As radiologists strive to improve reporting and service to referring physicians, the input of providers can help inform process improvement.

1. Recommendations within the radiology
report: implications for the primary care
physician
Andrew J. Gunn, MD
Dushyant V. Sahani, MD
Susan E. Bennett, MD
Garry Choy, MD

2. Financial Disclosure
The authors have no relevant financial disclosures
that would pose a conflict of interest with this
study

3. Introduction
• Radiology reports are the primary work product of the
radiologist
• Radiology reports are the principal means by which the
findings of an examination are communicated to the
patient’s care team
• The radiology report is of particular importance to primary
care physicians in the outpatient setting, who may not
have the time or ability to consult the radiologist in person

4. Introduction
• There is considerable interest in improving radiology
reporting practices
– RSNA Reporting Initiative
– American College of Radiology (ACR) has developed
“Practice Guidelines for Communication of Diagnostic
Imaging Findings”
– Multiple survey-based reports in the literature
assessing referring physician preferences with regard
to the radiology report

5. Introduction
TECHNIQUE: Two views of the chest
• It has been suggested that the
radiologist should make HISTORY: As provided in header
recommendations within the COMPARISON: None.
report for further diagnostic
FINDINGS:
studies or treatment, if Lungs: The lungs are well-inflated and clear. There
appropriate is no focal pneumonia or pulmonary edema.
Pleura: There is no pleural effusion or pneumothorax.
Heart and Mediastinum: The cardiomediastinal silhouette is
• At our institution, we place unremarkable.
recommendations in their own Bones: The bones are unremarkable.
section within the structured
IMPRESSION: Normal examination
radiology report, which helps the
reader recognize when a RECOMMENDATION: None.
recommendation has been
Figure 1 (above). Sample structured report for a
made (Figure 1). chest radiograph which includes a separate
“recommendation” section

6. Questions
• How do primary care physicians perceive
recommendations made by radiologists?
• Do recommendations made by radiologists affect the
practices of primary care physicians?
• Does the wording or location of the recommendation
within the report change how it is perceived?

7. Materials and Methods
An on-line survey was distributed to 229 primary care
physicians at our institution through an internal listserv
(Figure 2, next slide)

8. Materials and Methods
Figure 2. The on-line survey distributed to the primary care physicians.

9. Results
• Respondents
– 100 responses (43.6% response rate)
– Averaged 19.1 years in practice (range: 2-50 years)
– 95% order less than 20 examinations per week

10. Results
Referring Physician Satisfaction
1-5 scale
3.9
3.5
Satisfaction with reporting in general Satisfaction with recommendations
Figure 3. Mean physician satisfaction with reporting overall was 3.9 on a 1-5 scale while mean satisfaction with
radiologist recommendations was still 3.5, it was significantly less (p=0.02) than overall satisfaction

11. Results
Single Biggest Problem with Radiology Reports
Figure 4. “Too many
25%
recommendations for
8%
further diagnosis and
treatment” was
identified as the biggest
19% problem with radiology
reporting while “Not
36% enough
12% recommendations for
Too Many Recommendations for Further Diagnosis and Treatment further diagnosis and
Not Enough Recommendations for Further Diagnosis and Treatment treatment” was the third
Unclear or Non-Specific Language most commonly cited
Didn't Answer the Clinical Question problem.
Other*
Gunn AJ et al. JACR, in press

12. Results
• Referring physicians were Items Necessary in the Radiology Report
allowed to select items they
100
felt were necessary in a 90
88
radiology report 80
Number of Responses
70
60
50 43 42
40
• Figure 5 (right). Referring 30
20
physicians chose
10
“Recommendations for 0
further imaging” twice as Recommendations for
Consultation
Recommendations for
Further Imaging
Recommendations for
Treatment
much as other types of
recommendations

13. Results
Do You Feel Medico-Legally Obligated by Recommendations in a
Radiology Report?
3%
3%
Yes
No
Unsure
94%
Figure 6. 94% of primary care physicians feel medico-legally obligated by radiologist recommendations.

14. Results
Do You Feel More or Less Medico-Legally Obligated if
Do You Feel More or Less Medico-Legally Obligated if
the Recommendation has Qualifying Language?
the Recommendation is Set Apart in its Own Section
within the Report?
24%
12%
5%
2%
More Obligated
More Obligated
Less Obligated
Less Obligated 72%
No difference
No Difference
Unsure
Unsure 23%
0%
62%
Figure 7. 23% of primary care physicians feel more medico-legally obligated by the
recommendation if it’s found within its own section in the report (above left). 62% of
primary care physicians feel less medico-legally obligated by the recommendation if
qualifying language such as “if clinically indicated” is added (above right). Gunn AJ, et al
JACR, in press.

15. Results
Should a Radiologist Adjust the Recommendation Based upon
the Specialty of the Ordering Provider?
15%
6%
Yes
No
Unsure
79%
Figure 8. The majority of respondents felt that the radiologist should not change
their recommendations based on the specialty of the ordering provider.

16. Discussion
• Overall, satisfaction with both radiology reporting and
radiologist recommendations is good amongst primary
care physicians
• Primary care physicians, however, are less satisfied with
recommendations than they are with reports in general
– The reasons for this difference are unclear and likely
multi-factorial

17. Discussion
• There is wide variability of opinion amongst primary care
physicians as to the utility of radiologist recommendations
– “Too many recommendations” was the most commonly
cited problem with reports (36%)
– “Not enough recommendations” was the third most
commonly cited problem with reports (12%)
– The literature suggests this variability, however, is
shared by other physicians, even radiologists
– This is a difficult conundrum to overcome for the
radiologist

18. Discussion
• Recommendations for further imaging were the preferred
type of recommendation
– Primary care physicians do not prefer the radiologist to
suggest treatments or consultation
– Suggests that primary care physicians would rather
make those decisions themselves

19. Discussion
• Primary care physicians feel medico-legally obligated by radiologist
recommendations
• Placing the recommendation within its own section in the structured
radiology report increases this sense of obligation
– In this location, the recommendation, either intentionally or
unintentionally, has been given added significance
• Adding qualifying language to the recommendation decreases this
sense of obligation
– Qualifying language provides the primary care physician more
flexibility in clinical decision-making

20. Discussion
• Radiologist recommendations have an impact on the
practice of primary care physicians even though their
attitudes regarding these recommendations are variable
• This impact seems to be modulated by both the location
and wording of the recommendation
• Radiologists should consider these factors when making
recommendations within the report

21. Selected References
1. McLoughlin RF, So CB, Gray RR, et al. Radiology reports: How much
descriptive detail is enough? AJR 1995;165:803-6.
2. Friedman PJ. Radiology Reporting: Structure. AJR 1983;140:171-
3. Fischer HW. Better communication between the referring physician
and the radiologist (editorial). Radiology
4. ACR Practice Guidelines for Communication of Diagnostic Imaging
Findings. Revised 2010. Downloaded from www.acr.org.
5. Lawson DE, Siegel SC. A recommendation regarding
recommendations. AJR Am J Roentgenol 1997; 169:351-2.
6. Kessler HB. The contemporary radiologist: consultant or film reader?
AJR Am J Roentgenol 1997; 169:353-4.

22. Comments or questions?
Please feel free to contact me via email at
agunn@partners.org