Original article
Professional Norms Regarding How Radiologists Handle Incidental Findings

https://doi.org/10.1016/j.jacr.2012.10.003Get rights and content

The author reviews the dilemmas posed by incidental radiologic findings and provides an analysis of factors that underlie how radiologists handle them. Particular attention is paid to professional standards that mediate clinical decision making and communication in the setting of risk. The author concludes that individual radiologists should report the incidental findings they detect and use existing evidence-based recommendations when possible. Such recommendations, however, face their own challenge in maintaining consistency with norms around risk-related decision making in other clinical realms.

Introduction

Incidental radiologic findings are commonplace in research and clinical practice. With the dramatic rise in cross-sectional imaging, radiologists and nonradiologists are finding incidental findings increasingly problematic. In this paper, I describe the professional norms that underlie radiologists' management of incidental radiologic findings in the clinical arena. First, I briefly review the general scope of incidental findings in radiology and why they are a problem. Second, I discuss why radiologists diagnose incidental findings and the norms that underlie the practice. Finally, I argue that radiologists' actions regarding incidental findings ultimately reflect conflicting norms that pervade modern medical culture.

Section snippets

The Scope

Incidental findings have long been a fact of clinical radiology, regardless of imaging modality. They are commonly diagnosed more frequently than the diagnostic entities for which studies are primarily targeted. In one study of CT angiography for pulmonary embolism, for example, incidental findings requiring follow-up were nearly 3 times more common than emboli [1]. It is interesting to note that incidental findings have changed disease incidence. Because of the increasing use of thyroid

The Problem

Incidental findings are a challenging problem for radiologists, treating physicians, and patients. The potential harms to patients are multifaceted. Some patients may experience considerable harm from clinically important incidental findings that go unrecognized or unreported. Even when likely benign, unreported incidental findings may create confusion and anxiety when a radiologist encounters such a finding for a particular patient on new study, but no report of the finding exists for that

Why do Radiologists Call so Many Incidental Findings?

Few data are available to suggest what drives clinical radiologists' handling of incidental findings. Some posit that radiologists' age and experience may be important factors [5]. Compared with their more experienced colleagues, younger radiologists are more likely to recommend additional imaging examinations [15]. An evaluation of radiologists' compliance with Fleischner Society recommendations, however, found that the least experienced radiologists (<5 years) had among the highest rates of

Professional Norms Regarding Risk-Related Clinical Decision Making

Given that incidental findings are intrinsic by-products of radiologic practice and training, it would seem reasonable to ask individual radiologists to calibrate their sensitivities to reduce the number of reported indeterminate incidental findings. Herein lies a major conundrum: defining what the threshold should be for reporting any given radiologic finding or describing such a finding as benign. The professional norms governing this question are far from clear; indeed, they sometimes

Professional Norms Regarding Radiologists' Role in Reporting Incidental Findings

Do individual radiologists have ethical standing to make such risk-related decisions unilaterally on behalf of patients? Here, too, radiologists, like all physicians, are caught between competing standards regarding physicians' roles in patient decision making. Contemporary professional norms have moved strongly away from autocratic physician ownership of medical decisions. Beneficence today is best expressed not through paternalism but rather by enhancing autonomy through the promotion of

Conclusions

Incidental radiologic findings are unavoidable. In a culture in which patient autonomy is valued, standards are inconsistent, and malpractice fears abound, little room exists for individual physicians to decide unilaterally whether reporting or disclosing incidental findings will result in better or worse decisions for any given patient. This is ultimately for patients to decide, in the absence of societally established parameters for how much health-related risk individuals should tolerate.

Take-Home Points

  • Despite the potential harms, radiologists should report incidental imaging findings and frame reports to help patients make optimal decisions about them.

  • Radiologists' recommendations around incidental findings fall within the larger context of clinical decision making in the setting of risk.

  • Standards and practices regarding risk-related decision making in medicine are variable and inconsistent.

  • Radiologists should adhere to evidence-based recommendations regarding incidental radiological

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