Write it Backwards!

The Typical Report Organization:
Skilled formal neuropsychological (NP) report writing can take many years to develop. After seeing a patient, a trainee can write a 20-page report with pages of background information, give as many tests as possible and then describe the test and in minute detail its results, then s/he will organize those test findings under headings: e.g., Intelligence Test Results, Language Testing, Visuo-constructive Performance, Emotional Findings, etc. Finally the report may culminate in a summary. Lost in that 20-page report (the forest) are the answers to the initial referral questions (the trees). It seems as if the student puts everything down on paper in hope that the reader will divine the answers to the clinical questions from the content, rather than analyze the findings. S/he hopes that the more information written down, the more likely the answers will lie in there, somewhere, for the reader (often the patient and family, teacher or doctor) to devine.

In reality, the reader (usually a patient and their family) hired the psychologist for their expert opinion of what is causing a problem. With that information the reader believes the diagnosis will yield a treatment. Basically, it that opinion of what is going on (diagnostic formulation) with recommendations for its treatment that they really want to know. That can often be stated in a single paragraph, which is why most doctors read only a cover letter hoping for such a paragraph rather than deal with the 20-page report. That single paragraph requires the diagnostician to be able to make sense of the findings of multiple tests. To best do that, we need to start with a clear statement of the problems creating the medical necessity for the NP evaluation, if Medicare and other insurances are to pay for it.

The Problem Statement:
Given the average 7-minute doctor’s appointment, medical schools now teach students to spend the first minutes of an exam listening and refining the “problem statement” so as to laser focus their limited exam time. One reason is to avoid looking at too many issues, as medical insurance only pays for examination of a single problem per visit. So, step one is figuring out just one or two primary issues, that will comprise the problem statement, from the forest of complaints a patient/family brings to an assessment. This is important, as everything then flows from that specific statement of the problem(s).

Process Testing:
With a specific problem or two, the examiner can then design a test battery to objectively rule in/out hypothetical causes for those problems. In neuropsychology some factors are relevant in all cases and, thus, are tested/interviewed for in almost all patients; e.g., in a dementia evaluation level of premorbid IQ and educational background/level, short-term memory, word-finding and verbal fluency will always be assessed.

As hypotheses are ruled in or out, new questions arise and additional tests selected to follow those leads. This is called the “process approach” and a patient may be asked to come back for a second visit where even more tests are administered laser focused on more refined hypotheses.

Once a set of hypotheses is supported by the objective test results, the examiner should have in their head a good idea of what s/he believes is wrong (i.e., relative weaknesses unique to the patient) and what is right (their relative strengths) and how these strengths and weakness cause/affect the problem being evaluated. When that is done, hypothesis testing is complete and now it is time to write the report.

Report Writing:
Rather than generate a written Background covering Everything, Everywhere all at Once – the background should present only data relevant to the findings; i.e., the final hypothesized answers to the one or two problem statements. Thinking this way drastically reduces the length of the Background section of the report. So write the DSM5 Diagnoses (or brief narative formulation if preferred) first, and then write the Summary section. There should be nothing in the Summary not relevant to the Diagnoses. Next write the Test Results, which should only reflect what is stated in the Summary, for example:

Mr. Bill Smith, an 81-year-old widower, has reported short-term memory loss, social withdrawal and word-finding difficulty following the sudden death of his wife 13 months ago. The patient's daughter notes these problems have gradually worsened over the past year, leading his PCP to request this neuropsychological evaluation of possible neurocognitive disorder (NCD) vs. depression (pseudo-dementia) over unresolved grief. At this testing, Mr. Smith displayed evidence of Average premorbid intellectual ability. General measures of cognitive capacity (orientation, mental control, and visa-constructive ability) along with tests of reasoning (e.g., solving metaphors and determining similarities among different concepts) and long-term recall for remote events all fell within normal limits (WNL) for age and educational level. Tests of language function (e.g. word-finding and verbal fluency) and formal measures of cued and uncued short-term memory yielded results WNL arguing against NCD. In contrast, emotional measures found evidence of moderate depression with anxious features marked by unresolved grief. Treatment options with psychotropic medication, support group and individual counseling were offered…

Everything the patient, family and PCP need to know from the evaluation is in one paragraph. Test results can be expounded on, briefly, as another psychologist may need to know what they were if the patient is retested in future. The list of tests should be present for insurance documentation. Recommendations will likely have already been outlined, regarding options of prevention/treatment always emphasizing a patient’s strengths (cf. Testing Philosophy).

But, wait we have to do Observations. Once again, 90% of the observations should be directly relevant to the conclusions. One can eliminate much of the typical jargon in a NP report, if it is not called for by the results; e.g.

Mr. Smith presented as a thin, neatly dressed man appearing younger than his chronological age of 81. He was right-handed for all drawing and writing tasks and he displayed a normal pencil grasp with horizontal orthography, showing appropriate grammatical and syntactic content his his written language output. He rarely initiated conversation and interpersonal affect was flattened. Expressive speech was fluent without paraphasic errors. He became tearful when discussing his wife. However, his mood brightened with the challenge of this testing, and given his good effort all results are believed valid.

The Background can now be written, and need only include information relevant to Diagnosing and Recommendations. A short background covering:

How long was the patient married and are there interested adult children who could be enlisted to help carry out Recommendations. What medical conditions and medications (over-the-counter and prescribed) are being taken (or neglected) in this patient's diagnostic picture. What is his prior psychiatric history (any previous history of depression now exacerbated by grief?). What treatments, like counseling or psychiatric consultation, have been used and which worked before that could be used again. If the patient is a veteran as VA benefits could be used for treatment to pay for companionship via the VA aid-in-attendance benefit.

The report's Background should review previous social interests, hobbies and activities need to be described as they would be used in Recommendations to re-activate the patient from his withdrawal. Also, his activities of daily living, both basic and instrumental, should be described as they are used diagnostically to rule in/out NCD. And, so on. The Background becomes tight, directly relevant to the patient's unique situation and is as brief as possible.

Finally, the Problem Statement is written, which is easy since everything in the report, already written, and informs what problems were ultimately assessed. The method here evolved from this writer’s experience writing his dissertation at the Pennsylvania State University.*
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*When I showed the first 200+ page draft of my dissertation to my chief advisor, Dr. John Salvia of PSU, he glanced at the long Literature Review and said I had way too much information not relevant to the answers my research yielded at the end of the project. He told me to start over. As I had completed the research, analysis and knew what my findings were – he said write the dissertation backwards. In other words, write the Literature Review last, and start with the last chapter summarizing the findings and implications. I did not understand, but I followed his instructions of course.

So, I wrote the Results chapter stating only information directly relevant to the theoretical questions asked; I expounded on nothing else except the implications for future research. Next I wrote the Methods chapter, describing only what I did for research and statistics to yield the answers I had written up in the Summary. Then I wrote up the Literature Review, but only cited information relevant to what was presented in the Methods and Summary chapters. Lastly, I wrote the Introduction, which defined the purpose of the research; I.e., stating the problems the research attempted to address.

When finished, and edited for tightness, It was 65 pages long when I submitted it. At my defense one of my advisors actually hefted the finished product in his hand, saying “Seems a little thin [on content]?” I had brought the original draft, and when I pulled out that behemoth copy and plopped it on the table, I said “Would you have preferred to read the original draft?” He said not another word during my defense, and later my advisor rewrote the entire project (I was out of energy) and it was accepted at the premier refereed journal in my clinical area of study and continues to be referenced today. The article says everything needed about the year-long project, in just six pages.