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Not so incidental

By Timothy Cocks Metaphor and language, Education for all 20 Jan 2014

Medicine’s Problem of ‘Incidental Findings’

At first blush, these seem like intrinsically good discoveries—potentially serious illnesses that get uncovered early. But plenty of spots on livers and protein deposits in urine are benign, while the tests required to determine that may not be.

Early this year, I wrote an article about one of my patients with chronic abdominal pain who visited the ER of another hospital. The doctors there—who were not familiar with her decade of dyspepsia—ordered a CT scan. Her stomach, gallbladder, intestines and liver were all in pristine condition, but “incidentally noted,”—the report read—”was a 2-centimeter adrenal mass.” These adrenalomas are almost always benign, and almost always found only incidentally. They even have their very own appellation—the incidentaloma.

Nevertheless, I felt boxed into a clinical corner, forced to order expensive and complicated tests to rule out the minute chance of malignancy. The arduous process completely overwhelmed and panicked the patient, and we were never able to get to the actual diseases that she already had—diabetes, depression, and arthritis.

Two months later, I found myself in a Washington D.C. conference room, testifying before a razor-sharp committee of academics from law, nursing, medicine, philosophy, ethics, divinity, research, and government. This was a Presidential Commission for the Study of BioethicalIssues panel on incidental findings.  The ethical considerations of incidental findings turned out to be much broader and more intriguing than I, as a ordinary primary care doc, had ever imagined.

Certainly in a different category to adrenal masses and spots on livers, but the problem of incidental findings with people in pain has many similarities.

Scheuermann’s Disease, Schmorls nodes, disc bulges, ‘degenerative disc disease’, hypertrophy of the ligamentum flavum, thickened subacromial bursa… to name but a few. Each of these has the potential to drastically increase the sense of threat and danger that a person in trouble perceives with a direct impact on their pain, function and recovery.

Reassuring people that these are indeed incidental can be tough – you also need to be able to answer the question “Well if that’s not causing my pain, what is?”  Modern neuroimmune science is essential here.

– Tim Cocks


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