Tuesday, March 31, 2015

Incidental Findings

Medicine is oftentimes filled with surprises. Consider the issue of incidental findings. Suppose a patient had has bad back pain. They had lifted something and as their physician you just want a simple plain X-ray to see if it is really L4-L5 as you suspect. You get a call from the Radiologist, not the usual response, in fact you hardly know them. But they tell you that there are multiple thoracic lesions, possibly a lymphoma. Now what?

That is an incidental finding. Yow were not looking for zebras but you found a herd.

Now consider dermatological mobile apps. I saw one today that may or may not apply, but it was a mobile dermatological app. Looking at acne, a common ailment especially with younger people.

The article notes:

Users who want to consult with a dermatologist can select a condition they want to get treated for in the app, which is currently only available for the iPhone. After they choose their condition, the app will provide users with an explanation of what to expect from the service. From there, they can choose a doctor. If users want to get the opinion of the first available doctor, they are guaranteed a 24 hour response, but they also have the option to choose a specific doctor. All doctors have a full profile that shows users where the doctor practices medicine, where they went to school...Then, they can upload pictures of their condition and after 24 hours, they will receive a response from the doctor with a treatment plan and a prescription, if needed.

Now assume a patient uploads a picture of their acne. Next to an acne lesion is a suspicious pigmented lesion. The patient did not ask about it, this after all is an iPhone picture, but you are concerned. The patient may have a melanoma. Incidental finding, lots of zebras.

Now what do you do? Contact the patient immediately? Who does the biopsy, where, how fast? You are now faced with a plethora of issues and possibly legal issues as well. What is your responsibility?

The problems may be significant. The problem with many mobile apps is that there may always be incidental findings. If one were in a physicians office perhaps a dermoscope would be available, a biopsy made, a record of the visit detailed, a discussion had. But arms length apps may present significant problems and massive legal issues.