The quintessence of medical science and practice (2014)

This edition of Acta Radiologica features a paper on the quality of chest radiography reports. Mirja HirvonenKari and her team at the University of Helsinki analyzed the contents of chest X-ray reports by general radiologists, compared those to reports of the same examinations by a chest radiologist, assessed inter-observer agreement, and evaluated the clarity of the report contents from the viewpoint of the referring physicians. At first sight, one could consider this paper nothing more than a report of the results of peer review in the radiology department of one group of hospitals in a Northern European country: interesting as an instrument for local feedback and improvement, but not more than that. And indeed, peer review is a necessary and essential quality standard (1). The surrogate indicator of radiological excellence that has become accepted is consistency of assessments between radiologists, and the technique that has become the standard for evaluating concordance is peer review (2). Adherence to standards of care in radiology may be defined by the degree of interpretive agreement between readers (3). There is, however, much more to it. Although both length and content varied greatly depending on the author of the report, and the reports contained different quantities of information, Hirvonen-Kari et al. conclude that the quality of the reports in their study was rather high, whichever radiologist made them. That reports made by different radiologists would show a wide variation of style, length, and content, was easy to predict. As the guidelines of the European Society of Radiology (ESR) put it, there is no universally agreed definition of a good radiological report, and both radiologists and those who receive reports may hold differing views on optimal style and content (4). A few years ago, while I was working on a comparison of abdominal CT reports from eight medical centers in two countries, I discovered I could tell from most reports from which center they originated. In my daily work as a supervisor in an academic medical center, I can often link a report to the resident who made it without looking at the bottom line. Do try this at home, it’s great fun! The question is how desirable this situation is. In art, developing a style of one’s own is the hallmark of the transition of a novice to a mature artist. In radiology, the times when the reputation of a colleague greatly depended upon his rich vocabulary and style are long over. A large number of surveys among referring physicians have consistently brought forward a preference for structured reports in both radiologists and referring clinicians (5–9). As long as they are made by competent radiologists, such reports can only be impersonal, stereotypical, and mutually interchangeable. In Hirvonen-Kari’s study, more than one-third of the examination requests did not contain a clinical question. Apparently, the referring clinicians’ adherence to the conviction that radiologists need adequate clinical input to generate useful and reliable output is less pronounced in daily life than in surveys (7). In case a clinical question was present in this study, both the initial and the expert reports nearly always addressed the problem. As the reports by the chest radiologist were used as a de facto gold standard to judge the original reports, I could not help but wonder that these expert reports were 250–300% longer than the initial ones; and that despite this, only 7% had a conclusion, versus 22% of the initial, much shorter reports. In a study of abdominal CT reports by our own group, the radiology department that produced the longest reports was also the one where almost half the reports did not contain a conclusion (10). In my experience, the moment a radiologist dictates a conclusion is often the instance he/she reviews the clinical question and upgrades the report from a purely descriptive to a bayesian, truly medical level. Therefore, leaving out a conclusion, a radiologist not only complicates life for the referring clinician, he also bereaves himself of a moment of reflection and medical thinking. It is almost paradoxical that despite this, the referring clinicians in Hirvonen-Kari’s study thought the