The Art of Radiology Reporting

Dr. Weiss is Physician Coordinator, Imaging Informatics, Carilion Clinic, Roanoke, VA. He is also on the editorial board of this journal.

For my next career I should like to be a museum curator. I can easily picture myself dressed in a tweedy sport coat, casual pipe in hand, affecting the upper crust accent of a fourth-generation aristocrat. I suppose there is the occasional lawsuit over an unidentified forgery. Or the frantic middle of the night call — “We need you here right away. We’re out of picture hangers.” But overall it seems a bit less stressful than your average radiology practice. My first exhibition would be a retrospective of the radiology report.

Radiology reporting has a much shorter history than painting, however, early works have a number of similarities: simplistic hand-drawn attempts with little structure and no perspective. Just as early paintings consisted of tempera on wood or fresco on plaster, nearly all 20th century radiology reports used the primitive medium of ink on paper. One of the world’s most famous portraits, the MonaLisa, painted by Leonardo da Vinci during the Italian High Renaissance in the early 16th century, set a standard for the use of structure,often referred to in the art world as “triangular composition.” Consistent and reproducible structure is now being incorporated into modern radiology reporting.

An unfortunate similarity between early radiology reporting and Renaissance painting, what present day economists might refer to asa “negative externality,” was the development by da Vinci of a painting technique known as sfumato. Comprised of multiple layers ofthin glazes and washes of near-transparent pigment, his works evince a soft, hazy appearance described by the artist as “without lines or borders, in the manner of smoke.” Sadly, this style, known today as hedging, is still found in some contemporary radiology reports. Fortunately, it is increasingly difficult to achieve as structured techniques become more prevalent.

The Baroque period and its younger cousin Rococo of the 17th and 18th centuries produced, along with many supremely talented artists and excellent art, some excesses and overwrought techniques. The frothy ostentation and turgidity of this period is mirrored in certain radiology reports — the dreaded three pager. We have all seen these occasional pseudo-masterpieces that may be well constructed and entertaining but have little place in the now austere, time-challenged world of medicine. Pity the fool, either radiologist or clinician, who must slog through such pleonastic bathos to glean a few meager shards of useful data. The Rococo style of reporting has, happily, become much less prevalent with the advent of speech recognition and self-editing.

The Flemish Baroque period featured an extraordinary and prolific artist, Sir Peter Paul Rubens. As his art became more popular, Rubens was besieged with commissions and despite his energy (he began each day at 4 a.m.), he needed to employ other artists to help complete his vast number of works. Consequently, several of Ruben’s assistants, including Van Dyck and Jan Brueghel the Elder, went on to become well known masters in their own right. This arrangement is reflected today in the radiology residency program. Our residents often do the majority of work and create the reports that ultimately contain our signature. Perhaps an annotation such as “From the studio of Dr. David Weiss” would be more appropriate in such cases.

The bulk of my exhibit would be devoted to the Impressionism of the late 19th century. After all, most experts agree that all radiology reports should contain an impression. One such luminary, Dr. N. Reed Dunnick, Chair of Radiology at the University of Michigan Health System, has also weighed in on radiologist training. At a recent meeting of the Association of University Radiologists, he opined that there is a place for the general radiologist — the cemetery. Henri Rousseau was a self-trained Parisian Symbolist who painted toward the end of the Impressionist period. His fellow artists considered him talented but somewhat gullible and slow-witted. While he was accepted as a member of their circle, he was often teased and subjected to pranks and ridicule. As a general radiologist myself, I have a certain empathy for Rousseau and his simplistic style. I cannot approach the consummate artistry of the classically trained specialists of The Dunnick School with their bold brush strokes, muted tones and occasional explosion of palette. Nevertheless, I prefer to believe that my oeuvre, like the epigonic Rousseau, projects a certain primitive energy and unspoiled naïveté.

One Impressionist contemporary, George Seurat, developed the painting style known as pointillism. This method consists of the meticulous and organized application of small dots of color to a canvas. When completed, the separate points visually fuse to form a grainy, yet pleasing, aesthetic. Using this highly systematic and rigorous technique, Seurat required years to create a single work — he completed only seven major paintings in his relatively short career. Current structured reporting software also requires the tedious insertion of multiple data elements for report creation. Until a more streamlined approach is developed, this labor-intensive technique will remain unpopular for mainstream radiology reporting.

In the 1940s, the now famous Jackson Pollock began experimenting with drip paintings, creating a reticular network of random, intersecting thin lines of color. Pollock’s groundbreaking technique is emblematic of the 20th century movment known as Abstract Expressionism. His paintings often remind me of the confounding CT patterns of interstitial lung disease. Disturbingly, my reports of these cases tend also toward the “It means whatever you want it to mean” philosophy of the Abstract Expressionists.

The last feature of my exhibit would be devoted to two modern artists. In 1917, French Dadaist Marcel Duchamp turned a porcelain urinal upside down and signed it “R Mutt.” Postwar artist Robert Rauschenberg bridged the gap between the Dada movement and Abstract Expressionism. He once created a stuffed goat encircled with an automobile tire standing on a collage. Both artists were attempting to redefine what constitutes art and demonstrate that any materials or media can be used to create objets d’art. Our own current movement toward multimedia reporting, though still a work in progress, is similarly breaking the constraints of mere textual description of images, incorporating novel ways to both create and display medical information. In the future, new ideas and technologies will continue to enable innovative forms of communication that may be unrecognizable by today’s standards.