A patient presents to the emergency room after suffering trauma to the hip following a motor vehicle accident. A CT study of the pelvis to assess the injury is performed. The study reveals a broken hip, but also something else. A suspicious lesion on the kidney is noted. This lesion, which was unrelated to the accident and would normally not have been discovered had the accident not occurred, is known as an "incidental finding".
The Wall Street Journal reported on the phenomenon of incidental findings in "A Diagnosis Doctors Overlook" published on November 11, 2014. Incidental findings are previously undiagnosed conditions that are discovered during an evaluation of an unrelated condition. The discovery of incidental findings give physicians a chance to treat the patient early which can result in a better prognosis or at times, save a life.
Early diagnosis can be critical when dealing with time sensitive diseases such as cancers. When cancer is diagnosed at an early stage before it metastasizes, the prognosis is often much better. Many cancers can be successfully treated if identified in their early stages. When cancer grows, prognosis, treatment success and treatment options decline. The prognosis for most advanced staged cancers is generally quite poor.
Benign conditions may also benefit from an early diagnosis. The incidental finding may warrant early treatment or close monitoring to ensure that the condition does not worsen. The threat imposed by an advancing benign condition may vary from patient to patient. Heart conditions, acute kidney disease, endocrinological disorders and many autoimmune diseases often have less morbidity when diagnosed and treated at an early stage.
Modern technologies in medical record management allows physicians ready access to patients health information. Medical records are now maintained in electronic databases which can be easily accessed and shared among treating physicians. Sending medical records and radiology studies to outside facilities can be accomplished by electronic mail. Having better access to patients medical records by more physicians increase the opportunity for the discovery of incidental findings.
It is clear that patients must be made aware of and something done about an incidental finding, otherwise the discovery is moot. But whose responsibility is it to advise the patient and to follow up on findings? Is the interpreting radiologist responsible to report the kidney lesion to the patient? Must all physicians who read a report containing an incidental finding notify the patient of the lesion? Whose job is it to see that there is appropriate follow up care related to the finding? Is it the responsibility of every physician who knows of the finding to assure that the patient is aware of it and is referred for proper treatment? Will there be a medical malpractice claim if the patient is not notified?
Clearly the attending or "managing" physician bears the primary responsibility of seeing to it that the patient is properly advised and understands the implications of the finding. This notification must be documented in the medical records. The physicians who encountered the finding must make the attending physician aware of the condition and document that communication. Wherever practicable, a follow up by that doctor with the attending to assure that the information was given to the patient is recommended and should be documented.
Although there is some concern about subjecting patients to unnecessary tests and their associated costs in order to "work up" an incidental finding, it is apparent that the discovery of the findings will be beneficial to some patients. To the patient whose life may be in the balance, the finding is worth everything.
With the vast number of diagnostic tests being performed daily, incidental findings occur regularly. These findings mandate a heightened level of diligence to be sure that they are appreciated and acted upon. All incidental findings should be noted in the medical records and reported to the patient and the managing physician. Managing physicians must evaluate and steer the patient to proper follow up attention.
When incidental findings "slip through the cracks" and are not reported to the patient, the situation is ripe for a medical malpractice claim.
A common setting where incidental findings surface is the annual physical examination. The scope of an annual examination varies widely depending upon the patient's medical history, age, complaints and the practices of the examining physician. The examinations should include at least a comprehensive interview, a "head to toe" physical examination, blood work and an occasional chest x-ray. During the interview phase of the examination the physician should discuss with the patient any new physical complaints, nutrition practices, changes in social circumstances and medical history. This inquiry may lead to further testing, such as an EKG, echocardiogram or laboratory studies. The annual examination has long been the recommended minimum health care standard that the average adult person should receive.
Some skepticism has recently been expressed as to the benefits of the annual exam. On the Op-Ed page of The New York Times in an article entitled "Skip Your Annual Physical" published on January 8, 2015, the author, a physician, recommended against annual physical examinations.
Those who argue that the annual physical examination is a costly waste of time refer to a study performed at the Nordic Cochrane Center in Copenhagen in 2012. Over 182,000 people were studied from 1963 through 1999, each for a median of 9 years. The study concluded that general health exams (in Denmark) do not reduce morbidity or mortality. The applicability of the study is an issue since there may be significant physiological differences between the Danish people and their health care system, particularly a study that dates back to over 50 years ago.
Those who support annual examinations maintain that there is a substantial value in simply providing a patient with the assurance that he or she is in good health. In other situations, an early diagnosis of, for example a heart abnormality, may allow the condition to be stabilized before it advances to an irreversible state. The routine blood test can reflect the beginning stages of renal disease which can be successfully managed only if caught early. A patient who might mention a mild symptom during the interview which would not be enough to warrant a visit to the emergency room, might be reporting a significant early symptom worthy of investigation.
Incidental findings reveal pathological conditions that are unexpected. Whether it is a suspicious lung lesion discovered during a screening chest x-ray or a blood test abnormality, such critical findings may allow physicians to treat conditions before they worsen and are refractive to treatment.
Opinions regarding the usefulness of annual examinations will continue to be debated as to whether such examinations can reveal life threatening conditions that can be "nipped in the bud".
If knowledge gives us an advantage, then a chance to learn something about ourselves should not be overlooked. It might be said that the annual physical examination is a costly burden on the health care system for the vast majority of individuals who leave the examining room without incidence. Those patients who are only diagnosed with a condition after it has advanced and become irreversible because it was not uncovered at an early stage certainly have a different point of view. And the reassurance of a healthy outcome is of value to many.
So, is it "worth it" to throw those few whose early diagnosis would save their lives under the bus for the sake of saving money? Is sparing the pocket book a humane consideration in this context? I think not.
"A Diagnosis Doctors Overlook" from the Wall Street Journal (November 11, 2014)
"Skip you Annual Physical" from The New York Times (January 8, 2015)
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