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“Your CT scan showed a nodule. The radiologist recommends a repeat scan in 6 months. Okay?”

“Are you serious? I have lung cancer? Can you take it out? What does it mean? Am I going to die from this? But you said before the scan was fine!?”

I love being a physician. I give people more time to be, to create, to love, and to be loved. I prevail against pain, fear, and confusion. I am a machine of diagnosis and problem-solving, fueled by caffeine and smiles of people for whom my efforts were enough. But, I’ve always despised incidental findings.

The computed tomography (CT) scan is a powerful tool and a double-edged sword. It effectively rules out life threats and finds where we should cut and stent and when no intervention is best. It also sees every internal freckle crossing the 5-mm slices of gamma rays. The radiologist’s eagle eye captures the fleck in mental crosshairs and fires word shrapnel like “lesion” or “nodule.” Prudently, radiologists suggest nonintervention and close follow-up with repeat imaging. It is my job, the clinician who dared to look at the forest, and confronted with the trees, to drop the “bad nuisance” bomb on the unsuspecting victim.

The big negatives are usually reported first, and I have already reassured my patient that he is not going to exsanguinate and nothing is broken. Whenever the dreaded incidental findings follow (“the bad nuisance”), I don’t look forward to the impending task of poisoning the well of optimism that my patient needs to recover and move on. Selfishly, I hate transforming from “the good doctor who took the pain away and made sure I was okay,” to the messenger of fear. But it is part of the work I live to do. So I care about doing it right.

The medical literature has plenty to say on the art and science of breaking bad news. Most would agree that the “hit-and-run” disclosure that opened this essay is bad.1 Every major textbook has a thoughtful approach, and several creative mnemonics have been invented to help practitioners remember. SPIKES is a classic that nicely outlines the fundamental method shared by others.2

S: Setting up (private comfortable setting, eliminate interruptions).

P: Perception (assess what the patient already knows).

I: Invitation (determine if the patient wants themselves and/or someone else informed).

K: Knowledge (give a warning to prepare the patient and share the information).

E: Emotions (empathetically deal with the patient’s emotional response).

S: Strategy and Summary (discuss understanding and plan for the future).

While I truly appreciate the value of this sensible approach for breaking significantly bad news, I feel reservations about its effect on patients receiving “bad nuisance.” Is it wise to use a tool designed for cancer notification for information of likely minimal clinical significance? The worried patient will be frantic and miserable until he or she gets the follow-up study. In fact, the news may actually be lifesaving as early detection of lung cancer by CT is potentially effective at “providing both higher resectability and higher long-term survival rates.”3 Additionally, being informed of a clinically insignificant finding may lead the patient to stop smoking, improve his or her preventative care, and lead a healthier lifestyle. The patients often perceive medical information in a binary way (“I am well” vs. “I am dying”). So I find it helpful to divide news into a 2 × 2 table of “mostly good” versus “mostly bad” and “do something” versus “do nothing.”“Bad nuisance” has a definite place in this table, and patients need to see it as such.

My modification to SPIKES is SPOKES, like spokes on a wheel, with figurative emphasis on the direction in which the patient must roll with the mostly good information.

S: Setting up (private comfortable setting or safe and appropriate environment if notifying by phone, eliminate interruptions).

P: Perception (assess what the patient already knows).

O: Optimistic Invitation to Action (report that you have “mostly good news” that the patient “must do something about” and ask if the patient wants to be told or someone else—a relative or a primary physician—should be notified exclusively or additionally).

K: Knowledge (explain that incidental findings are common and likely benign, but could be vital and lifesaving, if appropriately managed; also explain the value of thoughtful nonintervention and importance of good follow-up with their primary physician).

E: Emotions (empathetically deal with the patient’s emotional response).

S: Strategy and Summary (discuss understanding and plan for the future).

I no longer dread notifying patients of incidental findings. I think of the time it will consume as an investment. I see an opportunity to do something well and savor a chance to make yet one more positive difference in my patient’s health and well-being.

I love being a physician.

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