We're unable to sign you in at this time. Please try again in a few minutes.
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Commentary | Less Is More

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

Michael L. Volk, MD, MSc; Peter A. Ubel, MD
Arch Intern Med. 2011;171(6):487-488. doi:10.1001/archinternmed.2011.63.
Text Size: A A A
Published online


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.

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

First Page Preview

View Large
First page PDF preview





Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment
Unsolicited Infromation
Posted on April 20, 2011
G Thomas A Morris, MD
Retired Internist
Conflict of Interest: None Declared
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?
Posted on March 31, 2011
Matthew A. Sutton, MD
University of North Carolina at Chapel Hill
Conflict of Interest: None Declared
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
Submit a Comment


Some tools below are only available to our subscribers or users with an online account.

8 Citations

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections

Care at the Close of Life: Evidence and Experience