I write daily. That’s the job of a radiologist. To look at a patient’s CT scan or ultrasound or MRI or x-ray, interpret what I see, and write a report. To put in writing that there is a new cancer, or the cancer hasn’t responded to treatment, or the appendix is ruptured.
I can’t even say the writing is good. It’s utilitarian — there’s no time to be creative when 30 more patients’ scans are waiting. There is no mass in the liver. What’s the shorter way to say that? No liver mass is seen. How about this: No liver mass. Here’s the award winner — Liver: Normal.
It’s funny how hard it can be to declare something “Normal.” There’s always the fear that you could be missing something small or even undetectable. Because of this uncertainty, I may find myself writing 200 words just to say, in the end, nothing to worry about here, move on. My gut says it’s a normal scan. But on rare occasions, tiny unassuming nodules might grow into dangerous masses, and we can’t always tell how they might behave. And there may be lawyers waiting in the wings…
So it is that I may write day in and day out something wholly routine and unsatisfying. Sure, you could say I’m delivering good news when reporting the study as benign. But then, I wonder: why was this CT or MRI even ordered? My internal medicine professor in medical school often reminded us that 90 percent of diagnoses can be made with history and physical alone. If that was put into practice, I’d be out of job. So, perhaps I should be appreciative, keep my head down, and just keep writing my reports.
But radiology reports can be tiresome, for reasons existential as well as aesthetic. By convention, a radiology report is a neatly divided combination of fact and opinion. In the first portion, the “Findings,” I describe the facts I see on the screen, and in the second section, the “Impression,” I offer my professional opinion of what these facts mean.
But if you were to read my report, you might not tell one section from the other. This is largely because convention also dictates that we write in the passive voice. The convention has been passed down from radiology attending to resident since the beginning, and the result is a semblance that the radiologist’s impressions represent the objective truth. No liver mass is seen. Seen by whom? By me?
It weighs on you, being so distanced from your own opinion. We radiologists are already distanced from our patients, providing unseen care, behind the scenes. Many patients think a radiologist is the technologist who perform the study. Our report may be the only contact we have with them. Sometimes, when reading a clinic note from one of the front-line clinicians, I’m a little jealous. “I explained to Mrs. A that I do not think she is a surgical candidate.” How freely they throw around personal pronouns, these internists! Or, in an operative report: “Then I retracted the colon, which separated quite nicely.” Quite nicely! How I wish I could write something so artistic and subjective! The liver looks quite nice; I don’t see any mass.
Instead, I usually write something unimaginative — Liver: Normal — or, worse, noncommittal and vague. Tiny density in the liver is too small to characterize but statistically, is likely a benign cyst. Please correlate clinically for history of malignancy. Because everything exists, on the radiologist’s monitor, in uncertain shades of grey.
Sometimes, for reasons I don’t understand, I insert a bit of myself into the Impression. I sneak an elusive “I” into my report.
The conclusion of this essay is available here.
Ali Tahvildari, MD, is a radiologist at the VA Palo Alto and an affiliated clinical assistant professor at Stanford, where he also serves as associate program director of the radiology residency program. He is a member of the Pegasus Physician Writers at Stanford and enjoys writing fiction and poetry.
Photo by Rayi Christian Wicaksono