Delivering Results: Are We Doing it Wrong?

Referral Question

Neuropsychologists are known (read: notorious) for lengthy reports and high-latency report turnaround times. Why do we write such long damn reports? Or, maybe stated more aptly, why are we taught to write such long reports? Is it because we, as psychologists, must document the entirety of a person’s life in the “four corners” of our report? Even if much of the information is not pertinent to the clinical question? Is it our job to summarize the complete medical record? Can we, as individual providers – or as a field – alter the traditions of report writing to be more practical?

As conscientious clinicians, we should seek to improve the effectiveness and quality of our practice, overall, including our throughput (speed and number of reports completed). We all have reports that take longer than others, but the time involved in writing your report, should rarely — if ever — delay any treatment(s).

Relevant History of Presenting Problem

Median report lengths, according to Donders (2001b)[1] (as reported by surveyed neuropsychologists) were five, six, and eight pages in Medical, Rehabilitative, and Private Practice settings, respectively. These numbers don’t even reflect the typically poor typography that characterizes many reports (10 pt. Arial font with very narrow margins anyone?). Data collected[2] for the Stakeholder’s Project In Neuropsychological Report Writing reveal that the average turnaround time for a clinical report is two weeks. Two weeks might be considered fast in some circles, but what about wait times for reports that exceed four weeks? Furthermore, respondents reported spending several hours writing reports that referral sources might not even read in their entirety. This last observation is likely unsurprising to many neuropsychologists.

Social History

There is a parallel between golf instruction and the teaching of certain neuropsychological responsibilities. We promise. Here it goes: if you’re new to the game of golf, your instructor teaches you things like a correct grip, stance, backswing, etc. If you have been playing for a while, then their job is a bit different: they have to initially help you break old/bad habits before they can work on ingraining new/good habits. As it turns out, most “golf lessons” are actually just “hitting lessons.” Hitting lessons are fundamentally different from actual golf lessons. The former focuses on ball striking and other mechanics of the swing; the latter on things like planning one’s approach, playing to the strengths of one’s game, and how to play different shots from different lies, working around obstacles:

“If the wind is in your face, club up one to keep from over-swinging; if your target is inside and the ball is above your feet, move your leading foot a little more up the slope, choke up on the club…; when you’re around the green, look at the distance to the pin - do you want to bump and run, or flop the shot to drop close to the pin?”

Put another way, golf lessons place emphasis on thinking more as a player, and less as a technician. Golf/playing lessons focus more on the goal, with a less rigid view of the individual steps needed to get there. The steps are important, to be sure, but we should not confuse one goal with another. In short, this is a different way to approach the game of golf. A successful approach is not about setting up, thinking about each component of the perfect swing[3]; it centers on delivering the end result and getting to the next target. As one last point, most people take hitting lessons; learning the game of golf is usually secondary.

Now, let’s replace the golf metaphor with broad ideals of neuropsychological education and training. There are “neuropsychological evaluation lessons” and “healthcare provider lessons.” The former deals with the mechanics and art of the neuropsychologist’s job, whereas the latter is patient-centered and goal-oriented.

See what we did there?

Educational History

As graduate students, and later during internship and fellowship training, we are steeped in learning the finest points of the neuropsychological evaluation. I recall the slow progression towards truly internalizing specific knowledge points, like:

‘how many individuals comprised the normative set for Test X?’

or

‘The 22^nd percentile corresponds to a Standard Score of 88 on the Normal Curve.’

I don’t, however, recall any particular emphasis being placed on understanding my role as healthcare provider.

Perhaps this has become more germane as I have learned to engage my patients in more meaningful ways[4]. Either way, our training (necessarily) focuses on the flow of an evaluation and all that it entails. Once the evaluation is complete, it is not uncommon to never see the same patient again[5]. Is this the reason that we so thoroughly document each patient’s history? Indeed, there does not seem to be a universal rationale for why our reports are so long.

Summary & Formulation

I find TED talks mildly annoying.[6] Though possibly an unpopular position, there are people that more or less share my sentiments. In short, I dislike these talks because I feel like there is too much grandstanding, with too little in the actionable solutions department. Indeed, implementing solutions to any given problem is much more challenging than talking about solutions. The point, here, is that this discussion is just another rant in the echo chamber without potentially viable solutions.

Neuropsychological reports are long. Teaching students to write long reports has value, as it forces the consideration of many facets of a patient’s life, and the subsequent consolidation of those facets into a narrative. We must then consider that narrative in the context of (a) the referral question and (b) neuropsychological testing results in order to arrive at a conclusion and answer a/the referral question(s). Beyond graduate school and training, however, generating a novella to answer a referral question is not always necessary. It may, in fact, be harmful to the patient (delay of treatment) and to your professional reputation (’Dr. X still hasn’t gotten that report back to me. It’s been weeks since my patient finished testing). Fortunately, the “problem” of reports being too long is one that has many solutions worth considering. So, let’s talk about some fixes.

Recommendations

Given the goal of delivering optimal care, consider the following questions before/as you write your next report:

• Does your average turnaround time delay treatment in any way?
• Is it acceptable for patients and providers to wait weeks for treatment recommendations?
• Is the patient getting appropriate and/or necessary care in the time between feedback and when they get the report?

In closing, here are some final observations and thoughts:

We know that most people are not reading our full reports, irrespective of audience.[7] So, why not provide an executive summary at the beginning? This way, the reader doesn’t risk sustaining major paper cut injuries to get to the bottom line! Alternatively, is it out of the question for us to write brief, bullet-point reports? Something akin to a progress note can sufficiently answer a referral question, taking up only a single page. There are several advantages to this latter approach.

First, there is a time savings. This is addition by subtraction: we can effectively spend more time on direct, billable hours, rather than spending several hours writing a report, for which we are not being paid directly.

Second, because the report would be inherently shorter, it could be written/dictated and delivered to the referring provider potentially on the same day of assessment. This means that recommendations for treatment could be delivered within 24 hours, say, instead of e.g. two (or more) weeks.

Third, by writing shorter reports, we are more in line with other, similar fields’ professional standards.

A shorter report does not mean that we collected less information or based our opinions on scant information: it means simply that we are delivering the most pertinent information as a means to an expedient delivery of healthcare. At the end of the day, this is the reason why we spent all those years “learning the perfect swing,” right?

References

Donders, J. (2001a). A Survey of Report Writing by Neuropsychologists, I: General Characteristics and Content. The Clinical Neuropsychologist, 15(2), 137–149. http://doi.org/10.1076/clin.15.2.137.1893

Donders, J. (2001b). A Survey of Report Writing by Neuropsychologists, II: Test Data, Report Format, and Document Length. The Clinical Neuropsychologist, 15(2), 150–161. http://doi.org/10.1076/clin.15.2.150.1902

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