At the AACN Conference in Chicago (June 2019), Dean Beebe Ph.D. presented on how to write better pediatric reports. I was thrilled to attend this presentation and heartened to see so many others there. The presentation essentially covered the material in these 2 articles, both of which are important reads. (Unfortunately both are behind a paywall unless you have access to The Clinical Neuropsychologist):
Baum KT, von Thomsen C, Elam M, Murphy C, Gerstle M, Austin CA & Beebe DW (2018). Communication is Key: The Utility of a Revised Neuropsychological Report Format.
Postal K, Chow C, Jung S, Erickson-Moreo, K, Geier F & Lanca M (2018). The stakeholders' project in neuropsychological report writing: a survey of neuropsychologists' and referral sources' views of neuropsychological reports.
The focus of both articles (and the first part of the presentation) is that consumers and referral sources tell us pediatric reports are:
Too long
Too time-consuming to write
Written at a reading level above what most of the audience can actually read (see for example my colleagues' and my poster on report readability)
Include extraneous information
Include too much jargon
Include a "wall of words." That is, long paragraphs, limited white space, and limited use of other visual formatting to orient the reader like bullets, bold, headings, table of contents, etc.
Bury the important information at the end
Give short-shrift to the summary and recommendations (the most important parts)
Given this info, it's clear the solution is to write shorter, more efficient, better organized, and more readable reports. The only question is.... how? If you're like me, you've seen a variety of report-writing suggestions before. These suggestions, which you've encountered in books and from supervisors, boil down to a few "common sense" strategies like:
Stop including every single piece of info about the child in the report
Try dictating, and of course
Just write less
As you've no doubt discovered, these "common sense" suggestions aren't actually all that helpful. Before we start the conversation on what actually might be helpful, it's worth stopping to examine these questions:
Why hasn't a general awareness of the problem and a few "common sense" strategies translated into shorter, more effective reports in our field? If we know what the problem is and have some ideas about what would solve the problem, why haven't we solved it?
Well, it's because there are complex, interrelated, and systemic reasons why most pediatric reports are really long. That is, there are barriers to writing shorter reports. Without first acknowledging the barriers to writing shorter reports, we risk having a conversation that continues to go nowhere. That is, we risk getting stuck at the stage where everyone wants to write better reports and no one actually does write shorter reports.
We have to identify these barriers and begin to address or dismantle the systemic issues keeping them in place before we can chart out a path to our goal. I've written before about these barriers in a post to the Pediatric Neuropsychology listserv. If you read that listserv, the following may be familiar, as I adapted it from a post from February 15 2019.
So, here are what I see as some of the barriers:
The Selection Problem
Many people who test kids are people who can write long, dense, nuanced, and rich text. And they are people who appreciate and value this style of writing. In fact, some of us have achieved much of our academic and career success primarily due to this ability. We may have selected our current career precisely because it's a good match for our skillset. Many people who test kids may also be exquisitely able to hold a lot of ideas and data in our mind at once. This makes the "need" to "prioritize" which important data to include and which important data to leave out for brevity's sake quite counter-intuitive and unappealing.
The Training Problem
Our field uses an apprenticeship training model, where you basically learn to write reports the way your supervisor(s) write them. If you happen to get a pithy supervisor, you might be in luck. Of course, woe betide the trainee who gets me as a supervisor, when I can't even write a short email. And if you turn to the few available books for ideas on how to write reports, those books mostly reinforce the status quo. In fact, your reports will probably get longer, because the books give you more ideas about what to include in your reports. (I mean, for goodness sake, even the BASC and BRIEF interpretative reports can run up to 40-50 pages long!) The books also offer very few practical suggestions on how to make your reports shorter, beyond of course "don't include all the milestones."
Lack of Consensus on the Important Elements
It's clear from every book ever written about reports that we're supposed to include only the "essential" stuff in a report. We're supposed to leave out the unessential stuff that is making reports too long. But..... what is that essential stuff exactly? Every single report I read includes different essential material. I see reports that primarily include the following sections, and reports that completely exclude the following sections (and everything in between):
A detailed and thorough history
The child's strengths
The process of how a child got a test score
Confidence intervals, percentiles, grade equivalents, W scores, etc
Real-world explanations of what the scores might mean for the child
Examples of answers the child produced (e.g., samples of their language, or spelling)
Rich behavior observations and info obtained from clinical interview
Detailed recommendations (beyond the 3 recommendations research says people can actually follow)
I could go on, but you get the idea....
Lack of Feedback from Stakeholders
Our main work product is our report, yet we have almost no real data about how useful, readable, memorable, or therapeutic our reports are. We sometimes have anecdotal data, in the form of comments from parents or referral sources. However, most of that is from parents who have nothing to compare our reports to because their child has never had another report. Or, the info comes from parents and referral sources who are comparing our reports to similar reports. (Though, see the Baum et al article above where they actually did compare 2 versions of the same report). We know from articles like Postal et al that many parents can't read our reports and physicians hate how long they take to write. Yet, many other parents and professionals tell us they "love" some aspect of our report that adds to the length. (This is often some part that seems baffling for them to value, like the test results section). And.... that's about all we know so far. It's hard to make a product more useful when we know almost nothing about how useful our product is currently, and why (or why not) any given part is useful.
Lack of Training in Effective Communication
I did not receive any training in effective information-communication methods in graduate school. Did you? There are whole disciplines dedicated to this question that we are ignorant of. As such, I can't even answer basic questions like:
Is it better to start with the main idea and work down to the details, or to start with the details and work up? (Related link: This post with some ideas on how to organize a summary, based on research in the field of library science.)
Is it better to start with the good news or the bad news?
What's the best way to deliver bad news? (Related link: This post on the SPIKES protocol doctors have developed for delivering bad news)
If the info is going to surprise the listener, is it better to give examples, or will examples give the reader something to 'argue' with in their head?
Can people actually follow more than 3 recommendations if they have a written list to refer to?
I've been using a reverse pyramid style for my reports recently where I start with the summary/impressions. Is there any data on if that's a good idea?
This list of basic questions I have no answer to could go on for days. Steve Finn and colleagues' model of feedback provision (featuring level 1, 2, and 3 information and specific guidelines about how much of each level to include and how to do it) is the only model I am aware of regarding these basic communication ideas (I'd love to know of others if they're out there!). How are we supposed to write better reports if we can't answer basic questions about how to best communicate?
Gender and Ethnicity
Speaking in wide generalizations , men are rewarded for being more direct and concise, whereas women are viewed as aggressive and arrogant for the same style. Failing to acknowledge this, and the impact it has on why some people write longer reports, is deeply problematic. I can't speak to what it would be like to be a person of color or whose second (or third) language is English, etc., but those factors also have to be part of the conversation about the potential barriers to writing shorter reports.
Practice Setting
Setting (and market) matter. This is not to say that those in private practice see more (or less) complex kids than people in medical settings. But, practice setting does have very practical implications for report length. In private practice, your report is your marketing. You don't have the allure of the hospital to bring in clients. Your clients are all people who have seen one of your reports, or people who know someone who has seen one of your reports. If you write long reports because that's how you were trained, the people who call you saw one of your long reports and want that.
This creates a virtuous/vicious cycle. You've created a market that appreciates and values long, nuanced, detailed reports. Maybe your market even specifically does not want the medical-style report their child got at the hospital last year. Some of our beliefs about what are market "wants" are in our head (e.g., I've halved my report length and it hasn't been that bad). However, some aren't (e.g., I've halved my report length and it definitely hasn't gone unnoticed by my customers!).
Time
At least at first, it takes to write something shorter. This means if you want to write shorter reports, you're going need to find extra time to do so. You'll have to spend extra time to do something that does not come naturally to you and that you're not sure your market wants. This problem was first noted by Blaise Pascal in his famous apology about a letter he was writing to a friend:
"I have made this longer than usual because I have not had time to make it shorter ." - Blaise Pascal
The High Stakes Problem
The families and kids who come to see us are in real distress, and the stakes are high. We all respond to this pressure by trying to write the best report we know how to write. For some people, that best report is a long, detailed, nuanced report. I'm still bumbling around trying to write shorter reports. It's hard to "experiment" with a shorter report style I know won't be my best work (since I'm still figuring it out) when I've got a real kid in front of me who needs my best work. These are hard circumstances to try to innovate under. The Money Problem
It's a truth universally acknowledged that psychologists and other helping professionals have mixed feelings about our monetary value. There are dozens of books and podcasts devoted to this problem. Helping professionals feel uncomfortable asking our clients for money. In private practice, this can lead to a strong pull to "justify" how much we charge by producing a tangible product that shows how hard we worked. I would imagine this is especially true for people who do not take insurance. This is something that we can and should develop more comfort around. However, we can't have the "shorter reports" conversation without acknowledging that this particular elephant is in the room.
This post is an effort to start the conversation about the systemic problems. As always, I'm so curious about others' thoughts!
In future posts, I hope to spark some discussion about how to overcome those barriers. I also hope to talk about ideas for how to actually write shorter and better reports. In the meantime, here's a post I wrote trying out a summary section that's written at the 9th grade reading level.
Note: The reading level of this post about 7th grade. This post is 152 sentences long. 36 of the sentences are "hard to read" and 11 are "very hard to read. There are 4 uses of the passive voice.
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