15 Jul, 14 | by Toby Hillman
Medicine is an ever changing discipline.
One field that continues to change the face of clinical practice, and throw up new challenges is that of radiology.
The body no longer hides it’s secrets beneath skin that requires a surgeon’s skills to open up and explore, but can be encouraged to give them up through the various modalities of imaging that have been developed over the past few decades.
I remember the importance of imaging from my days as a house officer – being instructed to go and ‘lie in the scanner until they agree to do the CT’
Although perhaps I should reflect on my centrality to the team if I could be dispensed for long periods of time essentially obstructing other people’s work…
The role of radiologist has changed over time too – from gatekeeper to service provider in the eyes of one US-based specialist. The close working relationship I have with my radiology colleagues, and my adventures into the world of imaging with my portable ultrasound remind me on a regular basis the pivotal role imaging plays in the work I do.
But, the advances of radiology throw up new challenges…
Incidental findings are both the blessing and the curse of anyone involved in the requesting, interpretation and communication of scan findings. The report which lands in one’s inbox with just the reassuring answer one was looking for, only to have another three or four lines highlighting a completely unforseen abnormality is the start of a challenging clinical problem. The issue tends to be outwith the usual scope of the clinical practice of the requester, and therefore usually requires the invovlement of another team to assist or advise on the next steps to further investigate, to a satisfactory conclusion for patient and clinician.
For the patient, the finding can be a distressing bolt from the blue – delivered by someone who is similarly surprised, and the news tends to herals a new round of investigations, referrals and appointments. However, incidental findings can also be a huge positive in the end – especially if the incidentaloma turns out to be something that would have progressed unchecked if it had not been noticed. Screening programmes – a notoriously difficult area of medicine almost rely on generating incidentalomas in asymptomatic patients for this very reason. The debates which rage around screening are well covered elsewhere, and I think I can leave you to look them out for yourself.
The paper which prompted my thinking about incidentalomas was this one on the management of adrenal incidentalomas in British district general hospitals. The authors looked at the reports of 4028 abdominal CT scans in Northumbria, and found that managment of adrenal incidentalomas was poor. There were 75 patients with adrenal incidentalomas. Only 13 were referred for specialist assessment, and sadly, of the 62 not referred, 26 were found to have inoperable metastatic malignancy. The authors discuss the potential implications for patients who aren’t investigated, and also note that a significant proportion of the requests for the abdominal CT was in the staging of other malignancies. The finding of an adrenal tumour in this context is a particular dilemma – as the consequences of delaying for biochemical evaluation can be significant, as can the consequences of not identifying a functioning adenoma, or even a phaeochromocytoma.
This dilemma encapsulates one of the challenges that modern doctors have to face – how to interpret a finding, adhere to guidance that is appropriate, and yet progress the care of the patient in a timely fashion that leads to the best outcome in that individual case. As the role of the doctor changes over time, one key aspect of the duties we have is to take the information available to us, and advocate effectively for our patients – in partnership with them. Therefore we owe it to our patients not to shrug our shoulders, or hang our heads when we come across the unexpected ‘gift’ of an incidental finding, but instead should try to embrace the opportunity to guide our patients through the often bewildering pathways that lead to a diagnosis.
So no, our imaging colleagues aren’t giving us too much information – it is up to us to use this immense resource wisely, and then, when unexpected findings are thrown up – it is up to us to manage them appropriately for each individual patient in their own individual context.