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Is Infiltrate a Useful Term in the Interpretation of Chest Radiographs? Physician Survey Results¹

¹ From the Departments of Pediatrics (H.S.P.) and Radiology (D.N.S.), Walter Reed Army Medical Center, 16000 Georgia Ave, Washington, DC 20307. Received June 24, 2002; revision requested August 22; final revision received May 31, 2004; accepted June 23. Address correspondence to H.S.P. (e-mail: harlan.patterson@na.amedd.army.mil).

	ABSTRACT

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PURPOSE: To determine how physicians interpret the word infiltrate when it is used in a chest radiography report and if the word is helpful in the clinical management of patients.

MATERIALS AND METHODS: Informed consent from participants was not required, and the study protocol was granted exempt status. One hundred sixty-five questionnaires were distributed, in conjunction with various physician meetings, at three separate nonaffiliated training hospitals. In the three-question survey, respondents were asked the definition of infiltrate, whether the term is helpful in guiding patient therapy, and whether it implies an etiology. The respondent demographic data obtained included date of graduation from medical school, amount of postgraduate training completed, primary or training specialty, and board or sub-board qualification.

RESULTS: There were 151 physician respondents, 94 (62.3%) of whom were house staff members. One hundred fifteen (76%) responders chose bacterial pneumonia as a condition consistent with infiltrate. One hundred thirty (86.1%) respondents replied that infiltrate implied more than one pathophysiologic condition. Eighty-two (54.3%) of those surveyed thought infiltrate could mean any of six or more different pathophysiologic conditions, including nonspecific pneumonia, interstitial pneumonia, viral pneumonia, consolidation, or nonspecific interstitial process. The number of terms selected did not vary according to level of residency training (P = .23); however, there was a significant specialty-related difference in the number of terms selected (P = .018). Internists selected a median of 10 terms, while others selected a median of six. Only 54 (36%) respondents thought that the term infiltrate was helpful in patient care, and only five (3%) thought that the term implied an etiology.

CONCLUSION: Infiltrate is a nonspecific and imprecise term when it is used as a radiograph descriptor, and use of this term does not usually enhance patient care.

	INTRODUCTION

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Language is a tool and sometimes the only tool with which the consultant may influence patient care. It is through this medium that the transfer of information occurs and has the optimal result of enhancing patient care. As with communications in general, the communication between the consulted and the consulter is not always easy. The radiography report (consult) must communicate precisely and in terms that facilitate a common understanding so that the correct information can be transferred (1,2). While there are many articles on the standardization and formatting of radiography reporting, most of them address the convention and consistency of vocabulary.

We have been unable to find articles that objectively address the issue of specific terms in the medical lexicon and whether these words actually communicate the intended messages. We would hope that all communications between physicians would have the intended outcome of correctly influencing the treatment of patients. In our experience, use of the word infiltrate by a radiology consultant can sometimes lead to further questionsfrom the clinician and thus delay the implementation of therapy. Inappropriate assumptions that both parties to a message agree on the common use of a term can be erroneous. Thus, the purpose of our study was to determine how physicians interpret the word infiltrate when it is used in a chest radiography report and if the word is helpful in aiding the clinical management of patients.

	MATERIALS AND METHODS

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We designed a three-question survey to determine whether the term infiltrate is useful to clinicians when it is included in a radiography report. The respondents documented their demographic data, including work position; date of graduation from medical school; amount of training received; primary or training specialty; board or sub-board qualification; and whether their primary work responsibility was patient care, research, or administration. The survey was administered to physicians at three separate and nonaffiliated training hospitals during a 3-month period. In conjunction with a meeting or training session, physicians were asked to participate in the survey. Participation in the survey was voluntary, and other than an explanation of the purpose of the study, no encouragement to participate was offered. All physicians who desired to fill out the questionnaire were allowed to do so.

The survey was conducted anonymously. Informed consent from participants was not required, and the study protocol was granted exempt status by the Walter Reed Army Medical Center Department of Clinical Investigation.

The survey questions were as follows:

1. Check any of the following terms (Table 1) you think are consistent with or implied by the descriptive term infiltrate.

The responses were analyzed by the statistical analysis section of the Department of Clinical Investigation at Walter Reed Army Medical Center. Computer statistical programs (SPSS for Windows, version 10.0, SPSS, Chicago, Ill; StatXact3, version 3.1, Cytel Software, Cambridge, Mass) were used to perform the data analyses. The number of terms used to answer question 1 was compared among the demographic groups by using Kruskal-Wallis one-way analysis of variance. Proportions were compared among groups by using the Fisher-Freeman-Halton exact test. P < .05 was considered to indicate significance.

	RESULTS

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Of the 165 surveys distributed and collected, 151 were selected for inclusion in this study. Responses were excluded when they indicated inappropriate credentials—that is, when the respondent was not a physician—or when the respondent provided incomplete demographic data or partially answered questions. There were 151 physician respondents, 11 (7.3%) of whom were fellows, 94 (62.3%) of whom were residents or interns, and 46 (30.5%) of whom were staff members. The numbers of years since their graduation from medical school ranged from 1 to 23, with 51.0% of respondents having graduated between 1 and 3 years ago (relative to the time of the survey). The following specialties and/or areas of training were reported: pediatrics (n = 70), none (n = 61), family practice (n = 9), internal medicine (n = 4), anesthesiology (n = 3), radiology (n = 3), and emergency medicine (n = 1). Fifty-six respondents had board certifications, and 19 had sub-board certifications. Almost all (n = 145) of the respondents listed patient care as their primary work responsibility.

The mean number of terms listed by each respondent as being consistent with infiltrate was 5.7 (standard deviation, ±3.2; median, 6.0). The number of terms used to define infiltrate did not differ significantly according to training level (P = .23, Kruskal-Wallis one-way analysis of variance). Interns selected a median of six terms (range, 0–13); residents, a median of six terms (range, 0–12); and staff and/or fellows, a median of six terms (range, 0–14). The same analysis revealed a significant specialty-related difference in the number of terms selected (P = .018). Internists selected a median of 10 terms (range, 7–12) compared with pediatricians, who selected a median of six terms (range, 0–14); all others selected a median of six terms (range, 0–13).

One respondent failed to provide an answer to question 2. There were no significant differences in response (P = .35) based on the respondent’s position and/or training with use of the Pearson ² test. The answers to question 2 were combined into two response groups for analysis. Answers 4 and 5 comprised the "helpful" response group, while answers 1, 2, and 3 were combined to form the "not helpful" response group. Only 54 (36%; 95% CI: 28%, 45%) of the physicians responded that the term infiltrate was helpful in guiding patient therapy. There was no significant difference in the percentage of interns who described the term infiltrate as helpful (39%, n = 24), as compared with the percentages of residents (34%, n = 11) and staff members or fellows (33%) who described the term as helpful (P = .76, Fisher-Freeman-Halton exact test). There also was no significant difference with respect to specialties (P = .23).

Answers to question 3 were analyzed with respect to the answers given to question 2. All respondents who reported that infiltrate was not helpful in question 2 also answered that it did not imply an etiology. Fifty-four (36%) respondents believed the term was helpful, but 91% (n = 137) of them reported that it did not imply an etiology.

	DISCUSSION

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The definition of infiltrate is context dependent. One definition is used in pathophysiologic descriptions, and another is commonly used by radiologists. In the pathophysiologic sense, infiltrate refers to "an abnormal substance that accumulates gradually in cells or body tissues" (3) or "any substance or type of cell that occurs within or spreads as through the interstices (interstitium and/or alveoli) of the lung, that is foreign to the lung, or that accumulates in greater than normal quantity within it" (4). In the radiologic sense, infiltrate generally means "any poorly defined opacity in the lung" (4). Is this nuance in definition always appreciated by the clinician? Do radiologists then sometimes unwittingly provide an unhelpful and ambiguous "hedge" as an interpretation? The results of this study suggest that this may occur more frequently than has been previously appreciated.

It is interesting that so many terms can be associated with the word infiltrate. Fifty percent of the physicians we surveyed thought that the term could mean any of six different pathophysiologic conditions. This response was consistent among those surveyed and was not confined to any one specific training level or position. Pediatrics was the most represented specialty, but there were almost as many respondents who did not list a specialty or specialty training. In general, the median number of definitions given for infiltrate by specialists was consistent with the median number of terms listed by all respondents. Internists were the exception, and their median number of pathophysiologic conditions consistent with infiltrate was 10. Although this difference was statistically significant, the number of internists surveyed was small, so we must be careful in drawing conclusions.

Question 2 was an attempt to address the end result of using the word infiltrate as a radiograph descriptor—that is, whether the clinician’s knowledge of the patient’s condition is enhanced by the use of this term. We suggest that if the use of infiltrate actually facilitated a transfer of meaningful information to the clinician, as the terms pneumothorax and mediastinal shift do, then by using the term, a clinician might gain insight into the pathophysiologic features of the condition and thereby facilitate the development of a narrowed differential diagnosis and consequently a therapeutic plan for a given patient. We sought to determine whether treating physicians understood their patient’s condition better when the word infiltrate was used in the chest radiography report. Since the term is used so commonly, we expected to find that most clinicians perceived it to be helpful. However, only 36% of the respondents thought that it was helpful in guiding therapy. The reason for this outcome is unclear, but responses were consistent across all strata.

Likewise, almost two-thirds of those surveyed reported that use of the term infiltrate was not helpful. While one cannot reliably conclude from this study that two-thirds of the medical community does not find the word helpful, one can justifiably propose that a sizeable portion of any medical community might be better served if the term was restricted from common use. Granted, there are times when imprecision or ambiguity is necessary in a description; however, we maintain that all would be better served if such uncertainties in interpretations were expressed in a more forthright manner. It is unclear whether the respondents to our survey understood that the preservation of uncertainty can be appropriate in some cases and sometimes helpful when interpretation uncertainties exist.

The answers to question 1 lead us to believe that infiltrate is a nonspecific term, at least from a pathophysiologic standpoint, and according to the answers to question 3, only 3% of the respondents thought that this word implied an etiology. While it is encouraging that most clinicians did not incorrectly perceive that this term reflects an etiology, the question of exactly what the term does imply remains. What it does imply is dependent on the understanding of the radiologic definition.

What does the term infiltrate really mean to the individual practitioner? It must be a largely nonspecific term whose usefulness is mainly that of connoting an abnormality within the lungs. There is, then, a distinct disadvantage to using the word infiltrate as a chest radiograph descriptor. Who among us has not seen a radiograph interpretation report that states that an infiltrate is present? Would not all parties be better served if a different word or phrase were used, as recommended by the Fleischner Society (4)?

The results of this study should not be interpreted as indicating that all medical specialties find the term infiltrate confusing or not useful. The results can, however, be interpreted as evidence that a substantial part of the medical community does not find the term helpful or to convey useful information. Infiltrate can thus be an impediment to proper communications since it is a term that is subject to misinterpretation. This impediment can be a problem for the receiver, as well as the originator, of a message. Both should have a common understanding of what the originator intends to convey. The English language provides a wide choice of words with subtle differences in meaning that allow a communicator to be exquisitely accurate when proffering an interpretation. However, when words are not properly understood, erroneous conclusions can be drawn.

Discussion about whether the term infiltrate is appropriate for general use is divided along two lines of opinion: that the term may be a helpful descriptor and that the term is too general to be useful (4–7). Until now, these discussions, although passionate, have focused on convention rather than utility and efficiency. To our knowledge, there have been no published studies that provide objective data that support either school of thought. Although this study involved the use of a small survey and had inherent limitations, its results provide objective evidence that the term infiltrate is such an inexact term that a substantial number of clinicians do not find its use helpful in guiding patient care. Despite the alacrity with which some radiology practitioners use infiltrate, the term seems to provide little insight into the disease process affecting a given patient. The use of this word could help guide the clinician in one respect, however—that of preserving the message that more information is needed. In this case, the use of infiltrate usually implies the presence of something abnormal that requires further diagnostic clarification.

Infiltrate has more meanings than may be commonly perceived by the radiology community. It is a nonspecific term that can represent any of at least 14 pathophysiologic conditions, as shown in our study. Does using the term infiltrate as a radiograph descriptor relay information that is of use to the clinician in patient care? We maintain that since this word is subject to various pathophysiologic interpretations, using it can impede efficient decision making. It may not be as much of a problem as we first believed: Few clinicians thought that the term implied an etiology. On the other hand, only a small number of respondents perceived its use as having a positive influence on patient care—that is, as being helpful in clinical management. Terms such as opacity and opacification might be less subject to misinterpretation, and, thus, using them might increase the clinician’s likelihood of correctly understanding the pathophysiologic features or anatomic location of an abnormality.

Is the lesion most likely within an airway? Is it large or small? Is it more likely to be in the alveolus, respiratory bronchiole, or interstitium? It seems that the answers to these questions might prove to be helpful in clinical management. After all, a more thorough understanding of the patient and of whatever process is occurring inside him or her is what the radiology consultant is called on to provide. Interestingly, in the glossary of terms for computed tomography (CT) of the chest recommended by the Fleischner Society, infiltrate is not listed as a descriptor (8). Although ambiguous descriptors are occasionally needed to properly communicate, it may well be that with a more precise examination, such as CT of the chest, the need for imprecise descriptors is lessened. Even the best radiologist is uncertain at times. Communicating this uncertainty in a meaningful and enlightening manner is part of the art of radiology.

Results of this study show that the proper relay of information is at risk when the commonly used term infiltrate is used as a chest radiograph descriptor. Although we agree that there are cases in which the chest radiologist must describe an abnormality in general and nonspecific terms, we maintain that a description that does not include the term infiltrate is more likely meaningful for the clinician and thus more beneficial to the patient.

	FOOTNOTES

 
² Current address: Department of Radiology, Medina Memorial Hospital, Medina, NY.

Authors stated no financial relationship to disclose.

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.

Author contributions: Guarantors of integrity of entire study, D.N.S., H.S.P.; study concepts and design, D.N.S., H.S.P.; literature research, H.S.P.; clinical studies, H.S.P.; data acquisition and analysis/interpretation, H.S.P.; statistical analysis, H.S.P.; manuscript preparation, H.S.P.; manuscript definition of intellectual content, editing, revision/review, and final version approval, D.N.S., H.S.P.

	REFERENCES

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1. Towers MJ. Etymology and misused terms in radiology (letter). AJR Am J Roentgenol 1993; 161:445-446.[Medline]
2. Daves ML. Language of certainty. AJR Am J Roentgenol 1986; 147:209-210.[Free Full Text]
3. The American heritage Stedman’s medical dictionary Boston, Mass: Houghton Mifflin, 2002.
4. Tuddenham WJ. Glossary of terms for thoracic radiology: recommendations of the nomenclature committee of the Fleischner Society. AJR Am J Roentgenol 1984; 143:509-517.[Free Full Text]
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8. Austin JH, Muller NL, Friedman PJ, et al. Glossary of terms for CT of the lungs: recommendations of the Nomenclature Committee of the Fleischner Society. Radiology 1996; 200:327-331.[Free Full Text]

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