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Vague: Wandering, roaming, unset-tled, uncertain…not definite in mean-ing, not explicit or precise, of indistinctideas…absence of clear perception orunderstanding…meaningless [1].

he Cases

Case 1

A 68-year-old woman with a clinical diag-nosis of pancreatitis underwent CT of the abdo-men (Fig. 1). The radiologist who interpretedthe study included the following sentences inhis report:

There is a nodular appearance of thepancreas. No definite mass is seen, but ifthere is any clinical suspicion of neo-plasm, an endoscopic retrograde cholan-giopancreatogram may be warranted.

No immediate follow-up studies were per-formed, but 7 months later the patient, nowseverely jaundiced, underwent another ab-dominal CT. The study disclosed a large tu-mor arising from the head of the pancreas.Biopsy confirmed carcinoma.

Case 2

A 37-year-old man underwent routinechest radiography (Fig. 2A) that was inter-preted by the radiologist as:

A 1

×

1.5 cm nodular density is pro-jected over the anterior portion of theright second rib in the right suprahilarregion. It is not clear whether this is dueto overlapping shadows, an area ofincreased density within the rib, or a pul-monary nodule. Appearance suggests agranuloma. Nevertheless, a follow-upchest film in 3 to 4 months is recom-mended to evaluate this finding.

Chest radiography obtained 3 months later(Fig. 2B) was interpreted by the same radiol-ogist as:

There is a persistent nodular densityin the right suprahilar region, unchangedsince previous study. Although I suspectthis is due to overlapping vascular shad-ows, correlation with computed tomog-raphy of the region may be of value todefinitely exclude a pulmonary nodule.

No follow-up chest radiography or CT wasperformed until 1 year later, at which time a

large right-lung tumor was easily seen (Fig.2C). Biopsy disclosed adenocarcinoma.

Case 3

A 42-year-old man who had been treated inthe past for a soft-tissue sarcoma of the leftlower extremity underwent chest radiography(Figs. 3A and 3B). The radiologist renderedthe following interpretation:

There is a 4 cm density in the frontalprojection on the left, which in the lateralview appears to lie in the major fissureand is compatible with a pseudotumor.

Pitfalls of the Vague Radiology Report

Leonard Berlin

1

Received November 30, 1999; accepted after revision December 20, 1999.

Case summaries are based on actual events and lawsuits, although certain facts have been omitted or modified by the author, who has supplied and obtained authorization for the reproduction of the radiographic images. All opinions expressed herein are those of the author and do not necessarily reflect those of the

American Journal of Roentgenology

or the American Roentgen Ray Society.

1

Department of Radiology, Rush North Shore Medical Center, 9600 Gross Point Rd., Skokie, IL 60076, and Rush Medical College, Chicago, IL 60612. Address correspondence to L. Berlin.

AJR

2000;174:1511–1518 0361–803X/00/1746–1511 © American Roentgen Ray Society

Malpractice Issues in Radiology

T

Fig. 1.—Case 1: 68-year-old woman with clinical diag-nosis of pancreatitis. Abdominal CT scan was reportedby radiologist as showing “nodular appearance of thepancreas…if there is any clinical suspicion of neo-plasm, an endoscopic retrograde cholangiopancreato-gram may be warranted.”

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Fig. 2.—Case 2: 37-year-old asymptomatic man who underwent routine chest radiography.A, Posteroanterior radiograph shows 1 × 1.5 cm density in right suprahilar region. Radiologist concluded, “It is not clear whether this is due to overlapping shadows, anarea of increased density within the rib, or a pulmonary nodule…. a follow-up chest film in 3 to 4 months is recommended to evaluate this finding.”B, Radiograph obtained 3 months after A. Radiologist reported that nodular density is unchanged and that “correlation with computed tomography of the region may be of value….”C, Radiograph obtained 1 year after B reveals extensive carcinoma.

CBA

C

BA

D

Fig. 3.—Case 3: 42-year-old man who had undergonetreatment for sarcoma of left lower extremity.A and B, Posteroanterior (A) and lateral (B) chest ra-diographic findings were abnormal. Radiologist re-ported 4-cm density on left, “which in the lateral viewappears to lie in the major fissure and is compatiblewith a pseudotumor.” Radiologist suggested compari-son with patient’s prior films.C and D, Radiographs obtained 6 months after A and Bshow round 12-cm diameter mass in left lung. Biopsydisclosed recurrent sarcoma.

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Comparison with the patient’s prior filmsis recommended to assess whether thisrepresents an acute or chronic finding.The chest is otherwise unremarkable.

No follow-up radiologic studies were per-formed until 6 months later, at which timechest radiographs revealed a large round 12-cm diameter mass in the left lung (Figs. 3Cand 3D). Biopsy disclosed recurrent sarcoma.

Case 4

A 38-year-old woman underwent routinechest radiography (Fig. 4A). The interpretingradiologist rendered the following report:

A soft tissue density in the rightchest overlying the seventh rib posteri-orly is seen. This could be a scar oreven neoplasm. If previous chest x-rayis available for comparison, this wouldbe most helpful. If not, then a 4-viewchest x-ray may be of benefit.

The patient was not seen again by her phy-sician until 22 months later, at which timechest radiography disclosed a 4

×

4 cm diam-eter mass in the right lung with associated in-filtration and hilar involvement (Fig. 4B).Biopsy disclosed adenocarcinoma.

Case 5

A 59-year-old man underwent chest radiog-raphy as part of a routine physical examination(Fig. 5). In his report, the radiologist stated:

Soft tissue density in right upper lungfield which appears to have some calcifi-cation within it and may represent agranuloma. However, would suggest anold chest film for comparison.

Eighteen months later, the patient returnedwith diffuse metastatic lung cancer.

Case 6

Chest and abdominal radiography was per-formed on a 61-year-old woman because of ab-dominal pain (Fig. 6A). The study was interpretedby the radiologist as follows: “Normal abdominaland chest radiographs except for band of atelecta-sis or infiltrate in the left lung base.”

Although the abdominal pain subsidedspontaneously, follow-up chest radiographywas performed 1 week later (Fig. 6B). The ra-diographic findings were “small patchy in-creased density in left lung base that is stableand probably chronic.”

Follow-up chest radiographic findings ob-tained 7 weeks later (Fig. 6C) were reportedby the radiologist simply as “slight decrease inleft lung base density.”

Ten months later, the patient was seen byphysicians at another facility. There, radio-graphs disclosed a well-defined 3-cm tumor inthe left lower lobe. Biopsy revealed carcinoma.

Case 7

A 53-year-old man underwent chest radi-ography as part of a preemployment physicalexamination (Fig. 7A). The radiologist inter-preted the study as follows: “Normal exceptfor an ill-defined density present in the rightupper lobe that is probably an artifact, but ifindicated, a repeat view is suggested.”

The patient did not return for follow-upstudies until 2 years later. At that time, chestradiography disclosed a tumor in the right up-

per lobe (Fig. 7B). Biopsy confirmed squa-mous cell carcinoma.

Case 8

A 59-year-old woman underwent an uppergastrointestinal radiography because of dys-phagia and epigastric fullness (Fig. 8). Theradiologist issued the following report: “Ir-regularity in the cardia of the stomach. Smallhiatal hernia.”

No additional diagnostic studies were obtainedat the time. Ten months later, the patient under-went endoscopic examination that revealed a largelesion of the cardiac portion of the stomach. Bi-opsy confirmed the presence of adenocarcinoma.

Case 9

A 55-year-old man with epigastric discom-fort underwent upper gastrointestinal radiog-raphy (Fig. 9). The radiologist interpreted thestudy as follows:

BA

Fig. 4.—Case 4: 38-year-old woman who underwent routine chest radiography. A, Radiologist reported this radiograph as showing soft-tissue density in right chest. Radiologist added, “This couldbe a scar or even neoplasm. If previous chest x-ray is available for comparison, this would be most helpful.”B, Radiograph obtained 22 months after A revealed 4 × 4 cm mass with associated infiltration and hilar involve-ment. Biopsy disclosed adenocarcinoma.

Fig. 5.—Case 5: chest radiograph of 59-year-old manwho underwent routine physical examination. Radiol-ogist reported, “Soft tissue density in right upper lungfield which appears to have some calcification withinit and may represent a granuloma. However, wouldsuggest an old chest film for comparison.” Eighteenmonths later, patient returned with diffuse metastaticlung cancer.

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There is gastroesophageal reflux andirregularity of the distal esophagealmucosa compatible with peptic esoph-agitis and a possible stricture. Reexami-nation of the esophagus after appropriatemedical therapy with either endoscopyor esophagram is recommended.

The patient did not return to his physicianuntil 14 months later. Endoscopy and biopsy atthat time revealed carcinoma of the esophagus.

Case 10

A 57-year-old woman underwent screen-ing mammography (Fig. 10A). The radiolo-gist interpreted the mammograms as follows:

There is an asymmetrical area ofincreased density and prominent dys-plasia with benign-appearing calcifica-tions in the upper outer quadrant of theright breast. Clinical correlation andfollow-up studies are recommended toexclude a mass.

Eight months later, the patient consultedher physician because of a palpable lump inthe breast. Mammography now revealed twomasses highly suggestive of malignancy(Fig. 10B). Biopsy disclosed invasive ductalcarcinoma.

Malpractice Issues

In all but one of the 10 cases described, at-torneys representing the patients in whomthe diagnosis of cancer was delayed filedmedical malpractice lawsuits against the in-terpreting radiologists.

Case 1

In the first case, a medical malpracticelawsuit was filed against the radiologist al-leging that the initial CT report was not“strong enough” to convince the referringphysician to order additional studies to eval-uate the patient for possible pancreatic can-cer. This case proceeded to trial, duringwhich an expert radiology witness for theplaintiff testified before a jury that the defen-dant radiologist should have used the words“suspicious for cancer” in his report andshould have “recommended” additional stud-ies such as an endoscopic retrograde cholan-giopancreatogram or biopsy, rather thanmerely stating that such a test “may be war-ranted.” An expert radiology witness for thedefense, along with the defendant radiologisthimself, contended that the findings on theCT scan were indeterminate and that thephraseology used by the radiologist in his re-port was acceptable. At the conclusion of the

CBA

Fig. 6.—Case 6: 61-year-old woman who underwent radiographic examination because of abdominal pain.A, Initial chest radiographic findings reported by radiologist were normal except for “band of atelectasis or infiltrate in the left lung base.”B, Radiograph obtained 1 week after A interpreted by radiologist as “small patchy increased density in left lung base that is stable and probably chronic.”C, Radiograph obtained 7 weeks after B, reported by radiologist as “slight decrease in left lung base density.” Ten months later, patient presented with 3-cm carcinoma inleft lower lobe.

BA

Fig. 7.—Case 7: 53-year-old asymptomatic man who underwent routine chest radiography.A, On Initial radiograph, radiologist reported probable right upper lobe artifact. B, Radiograph obtained 2 years after A shows large carcinoma.

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trial, the jury rendered a verdict in favor ofthe defendant radiologist.

Cases 2–7

Five of the cases alleging delay in diagno-sis of lung cancer resulted in the filing ofmalpractice lawsuits, all of which were set-tled before trial. Payments made on behalf ofthe defendant radiologists were not disclosedin cases 2, 3, 4, and 6. In case 7, a settlementof $1 million was agreed to on behalf of thedefendant radiologist and codefendant [2].

Incase 5, the plaintiff’s attorney did not believehe had sufficient evidence against the defen-dant radiologist and thus declined to institutelitigation [3].

Cases 8–10

Large settlements were paid on behalf ofthe defendant radiologists in cases 8 and 9, inwhich lawsuits alleging delay in diagnosis ofgastrointestinal malignancies had been filed.Case 8 was settled for a total of $900,000 [3]and case 9 was settled for $1.25 million. Themalpractice lawsuit in case 10, dealing withan alleged delay in diagnosis of breast can-cer, was settled with a payment of $1.5 mil-lion on behalf of the defendant radiologist.

Discussion

The common thread that binds these 10cases is the nature of the radiology reports—or to be more specific, the vagueness of theradiology reports. The reports were not trulyinaccurate—the pancreas in case 1 was nodu-lar but without apparent mass; the chest ra-diographs in cases 2–5 and 7 did revealabnormal densities that were not obviouslyindicative of malignancies; the radiographs incase 6 did disclose nonspecific left lower lobeinfiltration; the findings in the distal esopha-gus and proximal stomach in cases 8 and 9were described with reasonable objectivity;and an asymmetric density was present on themammogram in case 10. Notwithstanding thelikelihood that most radiologists might judgethese radiology reports as reasonably accu-rate in every one of these cases, the referringphysicians failed to take action that wouldhave led to the prompt diagnosis of malig-nancy. We must, therefore, ask ourselveswho, if anyone, was at fault and why.

The delay in diagnoses and the ensuing med-ical malpractice litigation that took place inthese cases may well have been the result ofsimple carelessness and lack of follow-up onthe part of the referring physicians. On the otherhand, we cannot ignore the possibility that these

Fig. 8.—Case 8: 59-year-old woman who complained of dysphagia and epigastric fullness. Representative radiographfrom upper gastrointestinal examination was reported by radiologist as disclosing “irregularity in the cardia of thestomach.” Ten months later, endoscopy revealed large infiltrating adenocarcinoma of cardiac portion of stomach.

Fig. 9.—Case 9: 55-year-old man with epigastric dis-comfort who underwent upper gastrointestinal radi-ography. Radiologist reported study as showing“gastroesophageal reflux and irregularity of the distalesophageal mucosa compatible with peptic esophagi-tis and a possible stricture. Reexamination of theesophagus after appropriate medical therapy with ei-ther endoscopy or esophagram is recommended.”Fourteen months later, endoscopy revealed carci-noma of distal esophagus.

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events also could have been the result of inade-quate if not negligent reporting on the part of theinterpreting radiologists. We know what the at-torneys and insurance companies that agreed tosettle the eight cases thought: they determinedthat both the referring physicians and the inter-preting radiologists were negligent and, there-fore, jointly liable for injuries sustained by thepatients. The legal culpability attributed to theradiologists clearly stems from a problem with akey link of the information chain that connectsradiologists to their referring physicians—namely, the radiology report. Let us now furtheranalyze that key link—the radiology report.

Over the years, a number of commentatorsin the radiology literature have discussed thesubject of radiology reports. Three quarters ofa century ago, Enfield [4] criticized radiolo-gists who issued written radiology reports that:

…describe in detail all that the roent-genologist sees in the film or on thescreen but does not tell what he thinksabout it, what conclusions he drawsfrom it, and what it means to him.

This kind of report “commits the roentgen-ologist to nothing except accurate vision andgood description.... It tells much, yet almostnothing,” wrote Enfield, who then exhorted ra-diologists to “give not only their opinion butalso their method of arriving at that opinion.”

Commenting 60 years later on radiology re-ports, Friedman [5] held that “it is the obligationof the radiologist to state what has been foundas clearly and pointedly as possible.” Fischer [6]added that the radiology report must be not onlyaccurate but also meaningful. Indeed, clarityand meaningfulness were the most valued qual-ities of radiology reports among 200 referringphysicians, according to a Canadian survey [7].Let us digress and focus on the definitions ofthese terms in more detail.

“Meaningful” is defined as “capable of beingunderstood or interpreted…the thing one in-tends to convey by language…exhibiting aspecified intent or purpose…” [1]. Meaningfulis an antonym of meaningless, which is definedas “lacking an assigned function…having nosignificance…vague” [1]. The definition of“vague” is given at the beginning of this article.

Spira [8] has urged radiologists to rendermore meaningful reports of radiologic stud-ies, going so far as to write that radiologistsdo themselves, their patients, and referringphysicians a disservice when they create avague report. He asserts:

A rambling description of findingswithout a reasonable conclusion doesnot add anything positive and often isperceived as an attempt to distance theinterpreter from the clinical issue athand…leaving the reader confused.

In its “Standard for Communication: Di-agnostic Radiology”

[9], the American Col-lege of Radiology steers away from usingsuch words as “vague” or “meaningful”

andinstead states simply that the radiology re-port “should use precise anatomic and radio-logic terminology to describe the findingsaccurately” and that an impression should in-clude “a precise diagnosis…whenever possi-ble.” The standard

also mandates radiologiststo “recommend follow-up or additional diag-nostic studies to clarify and confirm the im-pression …when appropriate” [9].

Let us now turn to the practical and legalquestion that is the crux of this article: did the10 radiology reports convey to the referringphysicians a truly accurate representation ofthe radiologic findings, the radiologists’ opin-ions of the meaning of the findings, and theradiologists’ recommendations for further ac-tion to the referring physicians?

In each of the cases described, the referringphysicians testified either in deposition or attrial or stated off the record to their attorneysthat if the radiologists had only been strongerin their reports, they would have acted (to pur-sue a diagnosis) much sooner. In some of thecases, the defendant radiologists acknowl-edged that the complaints of the referring phy-sicians had merit, but in other cases, theradiologists did not agree with the complaints.

Communication between two individuals is,of course, a two-way street. In the context of ra-diology reporting, sometimes the radiologist’smeaning is not accurately conveyed to the refer-ring physician, and at other times, the referringphysician misunderstands the radiologist. Afailure of communication between two physi-cian professionals is more likely because ofsome degree of fault in both. In not one of the10 cases discussed here did the interpreting ra-diologists use in their reports such phrases as“the radiographic findings are suggestive forcarcinoma” or “carcinoma is possible” or “car-

Fig. 10.—Case 10: 57-year-old woman who underwent screening mammography.A, Initial mediolateral mammogram was reported by radiologist as disclosing “asymmetrical area of increaseddensity and prominent dysplasia with benign-appearing calcifications…Clinical correlation and follow-up stud-ies are recommended….”B, Mediolateral mammogram was obtained 8 months after A because patient palpated lump. Mammography nowrevealed two masses suggestive of malignancy. Biopsy disclosed invasive ductal carcinoma.

BA

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cinoma should be considered,” all of which aremeaningful phrases. In not one of the cases didthe interpreting radiologist clearly recommendan additional radiologic study or biopsy, again,meaningful phrases. Such terms as “if clinicallywarranted”

or “if clinically indicated may be ofvalue” or “comparison with patient’s prior filmsis recommended” or “would be most helpful”or “may be of benefit” or

“

clinical correlation isrecommended” were all used quite freely—butthese phrases are vague rather than meaningful.

Is it because of the vagueness of these re-ports that the referring physicians did not ob-tain additional studies to diagnose carcinomaearlier? Did the language used in the radiol-ogy reports lull the referring physicians intoinaction and lethargy (conduct referred to as“soporific” by Goldsmith [10]), rather thanalert them to the fact that prompt action mustbe taken? Considering the amount of indem-nification paid on behalf of the defendant ra-diologists in these cases, the answers to thesequestions appear to be “yes.” Although itmay be true, at least in some of the cases,that the delays in diagnoses were more theresult of lackadaisical if not substandard con-duct of the referring physicians, the fact re-mains that the law holds radiologistsresponsible for lapses in their own conduct,irrespective of any liability that might be im-posed on other physicians [11]. This factshould provide a wake-up call for all radiolo-gists to review their technique of reporting.

Recognizing the wide variation and lack ofuniformity of reports rendered by radiolo-gists, Hickey [12] proposed 78 years ago thatnational radiology organizations try toachieve uniform reporting by developingstandardized nomenclature and writing style.Although such a system has yet to be imple-mented for general diagnostic radiology, ithas already been accomplished in the subspe-cialty of mammography. The American Col-lege of Radiology instituted the BreastImaging Reporting and Data Systems (BI-RADS) [13], which consists of a lexicon ofterminology and definitions to provide stan-dardized language in reporting mammogra-phy. By providing clear and succinct reports,BI-RADS has achieved its goal of makingcommunication of mammographic findingsmore accurate and decisive. Ambiguity and

vagueness have, for the most part, been elimi-nated in mammography [14].

Summary and Risk Management

Written interpretations by radiologists ofradiologic studies are extremely importantfrom both medical and legal perspectives.These reports provide an integral part of themedical record and are an essential link be-tween the diagnosis and treatment of a pa-tient’s illness. The legal authority andimportance of radiology reports were empha-sized by a federal appeals court that charac-terized them not simply as “reports ofdiagnosis or opinions,” but rather as “factualreports of analysis of [a patient’s] body” [15].The court added, “A radiologist’s enumera-tion of the contents of an x-ray is not …meremedical hypothesis, but, rather, a learnedstatement of an observable condition.”

Radiologists owe patients the interpreta-tion of radiologic studies in a manner that ismeaningful to the referring physician [16].Once a malpractice lawsuit is filed, the radi-ology report becomes important evidence—alegal exhibit—in the courtroom. It is then de-termined by a court of law whether a reportrendered by a defendant radiologist clearlyconveyed to the referring physician the re-sults of a given radiologic study—that is,whether the radiologist’s report conformed toor breached the radiologic standard of care. Ifit is determined that the phrasing of the radi-ology report is insufficient to meet the stan-dard, indemnification will be paid, eitherthrough settlement negotiations or a jury ver-dict. Radiologists must remember that theyhave an independent duty to be accurate andconcise, regardless of whether the actions ofthe referring physician are negligent [11].

Risk management in radiology practice canlessen the likelihood of incurring a medicalmalpractice lawsuit, maximize the chance fora successful defense if a suit is filed, and at thesame time enhance good patient care. The fol-lowing risk management pointers will help ra-diologists meet all three of these objectives:

• Radiologists should heed the words ofRothman [17], who wrote that because radiol-ogists are paid for using both their eyes andtheir brains, a complete radiology report must

include both sets of evaluations. The body ofthe report should contain a complete descrip-tion of all abnormalities—that is, everythingthat is seen with the eyes—but the conclusionshould discuss only those findings that are im-portant to the brain, contended Rothman. Thelength of the body of the report depends on thenumber of findings, whereas the length of theconclusion varies with the radiologist’s abilityto make sense of the findings.

• Before completing a radiology report, ra-diologists should ask themselves, “What do Iwant my referring physician to concludefrom my interpretation?” The interpreting ra-diologist should try to address in his reportthe following self-imposed questions: Whatdid I see on the radiographic studies, by whatdo I believe the findings are caused, andwhat do I suggest the referring physician donext? Radiologists should not sign their re-ports until these questions are answered in ameaningful manner.

• Radiologists should minimize, if not elim-inate altogether, the use of such phrases as

“

ifclinically warranted,” or “if clinically indicatedmay be of value,” when assessing abnormal ra-diographic findings. Because radiologists areacknowledged to possess radiologic expertisederived from training and experience, theyshould not relinquish to nonradiology physi-cians the responsibility of evaluating the po-tential significance of a purely radiographicfinding that is unexpected or unusual.

• When rendering radiology reports, radi-ologists should refrain from hedging, definedas the making of calculatedly noncommittalor ambiguous statements [1]. Radiologistsshould be mindful of the following aphorismcoined by one radiology educator: “Do notlet the fear of being wrong rob you of thejoy of being right” (Rogers LF, personalcommunication).

• A report need not always be brief but itcan always be concise [18]. Radiologistsshould attempt to convey important radio-logic findings as briefly as possible. Goodwriting is succinct, accurate, clear, and unam-biguous; it grabs the attention, conveys amessage, and elicits a response [19].

• Readers who want specific hints as towhat constitutes a good radiology reportshould consult specific references listed at the

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end of this article [3, 20–22]. All radiologistsshould read the 16 tips on how to write a radi-ology report by Revak [23]. They are as validtoday as they were 17 years ago when theywere first published.

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