Guest Editorial: It’s all in the words

By Marc S. Levine, MD
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Dr. Levine is Chief of Gastrointestinal Radiology, Hospital of the University of Pennsylvania and Professor of Radiology and Advisory Dean, University of Pennsylvania School of Medicine, Philadelphia, PA.He is also a member of the editorial board of this journal.

For as long as I've been in the field, radiologists have been reinventing the English language in ways that would impress even the late Dr. Seuss. From the text of our dictated reports, you might think that radiologists, as a species, had grown up in some faraway land where ancient Aramaic was the only recognized language. I'm not referring to silly stuff in the reports like the punctuation or the grammar but to the actual words and their meaning. Where do I begin?

Pick a diagnosis, any diagnosis. A word that has caught on like wildfire is concerning . A typical radiology report ends with "these findings are concerning for tumor." Huh? Not worrisome for, suggestive of, diagnostic of, compatible with, consistent with, or indicative of, but concerning for. I have no philosophical objections to concerning and am not advocating that this word be deleted from the English language, but it makes no sense whatsoever in the context of a radiology report. According to the second edition of the Unabridged Random House Dictionary , concerning means "regarding; related to; or about." In effect, the report is saying "these findings are regarding for tumor." How's that for weird? If you don't believe me, look it up yourself. I suppose some radiologists will refuse to abandon this phrase because of personal, political, or religious convictions, but if even a few of you compromise by saying "these findings are of concern for tumor," I will consider this column a success.

It doesn't end there. The ill-conceived use of words and phrases in radiology is "concerning" for a virtual epidemic. Take our infatuation with interrogate . My colleagues in CT, for example, love to interrogate the images. Here is a typical example from one of my colleague's reports: "Interrogation of the right lower quadrant reveals thickening of the cecal wall." Radiologists must have a subconscious longing for a career in law enforcement. Why? According to my Unabridged Random House Dictionary , interrogate means "to ask questions considered personal or secret," most often in a formal venue like the interrogation room at a police station. So when my colleagues in CT interrogate the right lower quadrant, they're actually grilling the right lower quadrant, maybe even smacking it around a little, trying to learn its secrets. But what if the right lower quadrant refuses to talk? Does one of our goons go after the left lower quadrant? You know, take a hostage, threaten the other quadrants, or whatever it takes to get the right lower quadrant to cooperate. This interrogation business is not for the faint of heart.

Then there's the spy stuff. When we see a soft or subtle finding on one of our studies, we have a particular affinity for the word appears . The report might say "there appears to be a nodule in the right lower lobe." This verbal sleight of hand is an effective strategy if you work for the CIA because you have to protect yourself in case you write an internal memorandum that unintentionally leads to World War III. If this is a legitimate defense for employees of the CIA, why shouldn't it work for radiologists? If you're wrong, and there isn't a nodule in the right lower lobe, you're covered because you never actually said there was a nodule, only that there appeared to be a nodule, and we all know that nothing is ever as it appears.

We can take it even one step further. One of my colleagues on the chest service gets really miffed when a resident puts in the report that "there is no pneumothorax." My colleague always amends the report to say "there is no evidence of a pneumothorax." That way, if we're wrong, and there really is a pneumothorax, we're not culpable of anything because we never said there was no pneumothorax, only that there was no evidence of a pneumothorax. Are we clever or what?

Even gastrointestinal (GI) radiologists like me haven't escaped this epidemic. After a known ulcer in the stomach has completely healed on a barium study, we put in the report that there is "no longer evidence of an active ulcer in the stomach." Is that as opposed to an inactive ulcer? To the best of my knowledge, a volcano is considered active when lava erupts from the crater on top (much like projectile vomiting), but I've never heard of lava erupting from an ulcer crater. Blood maybe, but not lava. I know I'm not a rocket scientist, or even a neuroradiologist, but it seems to me that an ulcer can no more be active than a pimple or a wart.

Then there are radiologists who are afraid to go out on a limb in their dictated reports. You know the ones I'm talking about. These are the same radiologists who are afraid of catching a cold or turning out the lights when they go to sleep. If these sissies see thickened gastric folds in the stomach on an upper GI study, they'll put in the body of the report that there are thickened gastric folds and then put it again in the conclusion without having the guts to say why. Of course, that's totally unacceptable because it begs the burning question of what in heaven's name is causing the thickened folds. Is it gastritis? Tumor? Ménétrier's disease? Gastric amyloidosis? Or perhaps something less common? In my opinion, radiologists who refuse to deal with this question have serious commitment issues. You have to wonder how they ever worked up the nerve to get married or choose a brand of shaving cream. This is a real problem. If you can't deal with something as trivial and insignificant as thickened gastric folds, how are you ever going to make a commitment to shaving cream?

But that's another story.

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Guest Editorial: It’s all in the words.  Appl Radiol. 

February 13, 2007

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