The harm of the over-attentive doctor and the incidentaloma

I was talking with one of my former co-residents tonight, reflecting on our practices with regards to lab and imaging investigations on various patients. In residency I was probably one of the most conservative providers. I ordered only a handful of MRIs my whole residency, rarely ordered X-rays, avoided routine laboratory blood work, and rarely follow up imaging or labs on various mild abnormalities. She is in line with me, one of the least investigative providers in our residency. As interns we classically order very little imaging and labs, and often they were inappropriate if we did order them. As we get further along we learn what really truly needs investigating and are asking more questions, balancing more diseases and patient concerns and our ordering goes up.

There’s a dichotomy to all this though. I am struggling with this right now, the balance of being an attentive doctor who notes things, pays attention, does the follow up work, and the reality of the expense and likely unnecessary bloat to all of this. We are taught in training to avoid ordering unnecessary tests because when you go looking, you find things. And likely these are things that either shouldn’t be intervened on or that interventions are fruitless. Or we just know that on a population level it doesn’t make financial sense to check all these things.

In practice, especially independent practice that I’m in now, I find myself looking into things I likely would have overlooked in residency. I had a patient with low level rumbling transaminitis (sign of liver injury) for years, chalked up to non-alcoholic steatohepatitis (fatty liver), never had actually been worked up though. I did a workup for viral and autoimmune hepatitis to rule out those treatable causes and it was all normal, probably a few hundred dollars later. Another patient with a sellar mass in his brain incidentally noted on an mri to rule out MS. Ordered a hormone workup I’ve never ordered before, probably another few hundred dollars, all normal. Had several patients with raging new onset hypertension, blood pressures in the 200s. I felt like it was a good idea to work them up for secondary causes of hypertension like pheochromocytoma, renal artery stenosis, hyperaldosteronism, all normal workup, another few hundred dollars. On the flip side I had a patient I managed conservatively for a common primary care complaint, managed her how I was trained, how the algorithms recommend, and overlooked a serious diagnosis for weeks, admittedly maybe wouldn’t have made much of a difference had I caught it earlier unfortunately.

I am struggling to balance this over-ordering, this investigating every incidentaloma (a finding on imaging that was discovered serendipitously), every mild lab abnormality versus missing crucial diagnoses. I’m in a moment of paranoia if my initial months as an attending for sure. I wake up in the morning thinking about these patients, go to sleep thinking about these patients. I can’t help but wonder about the medical bills that they are going to incur for my very algorithmic and protocol based workup of various unexplained abnormalities. But I also worry that in my inexperience I will miss very slight warning signs for more ominous pathology. I worry about this paranoia escalating into over-investigation; I worry about that over-investigation becoming habit and I worry about never backing out of that slippery trend to a more careful, thoughtful, frugal doctor. I worry about the bills these patients incur and the frustration they’ll have with the medical system, that they may avoid us after I blew up their finances because of some benign finding we never should have noticed.

There’s a reality in medicine that I am acutely aware of that we are fairly helpless. I’ve known this for years, and have become quite cynical at times. There’s an article for 2015 highlighting how mortality declines or stabilizes after doctors go on strike. The reality is, we’re pretty bad at our jobs and for most ailments cannot help. So how do I balance this cultural over-ordering, over-investigating with the reality that I know I am inflicting harm on my patients? Do I expose myself to missed diagnoses and litigation by practicing conservative medicine that ethically is much more palatable? I don’t know and I guess I probably shouldn’t rush the process of finding all this out.

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