Having Said That (in Radiologyspeak)

I’ve made a couple of Curb Your Enthusiasm references in this column, over the years. Recently, I cited the series’ mockery of the phrase “Having said that.” Upshot is that this magical little statement is often used to say something, and then to completely absolve yourself of any responsibility for it.

More or less directly from the dialogue: You say what you want to say, and then you negate it, winning either way. “A comedian goes up on stage, and tells the audience ‘You people are a bunch of morons. Having said that, I’m very happy to be here.’”

We’ve got a bundle of our own having-said-thats in diagnostic radiology. You probably make use of them, or at least encounter them numerous times per day in other people’s reports. “Cannot exclude,” or “cannot rule out” diagnosis X is a popular one. Meaning: “I’m going to give the name of a pathological entity, but at the same time I’m going to refrain from really saying whether I think this imaging study shows it or not.”

Sometimes people mix it up a bit, using a positive spin: “Possible” diagnosis X, or diagnosis X “is in the differential.” Then, there are even more noncommittal ways, like “Equivocal” diagnosis X, which doesn’t even state whether the interpreting doc was leaning towards a yea or a nay.

The dictating radiologist, in choosing particular phrasing, might think he’s clearly conveying one sentiment, and the referring clinician might comprehend things another way. Worse, the referrer might perceive one meaning, and a subspecialty consultant he’s called might construe another. An intended, “I’m 90% sure this is the diagnosis” might come across as “I have no idea what’s going on here.” Or a “Heck, I dunno, but maybe this is diagnosis X” is taken to mean “I’m hedging a little, but this is probably X and you should go ahead and treat for it.”

Let this not be mistaken for a condemnation of such tactics, used in moderation at least. There is plenty of uncertainty in what we do, and there would be even if (and that’s a massive if) we were routinely given imaging studies of pristine technical quality and proper, relevant clinical histories to go with them. Making diagnostic pronouncements with excessive certainty runs a number of risks, from tempting the QA and medicolegal gods to misleading patients and referring clinicians with the message: Here’s the diagnosis, look no further.

Efforts have been made to hold our feet to the fire. The simplest (and, in my humble opinion, best) is a good old fashioned discussion with the clinician who’s trying to figure out what to do with the diagnosis, or lack thereof, we have given him. In such a discussion, off the record, many rads are willing to plainly say what they think. No, I cannot exclude diverticulitis, but if it’s really there it’s going to be extremely mild, and certainly without complications like perforation or abscess. Yes, I know I only said lymphoma is in the differential, but I’ll be very surprised if this turns out to be anything else.

Of course, that approach only works as long as the rad is available and willing to have such conversations when the clinicians want them. Being evasive or tight-lipped will shut down such lines of communication. And, even if you’re eminently available and always willing to chat, if every report you render needs to be clarified with a phone call, referrers eventually aren’t going to be so keen on sending you cases.