Daniel McCollum MD
Take Home Points
- Written instructions are critical for patients with incidental findings.
- Instruct the patient to have a conversation with primary care about the need for additional work-up or imaging.
- In patients with high risk findings, make referrals yourself or copy primary care doctors on your note.
- Stress the importance of close follow-up.
- A 67 year old man presents with abdominal pain. A CT is obtained as part of his work-up. Hydronephrosis was not found but there was an incidental liver mass detected that was several centimeters across. The patient was discharged. Neither he nor his wife could remember being told about the mass. There was no written documentation provided about this findings. Two years later the liver mass was found to be metastatic cancer. What are we supposed to do about incidental findings?
- Incidental findings are something you weren’t looking for but discovered. These are classically radiographic. A nodule on chest x-ray or adrenal mass. It could also be lab values or blood found in the stool or urine.
- How common are these?A 2013 Annals of Emergency Medicine article found further imaging was recommended in 4.5% of radiology reports but the patient was informed of this less than half the time.
- Dutta, S et al. Automated detection using natural language processing of radiologists recommendations for additional imaging of incidental findings. Ann Emerg Med. 2013 Aug;62(2):162-9.PMID: 23548405
- A 2011 article found that a third of emergency department CT studies have incidental findings but less than 10% were mentioned in the discharge paperwork.
- Thompson, RJ et al. Incidental findings on CT scans in the emergency department. Emerg Med Int. 2011;2011:624847.PMID: 22046542
- This is not unique to patients in the emergency department.One study found that only 27% of trauma patients admitted with an incidental finding received further inpatient work-up, outpatient referrals or discharge information.
- Munk, MD et al. Frequency and follow-up of incidental findings on trauma computed tomography scans: experience at a level one trauma center. J Emerg Med. 2010 Apr;38(3):346-50.PMID: 18804935
- How should we approach this? Patients can be categorized into three groups; the “likely-nothings”, the “almost-certainly-somethings”, and the “I’m-not-sures”.
- The “likely nothings”.For example, patients with incidental adnexal masses. They have less than 1% chance of being malignant. It is benign 99% of the time. Adrenal adenomas lead to cancer only 1.2% of the time. Almost all cancerous adrenal adenomas were greater than 5 cm. The vast majority were metastatic lesions in patients with cancer. In patients without cancer, an adrenal adenoma is cancerous only 1 out of 300 times. Even among high-risk smokers (greater than 50 years of age with a 20 pack year smoking history), only about 2.6% of lung nodules were cancerous.
- What do you do? You need written and verbal instructions. Direct the patient to have a conversation with primary care. It is hard to defend a case if you didn’t provide written findings.
- If you have a concerning finding, it is possible the primary care doctor is already aware of it. They may have already assessed that the patient would not benefit from further testing. Maybe the 85 year old should not have further work-up of their liver mass as further testing might hurt them. Encourage the patient to have a conversation with their primary care doctor. Don’t tell them they need a CT, etc.
- The “almost-certainly-something”. For example, highly concerning masses or obvious evidence of metastatic spread.
- It is critical for these patients to get immediate follow-up with primary care and/or appropriate specialists. If it is within your system’s capability, forward your emergency department note to the primary care doctor. This is an excellent form of closed loop communication to make sure the primary care doctor is aware of a concerning finding on the CT. You can also make a referral from the emergency department to an appropriate specialist, highlighting the concerning finding.
- Recruit a family member if at all possible. Preferably in person but you can call someone if the patient likes. This makes sure there is someone other than the patient aware of this concerning finding so they can encourage the patient to get follow-up.
- It is a tightrope between the uncertainty of the work-up with the fact that the findings are concerning. “The pictures are very concerning but most cancers require us to get a piece of it to be sure.” Stress they need to be on the phone the next day to inquire about a referral and discuss with the primary care doctor.
- Not every patient with newly diagnosed cancer has to be admitted to the hospital. If you are in an efficient system that allows for close follow-up, that is great but have a low threshold to admit.
- The “I’m-not-sure” patients. These intermediate patients are some of the most difficult cases. You aren’t really sure if the radiology or laboratory findings were concerning or not. If you have the time, consider getting additional testing to push these patients into the low risk or high risk category but don’t feel obligated to work-up all these patients. Consider your other patients, resources and waiting room.
- The incidental liver mass was discovered to be metastatic cancer two years later. This was discovered by an excellent work-up in the emergency department during a follow-up visit for an unrelated reason. The patient was too sick to consider chemotherapy. He was placed on hospice where he lived for another eight months.
- That patient was McCollum’s father. This is difficult for him to talk about. His mother wanted him to share it with other emergency medicine doctors so it would be less likely to happen to another patient or family. They decided to not pursue medical malpractice claims against the original ED provider. They felt using the case as something purely educational would be more beneficial. He forgives the original provider. Emergency medicine is an impossible challenge. We are tasked every day with doing what is beyond any one human’s capability. We can’t be perfect. We all make mistakes.
- Missed incidental findings are a systems error not just an individual error. His father was not informed of the findings by the urologist he followed up with or his primary care physician. The radiology read could have been clearer.
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Dallas H. - May 8, 2019 11:47 AM
Thank you for sharing your story. It will definitely improve my clinical practice.
Nicholas L. - May 31, 2019 2:43 PM
I also give the patient/family the radiology report with incidental finding and rads recommended follow up testing highlighted. I ask them to bring this to their PCP/specialist follow up.
Daniel M. - July 9, 2019 6:42 PM
That's a great pearl! Doesn't take much longer and saves you the time of typing it out again.
gm - June 24, 2019 9:41 PM
Agree with Dallas - this story will also make me a better doctor. Thank you for sharing.
Daniel M. - July 9, 2019 6:43 PM
Thank you all for your interest! It is nice to have something positive come from this.
John C. - March 9, 2021 7:15 AM
I feel like a broken record repeating this to my clinical staff, maybe the problem is none of them know what a broken record is :)