Sunday, June 5, 2016

Is Same Day Colonoscopy Right for You?


Like nearly every gastroenterologist, we have an open access endoscopy system.  This means that patients can be referred, or refer themselves, directly to our office for a a procedure without an office visit in advance.

Why do we do this?  We offer it as a convenience so patients do not need to make two visits to see us when it is clear that a procedure is necessary.  For example, a referring physician doesn't need our consultative advice for his 50-year-old patient with rectal bleeding.  He just needs us to do a colonoscopy.  We have a strict screening process in place to verify that these patients are appropriate for our one-stop colonoscopy program.  If we have concerns about medical issues or potential informed consent capability, then we arrange for these patients to see us in advance.

However, no screening process is perfect.  On occasion, someone shows up whom we might have preferred to see in our office first. How should we handle these situations?  We don't automatically cancel the test, particularly after the patient and his driver have taken time off  work and the patient has already swallowed the delectable and satisfying colonoscopy prep.

No Appointment Needed!

We are meeting many of these folks for the first time, and they are often nervous.  We get this.  First, they are at a physician's office for an intrusive medical test, always a relaxing activity.  The doctor may be a stranger to him, another calming feature of the event.  They become victims of intravenous needle assault, always a pleasure even from our ICU nursing veterans.  They have been fasting and may have enjoyed the pleasure and delight of our colonoscopy cleansing cocktail.  They are naked except for a gown that by design covers about 40% of their body's surface area.  Ready to sign up?

Open access endoscopy also raises potential ethical issues.  On occasion, a patient arrives for a procedure that we may not feel he truly needs or needs now.  Or, the patient is sent for one of our procedures, which may not be the best choice to address the patient's symptoms.   These are delicate issues and I don't have an idealized response to offer here.  In the open access arena, we regard ourselves more as technicians than consultants.  This is similar to when a doctor sends a patient for a CAT scan, the study gets done regardless if it is medically appropriate, or the patient has had half a dozen of them over the past year.  Radiologists don't question the appropriateness of what we order. While patient care would be better served if radiologists offered their advice in advance, this is not how the game works.   Of course, they are happy to have these conversations about our patients, but their default system is open access.

How would you handle this scenario?  One of your best referring physicians sends a patient for an open access colonoscopy.  We interview him and realize he is 2 years early. He is prepped and took a day off of work.  He has a driver with him.  Do we tell the patient that he is 2 years early?  Do we send the patient home?  Do we say nothing?    Do we contact the referring physician and point out his error?

As you craft your response to the above hypothetical scenario, remember that this is not an ethics seminar, but is the real world.  Real life is not as neat and tidy as we would like.

4 comments:

Anonymous said...

If the patient is two years early for a screening/surveillance colonoscopy, would his/her insurance still pay? That is a difficult situation, but it makes it even worse for the patient if he/she gets stuck with a bill after an unnecessarily early procedure.

Michael Kirsch, M.D. said...

Insurance will cover. It's an ethical, not a reimbursement issue.

dog gone said...

As an ethical issue ...........should insurance cover? I definitely do not think it fair for a patient to get stuck with the cost; but if a procedure is NOT appropriate or necessary, I would love to see as a counter-measure to this that the referring doctor where there is one have to pay for this procedure, not the patient. (OBVIOUSLY whoever performs the procedure in good faith deserves to get paid.)

My thought process on this were the number of procedures undergone by women, from C-section births to hysterectomies, where real harm or greater risk occurred in order to increase the doctor's profit. There has to be some form of sanction or penalty and review to limit those abuses.

As our good author does not raise the issue of how or why inappropriate procedures are being sent his direction, I would like to know if profit for the referring entity is one of the reasons for these patients crossing his doorstep as part of addressing the ethical considerations.

Thanks for writing something so provocative. I sure wouldn't want to have one if I did not need to do so!

Michael Kirsch, M.D. said...

@dg, the procedure is always covered by insurance, but the ethical issue remains. Thanks, as always, for your thoughts here. MK

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