Just read this great article in The Atlantic by Danielle Ofri: The Ethical Implications of Incidental Findings  OK, so was posted over a month ago, but lots of things (like this) got in the way of reading it. Then suddenly, I had a lot of free time, and I found it.

I recently had a patient, whom I had not seen in over 2 years, call and ask to be put on prednisone due to an abnormality found on a chest CT ordered for a research study. Turns out she had bronchiectasis that was found “incidentally” during the study.  Clearly systemic steroids carry significant risk, and the patient was nearly asymptomatic, but worried about this finding. So this set off an avalanche of testing and referral to try to figure out what was going on. Of course, her insurance will pay for this, but should it?Should the study in question compensate her for this work-up? Thanks to the ACA, she shouldn’t be denied health insurance because of whatever we find, but she may be denied life insurance, or have other financial repercussions.  Alternatively, we may find something that we could intervene upon and extend her life.

I talk to patients about incidental findings quite frequently. It’s my mantra when trying to talk patients out of the “MRI of my whole body”, and various testing requests that are not indicated. As a primary care doctor, I’m often called upon to explain the scary/confusing findings that were uncovered by a study, the ER, or another physician. Sometimes I find a note in a radiology report that no one else mentioned. Or it might be buried in a discharge summary, but no follow-up was arranged. One study done at a trauma center estimates 1/3 of CT scans done on trauma patients had an incidental finding.  Nearly 2/3 of those were not mentioned in either the H&P or the discharge summary, just hidden in a radiological report.

So, how do you feel about these “incidental findings?” Who’s responsible for the follow-up and cost? For explaining things to the patient in the first place? How do you warn people about the potential for unintended consequences to testing?

Related content:

Another blog picks up this story (and thanks for the House GIF)

There was a Bioethics Commission report on this very topic released recently, here’s a summary from Science and here’s the whole report.