A recommendation on recommendations.

asked. “No,” we said. “Tell us about the days when you could look at a film, dictate the findings and a diagnosis or differential diagnosis. and go on to the next case. ” “Oh. those good old days. ” He laughed and walked away. Perhaps those good old days never really existed. But it seems that more and more, so much of a radiologist’s mental energy at the view box is spent not on making a diagnosis or differential diagnosis. but on deciding which, if any. recommendations regarding additional imaging studies or procedures should be included in the dictated report. We propose that the proper answer as to when recommendations should be included in a dictation performed with an imaging study, with few or no exceptions. may be never. In most radiology practices, the only written form of communication between the radiologist and the referring physician (excepting formal consultations for interventional procedures) is the radiology report. This report is often dictated with a near vacuum of clinical information (“chest pain.” “mass”) or with limited information (“cough in a smoker”). The patient’s full medical history and prior outside imaging studies are generally not available to the radiologist at the time of interpretation. Even without the availability of clinically relevant data, the radiologist generally has enough visual information from the radiographs to generate a report that describes any abnormalities present and offers a reasonable interpretation on the basis of these findings. A dictated report of this type should not cause angst for the radiologist or referring physician, because it is based on information found on the images. However, if the radiologist continues, recommending additional imaging studies or procedures to possibly help confirm or narrow the diagnosis, the time for guesswork and mind reading has begun. Do we know enough about the patient’s pertinent medical history to recommend biopsy or serial follow-up studies of a particular abnormality? Does the referring physician want a recommendation for a much more expensive but slightly more sensitive examination when results of the first study are negative, or was the first study ordered predominately for possible legal protection? Will we make the referring physician feel trapped legally when we make recommendations that are relevant only to the findings on the film. not to the entire clinical picture? It has been noted that “. writ en recommendations are frequently looked on by insecure physicians as fodder for lawyers and as obligations for themselves” [lj. Radiologists may also admit that they occa. ionally make recommendations for additional imaging studies on the basis of their own fears of legal malfeasance. Even the recently revised ACR Standards f oi Communication in Diagnostic’ Radiology [2] are ambiguous regarding the inclusion of recommendations in a dictated report, stating. “When appropriate, recommend follow-up and additional diagnostic studies to clarify or confirm the impression. ” Although this is well intended in that it doesn’t obligate the radiologist to make further recommendations, might it be as reasonable to simply omit this part of the impression? This would leave the impression to include, per the standards. a “precise diagnosis.whenever possible” or a “differential diagnosis.when appropriate. ” None of this implies that the radiologist should not be consulted if the clinician requests help in image evaluation. As imaging experts. our job includes guiding a patient’s radiologic workup. which could be done as an exchange of information between the radiologist and referring physician so that recommendations can best fit the patient’s needs. By establishing a dialogue, the radiologist is not perceived as a faceless signature on a report, or worse, a meddling intermediary telling the referring physician how to manage a patient. Written recommendations in a dictation may predispose trainees (interns or residents) to work up a patient on autopilot. They may or-