Your Nodules Don’t Impress Me Much

February 3, 2020

Repeated calls for nodule follow-up can feel like spinning your wheels.

I mentioned in a recent column that I’ve grown to rather loathe the word “nodule.”

This is purely a case of familiarity breeding contempt. There’s nothing wrong with the word itself. But, for an awful lot of radiologists like me, it turns up ad nauseum in a typical workday, usually accompanied by the also-overused “follow-up.” And, most of the time, represents mindless/tedious busy-work of no probable clinical import – drawing calipers to measure the little things, redrawing measurements on the prior study because you don’t quite know if you can trust the prior’s report, etc.

Couple a recurrent, intellectually-unsatisfying task with the theoretical potential for catastrophe, and the ho-hum-ness of reading such cases gets a dash of stress, even anxiety. That is, you might read 10,000 nodule-cases uneventfully (lesions mostly stable, rarely enlarged, once in a blue moon you correctly identify a growing malignancy and recommend further action.)

But, the 10,001st case winds up being an indolent cancer that drags you sideways into a medicolegal swamp for the next five years of your career. Whether because you missed it or you did everything you should have, some ambulance-chaser is willing to argue otherwise. After all, Someone Must Pay (if SMP isn’t an official credo of personal-injury law, it probably should be) whenever there’s a bad outcome.

So, trying to remain focused and on-task when reviewing these things, one might understandably come to dislike one or more aspects of the situation – even start finding fault with innocent little bits of terminology.

For instance, I can’t shake the feeling that a lot of referrers are affecting medical sophistication by hiding behind the word “nodule.” Folks outside of our field tend not to use the word…at least, not until they hear it from one of us. They might otherwise say they’re getting a CT for a “spot on the lung.” Same meaning: there’s something there, and nobody really knows what it is. But if doc/nurse/PA can refer to it in medical-ese (and “nodule” sounds less dangerous than “lesion”), the clinician might just succeed in looking wiser and more capable to the patient. Heck, if the provider repeats this charade enough times, he’ll start believing his own hype.

Just don’t expect a rad like me to be impressed when you refer the patient to repeat imaging with your reason for exam simply being “follow-up nodule.” What, exactly, are you contributing to the situation at that point? The first thing I’m going to do when I get the case is review the previous reports and see that there was a lesion that I (or one of my colleagues) identified. In other words, we told you there was a nodule, whether we said that it should be followed.

On that point, let me divert into a side-rant here: What is the point of our even offering recommendations on further evaluation or follow-up if they’re going to be completely ignored? Those good folks at the Fleischner Society and the ACR came up with lovely evidence-based guidelines, including when it’s reasonable to not follow lesions. But, multiple times in a typical workday I get “follow-up nodule” studies that blatantly ignore those rules. Like a 2-mm dot on someone’s lung which was stable for nine years, unchanged as of six months ago.

I don’t know that I would be outright impressed by these nodule-referrals, but I’d respect them a lot more if the clinician took a moment to “bring something to the table.” Tell me about clinical risk factors that heighten your suspicion regarding the nodule, or even that, knowing the patient, you can say that there aren’t any. Tell me how long you’ve been following this thing, and, if previous studies were done somewhere else, do some of the legwork in getting them. Even just telling us where and when would help us track down those relevant priors.

Otherwise, it does not take a physician, PA, or nurse to make these referrals. A monkey with a rubber stamp or a trained parrot, if verbal orders are locally permitted, could get the job done just as well.

For that matter, why even involve anybody outside of the radiology department and the patient? Rad groups could establish Nodule Clinics- after the initial referral, the patients would be directly managed by the clinics, including mailed or phoned reminders of when it was time to return for the next imaging study. When a patient no longer needed following, they’d be discharged from the clinic.

And, if during a visit to the clinic, a patient described any clinical issues, we could just refer them back to their primary care provider with a note saying “follow-up symptoms.”

Sauce for the gander.