AIM: Should radiology ignore incidental findings?
Not only in radiology, but across medicine, testing is often seen as a free screen, an opportunity to ensure that related physiologic functions and nearby anatomy are in working order.
“Nowadays in medicine we are getting access to more and more information—not just information we have solicited, we get a bunch of information we were not looking for, such as bundled labs or incidental findings on various types of x-rays…This can be a bad thing,” argued Michael L. Volk, MD, MSc, from the division of gastroenterology and hepatology as well as the Center for Behavioral and Decision Sciences in Medicine, both part of the University of Michigan Health System in Ann Arbor.
“We contend that patients would be better served if the medical profession adopted simple interventions to limit physicians' access to unsolicited diagnostic information,” wrote Volk and Peter A. Ubel, MD, from the Fuqua School of Business at Duke University in Durham, N.C.
Volk and Ubel cited a study finding that 7 percent of patients who underwent CT colonography were referred for additional workups due to extracolonic findings. “These workups occurred even though the extracolonic portion of the computed tomographic scan is essentially an average-risk screening for intra-abdominal disease, which is not recommended by any group of experts.”
In an even more extreme, non-radiologic example, the information on rare congenital disorders provided by neonatal testing leads to 25,000 false-positive results each year, with an average of 50 false-positives for every true-positive result.
Aside from costs, Volk contended that these ancillary findings create problems for patients and physicians. The same neonatal study also discovered that, many years ahead, parents who had received false-positive results became significantly more likely to seek medical attention for minor abnormalities in their children.
Volk anticipated that radiologists would be highly receptive to an abandonment of incidental findings, the free screens. “I’m not a radiologist…I’m a liver specialist, and as a specialist, I would like to answer the question that is before me; I don’t want to deal with a heart condition because that is not my area of expertise,” Volk said.
“I imagine a radiologist who is referred an MRI of the spine wants to deal with the spine and not some unexpected thing they see in the kidney because that may not be their area of expertise, it’s unexpected, out of their routine, and they have to figure out a way to deal with that...The other thing is, I think every radiologist worries that they will miss something, and even though that may just be an incidental finding, it is still be something they could get sued over.”
Volk and Ubel acknowledged that both patients and clinicians might find it odd to think that too much medical information can be harmful. “Rationally speaking,” they said, “information on its own should neither harm nor benefit patients.”
The problem comes, however, in that letting potentially important information sit—however remote that potential importance might be—is not easy for patients or physicians. What's more, payors and patients often incentivize further testing. To most, the benefits of testing are obvious, while the harms are less apparent, the authors considered.
“Given the difficulty of ignoring test results, we need to adopt policies and practices that shield us from distracting and unnecessary information,” Volk and Ubel wrote. In their view, blacking out non-indicated anatomy on imaging would be a good start, when possible—effectively placing a screen over these free screenings.
“CT colongraphy is the perfect test for this,” Volk said. “You could black out everything else except the colon. There are other tests too, like a CT of the spine, for instance.”
Other avenues would include limiting the results that computers display unless they exceed a certain threshold, or simply placing stronger emphasis to patients on the preliminary nature of most incidental results.
“Certainly there are going to be instances where ancillary findings will save a patient’s life, but I think there are many more instances where ancillary or incidental findings end up causing more harm than good,” Volk estimated.
“Every radiologist has to deal with this in clinical practice, and they probably would prefer not to, because they’re asked a specific question…and it ends up as a lot of work and worry for the radiologist. I’m sure every radiologist lives in constant fear of missing an incidental finding because that can be a source of lawsuit,” Volk surmised.
In Volk and Ubel’s opinion, in establishing policies that limit the incidental information that radiologists and other physicians can access, “the medical community will have found a way to acknowledge that more information is not always a good thing.”