Sunday, May 17, 2015

Is Office Colonoscopy Ethical?

While I consider myself to be an ethical practitioner, I am not perfect, and neither is the medical profession.
I will present a recurrent ethical dilemma to my fair and balanced readers and await their judgment.
Our gastroenterology practice, like all of our competitors, has an open access endoscopy option.  This permits a physician to refer a patient to us for a colonoscopy, without the need for an initial office visit.

Ready, Aim, Fire!

Patients can also schedule procedures themselves, such as a screening colonoscopy, without a physician referral, if allowed by their insurance carriers.  These patients enjoy the convenience of  bypassing an office visit.   We agree that an office consultation should not be required for routine screening procedures or to evaluate minor gastrointestinal symptoms.

Of course, if a patient wants to see us in the office in advance – and some do – we are happy to do so.  I enjoy these pre-op visits which allows me to develop some measure of rapport with the patient and to discuss the upcoming endoscopic adventure, before the patient is naked with an IV dripping into his arm.

When these open access procedures are scheduled, we carefully screen patients on the phone to verify that bypassing an office visit does not pose any safety risks for the patient.   We do not want to meet a patient for the first time for a screening colonoscopy, who is on kidney dialysis and uses an oxygen tank.

Here’s the rub.  There are times when I meet an open access patient who is prepped and primed for a colonoscopy that is not necessary.  In the most recent example, I greeted a patient who was poised to have a colonoscopy because there was a prior history of colon polyps.  However, according to current professional guidelines, the patient didn’t need the exam for a few more years.   I was meeting this patient for the first time.  She had taken a day off of work and had a driver with her.  She had enjoyed the delight of the gentle cathartic agent that colonoscopy patients imbibe with gustatory pleasure on the prior evening.  She believes, of course, that the procedure is necessary as her physician had recommended it.

What should my response, if any, to her be?

One of the pitfalls of open access is that we can never screen patients as carefully as we do during an advance office visit.  Should we halt a procedure that an internist has requested even if we may not believe the procedure is of medical necessity?   Should we be willing to serve as ‘technicians’ for referring doctors in the same manner that radiologists serve their colleagues?  When we order a  CAT scan, for example, the procedure is always done whether it’s needed or not.

I sit in judgment now awaiting your verdict.  May it be as probing and enlightening as a colonoscopy.  


Karen B. said...

If it were me I would appreciate your input before I went through an unnecessary procedure, even if my physician had thought the procedure necessary. I always want to make my own decisions but can't if I'm not given all of the information. Please, provide your patients with the information they should have to make a decision regarding their own bodies and the care of those bodies. It's the right thing to do.

Barbara said...

Although someone's colon may not need the enlightening procedure, their psyche may need it very much. I believe that should be determined beforehand. Fear is often more crippling than a physical ailment. But you knew that.

Michael Kirsch, M.D. said...

Agree, Barbara. Peace of mind is often an indication for a medical test.

Anonymous said...

GI is not my field, but I believe that every patient should have a pre-procedure visit with the physician or the physician's assistant performing the procedure- even if this is just a telephone conversation to review chief complaint (for non-screening cases), past medical history, & review of systems. Any questions can then be addressed before the colon prep and the procedure.

Anonymous said...

I am sure you understand the position you are in. Do you really want to explain to the patient that you disagree with her primary care physician and she does not need the procedure which he told her she did need? Does everyone here not understand those ramifications? I do cataract surgery. I love meeting my patients a week before surgery. That way I can determine their expectations. If an optometrist wants to send me a patient (they don't), I would consider it a second opinion by a more highly trained physician- and also, dear me, when it is all said and done and all the preop/postop care is concluded, I make more money doing the initial office exam!

PGYx said...

I think the right thing to do is to explain your reasoning to the patient and delay the test until it is indicated. Most patients do not want an unnecessary test and really, insurance should not pay for an unnecessary test. Peace of mind is a nice idea, but all procedures carry some risk and also cost money. One of the reasons reimbursements for procedures have declined is that too many doctors do tests when they are not clearly indicated.

As a physician who gets referrals for electrodiagnostic testing, however, I understand the pressure to do what the referring doctor has ordered. Not doing so may result in him/her choosing not to refer to you in the future. In a perfect world you could have this conversation with the referring physician and come to a mutual agreement. I do think this is worth a try, although neither you nor the referring doctor will be reimbursed for time spent discussing the best plan.

In the real world, however, the referring doc (who may have a bit of a chip on his shoulder as primary care docs often feel looked down upon, and definitely bear a greater proportion of the medical administrative burden than specialists) may view this as you questioning his judgment and/or condescendingly correcting him. I would like to think all doctors eagerly assimilate new information to improve the quality of care they deliver, but experience suggests some doctors would not appreciate you sharing your expertise as much as I certainly would.

Still, our first priority is the patient. If you do not feel the test is indicated at this time, then you must document your reasoning, ideally share it with the referring doctor, and not perform that test.

Anonymous said...

The fact that you question your behavior is a good start .

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