Sunday, November 18, 2018

Overdiagnosis Threatens Elderly Patient

Yesterday, a physician asked my opinion if a patient needed a colonoscopy.  My partner was already on the case and I was covering over the weekend.  The facts suggested that a colonoscopy was warranted.  The patient had a low blood count and had received blood transfusions.  Certainly, a bleeding site in the colon, such as a cancer, might be responsible.  We do colonoscopies to address similar circumstances on a regular basis. 

Why did my partner and I demur in this case?

We Placed this Sign on the Patient

Because to us, our medical judgment trumped the medical facts.  First, the patient was elderly and extremely debilitated.  The challenge of having an individual in her state ingest the necessary laxatives is likely insurmountable.  If any readers have enjoyed the delight of guzzling down a colonoscopy prep, contemplate doing so as an elderly, ailing and bedbound individual.

I asked the physician if the patient’s family would consent to surgery if a cancer was found. 

“Absolutely not”, she responded. 

Now there were two strikes against proceeding with a colonic invasion.  Beyond the near cruelty of the laxative prep, if a cancer were found, then it would be left in place.  So, why subject the patient to the risk and indignity of a diagnostic test that would not help her?

Readers here with medical knowledge can offer hypothetical diagnoses for this patient where a colonoscopy or scope exam of the esophagus and stomach could make a difference. I acknowledge this.  But, medicine is not a pure discipline like mathematics.  There are always exceptions and we are never 100% sure of anything.  Regardless, I believe that the evidence against subjecting this patient to scope examinations is beyond a reasonable doubt. 

When a diagnostic test is being proposed to you, make sure that it will make a meaningful difference in your care.  Will it yield information that you and your physician want to know or need to know?