Unexpected findings on medical imaging are usually harmless

Brain MRIImagine you go for an MRI or an x ray and the radiologist spots something they didn’t anticipate on your scan – you would be worried, right?

Well, maybe you don’t need to be. A study of more than 1,400 scan found that almost 40% showed at least one such “incidental finding” but only 2.5% were thought to show a genuine medical problem and required further clinical action.

Although spotting something by accident on a medical scan can mean that a disease or disorder is detected and treated early, the extra scans and tests that follow might be painful or dangerous if the incidental finding turns out to be clinically harmless. As such, it’s important that radiologists have some kind of idea which findings are worth acting on and which represent innocuous anatomical quirks.

The authors of this study raked through the medical records of patients at Mayo Clinic in Minnesota who had taken part in imaging research between January and March 2004.

Of the 1,426 scans for which three years of follow-up was reported, 567 (38.9%) had at least one incidental finding. Out of these people whose scan had an incidental finding, 35 (6.2%) underwent further clinical action such as follow-up imaging or invasive diagnostic tests like broncoscopy.

Four people turned out to have diseases or disorders that were medically serious or even life threatening, which would have gone undetected had they not been in an imaging study. Only one person was found to have minimal or trivial disease, which presumably would not have merited the further investigations conducted.

Six (1.1%) people with an incidental finding had treatment that resolved or improved the newly detected disorder or disease, whereas only three underwent medical or surgical treatment that resulted in lack of improvement. In the rest of the participants with an incidental finding the medical benefit or burden of the subsequent treatment was unclear.

The likelihood of an incidental finding varied considerably depending on the type of scan used – nearly two thirds (61%) of people who had computed tomography of the abdomen and pelvis had an incidental finding on their scan, compared with only 4% of people who underwent some sort of nuclear medicine procedure. However, only computed tomography and MRI of the head yielded incidental findings that received further investigation.

It seems that people whose incidental finding does represent serious disease are being checked out and few people whose odd findings on imaging are harmless are being pursued. However, the authors say: “the clinical investigation of a suspicious incidental finding that results in a benign diagnosis is not necessarily without clinical value or avoidable when presented with potentially life-threatening consequences (e.g. a solid renal mass).”

Orme N et al. (2010) Incidental Findings in Imaging Research: Evaluating Incidence, Benefit, and Burden. Archives of Internal Medicine 170:1525-1532. DOI: 10.1001/archinternmed.2010.317

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Medical students keep quiet about depression because of fear of stigma

Not only are a considerable proportion of medical students depressed, those who are believe they’ll lose the respect of their peers and their tutors if they speak out, according to new research in published in Journal of the American Medical Association.

The study of 505 medical students in Michigan found that more than one in 10 (14.3%) of them were depressed, almost three times as many as in the general population of the United States (prevalence 5.4%).

More than half of those who were depressed felt that telling a counselor would be risky and that fellow medical students would respect their opinions less if they knew (53.3% and 56.0%, respectively), whereas far fewer of their non-depressed peers held these views (16.7% and 23.7%).

The authors of this research invited all 769 medical students enrolled at the University of Michigan Medical School in September-November 2009 to do an anonymous internet survey on depression and their attitudes to the disease.

Women were more likely than men to have moderate to severe depression (18.0% vs 9.0%), and students who were depressed were nearly eight times more likely to have considered leaving medical school than had those with minimal depression (43.1% vs 5.6%). As many as 68% of those with depression had seriously considered committing suicide, although the overall number of students with “suicidal ideation” was small (22/505 (4.4%)).

Medical school is mentally and academically demanding, so it’s not surprising that rates of depression, burnout, and suicide are higher in medical students than in the general population. Yet despite no doubt being familiar with mental health issues given their training, medical students with depression are notoriously bad at seeking treatment. In this study, for example, approximately 70-80% of students with moderate to severe depression had not received a diagnosis or treatment for depression.

As well as worrying about what their tutors and peers thought of them, medical students with moderate to severe depression were more likely than those not depressed to think that asking for help would mean their coping skills were inadequate (61.7% vs 33.5%). They also felt that others would consider them unable to handle their medical school responsibilities (83.1% vs 55.1%).

It wasn’t just the students who were depressed who believed stigmas associated with the disease: those without depression were more likely to think that depressed medical students would be a danger to patients (25.7% vs 13.6%).

The fact that so many medical students seem to hold negative views of depression is rather worrying, not least because one study found that 30% of first year and second year medical students with depression cited stigma as a barrier to seeking treatment. It does seem counter-intuitive that this group exposed to health messages pretty much non-stop thanks to their course of study seems to sign up to negative stigmas surrounding depression.

The authors suggest that rather than the emphasis on academic excellence and professionalism scaring medical students out of reporting depression, medical education programmes could be tweaked so that students perceive looking after the mental health of themselves and their peers as a key aspect of being an outstanding doctor.
Schwenk T, Davis L, & Wimsatt L (2010) Depression, Stigma, and Suicidal Ideation in Medical Students. JAMA: The Journal of the American Medical Association 304 (11): 1181-1190. DOI: 10.1001/jama.2010.1300

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