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放射学报告:你认为自己在说什么以及他们认为你在说什么。

Radiology Reports: What YOU Think You're Saying and What THEY Think You're Saying.

作者信息

Lee Bonmyong, Whitehead Matthew T

机构信息

Department of Radiology, Johns Hopkins Medical Center, Baltimore, MD.

Department of Radiology, Children's National Health System, Washington, DC; Department of Radiology, The George Washington Hospital, Washington, DC.

出版信息

Curr Probl Diagn Radiol. 2017 May-Jun;46(3):186-195. doi: 10.1067/j.cpradiol.2016.11.005. Epub 2016 Nov 16.

Abstract

BACKGROUND

Image interpretation and translation into written language is an imperfect process. Yet, the radiology report represents the link between radiologist's opinion and patient's images. Increased access to images through remote viewing stations has made direct communication between radiologists and clinicians less commonplace. We are interested in how accurately the descriptive contents within radiology reports convey the feelings of the radiologist to the referring clinician. We hypothesize that certain words and phrases hold different connotations for radiologists and clinicians.

MATERIALS AND METHODS

A two part survey was designed. Medical specialty, level of training, and number of radiology reports read/week was contained in part I. Part II concerned the quantification of radiologists' diagnostic confidence in range percentages based on specific words and phrases. These voluntary surveys were emailed to all faculty at a single university medical center. Additional paper surveys were randomly distributed to medical students, residents, and physicians. A total of 100 completed surveys were collected (33 radiologists and 67 non-radiologists). Data was exported to EXCEL for statistical analysis. Direct comparisons were made between the survey answers from radiologists and nonradiologists.

DISCUSSION

Percentile ranges for most radiologists and non-radiologists were in agreement in 25/36 questions. However, the absolute percentage value was somewhat variable. 11/36 questions generated discrepancy between radiologists and non-radiologists. The following words and phrases were in disagreement: "diagnostic of", "consistent with", "compatible with", "evidence of", "may represent", "normal", "degraded by artifact", "obscured detail", "mildly limited", "moderately limited", and "nondiagnostic".

CONCLUSION

Sound physician communication is a critical component of quality healthcare delivery. Certain words and phrases carry different meanings for radiologists and clinicians. With structured reporting becoming more prevalent, the radiology lexicon should be defined in a more concrete manner. Ambiguous terms should be eliminated all together.

摘要

背景

图像解读并转化为文字是一个并不完美的过程。然而,放射学报告却是放射科医生的意见与患者影像之间的纽带。通过远程阅片站增加图像获取途径,使得放射科医生与临床医生之间的直接沟通变得不那么常见。我们感兴趣的是,放射学报告中的描述性内容能多准确地将放射科医生的看法传达给转诊的临床医生。我们推测,某些词汇和短语对于放射科医生和临床医生有着不同的内涵。

材料与方法

设计了一项分为两部分的调查。第一部分包含医学专业、培训水平以及每周阅读的放射学报告数量。第二部分涉及根据特定词汇和短语对放射科医生诊断信心的百分比范围进行量化。这些自愿参与的调查通过电子邮件发送给一所大学医学中心的所有教员。另外还随机向医学生、住院医师和医生发放纸质调查问卷。共收集到100份完整的调查问卷(33份来自放射科医生,67份来自非放射科医生)。数据被导出到EXCEL进行统计分析。对放射科医生和非放射科医生的调查答案进行了直接比较。

讨论

在36个问题中,大多数放射科医生和非放射科医生的百分位数范围在25个问题上达成一致。然而,绝对百分比值有些变化。36个问题中有11个在放射科医生和非放射科医生之间产生了差异。以下词汇和短语存在分歧:“诊断为”、“与……一致”、“与……相符”、“……的证据”、“可能代表”、“正常”、“因伪影而退化”、“细节模糊”、“轻度受限”、“中度受限”以及“无法诊断”。

结论

良好的医生沟通是高质量医疗服务的关键组成部分。某些词汇和短语对于放射科医生和临床医生有着不同的含义。随着结构化报告越来越普遍,放射学词汇应以更具体的方式进行定义。应完全消除模糊的术语。

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