How Do You Solve a Problem Like Incidentalomas?

Leonard Berlin, MD, FACR


Appl Radiol. 2013;42(2):10-12. 

In This Article

The Courtroom

There has as yet not been much malpractice litigation focusing on a radiologist's failure to report an incidentaloma. Thus, the standard of care that will be applied in such cases cannot be predicted with any degree of certainty.[26] Nevertheless, one such lawsuit that did proceed to trial might provide a hint. In the case, a 47-year-old man presented to a hospital emergency department (ED) with flank pain. In the CT scan report ordered by the ED physician, the radiologist stated that the exam was normal except for a "hypodense, well-circumscribed mass in the left kidney, most likely a cyst." One year later the patient was diagnosed with renal cell carcinoma; he ultimately died. A lawsuit was filed by the patient's family, and at trial the following interchange between the plaintiffs' attorney and the defendant-radiologist took place:

Q: Doctor, why didn't you mention the potentially abnormal finding in the impression?

A: Because I thought the finding was almost certainly of no significance and would have led to a number of unnecessary and possibly dangerous tests.

Q: Could it have represented an early cancer?

A: Yes, but probably no more than a 1% chance.

Q: Doctor, in this case it was 100%. Shouldn't you have let the patient and his private physician decide whether further testing was indicated? Did you not deprive the patient who is now dying of cancer, rather than cured and living, of his inalienable right to make his >own decision about his health?

The jury rendered a verdict in favor of the plaintiff. Why the jury determined that the radiologist was liable for failing to call attention to the incidentaloma is not difficult to understand. The era of "medical paternalism" ("I am the doctor; I know what is best for you.") is long past. Radiologists and nonradiologist physicians now live in a consumer-driven society, where physicians no longer make unilateral and arbitrary decisions regarding a patient's health; rather, they are a partner and an advisor to the patient.[27] Patients expect, and indeed want, to be informed of any potential laboratory or imaging abnormality that could possibly adversely affect their health, even if the probability that the abnormality could be injurious is highly unlikely. An example of this attitude was shown on a CBS television news program on April 1, 2012, that focused on a 19-year-old man who suffered cardiac arrest and died suddenly due to a malfunctioning cardiac monitor/pacemaker. Data revealed that the frequency of malfunction in such devices is 0.1%. During the TV interview, the father of the deceased man angrily lamented, "Why weren't we told that the device could fail? We should have been." While an adverse event with an incidence of 0.1% should be disclosed to a patient may sound unnecessary and unreasonable to physicians, it appears quite necessary and reasonable in the minds of the news media and the public.