Medicolegal Implications of Incidental Findings

Introduction to Incidentalomas

It's a pleasure to be here.

Thank you very, very much.

It's a pleasure to talk about the elephant in the room.

We don't see the elephant, but we know there's an elephant out there.

And the elephant, of course, is the medical elephant. Are we gonna get sued from malpractice?

And I have nothing to disclose.

Let me introduce the subject of incidentalomas with a couple of quotations.

On one hand, we have these philosophical quotations.

All men by nature desire knowledge. Knowledge is power.

If we value the pursuit of knowledge, we must be free to follow whatever that search leads us to.

On the other hand, there's the famous quotation where ignorance is bliss to be wise.

Do we really wanna know?

What do we wanna know about incidentalomas?

What are we gonna do? What should we do about incidentalomas?

It's been defined already this morning, and I won't go over that, except I wanna point out, of course, when my subject matter is not the finding that you're reasonably suspicious is abnormal, or that you're reasonably suspicious is malignant.

You've heard all about, and you'll hear more tomorrow about algorithms and so forth.

But we're really talking here.

What I'm gonna talk about is the lesion that you really think is nothing is innocent, but you're not a hundred percent sure, because if you're a hundred percent sure you're just gonna move on.

But let's talk about that gray lesion, that gray lesion where you're not sure.

Is it positive, is it negative? Should I mention it?

Should I not mention it?

Now, of course, obviously, we know that incidentalomas have increasing tremendously because of the increased number of CT scans approaching 80 million a year, and our increased spatial resolution, contrast resolution and so forth.

Now, I won't go over all this.

We've already heard about incidence of incidentalomas, but it's worldwide.

Prevalence of Incidentalomas

Here's a Greek report from Greece.

Prevalence of incidentalomas in stable blunt trauma patients, 34%.

There were incidentalomas, they did a third, they did additional testing.

In a third of those.

Here's from the Netherlands, a thousand patients, et cetera.

35% of thoracoabdominal CT blunt trauma patients had incidentalomas.

They further investigated 20% of them.

And malignancies were found in 2% and 2%.

And here's another one from the medical literature.

We've heard just heard all about the chest films, the chest nodules and so forth.

But here, this is an interesting, because this is a review of 16,000 patients that went ahead and had a transthoracic needle biopsy.

And you talk about the complications, pneumothorax and 15% hemorrhage in 1% of which 20% require transfusions.

And the authors pointed out that in smokers, the incident of complications is even greater.

And here's prevalence of incidental findings and imaging research and so forth, et cetera.

40% had at least one incidentaloma of CT of the abdomen, pelvis, and so forth.

Clear medical benefit was found in retrospect in only 1%.

And here's another one from patients undergoing aortic iliac CT angiography, et cetera, et cetera.

Again, incidentalomas in 50%, 18% was significant enough to postpone procedures.

There's an interesting book that was written last year by H. Gilbert Welch from Dartmouth University, and called Overdiagnosed.

And he has a whole chapter on Incidentalomas.

I'll refer to him again in a few minutes.

But nevertheless, he kinda lumped everything together.

And I think we pretty much agree on this.

Here's a table where 50% of chest CTs will show an incidentaloma.

15% of abdominal CTs will show an incidentaloma of the kidneys and liver.

Thyroid gland is up to two thirds and so forth.

But the bottom line is that overall, the incidence that these incidentalomas are malignant probably is 1%, and that's probably a pretty good average.

Responsible Use: Do We Report Incidentalomas?

So now we come to the basic question, and that is, what is responsible use?

Do we report these incidentalomas?

Well, we have interesting information on both.

Interesting opinions.

And as this comes from the medical literature, what is responsible use of information that nobody asks for, but once found is difficult to ignore.

And obviously it's someone who says, we probably shouldn't report 'em.

And this was a very interesting article in New England Journal of Medicine, Our Stubborn Quest for Diagnostic Certainty.

I won't read the whole thing, but basically it says, our task is not to attain certainty, but rather to reduce the level of diagnostic uncertainty.

Because the more we look, the more we want certainty, the higher the risk of the patient and goes on to say excessive testing results.

Will the desire is done because we want a desire to avoid malpractice and so forth.

But on the other hand, we're gonna do harm to the patients, the more we try to do to find out what a diagnosis is.

And here's another one from archives. Internal medicine. Less is more tests to provide information about unrelated condition, leaves doctors and the patient to contend with information they had not sought, but it's impossible to ignore.

And they conclude patients would be better served if the doctors limited their access to unsolicited diagnostic information, in the GI literature.

Interesting commentary in the GI literature, any new piece of information regarding a patient's health is considered valuable, worthwhile having.

It defies a basic tenet in medicine to question the benefit of diagnostic information.

But of course, the more we know, the more possible harm we can do to the patient.

And he goes on to say, beware of the negative consequences of unexpected information.

Striving to improve a medical condition by acquiring more knowledge may even make it worse.

And one last comment here, this is from the assistant director of NIH pointing out radiologic exams have the potential to do harm because exams can find tumors that would otherwise not have required treatment and so forth.

And it's like the lottery in exchange for those few who win the lottery.

There are many, many others who have to pay the price.

So yes, the more we look, we may save a few patients, but many, many, many patients are gonna have undesirable consequences as a result.

Welch the one who wrote this book, Overdiagnosis, actually in his chapter on incidentalomas, has a lamentation with radiologists.

And what he says in there is he tells radiologists, don't call it an abnormality.

Call it normal.

Protect the patient from over-diagnosis and overtreatment, don't mention the finding in the radiology report and don't tell the referring physician.

So he won't feel obliged to tell the patient we should lower the intensity with which we react incidental illness.

Now, it's very easy for him to say that, and he's a non-radiologist, and he's telling us radiologists what to do and what not to do.

That's certainly an interesting opinion, and that does present our dilemma.

That does present our dilemma.

So there are reasons then there are these people out there that say, maybe don't mention it or look at the damage you're gonna do.

Maybe avoid mentioning these incidentalomas.

Arguments for Reporting: Legal and Ethical Perspectives

Now, let's look at the other side of the coin.

And let's start off with a very basic court decision was made many years ago, in 1914, almost a century ago in New York, a very classic comment by one of the judges, any human being of adult years and sound mind has a right to determine what shall be done with his own body.

A court decision, another court decision from district of Columbia, a physician undertaking a physical exam, has a duty to disclose what he has found and to warn the examinee of any finding that would indicate the patient is in any danger.

You'll see where we're going on these court opinions.

Here's another one.

This is, again, a federal court out in the state of Washington.

Those who place themselves in the hands of a person who is skilled in the medical profession, have reasonable expectation that the expert physician will warn of any dangers of which he is cognizant by failing to inform the patient of the abnormality of the radiologist in this particular case, prevented the patient from getting treated and cured.

So basically, we're leaning towards the direction.

I'm obviously going in the direction where maybe all incidental illness should be reported.

And you may recall many years ago, actually, Schreiber from Texas, there had been several such surveys, but this was one dating back to 1995.

Actually, over 90% of patients want to be informed of any abnormalities found in the radiologic exams or other tests.

And if you look at the AMA code of ethics among the AMA code of ethics, this is the statement, the physician's obligation is to present the medical facts accurately to the patient.

Physicians should disclose all relevant medical information to the patients.

So here's our dilemma.

So we've said, yes, if we disclose every single incidentaloma, even though we think it's probably unlikely to be abnormal or significant, we're going to invoke a cascade of testing for the patients, not only cost, but maybe damage injury to the patient.

On the other hand, if we don't mention the incidentaloma, what happens if it turns out to be cancer?

And we got sued.

Wylie Phipps, who you know, is a very internationally known obstetrical sonographer, wrote a very, very interesting editorial back in 2000 in the Journal of Ultrasound, which is as relevant to this discussion as it was in 2000.

And he points out in 10% of normal pregnancy sonograms contain so-called abnormalities, which could be a marker for Down syndrome.

But they're unimportant.

And what should you tell the mothers to be if you suspect a marker for Down syndrome?

Should you really bother to tell 'em?

And he goes on to say, once the patients are informed of this so-called abnormality, you have lack of enjoyment of the anticipation of the birth.

Now you have anxiety from my vantage point.

He says, with these so-called abnormalities, you're really doing more harm than good by telling this to the parents and so forth for the tiny number of Down syndrome fetuses that potentially may come to light, and so forth.

You're putting 10% of all women at a disadvantage, and you're supporting the pregnancy and so forth for the woman and her husband.

Very interesting.

But then he goes on and he says, so what should I do tomorrow?

Should I have the courage of my conviction to simply ignore these features?

I wish I had the courage, but I don't.

Even with my considerable clout in the world of obstetrical sonography, I cannot unilaterally ignore the sonographic medical literature.

That's how the American medicine works.

It was true, obviously in 2000.

It's certainly true today.

Now, it's interesting.

I'm not here hawking a book, but Jodi Picoult, who writes a lot of fiction, did write this book very interesting a couple years ago on a case of osteogenesis imperfecta.

I don't know if any of you have read the book.

It's fiction.

And it's a child who was born in osteogenesis imperfecta, the mother to be, had a ultrasound done prenatally.

The obstetrician in this case was doing the ultrasound, saw something suspicious, maybe it was abnormal, wasn't sure, and decided not to tell the woman.

And then she delivers the child with osteogenesis imperfecta, et cetera, et cetera.

And now there's a lawsuit against the obstetrician.

And so, just briefly, it's very interesting.

There is the trial.

And the lawyer for the plaintiff addresses the jury as follows.

This case is about facts.

Facts that the obstetrician knew and dismissed facts that weren't given to a patient by the physician she trusted.

No one is blaming the obstetrician for the child's condition or saying that he caused the illness.

However, the obstetrician is to blame for not giving the family all the information that she had was a woman obstetrician.

When a patient, when a physician withholds information from a patient, that's malpractice.

And it's very interesting.

It's fiction.

But let me tell you, it's very realistic.

And this is the public perception.

Now, interesting letter to the editor on called Stu.

It was an interesting article on cancer statistics.

So for in the Wall Street Journal a couple years ago, and this is written by an internist, New York internist who said, my patients want to know if they have cancer as early in the process as possible so they can be treated.

They don't wanna have to rely on mathematical projections or statistics about hypothetical death rates.

And I must say, and we'll talk maybe a little bit about this in the panel discussion.

It's interesting, all the algorithms that were shown today, the flow sheets on making a decision, I can just imagine trying to defend in a court of law your decision to report or not report an incidentaloma.

No failure to report an incidentaloma because of these algorithms.

And if the doctors ourselves, if we ourselves don't understand or can't follow all the algorithms, how do we expect a jury to, but we'll come back to that a little bit later.

But anyway, the point is that the public, the public, the patient and the jurors will understand this, is they don't wanna, the patient doesn't wanna have to rely on all these calculations.

If you have something abnormal, they wanna know.

Standard of Care for Incidentalomas

Now it's all about standard of care.

What is the standard of care?

Well, the standard of care is usual and customary care, whether it be a local standard or a national standard.

Generally it's a national standard.

So when is a doctor negligent?

He or she is negligent for failing to follow the standard of care, for failing to adhere the standard of care.

And the standard of care is what is the usual practice under the same or similar circumstances.

So let's look at the literature and say, what is the standard of care?

What is usually done with incidentalomas?

Well, we find that there is no consistency.

We look at the literature, some radiology groups, some radiologists report incidentalomas some report, and then follow up on 'em.

Some ignore them.

In some institutions, every radiologist does something different.

And you may, so if we look at the literature, we can find, we could find articles that support the ignoring of incidentalomas.

And we can also find articles that say, no, you have to report every incidentaloma, because you never know when you're gonna have something serious.

And this, of course, from that, you may recall just a couple of months ago, actually, the end of the year here is here is Hopkins, here's our Stanford, here's Dr. Federle Stanford.

Here is Dr. Fishman's Hopkins, plus NYU survey of 27 radiologists.

So forth, 100% agreement.

None.

There was not one, there was no, there wasn't a hundred percent agreement.

Any of the reporting, the incidence rate of agreement range as low as 30% up to 85%.

Why?

Disagreement instances of the kidney, et cetera.

Lack of agreement, of course, academic institution, and within the individual institution.

So there's no agreement.

Now let's look at some more.

This is an interesting article.

This from the surgery literature here with the University of Pittsburgh.

They who hire a coordinator to follow up on every single incidentaloma, and they divided incidentalomas into three categories.

Those that require attention prior to hospital discharge, those that follow up and number three require no follow up.

But even though the number three was no follow up, they were still considered, they were still notified.

The patient was because they felt was necessary for both for patient care and so forth.

So here you have practices out there.

So here you have a couple of places, and number one, there's no consistency in one place.

Here's a University of Pittsburgh that says, we obviously report every incidentaloma because we wanna contact the patient even if we think it's not significant.

Here is an ethicist.

Lo is an internist ethicist outta California.

He points out researcher, this is incidental findings and research imaging studies.

Researchers have an ethical obligation to exercise reasonable care in identifying incidental findings.

Researchers should offer to disclose the findings that are likely to provide any net medical benefit to the patient.

It cannot be assumed that the family physician will notice the patient's report.

Some radiologist should do direct contact.

That's his opinion.

Now, here's from the neurology literature.

Management of incidental finding and neural imaging research, a review here of 8,500 MRI scans, et cetera, et cetera.

Incidental findings found at 34% in 20%, there was a referral to the physician.

So obviously there are many institutions out there that are indeed reporting all incidental findings.

Here is this is a very interesting, and this just appeared just last month.

This is, it is a very important slide, Journal of Urology.

Now, the data comes from Iceland.

And as a matter of fact, Fergus mentioned this earlier this morning, but the fact of the matter is, it's a large study, not this particular article, but it's the same principle, of all the patients diagnosed with renal cell carcinoma between 1970 and 2005 and so forth, mostly diagnosed by ultrasound or CT incidentally finding found.

But anyway, the bottom line here, incidental detection affects survival favorably.

So in other words, the morbidity was far less in those renal cell carcinomas that were found by incidental findings rather than symptomatic.

And as I say, Fergus mentioned it earlier, but I think that we're gonna come to the courtroom in just a second.

But if you're in the courtroom and you're a defendant and you're trying to explain why you did not report this renal density as something significant, and the plaintiff comes up and the plaintiff's expert comes up with this slide, and some slides like it that really go on to show, or at least indicate that the survival is much better if the finding of carcinoma is found on an incidental finding.

And so all this stuff is pointing.

You see where I'm going a little bit, and that is, I think, well, you'll see when I end up, but I think that we're gonna have to probably wind up reporting all the incidentalomas.

But these articles are very, very interesting.

Now, here's a very interesting, again, Archives of Surgery.

And look at this, what this surgeon says.

The most important take home point is the malignancy does occur in small tumors and also can be evident, ultimately, presumably benign lesions in lieu of a better understanding, physician should be applauded for endorsing an aggressive surgical stance against these diseases.

Is that after all it's cancer we're dealing with, this obviously is direct opposite of Welch, who says, radiologists don't bother reporting the incidentalomas.

We don't wanna know.

Courtroom Examples and Transcripts

Now, this is a transcript from a real trial.

And what it was, was a lung nodule where the radiologist wound up reporting a granuloma and just passed it off and it turned out to be carcinoma.

And here's the plaintiff's lawyer who now has the defendant radiologist on the witness stand.

He says, would you agree that when issuing a report that the finding is a benign granuloma, it's probably gonna cause the physician receiving it to engage in no further testing, which means that if it is cancer, it will continue to go undetected.

And of course, the answer is yes.

He goes on, if judgments are to be made about whether the doctor should or should not follow up with the lung finding, is it not your responsibility to leave the judgment making in the hands of the patient and the patient's physician?

In other words, why are you the radiologist deciding whether it's important to mention it or not?

Should you not mention it and then let the doctor referring physician and the patient decide what to do next?

So the radiologist says, yes, but I was the patient's physician at the time, and I used my own judgment, which sounded like a decent answer, but now look what the plaintiff comes back with.

The plaintiff's attorney, doctor.

Everything we do in life involves judgment.

When you're driving down the street and you see a red light, you exercise your judgment, whether you stop or go through it.

If you go through a red light and you injure someone, it is not a defense that you went through the light in the exercise of your judgment, is it?

He says, yeah, that would be bad judgment, correct?

To which the plaintiff attorney says, no, that would be negligent judgment.

And so it's very nice to say, it was my best judgment that this was probably negative and unimportant, therefore, I didn't mention it.

So this is, these are the worst case scenarios, but these occasions do help.

Now, here's another case.

Similar.

Here's again, a defense.

The defendant radiologist is on the stand.

Plaintiff's attorney says, as a radiologist, you did not make a diagnosis of lung cancer.

But is not what you do.

Like the screeners at the airport.

A suitcase comes through the x-ray machine, something shows up.

It might be a gun, it might not be a gun.

They don't know.

So they pull the bag off the line.

But that's what a radiologist does, doesn't it?

And when someone else takes a look at the bag, and sometimes it is a gun, sometimes it is, sometimes it isn't.

What the radiologist does is just to alert the people that there may be a problem.

He doesn't have to diagnose the gun.

Isn't his job just to tell the inspectors that there may be something here?

So isn't this the same when you read your x-rays?

It's not up to you to decide whether it's a carcinoma or not.

Isn't your job just to alert the family physician?

There may be something suspicious here.

And these kinds of arguments, these are the games in a sense.

They are games.

These are the games that the plaintiff's lawyers play in the courtroom, and they're pretty effective.

Now, here was a patient, a 47-year-old patient, for renal colic.

And the CT was done and so forth.

The radiologist interpreted the CT as normal.

He mentions a small cyst in the kidney in the body of the report, doesn't even put it in the impression.

And of course, later on, the patient comes back 60 months later, has his carcinoma, and so now there's a lawsuit.

And at trial, the plaintiff's radiology expert said that the radiologist should definitely have mentioned the cystic renal mass.

And he should have said, cancer cannot be ruled out.

The defendant radiologist, to his defense says, there was such a low likelihood of carcinoma.

I feel that ignoring it, I still met the standard of care.

'cause I didn't think it was likely enough for me to mention it.

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

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

Could it have represented early cancer?

Yeah, but probably no more than 1%.

Well, look at the answer to that.

Well, 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 living cured of his inalienable right to make his own decisions about his health?

These are the situations that occur in the courtroom.

Also, it's kind of interesting, this particular case was written up in the AMA journal a few years ago.

And but it's true, the argument that, I want to avoid a cascade of testing because it would've incurred a tremendous amount of extra cost to the patient and to society today, of course, today, of course, there's a big argument, and you'll see it in the newspapers.

The lawyer in this particular case asserted that evidence-based medicine is a cost saving method.

Lives will be lost in the interest of saving money.

And this is a winning argument right?

Now, you may recall the US Preventive Task Force two years ago that came out with the recommendations on mammography, limiting mammography to biennial rather than annual.

And recommending that there not be routine mammography in women under 40.

And of course, the argument that the profession came up with the cancer society, the ACR, so forth, and not so much them as the politicians saying, all it is is just rationing care to save money.

And so that's one of the counterarguments.

Yes, we do wanna avoid cascade of testing, but it can be easily misinterpreted to a jury as all you wanna do is save money.

And that's very interesting.

Okay, this was another interesting case.

This happened just last year ago in Chicago, 72-year-old woman, she was undergoing a colonoscopy.

The gastroenterologist was unable to get through everything, unable to get the sigmoid.

So they did a barium enema right away.

The radiologist found a small filling defect in the ascending colon, which she felt had a typical appearance of a small lipoma he didn't even mention in the report.

Of course, later on, she comes back 14 months later, and she has her adenocarcinoma, the ascending colon jury verdict, $2 million, $2 million.

Now, of course, for instance, is not proof, but nevertheless, it was for instance.

So for instance, is not proof, but nevertheless, for instance, does have impact.

Now, we heard this morning, I won't repeat this, Michael mentioned the Cassella, Cassella, who was former chairman of Emory, and he mentioned what happened to him and so forth with his colonography and so forth.

They found the incidentaloma, and he had all these complications.

And actually he wrote it up in Radiology back in 2002.

And what Cassella, what he, what Castella, concluded in that article, again, this is 2012, it's 10 years later, but it's just as realistic today.

He said, routine screening with CT will produce more incidentalomas in surgery.

He was a prophet because it's now 10 years later, and it's more so and more CT scans to monitor, to change.

We must understand the consequences of the patient.

It is not nihilistic to suggest that more research is needed to prove that searching for occult lesions will improve the length and the quality of life.

He said it then.

And of course it's true.

Media and Public Perception Examples

Now, for those of you that read the New York Times, there's a columnist there, Nicholas Kristof, who writes regularly the New York Times.

And a year ago, he had this article, actually, basic takes back to two years, almost a year and a half ago, A Scare, A Scar, A Silver Lining.

And what he wrote about was the fact that he had back pain and he went in for CT for a lumbar spine, and they found a den of his kidney.

His spine was normal, but the unexpected kidney mass was seen.

He underwent a partial nephrectomy.

It was done, but the lesion, of course, turned out to be benign.

Kristof was not angry, but actually he felt lucky and grateful.

He and the others claimed he survived a brush with death.

Schwartz, who works with Gilbert Welch at Dartmouth says, but he did not, he actually survived a brush with over-diagnosis, not with brush with death.

And so, actually, Kristof in his article says, so today I have an impressive scar, a bit less kidney, a big belly ache, and far more appreciation for the glory of life.

This is what Kristof says, and this is his opinion.

And so as Schwartz point out, incidentalomas, he says he disagrees.

Kristof thinks he had a silver lining, but Schwartz says, no, he's an internist.

Schwartz.

He said, incidentalomas may be treatable cancer, and the patient may undergo further test to find out.

More often than not, is a false alarm.

What a paradox.

The more false alarms, the greater the appreciation for life, the more unnecessary brushes with death, the greater the enthusiasm for testing.

And that is an issue.

Patients are very happy.

Michael told this morning, talked about his sister-in-law, of course, the surgery, the that would've been a big operation.

But nevertheless, had she not had her brother-in-law maybe to tell her, you're not gonna undergo this pancreatic surgery.

Maybe had she had the pancreatic surgery and the surgeon would've come out and says, guess what?

You had no cancer, she would've been happy.

And that's what happens with most of the patients.

And this is in, here's a very intelligent columnist, and he's very happy.

So anyway, Schwartz concludes that the moreover diagnosis of cancer that occurs, the more individuals there are who feel they owe their life to the test harm is interpreted as a benefit.

Overdiagnosis of cancer is a core problem for American medicine, so forth and so forth.

A more healthy skepticism about testing seems prudent again, very nice, very philosophical.

So now we come to one more thing, and for those of you that watched the Sunday morning CBS News Sunday morning show, I think it was very good myself.

Anyway, just on April 1st, three weeks ago, three, four weeks ago, there were those of you watching may have seen, it was regarding a 19-year-old young man who suffered a cardiac arrest and died suddenly.

Two malfunctioning Intermedics pacemaker monitor data revealed that the frequency of malfunction of these devices were one tenth of 1%.

The father was interviewed on television, a CBS television, lamenting the fact, why weren't we told, why didn't the company tell us?

Why didn't my doctor tell us that there was a 0.1% possibility that there would be failure?

Now, we talked about the statistics regarding incidentalomas.

Maybe 1% of these incidentalomas are carcinoma.

Here, he's lamenting the fact that it's one tenth of 1%.

I should have been told, and this is for instance, it's for instance, it's not proof, but it's very dramatic and it's very convincing.

Radiology Malpractice Dilemma and Recommendations

So obviously we have the radiology malpractice dilemma.

Radiology practice malpractice dilemma.

Should we, or should we not report every single incidentaloma?

Well, here's an ethicist says the physician's allegiance is toward the patient and championing what is best for that patient.

The issue in deciding is a matter of balancing the good that will result with the patient against the bad.

Nobody can disagree with it, it doesn't tell us what to do, but nobody can disagree with that statement, certainly.

Obviously, the era of paternalism where the doctor has said to the patient for years and years and years, up until maybe the past decade, I'm the doctor.

I know what's best.

I leave it to me to tell you what you have to know, and leave it to me to not to tell you what you don't have to know.

That is the era of paternalism.

That era is over.

We all know that that era is over today.

We live in a consumer driven physician as a partner and advisor to the patient society.

That's where we stand today.

And it is this attitude of a physician, of the older physicians, not so many the younger, but certainly up until a decade ago, I know what's best for the patient.

And let me inform the patient what has to be done and what does not have to be done.

That era is obviously over.

So what do we do?

My own look, number one, there's good news and bad news in a sense, because if we assume, the good news is that if we assume that 1% of all these incidentals are turn out to be cancer, that we may ignore.

If we assume that if it is cancer, maybe 50% of the patients will bother filing a lawsuit, 50% won't.

So maybe we're down to one half of 1%.

So if we decide that we're not gonna report these incidentalomas, the likelihood of getting sued is very remote.

I'm here with a worst case scenario and I'll tell you the worst cases and so forth.

But let's face it, these incidentalomas that you really think are unimportant or insignificant, 1% may be turning out be cancer.

And of those, maybe half of the people might sue you.

So the likelihood is you're never gonna get sued anyway.

The bad news is that if you do get sued, I think it'd be very hard to defend when you have these plaintiff's lawyers and jurors, 12 jurors that are being told, the doctor knew something, the doctor had some information that may have been adverse to the patient's health, and for whatever reason, whether he followed some scheme of algorithm or whatever, that he didn't report it, and it wasn't told to the family physician or the patient.

I think that that's a very weak defense.

You don't know what a jury's gonna do.

But anyway, that's the bad news.

But the good news is we're only talking about one half of 1%.

So what do I suggest?

I think we're gonna hear more tomorrow.

We've heard quite a bit today about how to report these things and the likelihood and so forth.

To me, I think a statement, something to the effect of an incidental finding of a five millimeter, let's say nodular density in the liver, kidney, whatever it is, is noted.

The likelihood that this represents significant pathology is extremely remote.

I kind of like that kind of a report.

You don't wanna give percentages, certainly not, because how are you gonna know?

You can't say 1% because then the plaintiff's lawyer is gonna, how do you know?

You know, it's 1%.

I mean, just because you've read some article that says it's 1%, how would you know?

So I think that in a way we should be a little nebulous.

It's just my own personal opinion, but I think it's gonna be very, again, we have to do the right thing.

And I think it's really up to the individual person.

I can't tell you what to do.

I really think that if you have any suspicion at all, that there could be a possible significant pathology, certainly you ought to mention it if it's something.

And then I think as Elliot and others have said already today, that you gotta use common sense.

And if it's something that's obviously in your own mind saying, this is really nothing, then just stick with it and do the best you can.

As I say, what the standard of care is really what the reasonable doctor or similar radiologist would do.

And you have to go along with that.

So with that, I started off with two or three quotations, and I'll leave you with this one from F. Scott Fitzgerald who said the test of a first-rate intelligence is the ability to hold two opposing ideas in the mind at the same time and still retain the ability to function.

So I think we have to retain the ability to function knowing that there's a pro and a con out there, but I think we have to do the best we can and do what's reasonable and what makes common sense.

So I thank you very, very much for your attention.