When Incidental Findings Cause an Incident
Not reporting harmless incidental findings can decrease anxiety and reduce downstream testing, but it's not without worry or risk.
Using a Bosniak category I renal cyst as an example, the authors of a 2016 JACR article suggest criteria for deciding to not mention the cyst at all in the radiology report:
1.The cyst is not the reason for the examination.
2. The cyst has no meaningful anatomic or physiologic consequence (eg, mass effect).
3. The cyst has no excess malignant potential given known or suspected patient-level risk (eg, von
4. The cyst is not likely to indicate a nonmalignant disease (eg, PCKD).
However, there is a paragraph immediately before this laying out potential pitfalls of the decision not to disclose such a finding.
One possible reason a radiologist may choose not to mention a simple renal cyst in an imaging study report has to do with the heterogeneity of radiologist reporting practices, which may lead to arguably irrational thoughts like: "If I don't report it and the next person does, then someone reading the report will think that I didn't even see it. And if they think that I didn't see that, then they may assume I didn't see something else, something that may be harmful to the patient, unlike the simple cyst." If to that slightly paranoid foundation you add a generous layer of heretofore largely unfounded concern about medicolegal risk, you have a guaranteed recipe for reporting behavior inertia.
Radiologists may be able to get more of their colleagues onto a nondisclosure-of-harmless-incidental-findings bandwagon if there was published expert consensus recognized as standard of care that could serve as a policy reference. But there is no expert consensus yet that is ready for implementation and thus no incentive to change one's "defensive medicine" posture with respect to incidental findings.
At this point, the closest facsimile in radiology to non-disclosure is non-action. The ACR white papers (such as about incidental findings on abdominal CT and incidental thyroid nodules) are robust and handy references for recommendations based on algorithms, including when no further imaging or other steps are needed. However, the white papers do not address leaving harmless incidental findings completely out of an imaging report.
JACR previously had a tweet chat about incidental findings. This month, a new chapter is added to the discussion as the tweet chat focuses on malpractice related to incidental findings reporting and more. The moderator will be H. Benjamin Harvey, MD, JD, who practices neuroradiology at Massachusetts General Hospital and has both medical and law degrees. The three tweet chat questions this month are as follows:
1. Is there significant legal liability associated with choosing not to report likely benign incidental findings?
2. Is the common fear of personal income loss due to medical malpractice justified?
3. What is the best way for a radiologist to reduce his/her malpractice liability exposure?
Please join the tweet chat on Thursday, March 23, at noon EDT. To find the tweet chat, just log on to Twitter and search for #JACR. To join in, add #JACR to all your tweets to be seen by other participants. Would you like to join in but you don't have a Twitter account? No worries! Use this handy guide.