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I'm a radiologist and writing helps me make sense of the world.

"My method is to take the utmost trouble to find the right thing to say, and then to say it with the utmost levity" -George Bernard Shaw

Saturday, 8 May 2010

Humour and the Radiology Report

It’s a hard, harsh modern world in which to practice radiology. On a background maelstrom of drastic annual “efficiency savings” (i.e. cuts) and tranches of impossible cancer targets, we are now we are all at the whim of truculent PACS systems. The radiological mottos of appropriateness and justification have been subsumed by a market-trader mentality.

With such a focus on quick turn-around and low costs, quality inevitably suffers. And no more so than in the radiological report. I’m not referring to the garbled medical English of a Belgian radiologist (don’t get me started…). More that, if the reporting target clock is ticking, you want to merely dictate a brief technically accurate report and move on. Your mind is on productivity. Especially in the new era of low fee-per-service scans.

Written reports have been the medium of the radiologist since year dot. Their clarity and accuracy are paramount, especially now that radiology is complex and yet so central to clinical practice. We hope the requesting clinician reads the subsequent report but sadly we are not assured of this. With the modern day investigational “chocolate box” open wide to anyone with a pen or computer password, it must be hard to keep track of precisely how many “chocolates” you have helped yourself to. It must only be a question of time until a dictat from the local cancer office demands that radiological investigations revealing unexpected cancer must not only be telephoned to the requesting doctor, then faxed to the GP and but also delivered in person to the appropriate cancer nurse specialist on a silver salver. I digress.

There are agreed rules for radiological reports that I have no argument with – always answer the clinical question, be concise, include relative negatives, avoid vague quantifiers, be as accurate as possible in your description, summarize a long report and so on and so forth. However, there is an odious move in certain circles towards standardized reports, occasinally using a proforma or (Gawd help us) a tick box approach. This seems to emanate more from across the North Atlantic where it seems the complexity of the study, blandness of language and subsequent length of the differential diagnosis are worshipped over and above their clinical utility.

And bizarrely, these tedious lists of normal and nearly normal organs, complete with technical descriptions, a lengthy differential but no opinion seem not only acceptable but often preferred to conventional modern reports. I suspect the problem here is that modern reports may be scientifically accurate but have lost their “art”; their style, charm and readability.

When I was a young registrar, we would sit at the knees of particularly venerable consultants listening to loquacious descriptions of otherwise bland-seeming plain films. His (always a he) hands were a blur as the films danced across the light-box whilst delivering a radiological soliloquy of brief yet lavish verbal pastiches. It was almost as he was trying to entice the Dictaphone to bed with the most charming and suave reports ever to hit magnetic tape. Later, in the typing pool, the secretary transcribing his reports would always be smiling unconsciously at the graceful language flowing from ear to fingertip.

Now this kind of style is refined over decades and tens of thousands of films. But it hasn’t stopped me mulling over why such reports are so attractive and pondering on how to emulate my radiological heroes. On reflection, I have come to the conclusion that it is not only the practised, flowing language, but the sparing use of humour that makes such a reporting style so enviable. More specifically, I would contend it is the use of “whimsy”.

Why whimsy? I would contend that lightly peppering a report with playful comments of a gentlemanly nature will enrich a report but will not offend. Overt attempts at humour or bitter cynicism in a radiological report may entertain but could cause offence. My GP father recalls a local radiologist some decades back issuing occasional seasonal reports that might read, “Normal heart and lungs. And a happy Christmas to all our readers”. I imagine this would be frowned upon these days.

Although an informal tone may make reports more readable, it is all too easy to slip into a conversational tone, thereby artificially elongating reports. Not only do these reports take longer to authorize but I would imagine that clinicians are loathe to wade through long swathes of semi-radiological pseudo-Socratic monologue.

Enticing as it may seem, one should never be offensive to the patient or use the patient as a butt of the humour. Not even remotely. We shouldn’t patronize them either. It will only get you in trouble.

Although you may be tempted to say, “I wish Mrs Lard had abstained from yet another a full fry-up just prior to heaving her fatty liver on my ultrasound couch as it was difficult enough to identify the pancreas through the rolls of blubber anyway”, I would counsel against this approach. Apparently, it is a sign of being unprofessional or even dysfunctional. A sonographer may preface their report “Technically difficult scan…” whereas the whimsical radiologist may say “Distinctly challenging scan. Might I suggest that Mrs Lard’s habitus makes her fundamentally unsuited to upper abdominal ultrasound?”

Not everyone is going to agree that there is role for humour in radiological reports. And fair enough, vive le difference and all that. Plus I’ve met some pretty mirthless radiological types who wouldn’t know their funny bone from a thrombosed haemorrhoid. Lord knows what the result would be if they tried their hand at a whimsical report.

Perhaps the best bit of adopting a faintly whimsical style is that clinicians spontaneously mention that they “like your reports”. Who knows if the sparing use of capricious observations in a report may even entice the clinician to read it through and not just skip to the conclusion? Moreover, it might raise a dry smile and even a chuckle. And in the modern NHS, there definitely aren’t enough smiles and we are seriously short on chuckles.

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