White Paper | Academic Radiology & Residency Training
A New Paradigm in Radiology Reporting
From Image Interpretation to Clinical Decision Architecture
Created by Dr. Sharad Maheshwari, imagingsimplified@gmail.com. 10.01.2026
The Inflection Point
Despite extraordinary advances in imaging technology, radiology reports frequently fail to deliver maximal clinical value—not due to incorrect interpretation, but due to misalignment with clinical decision-making.
We propose a redefinition: the report is no longer a descriptive document; it is a Clinical Decision Instrument.
Core Problem: The Four Failures
Conflating history with indication
Underutilizing prior imaging
Ignoring technical/physical limitations
Summarizing instead of deciding
Stakeholder Alignment
RSNA/ESR Frameworks
NHS Imaging Governance
PubMed/PMC Literature
"Converts expert intuition into explicit, teachable steps for residency training."
The Doctrine Rules
Doctrine Rule 1
The Purpose: History vs. Indication
Clinical History is the patient's context (risk factors, age, sex, chronic conditions). Clinical Indication is the acute question that must be answered today. Conflating the two leads to diagnostic drift.
History: 70F, smoker, PAD, hypertension. Indication: Acute onset severe periumbilical pain. Answer: Rule out Mesenteric Ischemia.
Doctrine Rule 2
Interpretation via Comparison
A report without comparison is incomplete. Change, stability, and progression must be explicitly articulated to define the clinical trajectory.
"Interval 5mm increase in spiculated nodule since [Date]."
Doctrine Rule 3
Technical Doctrine: Precision Acquisition
Parameters (kV, mAs, contrast dose, timing) must be tailored to the patient profile (Age, Sex, Weight) and Indication. A 'standard protocol' is often a diagnostic failure.
Pediatric: Low kV (70-80) to minimize dose while maintaining contrast. Timing: Must match the vascular bed of interest (Portal venous vs. Arterial).
Doctrine Rule 4
Hardware Before Anatomy
In post-operative scans, lines, tubes, and stents come before organs. Anatomy is altered; hardware defines the baseline normality.
Doctrine Rule 5
The Limitation Transparency
A limitation unstated is a diagnostic liability. If motion, suboptimal contrast, or lack of prior imaging limits the study, it must be stated as a "Diagnostic Contract" boundary.
"Suboptimal arterial timing limits assessment for subtle hypervascular lesions."
Doctrine Rule 6
The Defining Moment
Every report must actively search for and declare its Defining Moment (Medical → Surgical pivot finding).
Doctrine Rule 7
The Clinical Impression: Alignment & Hierarchy
The Impression is the final clinical decision. Line 1 MUST answer the indication. Prioritize findings based on management impact (Defining Moments) rather than anatomical size or alphabetical order.
Impression Line 1: No evidence of acute mesenteric ischemia.
Hierarchy: Life-threats > New Findings > Chronic stability.
Supporting Evidence Synthesis
Impact of Prior Comparison on Management
Source Entity
Reporting Focus
Alignment
AJR Oncology
Comparison Impact
30% Change
RSNA Templates
Structured Data
High
NHS Audits
Safety/L&T
Mandatory
Malpractice Data
Failure to Compare
Root Cause
Epistemology: The Diagnostic Contract
Transparency in limitations isn't about admitting failure; it's about defining the bounds of certainty.
Timing
Invalidates vascular phase if suboptimal
Motion
Limits assessment of subtle bowel enhancement
Contrast
Prerequisite for organ-specific characterization
The Defining Moment Concept
The central innovation of this architecture is the formalization of the "Defining Moment." This is the specific finding that triggers a management pivot.
Medical → Surgical
Active extravasation in a trauma patient; complete bowel obstruction with transition point.
Surgical → Conservative
Identification of a pseudocyst rather than a neoplastic collection; confirmation of ileus over obstruction.
Curative → Palliative
Distant metastatic disease in a patient previously scheduled for primary resection.
Mandatory Checkpoints by Entity
PancreatitisCollections, necrosis, venous patency
Ovarian CAPeritoneal nodules, omental cake
Bowel IschemiaArterial patency, pneumatosis
Competency Assessment
Test your alignment with the Decision Architecture Paradigm.
1. According to Doctrine Rule 4, what should be described first in a post-operative patient?
2. What is the fundamental difference between Clinical History and Clinical Indication?
🎓
Residency Competency Achieved
You have demonstrated understanding of the Clinical Decision Architecture framework.
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