid, some clinician might think me careless.
Lather, rinse, repeat over a course of decades, and one can really begin to hate these obligatory statements. The pain of making them can be diminished by putting them into macros, but I find that any canned phrasing I might save would rarely apply to specific situations. There are just too many variables.
It put me in mind of a bit from Curb Your Enthusiasm where a couple of the main characters joke about the phrase “Having said that.” It’s a disclaimer that sort of lets you get away with saying whatever you really meant without having to live it down. One of them gives the example of getting on stage in a comedy club and telling the audience “You are all a bunch of morons. Having said that, I’m really happy to be here.”
“I hate to say this, but” has a similar effect. You can put it in front of just about any criticism you lob at someone, and it gives just enough of a veneer of civility that they are somehow not supposed to resent you for it. Done properly, it can blame them for having behaved poorly enough to put you in the uncomfortable situation of having to call them out. Now they have two things to feel bad for.
We can’t routinely put such colloquialism in our reports, but sometimes the opportunity presents itself. I have seen rads use “unfortunately” in this fashion. “Ultrasound of the right upper quadrant was attempted. Unfortunately, the patient was not properly NPO for this exam and did not remain still.” “Restaging CT of the chest, abdomen, and pelvis was performed. Unfortunately, the study was specifically ordered without oral or intravenous contrast.” On one occasion, I saw a resident attempt the maneuver and get stopped by his attending: “Don’t do that. It sounds passive-aggressive.”
The vast majority of my “hate to say this” moments are far more benign. It might not surprise you that the biggest examples are when I have to report on pathology, specifically stuff that is unlikely to be treated or otherwise result in full recovery. I think folks in general, but especially physicians, never like to be the bearers of bad news. Being able to magically fix abnormalities on imaging, and thus in the patients themselves, would be a nifty superpower for a radiologist.
By extension, I suppose, most radiology reports are in the category of things one would rather not have to say. Even if the studies are spotless, we are reading them because there are signs or symptoms of badness. I would much rather be able to say that any given patient feels perfectly fine and has exhibited no clinical issues that prompted imaging in the first place. Of course, then there would be little need for me as a diagnostic radiologist.
I suppose, if I made my living reading nothing but routine obstetrical sonos with no abnormalities and densos, mammos, etc. that all miraculously turned out to be normal, that could be an exception. Folks are having healthy babies, and adults are growing to ripe ages without developing any badness. What’s not to like?
Aside from such “goodwill to all” sentiments, I have baser reasons for hating pathology. Every abnormality I see is something I have to describe, measure, and correctly diagnose. All of that takes more time than just signing a normal report template. Plus, each thing I say is another opportunity to be wrong, either on my own demerits, or because of technical failures such as voice-recognition screwups.
I have got a particular “hate to say it” venom for disclaimers. Volumes have been written about such things, including previous blogs of mine. While some are definitely avoidable (“clinical correlation recommended,” for instance), others are forgivable and sometimes downright necessary. That doesn’t make me happy to use any of them.
Every time I point out a study is limited, it is a reminder to me that I’m broadcasting to non-rads out there that our field is imperfect, and that I haven’t somehow made my little corner of it an exception. It also strikes me that the only folks who really understand such limitations are those of us reading the imaging studies. To outsiders, we probably sound like we are offering lame excuses.
Sometimes, we offer our “limited” disclaimers in the hope that the referrers responsible for them (for instance by ignoring our recommended protocols or ordering the wrong modality entirely) will learn from their misdeeds. However, if that does happen, we have no way of knowing it at the time. We therefore speak our piece with the same sense of hate-to-say-it futility as a parent telling their kid for the umpteenth time to do X or not do Y.
As frustrating and wasteful as such efforts can seem, they pale in comparison to my worst-of-all “hate to say” material, namely things I am forced to put in my report because non-radiologists (and even non-physicians) have somehow gained the power to require the verbiage. Does anybody other than a regulator or an insurer looking to deny payment care that we used 80 cc of contrast? As much as I may hate to say certain things, I am absolutely infuriated when someone — especially a person without credentials or experience approaching my own — literally puts words in my mouth.
