The Words Count — Radiology and Medical Linguistics
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《新英格兰医药杂志》
Thanks to European Union (EU) regulations, I, an Irishman, was recently permitted to pursue a radiology fellowship in France. Though free movement of labor within the EU is legal, it is not necessarily easy — not least because of language barriers. I soon came to appreciate that language is the lifeblood of radiologists. I also discovered that much of what we think is determined by what we can say.
When I arrived, I was proficient enough in French to formulate a radiology report, though it involved a long, painful process of interpreting the images and mentally translating my thoughts into French. My reports were short and full of curt, declarative sentences that read like barked military orders. ("The right lung is normal. In the left upper lobe there is a mass. A big mass. 5x6 cm. Probably lung cancer.") Subordinate clauses, subjunctives, and commas went out the window. When asked my opinion about something, I could only point to the relevant images and describe abnormalities as "cancer" or "infection," "big" or "small." There were no gray areas, no doubts, no conjectures. Sitting on the fence — a radiologist's stock in trade — necessitates using words for balance, weighing diagnostic probabilities, and leaning toward the heavier side. But because I couldn't use the subjunctive mood, I was forced into the realm of apparent diagnostic certainty.
Outside the interpreting room, things were even more difficult. Routine tasks such as triaging patients, choosing scan protocols, and having coffee involved multilateral conversations and usually required as much goodwill as medical knowledge. I became big on goodwill: I quickly recognized the power of "yes" — a self-sufficient word that enables things to happen, scans to be performed, and opinions to be verified. I didn't even have to understand what I was assenting to. Most clinicians will take a "yes" from a radiologist and run with it. A "no," by contrast, requires explanations and argument. So I said "yes" frequently and pretended I knew what was going on.
Fluency, however, involves more than uttering grammatically correct sentences with a comprehensible accent; the speaker must also get the words out of his mouth before everyone has left the room. Mentally translating from English into French was slow and bereft of spontaneity, and my utterances lost half their intended meaning owing to poor word choice and lack of context (my audience having moved on to other topics by the time I managed to express myself). I had to start thinking in French and using the language available to me, rather than groping for expressions to fit English thoughts. This required some dumbing down. I laughed at silly jokes (I laughed at any joke I could understand) and talked about the weather a lot. But at least I was talking more — and to people, rather than at them; profundity could follow when it might.
Back in the reading room, thinking in French had unexpected, enlightening consequences for my radiology reports. I stopped using sterile words plucked from a database of memorized vocabulary and began to use terms and expressions picked up from interactions with radiology colleagues and physicians. Instead of being my own translator, I began to speak the language used by the readers of my reports.
But I still had to formulate a message — to interpret images, a process that begins with the description of imaging abnormalities. In English, I had at my disposal an arsenal of semiologic terms for translating complex images into simple words. This is the basis of semiology, the science of signs — the recognition that certain signs mean something and others do not. The language of radiology includes myriad semiologic terms to help radiologists describe imaging signs, but these terms may not carry the same resonance for nonradiologists. When I was a junior clinician, before becoming a radiologist, I used to find radiology reports peppered with terms I didn't understand and descriptions the significance of which escaped me — what exactly were ground-glass opacities and tree-in-bud nodules? Was band atelectasis worse than other types of atelectasis, and could it explain why my patient was dyspneic? Is cephalization of blood flow good or bad? These, it turned out, are semiologic terms, not diagnoses; they help radiologists interpret images by corralling a range of appearances into a narrower set of diagnostic possibilities. Diagnoses, in turn, often rest on the application of unifying semantic — that is, descriptive — terms.
(Figure)
Tree-in-Bud Nodules — Arbre en Bourgeons (Left) and Ground-Glass Opacities — Verre Dépolis (Right).
Thus, in interpreting an image, one must translate into the language of clinicians by way of the language of radiologists. The radiologist is a sort of linguist, aiming to convey the meaning and significance of imaging abnormalities in a way that will enhance clinical care.
Words shape the way we look at things. Possessing the appropriate language to describe complex signs allows us to assimilate varied and nonspecific appearances that we would otherwise strain to analyze and fit into some pathologic pattern — or end up ignoring. It lets us present findings by means of a ready-made term that conveys, accurately and quickly, both their nature and their potential clinical importance.
Having the language available thus facilitates not only translation but also interpretation. The ability to describe the appearances of end-stage pulmonary fibrosis as "honeycombing" permits pattern recognition, sparing us the necessity of boiling down the appearance into intralobular and interlobular septal thickening, cystic airspace destruction, airspace dilatation, and bronchiolectasis. Similarly, the extensive disorganization and bony destruction of neuropathic arthropathy can seem overwhelming if you don't know that this pattern can be described as "Charcot's joint."
In my initial few months in France, I did not have a sufficient storehouse of French semiologic terms to describe and interpret imaging abnormalities. Without the words to shape my thoughts when I looked at an image, I had difficulty analyzing its semiologic information and, ultimately, interpreting it. Mentally translating my interpretation into foreign words took time, mainly because my limited vocabulary equipped me poorly for dealing with complex reasoning. When I acquired the right words to express myself, it was easier for me to understand what I was thinking: it is difficult to reason through a problem if you cannot articulate what the problem is.
If my experience in France taught me that radiologic language is complex, it also suggested something broader about communication in medicine. In writing reports, radiologists must use language that is shared by their audience. Since clinicians in different specialties undergo different training, preparing a single report intended for multiple specialties demands a certain agility of expression. As medicine cracks apart into a million different subspecialties, it is important that communication be served by a common language. Maintaining our ability to understand one another will help us read patients' conditions, decipher the signs and symptoms of disease, and translate accurate diagnoses into appropriate medical care.(John F. Bruzzi, F.F.R.R.C)
When I arrived, I was proficient enough in French to formulate a radiology report, though it involved a long, painful process of interpreting the images and mentally translating my thoughts into French. My reports were short and full of curt, declarative sentences that read like barked military orders. ("The right lung is normal. In the left upper lobe there is a mass. A big mass. 5x6 cm. Probably lung cancer.") Subordinate clauses, subjunctives, and commas went out the window. When asked my opinion about something, I could only point to the relevant images and describe abnormalities as "cancer" or "infection," "big" or "small." There were no gray areas, no doubts, no conjectures. Sitting on the fence — a radiologist's stock in trade — necessitates using words for balance, weighing diagnostic probabilities, and leaning toward the heavier side. But because I couldn't use the subjunctive mood, I was forced into the realm of apparent diagnostic certainty.
Outside the interpreting room, things were even more difficult. Routine tasks such as triaging patients, choosing scan protocols, and having coffee involved multilateral conversations and usually required as much goodwill as medical knowledge. I became big on goodwill: I quickly recognized the power of "yes" — a self-sufficient word that enables things to happen, scans to be performed, and opinions to be verified. I didn't even have to understand what I was assenting to. Most clinicians will take a "yes" from a radiologist and run with it. A "no," by contrast, requires explanations and argument. So I said "yes" frequently and pretended I knew what was going on.
Fluency, however, involves more than uttering grammatically correct sentences with a comprehensible accent; the speaker must also get the words out of his mouth before everyone has left the room. Mentally translating from English into French was slow and bereft of spontaneity, and my utterances lost half their intended meaning owing to poor word choice and lack of context (my audience having moved on to other topics by the time I managed to express myself). I had to start thinking in French and using the language available to me, rather than groping for expressions to fit English thoughts. This required some dumbing down. I laughed at silly jokes (I laughed at any joke I could understand) and talked about the weather a lot. But at least I was talking more — and to people, rather than at them; profundity could follow when it might.
Back in the reading room, thinking in French had unexpected, enlightening consequences for my radiology reports. I stopped using sterile words plucked from a database of memorized vocabulary and began to use terms and expressions picked up from interactions with radiology colleagues and physicians. Instead of being my own translator, I began to speak the language used by the readers of my reports.
But I still had to formulate a message — to interpret images, a process that begins with the description of imaging abnormalities. In English, I had at my disposal an arsenal of semiologic terms for translating complex images into simple words. This is the basis of semiology, the science of signs — the recognition that certain signs mean something and others do not. The language of radiology includes myriad semiologic terms to help radiologists describe imaging signs, but these terms may not carry the same resonance for nonradiologists. When I was a junior clinician, before becoming a radiologist, I used to find radiology reports peppered with terms I didn't understand and descriptions the significance of which escaped me — what exactly were ground-glass opacities and tree-in-bud nodules? Was band atelectasis worse than other types of atelectasis, and could it explain why my patient was dyspneic? Is cephalization of blood flow good or bad? These, it turned out, are semiologic terms, not diagnoses; they help radiologists interpret images by corralling a range of appearances into a narrower set of diagnostic possibilities. Diagnoses, in turn, often rest on the application of unifying semantic — that is, descriptive — terms.
(Figure)
Tree-in-Bud Nodules — Arbre en Bourgeons (Left) and Ground-Glass Opacities — Verre Dépolis (Right).
Thus, in interpreting an image, one must translate into the language of clinicians by way of the language of radiologists. The radiologist is a sort of linguist, aiming to convey the meaning and significance of imaging abnormalities in a way that will enhance clinical care.
Words shape the way we look at things. Possessing the appropriate language to describe complex signs allows us to assimilate varied and nonspecific appearances that we would otherwise strain to analyze and fit into some pathologic pattern — or end up ignoring. It lets us present findings by means of a ready-made term that conveys, accurately and quickly, both their nature and their potential clinical importance.
Having the language available thus facilitates not only translation but also interpretation. The ability to describe the appearances of end-stage pulmonary fibrosis as "honeycombing" permits pattern recognition, sparing us the necessity of boiling down the appearance into intralobular and interlobular septal thickening, cystic airspace destruction, airspace dilatation, and bronchiolectasis. Similarly, the extensive disorganization and bony destruction of neuropathic arthropathy can seem overwhelming if you don't know that this pattern can be described as "Charcot's joint."
In my initial few months in France, I did not have a sufficient storehouse of French semiologic terms to describe and interpret imaging abnormalities. Without the words to shape my thoughts when I looked at an image, I had difficulty analyzing its semiologic information and, ultimately, interpreting it. Mentally translating my interpretation into foreign words took time, mainly because my limited vocabulary equipped me poorly for dealing with complex reasoning. When I acquired the right words to express myself, it was easier for me to understand what I was thinking: it is difficult to reason through a problem if you cannot articulate what the problem is.
If my experience in France taught me that radiologic language is complex, it also suggested something broader about communication in medicine. In writing reports, radiologists must use language that is shared by their audience. Since clinicians in different specialties undergo different training, preparing a single report intended for multiple specialties demands a certain agility of expression. As medicine cracks apart into a million different subspecialties, it is important that communication be served by a common language. Maintaining our ability to understand one another will help us read patients' conditions, decipher the signs and symptoms of disease, and translate accurate diagnoses into appropriate medical care.(John F. Bruzzi, F.F.R.R.C)