Not Just What You Say, But How You Say It

My parents gave me one of my first lessons in how to be a decent diagnostic radiologist when I was a wee lad. Two of my grandparents lived far enough away that we only saw them a couple times per year, so we had weekly phone calls with them in the interim.

We kids were instructed, just before the weekly calls, to jot down a couple of things to talk about-what we’d done in the preceding few days, etc. It cut down on our wasting time with “ums,” awkward silences, and inappropriate subject matter.

Fast-forward to radiology residency, when I had an alternator full of chest films or a stack of CTs to go over with an attending. There was no way I’d be able to remember every little detail of my preliminary interpretations, nor the numerous corrections I received as we went through the studies. And this was the time of human transcriptionists, whose time was not to be wasted with half-baked residents’ prelims.

So we jotted down, with good ol’ pen and paper, what we thought-or were told-such that, when the time came to pick up the dictaphone, we’d have all the relevant details nicely laid out in front of us, in some semblance of order and priority.

Indeed, we saw that even some of our attendings who dealt with advanced imaging like abdominal CT or MR wouldn’t even start dictating until they had thoroughly gone over a study. Yes, some of it was because measurements had to be taken, and in those days, that meant reaching for the china marker, but it was also so they would have the full picture, so to speak, in order to put together an organized, cohesive report. One of them routinely proclaimed “TTD” (time to dictate) at the moment of truth.

The changing of times, I think, has made this two-step process much less prevalent. With voice-recognition instead of transcriptionists, we have our dictated statements instantly appear on the monitors in front of us, alongside the images. Thus, the pre-dictation notes we used to jot down are right in front of us on the screen.

It’s much more conducive to a “dictate as you go” approach; if further review of images or additional findings change your thinking about what you reported a paragraph or two earlier, revising what you said is far quicker and easier than back when you were recording your report on a tape or digital device.[[{"type":"media","view_mode":"media_crop","fid":"62787","attributes":{"alt":"Organizing radiology report","class":"media-image media-image-right","id":"media_crop_7827288347356","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"7993","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 97px; width: 150px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"©igor kisselev/Shutterstock.com","typeof":"foaf:Image"}}]]

This “progress” hasn’t been 100%-gain, zero-loss. Especially with pressures of productivity and turnaround time, such in-process report revision might not be as careful or thorough as it should.

Further, there’s a lot to be said for having all the details of an imaging study arranged in your mind before constructing a verbal description of it…something that doesn’t really happen if you are spewing out your observations as you go along, without taking a minute or two to read through the whole report once you’ve dictated your last word, rather than hurriedly glancing it over for major errors before clicking on Sign so you can move on to the next case.

I still do some of my work the old-fashioned way, for instance when reading PET or anything else that involves more than a couple of measurements. I find it a smoother, more efficient process if I first go through the exam drawing whatever annotations I need, and making notes of stuff like SUV and cross-sectional dimensions, then rattling them all off into the microphone in an order that makes sense (lymph nodes all addressed in one section, lung nodules in another, liver mets in a third, etc.).

This is, to some extent, swimming against the current. Society has steadily marched on in the direction of saying whatever is on your mind, while it’s on your mind. Thoughts of formatting, consequence, and the like are secondary concerns (if considered at all)…hardly surprising when Twitter is a prime means of communication, even for the tippity-top of our governmental leadership.

That said, until it becomes acceptable to “tweet” out our findings (God forbid) on someone’s multi-trauma panscan or malignancy-restaging workup, we should probably be holding ourselves to higher standards.