Wet Read: (Un)structured reporting

“We call ourselves creators and we just copy.”

—Lauryn Hill

Bear with me here. I know this topic has opposing viewpoints. There is a certain logic to having your reports look the same: A description of what you did, what it looked like, and finally the cosmic significance of that. The “structured/template” form of reporting is growing popular.

In the spirit of full disclosure, I utilize a number of these. I love macros. Temporal bones, necks, and even my spine dictations are very structured, and I use a boatload of macros. And, my reports always look about the same, and clinicians know where to look in my report for a specific finding they may be interested in. I think it is fine. It works for me. May not work for you, but that’s life.

So, where in the world is he going with this?

Trainees are a strange and wonderful group. As I’ve heard stated most succinctly, in the novel, The House of God, by Samuel Shem,“ Show me a medical student that only triples my work and I’ll kiss their feet.” So, with a standardized report, designed to MAKE EVERYTHING EASY, how can the resident/fellow triple my work? Oh, that’s easy. Using a normal structured report or macro.

So, in the course of simplifying work, the following work effort is produced:

“There is a complex mass that is both cystic and solid and measures way big by way big by way big and has diffusion and susceptibility and other stuff that is pretty significant, and it is in the left hemisphere,” and the next two lines are, “No mass or hemorrhage. No mass effect or shift.”

Or, “There is an acute infarction in the cerebellum with significant mass effect and other awful stuff going on and the referring physician was sent for and came immediately to our reading room where we demonstrated all this stuff and all beat our chests.” The next two lines are—obviously—“No mass or hemorrhage. No acute infarction. No significant findings.”

Some of my colleagues don’t allow trainees to use any form of macro/structured report. That leads to chaos and oft times an amazing display of odd grammar and syntax. Others limit their use.

Me? I prefer to dictate myself. Stand back, young one, and watch how it’s done.

Mahalo.