Consider this. You’re working your next shift and it’s a busy one. The waiting room is full and you haven’t even had a chance to eat lunch.
While trying to disposition that patient with hematuria and back pain, you quickly glance at their CT scan and then review the radiologist’s read. Boom, kidney stones, just like you thought. But, as you continue to scroll through the entire reading you come across the dreaded incidental finding of a pulmonary nodule. What do you typically do with this information?
In workups, we’re often left with imaging findings that are seemingly irrelevant to the patient’s presentation in front of us. However, there’s some serious medico-legal risk involved in not informing the patient of these findings before they leave your care.
Unfortunately, the legal case literature is full of examples of high-settlement payouts for missed pulmonary nodules, fractures, aneurysms, and masses, just to name a few. Even though these secondary findings were completely unrelated to the patient’s presentation (and they may not have had complications from these findings for years), the legal system has been shown to side against providers in many cases for failure to diagnose.
As much as no one likes getting sued, the bigger picture here is that these incidental findings are sometimes red herrings for problems to come. That pulmonary nodule, if not followed appropriately, may turn into metastatic lung cancer the next time the patient is evaluated for a pulmonary complaint.
In other words, our encounter may be the only chance to alert that patient of a potentially life-threatening future diagnosis. It’s empowering to know that we can have a crucial impact on our patient’s outcomes, but also terrifying and overwhelming to feel responsible for all of this data.
So, what can we do? First, being aware of the gravity of the medico-legal risk associated with these incidental findings can allow us to shift our mindset when it comes to approaching our radiology readings. Finding that balance between being efficient and thorough on shift isn’t easy. So here are some bulletproof strategies to help you tackle your next incidental finding:
1. Read the entire study carefully
Being methodical and systematic here is critical. Remember to take a step back when reviewing your films and don’t fall into the trap of diagnosis momentum. Even if you’ve found the most likely diagnosis, there can always be more insidious findings in the body of the report or your interpretation of the image.
Reviewing your inbox routinely and in proximity to your last shift for formal reports on films you may have read yourself on shift is also a great way to pick up an incidental finding you may have overlooked.
2. Have a plan
First, it’s imperative to make the patient aware of any relevant incidental findings. The art of having this discussion can oftentimes be tricky. Typically, we’re discussing things that are unrelated to the patient’s current presentation. While we don’t want to distract or confuse our patients from their acute issues, we also don’t want to minimize the incidental findings. Practice incorporating these findings into your review of the results with your patient AFTER discussing the main problem and plan. Kind of like an FYI.
Being aware of which incidental findings will require follow-up and what that entails is important, but can admittedly be difficult. Lean into and review your health systems protocols and policies regarding these findings, as the follow-up procedure and guidelines may already be established.
If you can, you should also place the referral for specialty follow-up of the incidental finding, or try and set up an appointment with the patient’s PCP.
Finally, remember that complex and unclear radiology reports come with the territory of our jobs. We must be vigilant to make that extra clarifying call to ensure the proper attention is being paid to these findings.
3. Document, document, document
Using a dot phrase in your chart such as “incidental findings were discussed with the patient and it was recommended that the patient follow-up with PCP for further workup as needed,” can help automate the process of reminding you to address the incidental finding, while also covering you medico-legally.
Placing time and actioning specific discharge instructions for incidental findings can be another way to dot your I’s and cross your T’s. This could be as simple as recommending the patient follow up with their PCP regarding X incidental finding, to something as specific as giving repeat imaging recommendations for a finding. These recommendations can sometimes be found within the body of the imaging report (ie pulmonary nodules) and can be as easy as copying and pasting this in your discharge paperwork. With either approach, the patient will leave with a plan in hand with a paper trail to prove it!
Remember, it’s our responsibility to provide the best and most comprehensive care for our patients. And let me tell you, they’ll appreciate your attention to detail when it comes to incidental findings!
For more information on how to navigate and tackle incidental findings on your next radiology read, listen to Legal Lessons: Incidental Findings on this month’s Urgent Care RAP podcast. We’d love to hear your thoughts! Leave us a comment (UC RAP > November2023 > Chapter 2: Legal Lessons: Incidental Findings > Discussion) and join us in discussing this important topic.
