The surgical pathology report represents the focal point for determining the clinical management of cancer and it therefore is a highly technical document in which the details must be clearly articulated and logically presented. However there are wide variations in report formats, styles, and contents, which are often designed to demonstrate the wealth of histological detail accumulated rather than a clear concise report aimed at patient care decision-making.
In the last decade studies have shown that a change from the traditional narrative style of report to a structured or synoptic style significantly enhances the completeness and quality of data provided to clinicians17-21. This change standardises the information within a pathology report (using approved data elements) as well as the way in which this information is structured (discrete question and answer). There are several publications which review the types of information to be included in these cancer specific report (examples22-23) as well as national standards published by the US24, UK25, and Australia26. Some publications which favour structured or synoptic reporting while focussing on content also include broad recommendations in regard to placement of information and style such as “placing all demographic information in the top portion of the report”; making sure “printing is of sufficient quality to be read easily”. However on the whole little has been done on the investigation of appropriate style (text layout) in which to display the recommended information.
The standardisation of style and layout has been recognised as a safety mechanism in health such as the development of the Australian National Inpatient Medication Chart (NIMC)28, the 2009 report by NEHTA on the pathology industry29, the RANZCR Radiology Written Report Guideline Project30, the National Health Service(UK) Common User Interface (CUI)31, as well as in other industries such as that described by Valenstein2 in the standardisation of aircraft instrumentation in the post war era. This is largely to do with consistency in positioning and style; having the same information presented in the same relative position and manner each time thereby avoiding delay in locating and recognising critical information. Consistency in presentation facilitates human perception, cognition, visual scanning, learning and remembering32. The facilitation of learning and remembering occurs by matching each visual stimuli to a stored representation33, allowing a user to quickly view and then understand the information being displayed. According to Ponton34 consistency should be applied to font, colours, terms, units, layouts , typography, margins amongst other characteristics.
Nygren et al35,36,37 in their analyses of the way in which doctors searched medical records, observed that doctors tended to skimmed rapidly over pages of text while continuously making assessments of relevance. Experienced physicians had developed perceptual skills that enabled them to use pattern-recognition as a complement to normal reading. So given the same content, document structure and format determined the time and effort needed for relevant information to be extracted. Consistency of format assisted in the speed of the ‘skimming’ process and enabled doctors to find the information they needed faster. They found that a standardised set of headings and subheadings in a predefined order enabled the doctors to locate themselves in lengthy documents. Indenting of subheadings created visual landmarks, making specific data items easier to find. This information grouping was also noted to improve decision making in ICU’s as well38. Similar findings were also noted with respect to abstracts by Hartley39 who recommended that texts be opened-up and clearly subdivided into their component parts, so that readers perceive their structure and the information should be sequenced in a consistent order under consistent subheadings to facilitate search and retrieval.
This consistency in style (layout) supports the development of a “cognitive map”. Cognitive maps enable a user to analyse and interpret the information available to them at speed40 and orientate themselves through an area/display. Cognitive maps are generally discussed in wayfinding literature, that is, car or pedestrian travel; and more recently in 3D virtual environments. As a user ‘interacts’ with a certain layout or display they acquire information and start to form an internal cognitive model of the structure, organisation, and relationships between the parts34.
There is also evidence that the style (text layout) in which information is presented significantly influences clinical decisions in a range of different medical settings such as the accuracy of obstetric judgements41, to the speed of interpreting laboratory tests42,or the review of intensive care data43. Elting’s study44, showed that doctors’ decisions can be manipulated by changing the format of words and data, for example, by presenting information in tables, graphs, or pictograms.