The Telling of Tales on Radiology Reports

I did a lot of reading as a kid. Regular visitors to this blog won’t be surprised that sci-fi and fantasy were my faves, but I wasn’t too particular beyond that. It flowed naturally when I followed that up with a fondness for writing.

Go figure. I liked reading fiction, so I liked writing it too. I was mildly baffled at why anybody would choose nonfiction. One spent enough time living in the “real” world. Why wallow in it on the lettered page? My imagined future as a successful writer was full of novels and short stories.

If you told young me that his future writing would be mostly nonfiction (nearly 14 years of this weekly blog for instance), he probably wouldn’t believe you. Alternatively, he might be disappointed at what a boring ol’ poop grownup me became.

I haven’t completely squelched that inner child. I have tossed a radiology-themed short story into this blog once or thrice, and my computer’s desktop has a folder called “Writings” filled with some enjoyable wastes of my time. Well, they were enjoyable to me. If anybody else ever sees them, it will probably be after I am gone, and they are sifting through my stuff. They can write an “in memoriam” blog here to tell you why it was a good thing I didn’t quit my day job.

It has occurred to me that a diagnostic radiologist’s work has a certain element of fiction to it as well. On some level, that might have contributed to my entering and enjoying the field.

There are, of course, rad reports that are solidly nonfiction. A typical densitometry exam, for instance, doesn’t have much room for personal expression or creativity beyond the numbers and what they mean.

Others take a little step into storytelling. The rad has to describe how the study was done, what prior exams were used for comparison, what clinical background he or she has been told (or found out on his or her own, what the findings are, and what diagnostic conclusions have been drawn.

This can be solidly nonfiction as well. A stone-cold normal study with routine findings has little need for variability between rads. One might throw in more pertinent negatives than another, but the story, if any, is “Here’s what’s going on with this exam.” It has no more fiction to it than, say, a well-researched, unbiased biography.

Another step into story land is when there is a slam dunk abnormality that the rad can read out with no uncertainty whatsoever. For example, a history of right lower quadrant (RLQ) pain and a clearly inflamed appendix is as clear-cut as a description of yesterday’s weather. Still, folks can differ about how to report the appy. Were adjacent reactive nodes worthy of mention? Was there a mild secondary ileus? One rad’s fiction can be another’s nonfiction.

Now suppose you are absolutely certain of your diagnosis, but you are the only one. I am dipping my toe into philosophical waters here, but if you are right about something and an overwhelming majority of others wrongly disagree with you, might your position be considered, in essence, a fiction? Folks have faced some pretty harsh consequences for going against what others called “settled science.” That’s not a new phenomenon by the way. Galileo would like a word.

More storytelling creeps in when you introduce subjective elements. A case with deficiencies might prompt rad A to dictate issues with the provided history, rad B to talk about patient noncompliance, and rad C to babble about something the tech did wrong.

Fiction-like elements increase when there are uncertainties that rads might see/describe in different ways. They don’t necessarily mean to say anything other than what they think is true (nonfictional), but they are not 100 percent sure. When you are not 100 percent about a case but have to make a pronouncement about it anyway (such as a radiology exam), you are essentially using fiction to bridge the gap of your certainty deficit. A lot of rads try to be honest about it by throwing in hedging language, but the only purely nonfictional statement you could make would be something to the effect of “I don’t know.” Try doing that in a bunch of your reports and see how well that goes over at your job.

Instead, we might offer a diagnostic differential, but that is essentially a “choose your own adventure” fiction we are offering the reader of the report. Alternatively, we may shy away from diagnosis at all, blaming it on imperfections of the exam we have been given.

I have known a rad or two who dogmatically reported everything out as a definitive, no matter how uncertain they were. “Either I am right, or I am wrong” is their attitude. That requires a certain type of personality and level of confidence that I have never had.

I feel like I have drifted into my most fictional waters when trying to handle a particularly technically messed up study or a diagnostic zebra, and I am far outside of my comfort zone. That is easy enough to handle if I was trying to be helpful and clear the lists of exams that are not in my subspecialty. Whoops, this turned out to be advanced musculoskeletal (MSK) stuff. I should leave it to a rad who knows better than I do.

When there is nobody particularly suited to the situation, however, or it’s actually supposed to be in my area of expertise (body imaging), I can’t appeal to anyone else’s authority. I can of course try to curbside a colleague, but most of the time if I am struggling, he or she will find the scan just as troublesome. Meanwhile, someone has to furnish a report. So I muddle through and what I come up with rarely feels like a solid work of nonfiction.

Rather, it feels like I am trying to piece together a short story and hoping it will be believable. It is like I am trying to bluff my way through a bad hand of poker, or otherwise get away with a lie. It can incite an episode of “imposter syndrome;” an inner voice murmuring that a real radiologist wouldn’t be having such struggles.

Under such circumstances, I try to disregard how long it is taking me to read the study. I recognize that when I do complete it, I won’t have the clean and confident “Next case!” feeling I get from most exams. Afterwards, a palate cleansing is in order, whether it is a brief break or some low-intensity XR and ultrasound to get back in my stride.