Sunday, September 1, 2013

Unnecessary Colonoscopies: Confessions of a Gastroenterologist

We gastroenterologists are regularly summoned to bring light into dark places.   We are the enlightened ones who illuminate anatomical shadows.   Sure, we have ‘tunnel vision’, but we like to believe that we can think broadly and creatively as well. 

We are the scope doctors.

Am I Just a Tool?

We are commonly consulted by primary care physicians and hospitalists to perform colonoscopies, upper endoscopies (EGDs) of the esophagus and stomach and other gastrointestinal delights.  We deliver a probing element to patient care. 

We are called to serve as technicians – plumbers, if you will - although we actually have cognitive knowledge of our specialty.  Yes, we can think.  Often, we have tension over what we are asked to do and what we think we should do.

Do I think that every procedure I am asked to do is medically necessary.  Of course, not.  Before you target me for investigation and professional censure, realize that every physician in America and beyond would fall under indictment.   Indeed, a legal defense often offered by accused individuals is that they have been unfairly and selectively targeted.   For example, if a company’s human resource officer puts an employee on warning for habitual tardiness, her case may be weakened if others who commit the same offense are left alone.

So, before you throw me in the dock for pulling the procedure trigger prematurely, I will depose physicians across the land to respond to the following interrogatory. 
  • Have you ever prescribed an antibiotic that was not medically essential?
  • Have you ever admitted an individual to the hospital who could have been safely treated as an out-patient?
  • Has every CAT scan you ordered been medically essential?
  • Has every cardiac stent you have placed been in accordance with best practices?
  • Do you consistently practice evidence based medicine?
  • Has every batch of chemotherapy you prescribed been reasonably shown to improve patients’ lives?

My point is that the system is riddled with overdiagnosis and overtreatment and it won’t be easy to clean the rot out.  While physicians have responsibility here, they are not exclusively culpable.  Indeed, no player at the table has clean hands.  Whistleblower readers have endured many posts on these issues.  Those who are new to this blog, can't even imagine what they have been missing and are encouraged to invest the time necessary to memorize prior posts.

I wish that physicians who consult me would ask more often for my head and not just for my hands.   Typically, we are asked specifically to do a colonoscopy or some other procedure.  We usually acquiesce in the same manner that radiologists perform every x-ray test that they are asked to do, whether it is needed or not. If you order an ultrasound of the gallbladder, it will be done even if it makes no medical sense.  (Good doctors consult regularly with radiologists in advance so the correct radiology exam can be arranged.  Radiologists, who can also think, find these conversations to be useful and refreshing.   In my case, they have often spared my patient from the wrong test.)  Referring physicians order a colonoscopy in the same manner that they order a chest x-ray.  They expect that the test will be done on demand.   A scope, however, unlike an x-ray, has risk of harm and should not be blithely done. 

Medicine is not a math problem that has a single solution.  Just because I might not advise a colonoscopy that another physician has requested, doesn’t mean the procedure is a wrong choice.  There’s nuance and judgment in the medical world.  Of course, if a procedure would be reckless or idiotic, then we keep our scope securely holstered.

On those occasions when my opinion is being sought, I consider a few issues before greasing up the scope.

  • Is the scope essential to the patient’s care?
  • Is there a safer alternative to answer the clinical question?
  • When should the procedure occur?  (We are often asked to do routine procedures on very sick hospital patients that should be deferred until after the patient is discharge and has recovered.)
  • Has the patient provided informed consent to proceed?

Do you want my advice or don’t you?   Or, am I just a tool using tools?

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