The medical arena, like society at large, is permeated with self-interest. In medicine, every health care reform measure, new medicine, new medical device or revised medical practice guideline is at some constituency’s expense. Recognizing and dismantling conflicts of interests is one of medicine's greatest challenges and threats. It does not seem that all players in the medical arena prioritize the greater good and make patients' interests paramount.
We gastroenterologists sincerely champion screening colonoscopy, although we acknowledge that it is rather imperfect. Consider some drawbacks.
What will gastroenterologists' reaction be when a better test threatens to retire our colonoscopes? Will we defend colonoscopy when a superior stool or blood test emerges? Will we claim that the research behind the new developments is flawed?
I expect that routine screening colonoscopy will be retired in the foreseeable future. Colonoscopy will still be performed, but only when some new and improved screening test indicates that an individual has a high probability of harboring polyps. In that era, the number of colonoscopies that will be performed will be a fraction of today's volume.
When that happens, patients will emerge as clear winners. But there will be many losers as well, as always occurs with medical progress. All those who currently benefit financially from the colonoscopy industry - gastroenterologists, hospitals, scope manufacturers, ambulatory endoscopy centers, laxative prep companies and scope repair companies - will lose substantial income. But when a monumental milestone in colon cancer screening finally occurs, and the colonoscope is set aside, we should all celebrate that the greater good. has won.
When I was a gastroenterology (GI) fellow decades ago, our GI department was active in new technologies to crush and dissolve gallstones and stones that had wandered from the gallbladder into the liver pipes. Millions of dollars of R & D were spent and the procedures were done in specialized centers in the U.S and abroad. The treatments were cumbersome and only modestly effective, but the treatments continued year after year. Then, laparoscopic cholecystectomy arrived, a new operation that could remove gallbladders with much less pain and recovery time. At that moment, the gallstone dissolving business dissolved. As endoscopic techniques improved, gastroenterologists could safely and easily remove stones from the liver pipes, which became the preferred method for accomplishing this objective. These outcomes served the public good, which should be our north star.
Medical advances create winners and losers, but when patients are listed in the win column, then in general I regard the innovation to be an overall win. I am not a purist, however. If a new drug, for instance, is only trivially superior than an existing medicine, but costs 10 x as much, than I would not regard the new drug to be a 'win'. You get my point here.
New medical developments are often pursued for both marketing and medical reasons. Large medical institutions will spend mightily for the latest high-tech futuristic anti-tumor ray gun, especially if the competitor across the street already has one. Does this really serve the greater good? Here in Cleveland, I suspect we have mind numbing duplications of medical services in a very tight geographic region. Since availability correlates with usage, I surmise that we are a laboratory of overtesting and overtreatment. I am not assigning blame here. Indeed, I need to be reeducated as much as anyone since we all practice medicine in a culture of excess.
In general, the prism that should be used to view new medical developments is if it serves the greater good. (Of course, there are always exceptions such as rare diseases which may deserve dedicated attention and resources.) Many folks, however, narrowly define the greater good to be an outcome that happens to coincides with their own parochial interests. Conversely, if a particularly group or organization is threatened by a medical advance, then they might allege that the greater good is actually at risk!
New medical developments are often pursued for both marketing and medical reasons. Large medical institutions will spend mightily for the latest high-tech futuristic anti-tumor ray gun, especially if the competitor across the street already has one. Does this really serve the greater good? Here in Cleveland, I suspect we have mind numbing duplications of medical services in a very tight geographic region. Since availability correlates with usage, I surmise that we are a laboratory of overtesting and overtreatment. I am not assigning blame here. Indeed, I need to be reeducated as much as anyone since we all practice medicine in a culture of excess.
In general, the prism that should be used to view new medical developments is if it serves the greater good. (Of course, there are always exceptions such as rare diseases which may deserve dedicated attention and resources.) Many folks, however, narrowly define the greater good to be an outcome that happens to coincides with their own parochial interests. Conversely, if a particularly group or organization is threatened by a medical advance, then they might allege that the greater good is actually at risk!
We gastroenterologists sincerely champion screening colonoscopy, although we acknowledge that it is rather imperfect. Consider some drawbacks.
- Pre-colonoscopy cathartic cocktail
- Prep, procedural and outcome anxiety
- Cost
- Risk of complications
- High rate of negative results for finding significant lesions
- Loss of a day’s wages or of personal enjoyment
- Need for a driver
Screening the colon, highlighted in blue above, may not need scopes much longer.
I believe in colonoscopy and have performed at least 40,000 of them in my career. However, the test is not ideal and will surely be replaced by a screening test that will be prep-free, highly accurate, extremely convenient and safe.
I expect that routine screening colonoscopy will be retired in the foreseeable future. Colonoscopy will still be performed, but only when some new and improved screening test indicates that an individual has a high probability of harboring polyps. In that era, the number of colonoscopies that will be performed will be a fraction of today's volume.
When that happens, patients will emerge as clear winners. But there will be many losers as well, as always occurs with medical progress. All those who currently benefit financially from the colonoscopy industry - gastroenterologists, hospitals, scope manufacturers, ambulatory endoscopy centers, laxative prep companies and scope repair companies - will lose substantial income. But when a monumental milestone in colon cancer screening finally occurs, and the colonoscope is set aside, we should all celebrate that the greater good. has won.
As well there is the problem that many people who have had colonoscopies decide they dont trust the surgwons any more.
ReplyDeleteI bled from alleged diverticulitis and after the colonoscopy (third) was told if I bled again I would get my colon cut out.
Luckily for me I worked out that I was bleeding from regular aspirin taking. Stopped that and AOK.
I believe the government and other insurers which reimburse primarily for procedures and testing are a central problem. The patient is peripheral. Healthcare is shielded from usual market forces. For all else, cars, computers, and other services (including cosmetic surgery) market forces help drive down cost and promote innovation.
ReplyDeleteColon cancer is really common to people who loves to eat burnt meats. Rumors spread that burnt meats contain carcinogens which may cause certain cancers. Is it true?
ReplyDeleteThere are also certain kind of stomach pains which is caused by "Diverticulitis?" I never heard of it until I found this (http://technoflake.info/what-is-the-difference-between-diverticulosis-and-diverticulitis/) blog.
I think there will be innovations that do replace cumbersome colonoscopy. Perhaps a test strip that detects changes in DNA or cell enzymes. Until that time, colonoscopy will prevail. There is no reason, however for the high cost. It could be performed by trained technicians, assembly line style. The cost for the procedure and the facilities charges are grossly out of line.
ReplyDeleteDespite all of this, colonoscopy is the only "screening" test that can cure cancer. It is important to have it.
Hi,
ReplyDeleteThanks, for sharing such great post. Colonoscopy is the endoscopic examination of the large bowel and the distal part of the small bowel with a CCD camera or a fiber optic camera on a flexible tube passed through the anus.
Thanks,
Colonoscopy
“It is difficult to get a man to understand something, when his salary depends on his not understanding it.”
ReplyDelete― Upton Sinclair, I, Candidate for Governor: And How I Got Licked
Carolyn Kay
www.ManyYearsYoung.com
I love what you're doing here, Dr. Kirsch, especially since it so comports with my own postings. However, I just had my third colonoscopy and, while acutely sensitive to the self-interests you describe, still find it one of the less controversial screening procedures with a far better risk-to-benefit ratio than most. I wrote about it here - http://bit.ly/UzPb8p
ReplyDeleteFantastic post, Dr. K!
ReplyDeleteI TOTALLY agree, and have been telling my colleagues in Clinical Research for years, that, for the reasons of self-interest that you highlight, Comparative Effectiveness Research will never truly see the light of day. No drug company wants risk finding out that the product they've spent upwards of a billion dollars testing in Phase III trials is no better, or even worse, than the standard of care.
Ditto for the physician-scientist who just so happens to be the co-inventor of said drug company's blockbuster-in-the-making.
Policy makers and some enterprising pharma firms may dance around the topic, or even allow a token trial or two between two branded drugs that already have a branded-generic waiting in the wings for the expiration of the patent, but until our medical expenditures are so astronomically ruinous that even members of Congress cannot afford their care, nothing will change.
Bank on it.
People might consent to colonoscopy more if it weren't for the horrible misery of the laxative prep. That's really horrible for anyone to go through. I'm an R.N., and I won't do it.
ReplyDelete