Incidental Radiology Findings

[ColonelForbin]

Has anyone else practicing primary care noticed there to be an increasing burden of incidental findings to keep track of? With patients having more and more advanced imaging in various settings it seems many patients often have multiple.

1.4 cm TIRADS4 thyroid nodule found incidentally as a result of carotid doppler for bruits. Follow-up serial thyroid U/S per guidlines.
7 mm lung nodule incidentally noted on CTA for ED visit for chest pain. Follow-up serial CT chest per Fleischner criteria.
4.2 cm ascending thoracic aortic aneurysm seen on echo or CT chest done for something else. Follow serial echo.
3.8 cm AAA seen on random CT abdomen. Follow-up serial aortic U/S.
Indeterminate complex liver cyst seen on RUQ U/S done for mild chronic LFT elevation. Leads to a series of follow-up advanced imaging.

The follow-up is of course recommended and necessary, but a lot to keep track of and send patients for when you're already addressing all of their chronic problems, routine screening, vaccinations, new acute issues, etc.

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[Kaustikos]

Are you complaining about a Radiologist doing their job? Would you rather they not mention something and lose their license?

 

[ColonelForbin]

Are you complaining about a Radiologist doing their job? Would you rather they not mention something and lose their license?

Of course not. I didn't suggest anywhere that Radiologists are at fault or that they not do their job. As I said, the follow-up is necessary.

 

[chessknt]

You could always go to the inpatient side and take care of 30 COVID patients a day who want to talk about ****ing ivermectin with a stupid internet printout.

 

[Clean7795]

Has anyone else practicing primary care noticed there to be an increasing burden of incidental findings to keep track of? With patients having more and more advanced imaging in various settings it seems many patients often have multiple.

1.4 cm TIRADS4 thyroid nodule found incidentally as a result of carotid doppler for bruits. Follow-up serial thyroid U/S per guidlines.
7 mm lung nodule incidentally noted on CTA for ED visit for chest pain. Follow-up serial CT chest per Fleischner criteria.
4.2 cm ascending thoracic aortic aneurysm seen on echo or CT chest done for something else. Follow serial echo.
3.8 cm AAA seen on random CT abdomen. Follow-up serial aortic U/S.
Indeterminate complex liver cyst seen on RUQ U/S done for mild chronic LFT elevation. Leads to a series of follow-up advanced imaging.

The follow-up is of course recommended and necessary, but a lot to keep track of and send patients for when you're already addressing all of their chronic problems, routine screening, vaccinations, new acute issues, etc.

Lung, thyroid, and adrenal nodules are a major burden as you said. These can't really be stopped unless one day we just say "we are okay missing 1-2% of cancers in a scan that had a small nodule in X organ". The current reality is that we will scan 99 normal patients to find 1 cancer.

This isn't just patients being anxious. Most docs would rather have 99.9% certainty rather than 99% certainty that they aren't missing a cancer, so they will work up a random ditzel found on a scan.

 

[gutonc]

Has anyone else practicing primary care noticed there to be an increasing burden of incidental findings to keep track of? With patients having more and more advanced imaging in various settings it seems many patients often have multiple.

1.4 cm TIRADS4 thyroid nodule found incidentally as a result of carotid doppler for bruits. Follow-up serial thyroid U/S per guidlines.
7 mm lung nodule incidentally noted on CTA for ED visit for chest pain. Follow-up serial CT chest per Fleischner criteria.
4.2 cm ascending thoracic aortic aneurysm seen on echo or CT chest done for something else. Follow serial echo.
3.8 cm AAA seen on random CT abdomen. Follow-up serial aortic U/S.
Indeterminate complex liver cyst seen on RUQ U/S done for mild chronic LFT elevation. Leads to a series of follow-up advanced imaging.

The follow-up is of course recommended and necessary, but a lot to keep track of and send patients for when you're already addressing all of their chronic problems, routine screening, vaccinations, new acute issues, etc.

These are actually easy.
1. Refer to endo or thyroid surgeon if you’re fortunate enough to have one nearby.
2. Refer to pulm. Seriously…our rads department now does automatic referrals to Pulmonology for anything that gets a Fleischner criteria mention. This was at Pulmonology’s insistence.
3 and 4. Vascular or CT surgery, depending on who manages those where you are. You can’t do s*** about it so let someone who can follow it.
5. GI all day.

 

[ColonelForbin]

Lung, thyroid, and adrenal nodules are a major burden as you said. These can't really be stopped unless one day we just say "we are okay missing 1-2% of cancers in a scan that had a small nodule in X organ". The current reality is that we will scan 99 normal patients to find 1 cancer.

This isn't just patients being anxious. Most docs would rather have 99.9% certainty rather than 99% certainty that they aren't missing a cancer, so they will work up a random ditzel found on a scan.

Yeah they have to be worked up and followed appropriately like you said. It would be great if there was an automated mechanism for following some of these in more medical systems, such as a supervising Radiologist automatically providing the patients with the result and then scheduling follow-up at the appropriate time interval or providing an automatic specialist referral. Not to avoid responsibility as the PCP, but there's just so many places these findings can get lost. Imaging report is faxed, but never reaches ordering provider. Patient never follows up appropriately with ordering provider. Patient does follow-up with ordering provider and vague plan is made to repeat imaging at some time interval, but then when patient returns they see a different provider in the practice and it somehow gets lost in the shuffle. So many places where appropriate follow-up can be missed. I believe this is the law in some states with Mammo. Patient must be given results by the radiology facility. I believe some even schedule the appropriate follow-up if there is an in-house provider such as a breast surgeon.

 

[ColonelForbin]

These are actually easy.
1. Refer to endo or thyroid surgeon if you’re fortunate enough to have one nearby.
2. Refer to pulm. Seriously…our rads department now does automatic referrals to Pulmonology for anything that gets a Fleischner criteria mention. This was at Pulmonology’s insistence.
3 and 4. Vascular or CT surgery, depending on who manages those where you are. You can’t do s*** about it so let someone who can follow it.
5. GI all day.

It's helpful to hear your perspective that these are appropriate referrals. It feels like punting in some of these more likely benign cases when cognitively the PCP should be able to follow the guidelines and order the appropriate follow-up imaging, especially in areas where wait times for specialists for more pressing things are already longer than they should be. But practically, it probably does cause less confusion for the patient with less things covered in one visit and having them linked with the specialist should they need them for management.

 

[Kaustikos]

These are actually easy.
1. Refer to endo or thyroid surgeon if you’re fortunate enough to have one nearby.
2. Refer to pulm. Seriously…our rads department now does automatic referrals to Pulmonology for anything that gets a Fleischner criteria mention. This was at Pulmonology’s insistence.
3 and 4. Vascular or CT surgery, depending on who manages those where you are. You can’t do s*** about it so let someone who can follow it.
5. GI all day.

Anyone with a colon that has any abdominal imaging gets GI referral in my books. ESPECIALLY a colon with small bowels and a stomach.

But, yeah, agreed. There is no real "burden" in doing referrals for these. People refer to other specialties for worse things/inappropriate things. To make it easier for you - all HIV/HepB/HepC patients get auto-referred to ID. It's not a complaint, it's a reality. I know some GI/PCP manage HepB/HepC in some places, but just punt it our way.

 

[rokshana]

Has anyone else practicing primary care noticed there to be an increasing burden of incidental findings to keep track of? With patients having more and more advanced imaging in various settings it seems many patients often have multiple.

1.4 cm TIRADS4 thyroid nodule found incidentally as a result of carotid doppler for bruits. Follow-up serial thyroid U/S per guidlines.
7 mm lung nodule incidentally noted on CTA for ED visit for chest pain. Follow-up serial CT chest per Fleischner criteria.
4.2 cm ascending thoracic aortic aneurysm seen on echo or CT chest done for something else. Follow serial echo.
3.8 cm AAA seen on random CT abdomen. Follow-up serial aortic U/S.
Indeterminate complex liver cyst seen on RUQ U/S done for mild chronic LFT elevation. Leads to a series of follow-up advanced imaging.

The follow-up is of course recommended and necessary, but a lot to keep track of and send patients for when you're already addressing all of their chronic problems, routine screening, vaccinations, new acute issues, etc.

speaking as an Endocrinologist, thyroid nodules are fairly common and probably 40-60% of the general population has them and for the most part are benign and non functional...but now that we do all this imaging… bound to be seen.

interestingly enough, just was at a conference…virtual… and one of the lectures was on adrenal incidentalomas and said approx 50-60% of adrenal nodules don’t get further work up.

and I would rather have the consult for the incidentally found nodule than the POSITIVE thyroid antibodies in a euthyroid pt…that’s a waste of my time.

 

[maxxor]

Has anyone else practicing primary care noticed there to be an increasing burden of incidental findings to keep track of? With patients having more and more advanced imaging in various settings it seems many patients often have multiple.

1.4 cm TIRADS4 thyroid nodule found incidentally as a result of carotid doppler for bruits. Follow-up serial thyroid U/S per guidlines.
7 mm lung nodule incidentally noted on CTA for ED visit for chest pain. Follow-up serial CT chest per Fleischner criteria.
4.2 cm ascending thoracic aortic aneurysm seen on echo or CT chest done for something else. Follow serial echo.
3.8 cm AAA seen on random CT abdomen. Follow-up serial aortic U/S.
Indeterminate complex liver cyst seen on RUQ U/S done for mild chronic LFT elevation. Leads to a series of follow-up advanced imaging.

The follow-up is of course recommended and necessary, but a lot to keep track of and send patients for when you're already addressing all of their chronic problems, routine screening, vaccinations, new acute issues, etc.

Do your rads not put what the followup is? Or do they just tell you to look up the guideline? If it's the second, that's kind of lazy. I have built in templates for all of those. The only time I might be little wishy-washy is if I know the patient bounces around and suspect they may have prior imaging that I don't have access to. In those cases, I give the total duration of stability.

I do think it would be a nice "population health thing" if I could trigger orders being sent to the referring for incidentals that need followup that they could just accept / sign. One health system I worked at had that for Lung Cancer Screening. Depending on the LungRads, it would trigger a task in Epic which included the followup order which would be paired with the results so the PCP could just hit accept and the order would route to scheduling. That was pretty slick.

 

[NewYorkDoctors]

In my EMR i just keep an active flow sheet of whatever problem I am following .

for example under solitary pulmonary nodule , I would transcribe a one liner with time and date of the scan . Then each note I copy forward the assessment and plan (including that brief blurb with scan one liners ) then I update the plan. It’s a built in way for me to keep track and not forget . If it’s buried as a result page scanned somewhere in patient docs , then it’s very likely to be forgotten.