Defensive Medicine and the “Incidental Finding”

With today’s increasing use of sophisticated imaging and the increasing  precision of today’s imaging studies, more and more incidental findings are turning up – findings that would not have been noticed even five years ago.  Incidental findings are those which were not the subject of the test but happen to be noticed in the image.  They can range from a lung cancer nodule, to an enlarged organ to tiny dots of unknown significance and everything in between.  The debate in the medical community is what should a radiologist do when an image he or she is interpreting contains an incidental finding.

Sometimes the answer is clear.  If the incidental finding indicates the presence or possible presence of serious disease, it must be disclosed to the ordering physician and to the patient.  When the incidental finding is insignificant or apparently so, the question becomes more difficult.  To report every incidental finding is to run the risk of overwhelming the system and damaging the patient as incidental findings very often lead to more testing, which may beget even more testing and ultimately treatment.

There is a legitimate concern among radiologists that to fail to report an incidental finding exposes them to a malpractice claim should the incidental finding ever turn out to have been evidence of serious disease.  “Better safe than sorry.” is the operative philosophy here.  This usually means that the radiologist remarks upon the existence of the incidental finding and its possible significance and then tosses the ball back to the ordering physician with the observation that “clinical correlation should be considered.”  In other words, you, ordering physician, have to decide what to do about this.  This usually prompts more testing and perhaps even surgery for what may turn out to have been a false alarm.

A recent article in the Wall Street Journal discusses the ethical issues surrounding this question.  Ethicists are trying to develop guidelines based on scientific evidence rather than leave everything up in the air.  Unnecessary testing and unnecessary treatment are not good for the system or for the individual patient.  How to follow up on those findings which have the greatest chance of being significant without following up on everything out of fear of second guessing is the issue with which the profession is struggling.

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