Tests have side effects

Just like pharmaceuticals, all tests have side effects that go well

beyond their wallet toxicity. Intuitively, the more invasive tests such as

catheterizations, biopsies, or scopes of one sort or another, carry the greatest

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likelihood of serious mishap.

tests beget

tests. An eighty-year-old man with a known aneurysm of his aorta, a widened

and weakened major artery that carries a risk of rupture and sudden

rapid death, is sent by his vascular surgeon for a CT scan of the abdomen.

The report from the radiologist indicates that the aneurysm is small and

stable. This is good news, but there is a little density in the right adrenal

gland that wasn’t there before—bad news, maybe. The radiologist concludes

his report by recommending that the patient undergo a repeat CT

scan at three months, and again at six months to ensure radiographic stability,

that is, to be sure that it is not a growing cancer, rather than a benign,

harmless growth called an adrenal adenoma. This sort of unexpected, or

incidental, finding is sometimes referred to as an incidentaloma (Mirilas

and Skandalakis 2002, 1026). The suffix-oma means “a mass,” so this neologism

means an incidentally noted mass lesion of uncertain significance.

It is not what we were looking for, but now it too commands our attention,

resulting in more CT scans with more radiation to the patient.

The problem of the incidentaloma highlights three negative aspects associated

with frequent utilization of diagnostic imaging. The first is that

the more you look, the more you find. The patient gets caught up in a

vortex of testing. The second is a potential pitfall in the reporting and

follow-up of test results.

“four weeks after a specific referral visit, 25% of primary

care physicians still had not received any information from specialists”

For example, I might say,

“Would you see Mrs. Jones, an eighty-five-year-old woman with declining

renal [kidney] function? She’s definitely not the sort of person who

would tolerate a kidney biopsy, and she’d never consider dialysis, but it

would be helpful if you just took a look at her for me.” A lot of information

about Mrs. Jones was thereby conveyed in a short but personal, casual

conversation

Fast-forward to today. The physician making rounds now carries on his

belt an electronic beeper, a cell phone or BlackBerry, and a PDA (personal

digital assistant) loaded with information. He is likely to be carrying a

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laptop computer from bedside to bedside as well for record keeping. He

looks like some sort of commando from Mission Impossible. Yet, for all of

his telecom apparatus, he actually is communicating less effectively with

his peers than did his predecessors who made rounds before him.