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Incidental Findings helping or scaring patients?

With American healthcare under strain of an aging population and rising expectations for early disease detection and correlating life saving treatments, can the system continue to focus on incidental findings? What about the patients caught in the middle?

Proponents of frequent imaging point out that life is precious and costs, no matter how high, are irrelevant when compared to the opposing outcome. After all, incidental findings catch aneurysms, tumors, gall bladder and kidney stones, and kidney obstructions early on. Is this not one of the benefits of having advanced technology in that we can improve lifespan longevity and quality of life during those years? How can human life become little more than an entry on a ledger sheet?

No one advocates doing away with medical imaging, but there are experts who say that we now have a case of too much of a good thing. A ‘majority’ of those incidental findings are slight abnormalities; things noted as being a little off but not enough to raise concerns. Or the findings are so small like the loose nail, which in the overall picture, there is not enough evidence or an adequate sample size to warrant further investigation.

Contrasting the ideas of the more testing the better are the opportunity costs both doctors and patients bear. Patients end up having to miss time from work for each subsequent reassurance test. This is nothing compared to the turmoil and anxiety an individual would experience during the waiting periods for both the test and the outcome.

Anxiety is difficult to quantify but its implications are far-reaching in daily life. Worrying about whether you have the dreaded disease adds to the stress load. Of course, the positive outcome of a false alarm is reassuring but some doctors wonder if the mental anguish is better off avoided altogether.

Another concern is the additional exposure to radiation with each medical screening. Critics warn that all of this radiation may be putting patients at a greater risk of developing the very conditions that they are being tested for in the first place. Some people believe the small risk is worth it if it leads to early detection, others would prefer to avoid tests as much as possible and undergo only the necessary ones.

Just what constitutes 'necessary' and how do doctors even begin to make that distinction?

The referring physician is caught between patient care and the reality of increased medical costs. More testing means more clinical data to sort through and requires even more testing with even more results. Too much information means losing the most important points in all the cacophony. Doctors also complain about extra paperwork and costs involved in requesting referrals to justify the testing.

This sounds mercenary but in a time of doctor shortages, time-crunched physicians would rather put their services to work for more patients and less paper. It is a double-edged sword in deciding what type of care and how much each patient requires. Moreover, if the data is confusing or questionable, healthcare providers are less certain that their decisions are based on the most reliable information versus the latest sound byte.

Radiologists as well as referring physicians also fear the fallout legal fallout of living and operating in a litigious society. The uncertainty of an incidental finding could translate into potential lawsuits down the road if a matter, no matter how small, is not addressed. It is simply easier to order another test than to try and reason with an understandably concerned patient once the lid is off the incidental-finding box.

Human life should not be boiled down to matters of dollars and cents because every life is important and Americans deserve access to the best healthcare technology. But as the costs of maintaining that care soar, the catch-22 will stubbornly remain. Will that loose nail be better off out of sight out of mind? Or should we pick up the hammer no matter what the financial and emotional costs?

This piece draws on the information presented in ‘Incidental Imaging Findings: Strategies to Minimize Their Impact’ Alec J. Megibow, MD, MPH, FACH, New York University – Langone Medical Center, New York, NY as part of the Presidential Symposium “Incidental Findings on Imaging: Friend or Foe?” NAMS 22nd Annual Meeting Washington D.C. 2011.

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