Radiology reporting-from Hemingway to HAL?

Abstract

The job of the diagnostic radiologist is two-fold: identifying and interpreting the information available from diagnostic imaging studies and communicating that interpretation meaningfully to the referring clinician. However skilled our interpretive abilities, our patients are not well served if we fail to convey our conclusions effectively. Despite the central importance of communication skills to the work of radiologists, trainees rarely receive significant formal training in reporting skills, and much of the training given simply reflects the trainer's personal preferences. Studies have shown a preference among referrers for reports in a structured form, with findings given in a standard manner, followed by a conclusion. The technical competence to incorporate structured report templates into PACS/RIS systems is growing, "...and radiology societies (including the European Society of Radiology (ESR)) are active in producing and validating templates for a wide range of modalities and clinical circumstances. While some radiologists may prefer prose format reports, and much literature has been produced addressing "dos and don'ts" for such prose reports, it seems likely that structured reporting will become the norm in the near future. Benefits will include homogenisation and standardisation of reports, certainty that significant information has not been omitted, and capacity for data-mining of structured reports for research and teaching purposes.

Teaching points: • The radiologist's job includes interpretation of imaging studies AND communication. • Traditionally, communication has taken the form of a prose report. • Referrers have been shown to prefer reports in a structured format. • Structured reports have many advantages over traditional prose reports. • It is likely that structured reports represent the future standard.

Keywords: Clinical decision-making [E01.055]; Diagnostic imaging [E01.370.350]; Image interpretation, computer-assisted [E01.158.600]; Observer variation [E01.354.753]; Quality assurance, health care [N05.700].