Deciding what to include in the conclusion of a report is one of the most difficult but important challenges faced by a radiologist. It will come as no surprise to you that clinicians love a conclusion, so much so that it is often the first and only thing they read. And so here's my list of the top 5 radiology conclusion pitfalls and how to avoid them.
1. Not having a conclusion
If your report is longer than three or four sentences then it really should have a conclusion. In my experience, radiologists most often omit a conclusion when they are unsure how to interpret the findings. Unfortunately this is precisely when a conclusion is most valuable, as it's likely the clinician will find the case difficult too.
Solution: Don’t be afraid to admit when you are uncertain. Write your conclusion as if you are talking face to face to the referring clinician.
e.g. The parenchymal appearances in the lung bases are of uncertain significance and not clearly pathological. Comparison with previous imaging or a follow-up study may be helpful.
Repeating your findings and descriptions such that the conclusion is almost as long as the body of the report defeats the whole purpose! Often I find it is the radiologists who are insecure about the significance of their many findings that are most tempted to repeat them all in the conclusion.
Solution: Restrict your conclusion to short relevant descriptions only and never have a whole sentence without an interpretation.
e.g. Right anterior cranial fossa mass with appearances characteristic of a meningioma.
3. Not answering the question
Good clinicians almost always ask one or more specific questions in their referral. Ignoring or failing to address a question is a sure fire way to alienate a referrer and may stop them ever sending a patient to you again!
Solution: Explicitly address the clinician's question in your conclusion.
e.g. Normal study, with no evidence of appendicitis.
4. Irrelevant incidental findings
Including irrelevant incidental findings in a conclusion makes the important points harder to find. When the study is otherwise normal then it might be permissible to add one irrelevant incidental finding to the conclusion but even this is a questionable practice.
Solution: Only include an incidental finding in the conclusion if it warrants its own follow-up or management (e.g. Bosniak 2F renal cyst) or if it impacts the management of the primary condition (e.g. deviated nasal septum in a patient undergoing transsphenoidal surgery).
5. Guess what I am thinking
Many conclusions I read never actually state what the author thinks is going on. A statement of facts can mean nothing to a clinician without an encompassing impression. For example, “Gallstones. Dilated common bile duct.” is nowhere near as useful as “Gallstones. Although choledocholithiasis is not definitely seen, given the common bile duct is dilated, a small distal stone is suspected.”
Solution: Always assume the clinician reading your report is tired, rushed and not familiar with the condition. Don't hide your diagnosis or the patient may be managed incorrectly.
So that rounds out the top 5 mistakes made in radiology report conclusions. Hopefully now you can successfully avoid these pitfalls in your next reporting session. If you think of other important ones to add to these five then please leave a comment below.
Frank Gaillard & Andrew Dixion