Sunday, April 4, 2010

Obama Passes on Colonoscopy: Oh, What Might Have Been!

Does anyone out there know why President Obama underwent a virtual  ‘colonscopy’ (VC) instead of a conventional colonoscopy earlier this year? In my gastroenterology practice, we do not offer colon cancer screening to 48-year-old individuals, unless special risk factors are present. Of course, maintaining the president’s health is in the national interest, so I understand why professional screening guidelines might not apply to him. For similar reasons, airline pilots are subjected to routine cardiac testing, not to protect the pilots' health, but to protect the passengers.  Stricter scrutiny of the president's health is proper.

So, if the national interest required that the First Colon be studied prematurely, then why didn’t the president choose the screening test that nearly every physician opts for when we turn 50?  I’m baffled.

It is inarguable that a colonoscopy is more accurate than VC and can remove polyps and obtain biopies at the time of the examination. In every instance that I recommend a colonoscopy, I present virtual colonoscopy as an alternative adventure of the lower bowel. Patients invariably reject it, despite its safety advantage, because they do not want to endure a VC laxative prep to discover afterward that they need a colonoscopy to remove a lesion.

VC also has radiation risk, which is belatedly capturing the attention of the press, physicians and the public. The FDA acknowledges that radiation exposure from VC is equivalalent to about 400 standard x-rays. We have been broiling too many patients for too long.  I am also concerned that VC, like all CAT scans, will discover incidental ‘abnormalities’ outside the colon, that will generate anxiety and a medical cascade chasing these faux lesions that are nothing more than radiographic curiosities.

Medicare has declined to cover VC for colon cancer screening, presumably as they have not been persuaded by available data.  Interestingly, ABC news reported last week that Julian Nicholas, a former FDA scientist (can I call him a ‘Whistleblower’?), stated in an interview that "there was an absence of sufficient, valid scientific evidence to conclude that the use of CT devices for colorectal cancer is both safe or effective." Nicholas alleges that after he declined to withdraw his objection to VC, he experienced a VT, a virtual termination. The FDA states that there was no retaliation against Nicholas for his dissenting view. Yeah, right. Sounds like the agency spokesman was engaging in some VS, or virtual spinning.

Perhaps, President Obama wanted to avoid the sedation that is administered before a conventional colonoscopy. Was he scared to transfer his presidential powers to the Vice-President? Did he fear that during these few hours, that Biden might go soft on Netanyahu, invite Jeremiah Wright to a White House prayer breakfast or simply start spewing ‘BFD', as he did in the president’s ear – and in ours- just prior to the signing of the health care reform bill?

What would I have done if I were the president’s gastroenterologist? I would have devised a solution that would have met two tests:

  • Provide premier presidential colonic protection
  • Permit the president to retain his powers
This is easy. I would have advised the president to undergo a traditional colonoscopy without sedation, as routinely occurs in many nations whose citizens do not have the expectation of comfort that we Americans do. In addition to receiving Cadillac colonic care, there would be a political dividend. The president, by shrugging off a few stomach cramps, would show the world his toughness. This would earn him deserved respect from his political adversaries here at home, and might induce some leaders abroad to reconsider their policies. While all of this is hypothetical, here are some headlines that might have followed a presidential colonoscopy sans sedation:

Nervous Ahmadinejad Invites U.N. Inspectors Back
Kim Jong-il Surrenders Nukes. Sends Obama Flowers
Chinese President Hu Demands Sanctions on Iran
Senator Mitch McConnell Supports Public Option
Hillary Clinton States, “Honored to Serve as Obama's #2”
Washington Monument Renamed the Obama Obelisk
Obama Promised Nobel Prize in Medicine 2011
Dick Cheney Invites President on Hunting Trip
Mr. President, your colon cancer screening choice had geopolitical ramifications. While this damage is done, there may be a way to restore some of our power and prestige. Find out when Biden is due for his next colon exam. If it's not due for a while, then declare it to be necessary now by executive order. Direct him to proceed without sedation, so the world can fear and respect the man who is a heartbeat away from the presidency. If he balks, tell him that he needs to take one for the team. Afterwards, at his bedside, let him know that his sacrifice was a 'BFD' for the nation.

Unsedated colonoscopy could become a new standard for political candidates. Their handlers would make sure that after the candidates kiss the babies, eat rubber chicken, acknowledge the local mayor and dignitaries, wear a hard hat and reject polling data; that they will jump on board the GI Colon Express with only a bullet to bite on for anesthesia.

Are you listening Mitt Romney? Here's your opportunity to vault ahead before this procedure becomes as politically required as eating at the local diner. Go for it, Mitt.  There will be light at the end of the tunnel.


Anonymous said...

Dr. Kirsch,
Loved this post. "First colon" and Biden's BFD colonoscopy were priceless--the type of thing you read and think, "I wish I had come up with that." Humor is not that easy to pull off and you are so good at using it to make a point. Thanks to family history, I'll have my third colonoscopy before my husband has his second one. After reading your post, if anyone offers the virtual option I'll just say "No thanks." Luckily I have no influence on U.S. reputation so I'll opt for sedation.
Jackie Fox

Evinx said...

Great post Dr K -- both informative + funny.

Being serious for a moment, I have trouble with the Pres making this decision AND still being a smoker. Why would anyone take health related advice from someone like him? (Remember, he never released his medical records during the campaign either).

He knows everything he does and says is of import. This was a bad example.

The only possible excuse is that he did not trust Biden - who I personally think is a buffoon (but then I did not really care for any of the four headliners from the 2008 election).

Again, thanks for the education + "colonic humor."

Anonymous said...

I assumed he had the virtual colonoscopy to avoid sedation and the need to pass off presidentship or whatever you call it to the VP...

Terri R.,RN BSN said...

Dr. Kirsch,
Love your post! Hilarious! I automatically thought the same thing when I read that. Why is he not having a routine colonoscopy like everyone else? Virtual CT colonoscopies are rarely done(and approved by any health plan, private or not), like you said unless routine colonoscopy is contraindicated. Guess I would have been concerned about leaving Biden in charge too! lol. Love your humor and your blog.

kennylin said...

Terrific post - informative and funny. Thank you!

Michael Kirsch, M.D. said...

Thanks to all for comments. The president opted for a virtual colonoscopy. I think that the country received an unsedated colonoscopy, and the exam is still in progress.

Anonymous said...

Although I agree 100% about the unsedated colonoscopy. The 09 screening guidelines for colorectal cancer. The latest is that African American males require screening colo at age 45 because of the higher incidence of colorectal cancer in AA males compared to other ethnic groups in the country. Everyone else still gets their screening colo at age 50.

Anonymous said...

Typical gastroenterologist screed. Lots of scary talk about radiation damage. No comment about the rate of serious complications of colonocscopy (1 in 300) or death (1 in 3000 to 1 in 30,000). In this case, the pilot of this plane has 300 million passengers.

Anonymous said...

The ACG guidelines state that African Americans should start colonoscopy screening at age 45. His smoking increases his risk of CRC and polyps.

Anonymous said...

Read this article in this month's Gastroenterology and Endoscopy News. While I agree with most of your piece, you do look silly overlooking the fact that the screening age for African-Americans is now 45. Not only do I think it was age-appropriate, it was a little late. However, the chance that a high-risk lesion was missed approaches 10%, and I think that Obama took an unnecessary risk by pursuing VC. The only obvious reason he did it, of course, is to avoid having to temporarily pass off the presidency to Biden like Bush did, and I agree that an unsedated colonoscopy would have been a great statement, and probably would not have caused much more discomfort than the VC.

Karen Martinelli said...

I am curious - with a tag like MD Whistleblower, I am writing to ask how you are able to get the attention of those who need to have it - like about a fraudster who is a doc, who is so arrogant and open about his ongoing and patient centered fraud, in spite of turning over to the state AG (who is also this doc's neighbor and friend) 8 years of 990's filed by the same with the lies on it highlighted - 2 years of research to provide the AG's office with factual info so they could not say they did not have the man power or ability to research my claims - they did open a public inquiry - and 3 months later - nada! How is this possible? Just curious. As thhis really is a matter of life and death, and I will ot give up until someone stops him - I was intrigued by your post and the fact that it caught my eye - well - nothing happens without a reason. Any thoughts??? Thanks for your time - Karen Martinelli

Anonymous said...

What a crock. Unsedated colonoscopy is the standard is most parts of the world; to say that is should be performed on political candidates is silly. U.S. docs overuse sedation, especially Versed because they want to render the patient amnestic and has nothing to do with patient comfort....sedation lets the slob gastros do the exams quickly (and poorly)..then the patient (up to 10%) is left with long-term memory loss.

Anonymous said...

No offense to the ACG, but the 45 y.o age screening for African Americans and smokers are ACG guidelines. These are NOT "national/Federal, or other policy setting agency/ies guidelines.

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