Incidental findings have some PCPs ‘chasing ghosts’

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Primary-care providers (PCPs) trying to explain incidental findings in radiology reports to their patients may be prone to offering insufficient or inappropriate follow-up instructions. The problem points to an opportunity for radiologists to give explicit recommendations along with the results.

However, radiologists making recommendations must recognize that many factors influence how PCPs communicate and manage incidental imaging findings—and rads would have an impossible task trying to take all possible factors into account.

One solution: more radiologists getting better acquainted with more PCPs, who on the whole are more likely to trust, and ask questions of, radiologists they know personally.

That’s one takeaway from a study published in the June edition of  Radiology.

Hanna Zafar, MD, MHS, Perelman School of Medicine at the University of Pennsylvania, and colleagues used semi-structured interviews to explore concerns and perspectives of 30 PCPs (15 family medicine, 15 internal medicine) as they regard receiving and acting on incidental imaging findings.

The researchers’ key observations included the tendency of some PCPs to “feel compelled” to follow up on incidental imaging findings of limited clinical importance.

Often this tendency traced to such difficult-to-anticipate intangibles as low tolerance for ambiguity, institutional or national culture and “fear prompted by outlier reports of malignancy in young patients.”

Zafar and team further found that, absent an explicit recommendation from the radiologist, PCPs may not follow up on unfamiliar incidental findings or those that turn up in an unusual clinical context.

Either way, the end result is sometimes inaction on the part of the PCP.

In the study interviews, some of the 30 PCPs said they prefer a uniform approach to communicating and managing incidental imaging findings, while others claimed to adapt their approach to the patient and the finding.

The study report includes verbatim excerpts from the interviews. One PCP told the researchers:

I always take radiology reports within the context of the system that I work in and understanding that there’s a certain error rate and that a recommendation is a recommendation is a recommendation and that’s that. I’ve also then gotten on the phone with radiologists who say “You have got to do this (follow-up).” And I hear those recommendations within the context of my practice, the context of the relationship I have with the patient, and often the unspoken response, which is “Yeah, and one day you should be a primary care doctor and try and understand what these discussions are about.”

In a quote that inspired the teaser headline framing the study report, another PCP says, “I sometimes wonder how much we are chasing a ghost that is expensive but not necessarily going to lead to better outcomes.”

In their discussion, Zafar et al. note that the communication and management of incidental imaging findings “has gained increasing attention among physicians and policy makers because of the frequency with which these findings are detected during routine clinical testing.”

“Further research is needed,” they conclude, “to determine whether specific changes in radiology reports, such as including evidence-based treatment recommendations for incidental imaging findings, can alleviate patient and PCP distress, enhance communication, increase appropriate imaging use and improve patient outcomes.”

To read the full study report, “‘Chasing a Ghost’: Factors that Influence Primary Care Physicians to Follow Up on Incidental Imaging Findings,”  click here.