Association d'Imagerie Médicale, Avignon, 23, rue de l'Oriflamme, 84000, Avignon, France.
J Digit Imaging. 2018 Feb;31(1):5-8. doi: 10.1007/s10278-017-0014-2.
Whereas the creativity and intellectual power of the radiologist are measured against his/her written report, the value of the message will not only be judged by the precision of the medical statement. The same result can be attributed to different words. Numerous common and accidental factors exert influence on the decision on what is said and what is not said, how it is assessed and what is ignored. The less certain a diagnosis is and the less favourable its possible consequences are, the more subtleties and periphrases are to be expected within the report. The decision on the nature and the volume of the written report will not only be taken by the time of recording, but is likewise prepared by the knowledge of the patient's history and symptoms, the personal relationship to him/her as well as by a set of conditions throughout the inspection of the images. The intuition that accompanies the information transfer in imaging diagnostics does not only explain the differences in volume and depth of diagnosis and differential diagnosis, but also the range of diagnostic and therapeutic recommendations.
虽然放射科医生的创造力和智力水平可以通过其书面报告来衡量,但信息的价值不仅取决于医学陈述的准确性。相同的结果可以用不同的词来表达。许多常见的和偶然的因素会影响到报告中所说和未说的内容、评估的方式以及被忽略的内容。诊断越不确定,其可能的后果越不利,报告中就越需要使用微妙和迂回的措辞。书面报告的性质和篇幅的决定不仅取决于记录的时间,还取决于对患者病史和症状的了解、与患者的个人关系以及在图像检查过程中的一系列条件。在影像学诊断中伴随信息传递的直觉不仅可以解释诊断和鉴别诊断的深度和广度的差异,还可以解释诊断和治疗建议的范围。