Two Words in a Results Letter Tell Patients the Opposite of What You Mean

MammoCommunicate · Patient Communication · Richard D. Lippert Jr., President & Founder, Mammologix · Breast Imaging Operations since 1995

Positive and negative are clear to a radiologist and backwards to the woman reading them at her kitchen table. Here is what the research shows, and the plain words that work better in the patient summary.

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Picture the moment a woman opens the letter from the imaging center and reads that her mammogram was negative. Her stomach drops. Negative. She keeps reading and learns that negative is the good word here: nothing of concern, come back next year. The fear was real, and one word caused it, a word that means one thing in a report and close to the opposite at a kitchen table. The scene is a composite, but anyone who has fielded the follow-up phone calls has heard it.

Two words can cause a surprising amount of avoidable confusion, and they're the two a results letter reaches for first: positive and negative. They're precise, they're standard, and in a note meant for a patient they're among the riskiest words available.

What the research shows

Federal rules already take the patient's side here. Since September 2024, the amended Mammography Quality Standards Act has required every facility to send each patient a lay summary of her results written in terms a non-specialist can understand.¹ The rule says the summary must be plain. It doesn't say which plain words work. That part is where the research comes in.

The clearest evidence doesn't come from breast imaging. It comes from a randomized trial in Germany that tested how ordinary people read test results. More than eleven hundred adults, matched by the country's age, gender, and education, each read the same result written in one of two ways. When it was framed as positive versus negative, 54 percent of readers without a medical background understood it correctly. When the same result was written as abnormal versus normal, 65 percent did. Same finding, different adjectives, and eleven more readers in every hundred got it right.² The trial used a breath-test scenario, not a mammogram, so the numbers shouldn't be read as a measurement of breast imaging letters. The direction is the useful part: neutral, descriptive words land better than words that carry a judgment in everyday speech.

The reason these two words fail is that they flip what they mean in ordinary life. Outside a clinic, positive is the good column and negative is the bad one. A positive attitude, a negative review. Inside testing the logic reverses: a positive result found the thing being looked for, and a negative result didn't. For a cancer screen, that makes negative the result a patient wants and positive is the one that calls for a closer look. The letter is asking the reader to hold two opposite meanings in mind and pick the medical one under stress. Many don't.

Patients say so in their own words. In a study of how people read results in online portals, one man described opening an HIV result that read reactive and nonreactive instead of the plain negative he expected — and not knowing what he was looking at.³ The problem is common enough that a 2023 review of these barriers was titled, plainly, When Positive Is Negative.⁴

What to write instead

The fix has a real limit, and it matters. It does not mean stripping required terminology out of the official report. The amended MQSA still requires that report to carry the final assessment in fixed categories, and Negative is one of them. The American College of Radiology recommends the report show both the word and the category, such as BI-RADS® Category 1, Negative.⁵ That language belongs in the report to the referring provider. The patient's lay summary is a different document with a different job.

In the lay summary, the move is to lead with the plain meaning. Instead of telling a patient her mammogram was negative, the letter can say it looked normal and that no signs of cancer were seen. If a required term must appear, it reads better after the plain explanation, with the term defined rather than left to be decoded. A result that needs follow-up deserves the same care: the radiologist saw something that needs another look, more pictures are needed, and this is common and usually not cancer. ACR's own sample lay letters, revised in 2024, take this approach and pair any abnormal summary with a clear next step.⁵ The descriptive version says what happened and what to do in the same breath, so the reader doesn't have to translate.

This isn't about dumbing down a result. Swapping one clinical word for another wouldn't help much, because abnormal on its own can frighten a patient as easily as positive does. The gain comes from plain description. Phrases like looked normal or more pictures are needed are honest, because they say what the image showed instead of scoring it good or bad — and they're the wording the research found people understand.

A low-cost patient-safety improvement

There's a quiet reason this matters more than it looks like it should. Most efforts to make breast imaging safer cost real money and take years: new equipment, new tracking systems, more staff. Rewriting a lay-summary template costs almost nothing and can be done this quarter. It's a low-cost patient-safety improvement, and it lives in a document the facility is already required to send, in the exact moment a patient is most anxious and least able to decode clinical shorthand. That's the moment to use words that land the first time.

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Sources

1. US Food and Drug Administration. Important information: final rule to amend the Mammography Quality Standards Act (MQSA). Enforcement effective September 10, 2024. fda.gov

2. Auschra C, Müller J, Berthod O, Mazheika Y, Borusiak P. Communicating test results in a comprehensible manner: a randomized controlled trial of word usage in doctor-patient communication. Z Evid Fortbild Qual Gesundhwes. 2020;156–157:40–49. doi:10.1016/j.zefq.2020.07.007

3. Zhang Z, Citardi D, Xing A, Luo X, Lu Y, He Z. Patient challenges and needs in comprehending laboratory test results: mixed methods study. J Med Internet Res. 2020;22(12):e18725. doi:10.2196/18725

4. Lazaro G. When positive is negative: health literacy barriers to patient access to clinical laboratory test results. J Appl Lab Med. 2023;8(6):1133–1147. doi:10.1093/jalm/jfad045

5. American College of Radiology. Mammography (sample) lay report letters. Revised September 2024. acr.org