First posted on his blog on 01/23/2013
I can remember making rounds with a seasoned surgical attending in medical school. In typical fashion, surgical rounds were a lot like the military. The “General” (attending physician) at the front, always commanding respect (and often fear) followed by the chief resident, junior residents, interns and finally medical students. Cases were presented, statuses were updated and plans were formulated. Then came the barrage of medical fact questions–mostly directed at the interns and medical students. These questions were akin to an oral exam conducted in front of the entire school. When discussing one particular case where a lung mass was discovered on a routine yearly chest x-ray, we were asked for a single diagnosis–I knew that all the biopsies were negative and that the patient did not have cancer. The entire work up had been negative. Most answers revolved around the tissue diagnosis of “fibrotic changes likely related to prior fungal infection”. This was not the answer our fearless leader was looking for–like most questions during rounds with the “General”, there was always a twist that would lead to an important teaching point.
Here is a little background on the case…The chest x-ray had been ordered during a yearly physical exam in the patient’s internist’s office in addition to yearly blood work such as thyroid panel, chemistries and cholesterol. There had been no suspicion of lung disease and no specific symptoms that would prompt this examination. The patient was quite healthy, exercised daily and was in great shape overall. But, once a mass was discovered, the finding had to be worked up. CT scans revealed a suspicious looking abnormality. Review of old chest x-rays did not show the mass in the past. Tissue diagnosis was then the next step. We had to make sure the patient did not have cancer and utilize every possible test in the medical arsenal to rule out the “bad”.
The patient subsequently underwent an invasive procedure in the pursuit of a definitive diagnosis. Along the diagnostic journey a few complications occurred including a pneumothorax (collapsed lung). The complication resulted in yet another procedure to re-inflate the lung (insertion of a chest tube) and subsequently more X-rays and scans were required. The preoperative testing, the biopsy itself, the hospital stay following the complication and follow up imaging resulted in both emotional and physical pain and anguish for the patient. The patient worried over a possible deadly diagnosis and then suffered through the pain associated with the insertion of a chest tube. Moreover, significant costs were generated and borne by both patient, hospital and insurer. Imagine the cost to the healthcare system if this had been an uninsured patient.
During the course of questioning by the attending, answers were put forward from every student and intern and he was dissatisfied with all of them. The answer he was looking for: “Incidentaloma”. He defined an incidentaloma as a medical finding that occurs by chance and that often leads to further testing and procedures–often putting patients at risk for complications. The “General’s” point was that we must order tests responsibly and we must be prepared for the results–either positive or negative. A test should serve as a map that directs us to the left or the right when we come to a fork in the road. Simple Bayesian statistics, right? Always begin a test with a hunch, a “pre-test probability”. A test works best when the pre-test probability is in the intermediate range. If the pre test probability is very low, you don’t really need to perform the test. If the pre test probability is high, then you need to begin therapy rather than conduct another diagnostic test. Well, as we all know, medicine is NEVER just that simple…
Last week in the New York Times, an article was published by Dr Danielle Ofri discussing the “fallout” of chance medical findings such as the case I have described. In similar fashion, her case demonstrated the costs and frustrations that can be associated with an “incidentaloma”. Certainly, neither my well respected, learned surgical attending nor I would ever suggest that we do not look into abnormal findings. I am also not suggesting that we do not perform routine screening tests. What I am suggesting is that we order tests thoughtfully and with purpose. We must do our very best to use the best data we have to evaluate the value of available screening tests. We all know that early detection of breast cancer, colon cancer and other potentially life threatening diseases can certainly impact outcome. There will always be controversy when it comes to using diagnostic tests for routine screening of asymptomatic patients. Even today, there is much debate over screening for prostate cancer and when to begin routine mammography scans. Ultimately, we must continue to take a reasonable and academic approach to testing. We are still going to discover the “incidentaloma”. Our challenge is to carefully handle these occurrences–we must balance them in a way that protects our patients from undiagnosed occult disease while at the same time, protects them from the dangers of the “10 million dollar” workup of the chance medical finding.