The blog of the 2009 – 2017 Presidential Commission for the Study of Bioethical Issues

Incidental Findings in the Clinic: Extra Information and Extra Worry

During today’s meeting of The Presidential Commission for the Study of Bioethical Issues, it soon became clear that dealing with an incidental finding can involve more than just reporting to the patient impacted. As Haavi Morreim, J.D, Ph.D. Professor of Internal Medicine at The University of Tennessee Health Science Center, stated, there may be a difference between “standards by which care should be provided… and standards by which care should be assessed.”

Danielle Ofri, M.D., Ph.D., Associate Professor at the New York University School of Medicine, spoke of a patient with gastrointestinal pain. While Ofri, as her primary care physician, Ofri knew that the gastrointestinal pain was a common occurrence and probably nonthreatening. However, when her patient checked into the Emergency Room, the doctors, who did not know the patient’s history, performed a CT scan. The CT scan showed no cause of gastrointestinal pain. But it did turn up something else: “a 2 cm nodule in the right adrenal gland” or as Ofri wryly called it “The dreaded incidentaloma.”

Nodules in the adrenal glands are common, and while Ofri notes that 98% are entirely benign, in rare cases they can lead to problems such as the overproduction of hormones, or to cancer. “Nevertheless,” Ofri said, “once the incidental finding had been given life, so to speak, it was no longer incidental.”

Ofri had to refer to the standard-of-care for an adrenal incidentaloma, which involved a list of complicated tests. “As clinicians,” said Ofri, “we have a bias toward doing something, as opposed to doing nothing…Our patients, almost uniformly, want us to do something. Both doctor and patient are enthralled within this overwhelming medical imperative to act.” The tests would cost thousands of dollars, and also threatened to expend Dr. Ofri’s medical capital with her patient.

There was only so much time she had to spend with the patient, and with all of the information required to discuss the incidental finding, Ofri was obliged to skip over many other issues that the patient needed to have discussed, such as high blood pressure, cholesterol, and diabetes. These issues “…ended up with the short end of the clinical stick that day—an outcome” Ofri noted, “that is surely not incidental.”

Next, Carol Krucoff spoke of her experience as a patient who received an incidental diagnosis of a small acoustic neuroma. Even though her so-far benign neuroma has caused her significant anxiety, Krucoff stated that she would rather know about the presence of the neuroma than not. She recommended policies to help patients deal with incidental findings, including keeping patients informed in simple, direct language, training providers with communication skills to ensure both compassionate and clear communication, and to add a support person to the healthcare team, to help patients and their families process difficulty information.  And, she says “Unless it’s a necessity, don’t rush to treatment.”

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This is a space for the members and staff of the 2009 -2017 Presidential Commission for the Study of Bioethical Issues to communicate with the public about the work of the commission and to discuss important issues in bioethics.

As of January 15th, 2017 this blog will no longer be updated but continues to be available as an archive of the work of the 2009-2017 Presidential Commission for the Study of Bioethical Issues

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