Table of Contents Chapter 1: Perfect Pictures, Imperfect Prose...13 Part I: Practical Advice...21 Chapter 2: Expressing an Imaging Observation...

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2 Table of Contents Chapter 1: Perfect Pictures, Imperfect Prose...13 The Earliest Radiology Reports Radiology Communication a Century Later The Radiology Report at a Turning Point A Guide for the Reader Part I: Practical Advice Part II: History and Foundations Part III: The Future Special Features Part I: Practical Advice...21 Chapter 2: Expressing an Imaging Observation...23 Short Declarative Sentences A Spectrum of Imaging Observations Anatomic Location Spatial Relationships Observation and Location Modifiers Expressing Uncertainty Locating Observations on the Images Building a Rhetorical Foundation Chapter 3: Radiology Reporting Best Practices...31 Develop a Reporting Routine The Virtues of Normal Normal Impostors Formal Disclaimers Within Normal Limits Pertinent Negatives Relevance: Making the Cut How to Say I Don t Know Uncertainty versus Vagueness Reporting a Differential Diagnosis Uncertainty and Belief Size Matters Extremely Small Too Small to Characterize Enlargement Impersonators Expressing Severity Locating the Summary Making Recommendations v

3 THE RADIOLOGY REPORT Suggesting Clinical Correlation The Cannot Rule Out Hedge Sentence Fragments Associated Studies Summary of Reporting Best Practices Chapter 4: A Guide to Reporting Style...51 Choose Your Words Carefully The Images about Which We Report Can You See an X-Ray? Confusion about Density Film versus Image Archaic Terms Escape the Muddled Middle The Observational Detachment Hedge Severity Straddling Content-Free Sentences Ambiguous Associations The Self Referential Summary Words to Avoid Nonspecific Borderline, Equivocal, and Top Normal Suspicious and Indeterminate Irregular Emotional Content Positive, Negative, and in Between The Ambiguity of Positive Impertinent Negatives Gratuitous Pessimism Eschew Formality and Pomposity Latin Forms and Plurals Abbreviations and Jargon Eponyms in Radiology Repetitive Redundancy It s Ancient Greek to Me Inventing New Words Don t Call Me -Al Specific Clinical Situations Malignant Neoplasms Finger Names vi

4 TABLE OF CONTENTS Fracture and Dislocation The Fine Points of Location and Laterality Getting Your Ducts in a Row A Bone to Pick Bone Density The Meaning of Infiltrate Distention and Dilation Die Contrast Dye Findings of Doubtful Clinical Significance Chapter 5: Mastering Speech Recognition...69 How Speech Recognition Works The Acoustic Model and the Language Model The Gory Mathematical Details Optimizing Your Speech Recognition Speech Fail Nonsense Dictionary Bloat Who Is Training Who? Remember the Tri-Gram Sound-alikes Date Problems Syllable Emphasis Templates and Macros Why Templates Matter Template Fields Template Reporting Styles Speech Recognition: A Critical Analysis Transcription Is Error Prone, Too Return on Investment The Radiologist as Editor The Correctionist Model Factors Leading to Successful Adoption Chapter 6: Organizing the Radiology Report...87 Patient Identifiers Clinical History Imaging Technique Image Quality Comparison Exams Findings or Observations Summary or Impression Standard Report Elements: A Reference Guide vii

5 THE RADIOLOGY REPORT Part II: History and Foundations...97 Chapter 7: The History of Radiology Reporting...99 The Narrative Report Anatomic Diagrams Handwritten Checklists Computer-based Reporting Alphanumeric Codes Touch Screens Mark-Sense Forms Speech Recognition Alexander Graham Bell and Dictaphone The Advent of Automated Speech Recognition Speech Recognition in the Clinical Environment Corporate Consolidation and Scandal The Current Market Landscape Chapter 8: Toward Structured Reporting Radiology Reporting a Century Later Structured Reporting: A Case Study A Rigorous Evaluation Lessons Learned Structured Reporting: A Definition Uniform Logical Format Consistent Organization Standard Terminology A Surprising Consensus Emerges The ACR Intersociety Conference The RSNA Template Library Raising the Bar for Radiology Report Templates Radiology Report Search and Analytics Google Has Its Limits Structured Reporting: A Critical Analysis The Checklist Analogy Effects on Training and Education Radiologist Decision Support Reuse of Report Information Effect on Productivity Structured Reporting: What Your Practice Can Do Today Adopt Standard Report Headings Standardize Templates to Ensure Regulatory Compliance viii

6 TABLE OF CONTENTS Track Discrepancies between Trainees and Faculty Adopt Common Templates for Divisions and Sections Create Selection Lists with Trigger Words Use Global Assessments Chapter 9: Standard Terminology for the Radiology Report Lessons from Aviation BI-RADS: The Advent of Standard Terminology BI-RADS Benchmarking Assessing BI-RADS RadLex: Clinical Terminology for Radiology The RadLex Playbook The Benefits of RadLex Chapter 10: How to Think about Imaging Information Logic and the Radiology Report Professor George Boole and Logical Inference Boolean Logic Boolean Logic Applied to the Radiology Report Probability and the Radiology Report Reverend Bayes and Updating Uncertain Belief Marquis de Laplace Makes Probabilistic Reasoning Practical Subjective Probability: It s All in Your Head Reasoning under Uncertainty and Diagnostic Imaging Pearson s Two-by-Two Table: A Simple Tool The Two-by-Two Table Applied to a Radiology Test Sensitivity and Specificity Sensitivity: Probability of Disease Detection Specificity: Correct Identification of Normal Patients Which Is More Important: Sensitivity or Specificity? Limitations of Sensitivity and Specificity ROC Curves: Comparing Diagnostic Tests Clinical Limitations of ROC Curves Predictive Values: How Likely Is the Disease? Positive Predictive Value Negative Predictive Value Clinical Utility of Predictive Values Limitations of Predictive Values Likelihood Ratio: Measuring Change in Probability Practical Value of the Likelihood Ratio Limitations of the Likelihood Ratio Summary of Tips for Thinking about Imaging Information ix

7 THE RADIOLOGY REPORT Chapter 11: Decision Making for Diagnostic Imaging Blaise Pascal and Decision Making under Uncertainty A New Theory of Decision Making A Clinical Decision Model Analyzing the Value of Information Weaknesses of Decision Theory Decision Biases The Representativeness Heuristic Availability Bias Anchoring, Framing, and Regret Using Theory to Answer Practical Questions The Toss-up The Value of a Negative Study Belief Update or Posterior Probability? Foundation for a Lifetime Part III: The Future Chapter 12: The Future of Radiology Reporting Radiology The Primary Care Encounter Patient Arrival Creation of Images Image Interpretation and Reporting Automated Radiologist Assistance Communication of Results Performance Improvement Image Exchange The Radiology 2025 Vision The Radiology Report in The Future of Speech Recognition Attribute-Value Format Prefilling the Radiology Report Global Assessments Structured Report Databases More Sophisticated Radiology Report Templates The Multimedia Report Natural Language Processing Machine Learning The Future of Report Communication Nonroutine Communication x

8 TABLE OF CONTENTS The Future of Electronic Access by Patients Patient Expectations for Radiology Reports The Possible Extinction of the Radiology Report References Index Disclosures Acknowledgments xi