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March 28, 2011

Better Off Not Knowing: Improving Clinical Care by Limiting Physician Access to Unsolicited Diagnostic Information

Author Affiliations

Author Affiliations: Division of Gastroenterology and Hepatology and Center for Behavioral and Decision Sciences in Medicine, University of Michigan Health System, Ann Arbor (Dr Volk); and Fuqua School of Business, Duke University, Durham, North Carolina (Dr Ubel).

Arch Intern Med. 2011;171(6):487-488. doi:10.1001/archinternmed.2011.63

A 70-year-old woman with back pain unresponsive to conservative measures underwent magnetic resonance imaging of the spine, which incidentally revealed a complex cyst in the kidney. Her physician felt obligated to investigate, but the cyst was beyond the reach of the radiologist for biopsy. Several anxious weeks later, the patient lay in a hospital recovering from a total nephrectomy. Final diagnosis: benign renal cyst.

Most clinicians recognize a variant of this story from their clinical practice. A test is ordered for appropriate indications but provides information about an unrelated condition, leaving the physician and patient to contend with information they had not sought but which, nevertheless, they find impossible to ignore. We contend that patients would be better served if the medical profession adopted simple interventions to limit physicians' access to unsolicited diagnostic information. We discuss herein how this information can end up harming patients and suggest steps the health system could take to reduce the availability of such information.

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    2 Comments for this article
    Unsolicited Infromation
    G Thomas A Morris, MD | Retired Internist
    Retired Internist Send reply to journal: Re: Unsolicited Infromation

    E-mail G Thomas A Morris

    I would prefer that my internist have no limitation on information if I were to be in situations mentioned. The 70 year old has a life expectancy of 15 years or more, and malignancy is a consideration. The knowns and unknowns can be explained and appropriate consultation(s) obtained. Your contention that patients would be better served seems bolstered by finding a benign neoplasm in this patient; however society may be better served if physicians " endure the evils we know than to
    flee to others we know not of".
    Conflict of Interest: None declared
    Ignorance is bliss?
    Matthew A. Sutton, MD | University of North Carolina at Chapel Hill
    In their commentary "Better Off Not Knowing," Volk and Ubel ask us to consider that harm may be avoided by concealing diagnostic data from the physician's eyes if it is deemed impertinent to the clinical question at hand. This idea and the proposed solutions shift the blame from the interpreter of the data to the data itself. Before physicians even fill out a lab slip or radiology requisition, we have sorted through uncountable details from the patient's history, review of systems, and physical exam, carefully choosing the appropriate weight, if any, to assign each bit of information. Every question asked and body part examined is a diagnostic test. And so, even at the early stages of the clinical encounter, the possibility of "incidentaloma" discovery exists.
    Suppose I ask a patient to remove his shirt for cardiac auscultation. As he does so, I incidentally notice a nevus on his shoulder with suspicious features. Would it be better that I simply ignore such a finding since I was not explicitly performing a screening skin exam and there is no evidence that such screening exams should be performed universally? Does the unexpected discovery of an intra-abdominal mass on routine abdominal palpation not also represent an incidentaloma of sorts?
    Sifting through and assigning importance to vast quantities of unfiltered information is a defining skill of our profession. One of the unintended yet unavoidable consequences of increased diagnostic information is increased false positives. Ironically, the authors identify the solution to this dilemma in their description of the problem: "If physicians could recognize the low pretest probability of serious conditions and the inaccuracy of most tests and simply ignore 'incidental- omas,' and patients could calmly accept physicians' reassurances about these findings, then no harm would be caused." What is required is improved training in test interpretation and patient communication, not a blindfold.

    Conflict of Interest: None declared