Incidentalomas: Are White Papers the Answer?
When it comes to incidental findings, white papers may not give you all the answers, but they're an excellent springboard to a broader conversation.
Management of incidental thyroid nodules doesn't seem like a sexy topic that would capture the interest of many radiologists. A white paper on the topic seems about as dull as an afternoon watching gray paint drying on a wall. Yet the ACR's white paper on incidental thyroid nodules was a big hit. Don't believe me? Just take a look at the "Most Read" articles tab on JACR's homepage.
The top two articles are about managing incidental findings. The only article to beat the white paper on incidental thyroid nodules is about managing incidental abdominal CT findings.
Why all the interest in incidental findings? I suspect many radiologists are looking for leadership and guidance in an area of professional frustration: "So many incidental thyroid nodules, but so little clinically significant thyroid nodules. What should I say? What should I do?" As a chest radiologist, who not infrequently sees thyroid nodules on the uppermost sections of chest CTs, I feel their pain. "Couldn't the CT tech have just started a centimeter higher so I didn't have to see that thing? Now that I've seen it, I can't un-see it," I lament.
Out damn'd spot! Out, I say!– Lady Macbeth in "Macbeth" by William Shakespeare
For chest imagers, the Fleischner Society guidelines for incidental pulmonary nodules on chest CT have already been a helpful go-to for years, especially this handy little reference table:
From: MacMahon H, et al. Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society. Radiology 2005;237:395–400.
The white paper on thyroid nodules follows in the tradition of the above recommendations table of Fleischner Society guidelines in the form of a succinct algorithm for radiologists to refer to (caption details not included):
From: Hoang, JK, et al. Managing Incidental Thyroid Nodules Detected on Imaging: White Paper of the ACR Incidental Thyroid Findings Committee. JACR 2015;12:143–150.
It's so convenient to just reference the white paper in the recommendation section of your report, so that a referring provider can independently read the article (if they choose to) and see the evidence basis for that recommendation.
So I bet you are wondering: if the recommendations in this white paper (and others) are so robust, why is JACR having a tweet chat on this topic? In a perfect, one-size-fits-all world, you could just use the algorithm as is for your report and call it a day. But the ACR White Papers, ACR Appropriateness Criteria, and other evidence-based expert consensus cannot possibly address every conceivable patient-specific circumstance. Physicians aren't expected to abrogate their responsibility to their patients and blindly cede decision-making to guidelines that cannot possibly encompass all scenarios. This is where published recommendations and physician judgment (hopefully) intersect to best meet patient needs.
In addition to their impact on patient care, the popularity of these incidental findings white papers may belie a different motivation for getting a better handle on incidental findings recommendations. It might also hint at why those recommendations may not be strictly followed. In a recent interview, ACR 2015 Leadership Luminary Award winner Leonard Berlin, author of the much-consulted book, Malpractice Issues in Radiology, said,
There have been recent articles looking at scrolling errors, where we tend not to look very closely at the beginning or ending slices in a CT series. As a result, some incidental or peripheral findings get missed. That's an interesting thing that we have to be aware of. We're going to scroll through a bunch of images, but we have to look at the first image and the last image. They can be just as important as are the middle images.
We are reminded that every diagnostic imaging pixel contains data that may be impactful both clinically but also medicolegally. Are you concerned about the potential legal ramifications of closely following (or ignoring) white paper recommendations? Is there something fundamental that needs to be changed in how these recommendations are created? Is the content sufficiently encompassing? What is the best way to disseminate the information in these white papers?
It is in the best interest of radiologists and other providers who are using these white papers for guidance to give feedback to ACR leaders working to refine these guidelines. Why not take the opportunity to share to your experiences, opinions, and concerns in the upcoming JACR tweetchat? Take advantage of this great opportunity to impact the practice of radiology.
Join the Conversation
#JACR Tweet Chat on Thursday, Feb. 25, 2016, at 12 noon EDT with moderators Jenny Hoang, MD (@JennyKHoang), from Duke University and Lincoln L. Berland, MD, (@linkberland), from University of Alabama at Birmingham. Hoang and Berland are the lead authors of the ACR white papers on managing incidental thyroid nodules and incidental abdominal CT findings, respectively.
How? Just go to Twitter and search for #JACR in to get started. It's always a lively exchange with the JACR Twitter Team (@ruthcarlosmd, @Jim_Rawson_MD, @DavidNaegerMD, @MattHawkinsMD) and many others!
They will be discussing the following thought-provoking questions:
T1: Should all radiologists be adopting the ACR recommendations for incidental findings? Are there disadvantages of standardized reporting?
T2: Should the radiologist just describe the incidental findings and leave the workup criteria to the referring physician?
T3: Are the ACR white papers used in your practice? Have they changed practice?
Before or after the tweetchat, use the comment box below to share your thoughts with the authors and your radiology colleagues.
In addition to the referenced ACR White Papers above, here is further reading about incidental findings:
Dr Czum; please allow me to congratulate you on a timely, thoughtful, and essential topic of discussion. As we seek to improve healthcare delivered to our society and patients, we must understand best practice, we have to have a clear idea of how we introduce consistency of care delivery so that we can give our patients the best care possible in the greatest number of instances. We appreciate this not only from the perspective of physicians, but as individuals with selves and significant others inevitably seeking care at some point in our lives.