ACR Bulletin

Covering topics relevant to the practice of radiology

The Ambiguity Fallacy

By using specific radiology lexicons, radiologists can ensure clinician understanding and facilitate inclusion in cancer registries.
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“The patient can now hold not only their own primary care doctor accountable, but now they can hold the radiologist accountable for how the radiologist chooses his words.”

—Frank Landino, DO
July 08, 2021

Ambiguity is certainly medicine’s foe. Vague language in radiology reports has long been a point of debate — by both imagers and referring clinicians who receive reports. At the VA Medical Center in Martinsburg, W.Va., two staff members decided to combat this problem. Their 2019 article, “Ambiguous terminology in your reports…do YOU really know what it means in reporting cancer cases?” aims to help radiologists understand how ambiguous terminology can negatively impact a patient’s inclusion  in cancer registries — therefore affecting lifetime care, unnecessary testing, and financial burdens. The Bulletin sat down with Sheryl L. Goins, RHIT, CTR, surgical service cancer registrar, and Frank Landino, DO, staff radiologist, both at the Martinsburg VA Medical Center, to discuss their project and the powerful consequences of vague terminology.

How did you come up with this project?
FL: I would say that most radiologists probably are not aware of the specific ambiguous terminology lexicon outlined in the Standards for Oncology Registry Entry (STORE). We didn't develop the lexicon ourselves, but we are rediscovering it, so to speak, in terms of presenting this lexicon to the radiology community.
SG: The 2018 STORE manual is what all cancer registrars across the U.S. use while abstracting cancer cases. This ensures unified instructions for the information going into the registries. 

Why is the terminology so important for decisions about the registry?
SG: If the radiologist says that there’s a nodule and it is likely lung cancer, the cancer registrars will not pick it up. But if a radiologist says its most likely lung cancer, we will pick it up. Once the patient’s information is entered into the cancer registry database, the cancer registrars follow that patient for their lifetime. We pick it up if they have any recurrences or if they have additional treatment, so their data continues. Ultimately, that’s how the American Cancer Society comes up with the statistics that we all rely on — it all comes from the grassroots effort at the hospitals. That's why it’s really important that the radiologists all over the U.S. know the importance of consistent terminology. 

What are some of the consequences of using ambiguous terminology? 
: Without clear terminology, patents may not be included in the databases and captured in state files. As a result, the government makes decisions to increase the number of dollars spent based on prostate or cervical cancer cases. It could have financial implications for hospitals. 

FL: The use of ambiguous terminology also affects the clinical administrative burden on the physician and can significantly influence how the patient is clinically managed. Clinicians may not understand some of the ambiguous terminology, and they are struggling to manage the patient as accurately as possible. If there’s a common understanding of this lexicon, the clinical administrative burden could be reduced. 

Will the provider’s understanding and the patient’s empowerment hinge on how radiologists present findings?

FL:I think it promotes specific elaboration from the provider in terms of the clinical history that’s given to the radiologist when reviewing this study. A more precise elaboration of that clinical history will guide the radiologists in reading the case — and as a result, the radiologist will be able to select the most appropriate words from the lexicon, which would drive the case to be categorized correctly in the cancer registry. EMRs are now available to patients in their homes, on their phones, and in their cars. The patient is now empowered to be more involved in their own care because they have access to their own medical records. They can now advocate for themselves in a more informed way — and because of that, it creates accountability. The patient can now hold not only their own primary care doctor accountable, but now they can hold radiologists accountable for how they choose their words.