Incidental findings on imaging exams are common, and often primary care physicians (PCPs) aren't clear which ones need follow-up and which do not. The expertise of radiologists can go a long way toward clarifying the clinical situation, according to a new study published in the November issue of Radiology.
Dr. Hanna Zafar from the University of Pennsylvania.
"Unlike specialists who command detailed knowledge of an organ system and can defer findings outside that organ system to the PCP, PCPs are responsible for caring for the whole patient," Zafar told AuntMinnie.com. "They're swamped -- in addition to patient visits, PCPs can spend upward of 70 minutes each clinical day managing test results -- and they just can't be aware of all the specialty practice guidelines for each organ system. As radiologists, we need to do a better job in our reports by being more explicit, both about when imaging findings should prompt further follow-up and when no further follow-up is warranted."
Overcoming inertia
To explore provider and patient characteristics that inform how primary care physicians deal with incidental findings, Zafar's team interviewed 30 primary care physicians (15 family medicine and 15 internal medicine providers) using open-ended, semistructured questions to spark dialogue.
"We wanted to take a qualitative approach so that we could hear directly from providers the factors that influence how they communicate incidental findings to patients and manage these findings -- rather than imposing our biases as radiologists about what we think are the most important factors," she said. "We did this by examining transcripts of the interviews for common themes, and then built a model to capture the interplay of these themes."
Overall, Zafar and colleagues found that some primary care doctors felt bound to pursue costly follow-up for incidental imaging findings of limited clinical importance. Other physicians did not act on findings that were unfamiliar or occurred in an unusual clinical context when follow-up recommendations were not given, perhaps because of the time needed to research the clinical importance of these findings or consult with a specialist.
Some physicians used a consistent approach to communicate and manage incidental findings, while others adapted their approach to the patient and the finding. In addition, the researchers discovered that primary care physicians are more likely to trust a report issued by a radiologist they know personally, and they value clear recommendations from radiologists about whether to follow up on incidental findings.
"PCPs felt uncomfortable managing incidental imaging findings outside their scope of practice," the group wrote. "They indicated the value of clear descriptions and explicit radiologist recommendation for follow-up of incidental findings in two situations: (a) when they had no personal experience with a particular findings or (b) when a finding occurred in an unusual clinical context. ... In the absence of such recommendations, PCPs had to invest more work to determine how to proceed; one provider stated that this additional work led to 'inertia' in acting on a finding."
Bridging the gap
How can radiologists help their primary care colleagues when it comes to incidental findings? The researchers offered a number of suggestions:
- Include a range of evidence-based treatment options in the report. "For example, alternative recommendations could be given for patients with limited and extended life expectancy or for those with low, average, and high disease risk factors," they wrote.
- Use qualifying language in recommendations, such as "if clinically indicated." This kind of language "may reduce PCPs' feelings of medicolegal obligation associated with radiologist recommendations," the authors wrote.
- Increase radiologist interaction outside of the department, perhaps by establishing reading rooms in clinical areas or increasing radiologists' participation in multidisciplinary conferences. "These efforts come at the cost of time ... [but] justifying these costs may be easier ... as payment models evolve to reward appropriate healthcare use rather than simply high volume," they wrote.
The last suggestion is key, Zafar told AuntMinnie.com.
"Radiologists and primary care providers have all gotten busier, and outpatient offices at our health system are geographically further removed from our main hospital," she said. "So the level of interaction between us has changed. Because outpatient primary care providers rarely have the opportunity to come to the reading room at our hospital, it's important to foster relationships with them by being responsive to their phone calls and emails, and making clear recommendations so that they don't have to guess how to handle an incidental finding."
