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No Longer Lost in Translation

May 24, 2018 05:06PM ● By MED Magazine

By Anne Geske

Getting the diagnosis right—what could be more important in assessing a patient’s symptoms? Imaging tests such as X-rays, CT scans, MRIs, ultrasounds and mammograms are essential tests within the diagnostic toolbox. So, it follows that any communication between the radiologists interpreting these exams and the clinicians who order them is essential. And yet, it’s not so simple.

Radiology is a complex specialty, and radiologists use their own intricate language, which must then be translated, so to speak, into a clear and comprehensible interpretation—even for the highly trained medical professionals who order them. Given that communication between radiologists and clinicians usually takes place within written reports and the electronic health record (EHR)—not in person or via phone—the potential for error is significant. In fact, MMIC found that the misinterpretation of tests and results, including radiologist-to-clinician communication, is a contributing factor in 27 percent of malpractice allegations.1 More effective communication between radiologists and ordering clinicians may have made a difference in these cases.

The Reference Process

The American College of Radiology (ACR) is actively engaged in defining processes to reduce diagnostic error. In 2015, the ACR supported a process radiologists could use when communicating to referring clinicians through the radiology report: The radiology report should include a standard management recommendation suggesting next steps for evaluation and a reference supporting that recommendation.2

Sue A. Crook, MD, FACR, is a radiologist with Suburban Radiologic Consultants (SRC) in Bloomington, MN, whose staff works with large Twin Cities health systems that have been rolling out the “reference process,” as it’s referred to in short, since 2015. “We help clinicians know what the next step is, if they’re unaware of it,” says Dr. Crook. “Following the impression of our report, we suggest further follow-up—such as another imaging test or a recommendation for a specialist—and what the evidence-based reference is for that.”

In her work with larger systems, the move toward having all clinicians follow similar protocols for work-ups involving radiologists is progressing. The reference process is a way for radiologists to uniformly use consensus guidelines in their recommendations.

Reducing Human Error

Without such a process, the referring clinician interprets the complex terminology in the radiologist report and makes their own determination for next steps. And because clinicians are human, perceptions and second-guessing may come into play. Radiologists have sometimes had to work to overcome perceptions by striking a balance between what might be seen as over-diagnosing, which is making sure results aren’t dismissed that point to further work-up, and under-diagnosing, in which more serious issues might fall through the cracks.

“In the past, there have been lawsuits where a radiologist interpreted results correctly,” Dr. Crook explains, “but the referring physician thinks the radiologist overcalled it and decides to dismiss the issue. With this new process, I can say in my report, ‘I’m worried this patient may have cancer. We need to do the next test, and here is the evidence-based reference.’” The reference process helps ensure that patients who need further evaluation get it.

It’s not surprising, then, that this relatively new patient-safety process may soon become a common best practice. Its implementation is recognized as a cutting-edge way to ensure that communication between radiologists and busy clinicians doesn’t fail. “Along with physicians, we have PAs and NPs referring patients to us,” Dr. Crook says. “They’re busy, and when they see the report—the history, findings, impression and, at the very end, the management recommendation—it kind of pops out to them. It’s something they can look at and pay attention to make sure that they understand the report, the words used and why those words are important.”

At SRC, the management recommendations started with the Fleishner Criteria for pulmonary nodules and has branched out to more and more areas as the ACR collaborates with societies, creating consensus papers. “These consensus papers are great,” Dr. Crook explains, “because, as a radiologist, they help give guidelines that may help protect you legally. We’re using published guidelines for our decision-making processes.”

Culture Shift

In Dr. Crook’s experience, health care culture is becoming more collaborative. More radiology groups are using management guidelines to prevent diagnostic error, prevent follow-up system failures and improve communication with clinicians. But it wasn’t long ago that the atmosphere was less collaborative.

“Ten years ago, if a management recommendation was included in a radiology report back to a physician, it may have been perceived that the radiologist was encroaching on their turf and ability to decide the next steps for their patients,” says Dr. Crook. “Now, clinicians are asking for more management recommendations encompassing multiple diagnoses. The expectation is to integrate management recommendations as a support tool into the EHR, which is a radiologist-driven way to help the clinician with evidence-based tools that are easily available to them in the EHR.”

As medicine—the tests, procedures and knowledge base clinicians are expected to have—gets more complicated, medical professionals are realizing they can’t do it all. “That’s why you look to the expert in that area,” Dr. Crook says. “Just in radiology, there are ten specialties. If I can’t know all of radiology, I certainly can’t know all of medicine. As we get more collaborative, physicians are happy for the help—they’re more accepting of it. Health care is becoming more patient-centered and more of a team effort.”


Anne Geske is Managing Editor of Brink magazine, which is published by Constellation, a partnership of mutual liability insurers, including MMIC. This article originally appeared in the Spring/Summer 2018 issue. To learn about the services MMIC provides to physicians, hospitals and health systems, visit


1. Brink, 2017 Spring Issue. Accessed December 4, 2017.

2. American College of Radiology. ACR supports collaboration to reduce medical diagnostic errors. Published September 22, 2015. Accessed December 7, 2017.