Skip to main content

Measuring Colonoscopy Quality: Who Should Do My Procedure?

I have penned a few posts recently illustrating the difficulties in measuring medical quality.  Indeed there's a category on this blog entitled, Medical Quality, ready for your perusal.

How do we measure something that is very difficult to measure?  Why is a painting hanging in a museum considered to be a masterpiece while others – which appear quite similar to most of us – are relegated to a much lower status?  And art experts may not agree on these designations!

I have already performed approaching 50,000 colonoscopies in my career, and my colonoscopy counter notches more of these each week.  This is my gift to humanity.  Quite often, I am stopped in a store or on the street by a grateful recipient of one of my probing endeavors.  Clearly, patients regard the event as a bonding experience.

Found this in a garage sale.  Worth anything?

But how do they or anyone know if I am any good?  How do you assess the quality of a proceduralist? It sounds easy enough, except that it isn’t.  Here are some possible parameters to consider with regard to colonoscopy quality.

Percentage of complete colon exams.  How often should the doctor reach the end of the colon, which will never be 100%.   95%?  90%?   It’s hard to compare percentages without knowing the types of patients that each physician treats.   A geriatric practice may not be comparable to a younger population with regard to procedural success.

The complication rate.  Is a doctor who has a 1% complication rate more dangerous than one with a 0.5% rate?   Perhaps, the former doctor treats sicker patients which might more than account for the discrepancy.   Or, perhaps, the ‘safer’ physician with the lower complication rate is overly timid and ends up referring cases to experts to remove lesions that he was reluctant to remove?

Rate of polyp discovery.  Gastroenterologists (GI’s) are now measuring how often polyps are found.  The hypothesis is that physicians who discover polyps more often are more careful examiners and offer better protection against colon cancer.  While there is supportive data, there is also an opportunity to game the system.  Physicians who want to rate better may simply remove very tiny polyps – unlikely to ever cause harm – in an effort to improve their polyp stats. 

Patient satisfaction.  No, I really mean this.  This is increasingly included in assessing physician quality.

I hope that you agree that the above parameters are rather crude tools for quality measurement.  But what really determines the quality of a proceduralist cannot be measured.  How would you measure the following examples of stuff that really matters?

  • A GI is referred to a patient for a colonoscopy.  After a thorough evaluation, the doctor determines that the colonoscopy is not necessary.
  • A GI performs a colon exam and recognizes that the prior diagnosis of Crohn’s disease is likely to be incorrect. 
  • A GI confronts a lesion in the colon and recognizes that it needs to be removed by a surgeon, not through the scope.
  • An experienced GI is trained to recognize a huge array of colonoscopy abnormalities places them in context with the individual patient and then customize a treatment plan.  Easy to measure?

So, how good am I with the scope?  My patients seem quite comfortable with my work and I feel that I am a skilled practitioner.  So, while I think that I measure up, I don’t know how you could measure me to prove this.




  1. Very insightful as usual. It is like most everyone feels they are an above average driver. But how to measure - speeding tickets, rider satisfaction, on-time percentage, staying within the lines? Quality, like beauty is often in the eye of the beholder. I did enjoy hearing about your 50,000 voyages around the colon! More on this topic please!


Post a Comment

Popular posts from this blog

Why Most Doctors Choose Employment

Increasingly, physicians today are employed and most of them willingly so.  The advantages of this employment model, which I will highlight below, appeal to the current and emerging generations of physicians and medical professionals.  In addition, the alternatives to direct employment are scarce, although they do exist.  Private practice gastroenterology practices in Cleveland, for example, are increasingly rare sightings.  Another practice model is gaining ground rapidly on the medical landscape.   Private equity (PE) firms have   been purchasing medical practices who are in need of capital and management oversight.   PE can provide services efficiently as they may be serving multiple practices and have economies of scale.   While these physicians technically have authority over all medical decisions, the PE partners can exert behavioral influences on physicians which can be ethically problematic. For example, if the PE folks reduce non-medical overhead, this may very directly affe

Should Doctors Wear White Coats?

Many professions can be easily identified by their uniforms or state of dress. Consider how easy it is for us to identify a policeman, a judge, a baseball player, a housekeeper, a chef, or a soldier.  There must be a reason why so many professions require a uniform.  Presumably, it is to create team spirit among colleagues and to communicate a message to the clientele.  It certainly doesn’t enhance professional performance.  For instance, do we think if a judge ditches the robe and is wearing jeans and a T-shirt, that he or she cannot issue sage rulings?  If members of a baseball team showed up dressed in comfortable street clothes, would they commit more errors or achieve fewer hits?  The medical profession for most of its existence has had its own uniform.   Male doctors donned a shirt and tie and all doctors wore the iconic white coat.   The stated reason was that this created an aura of professionalism that inspired confidence in patients and their families.   Indeed, even today

Electronic Medical Records vs Physicians: Not a Fair Fight!

Each work day, I enter the chamber of horrors also known as the electronic medical record (EMR).  I’ve endured several versions of this torture over the years, monstrosities that were designed more to appeal to the needs of billers and coders than physicians. Make sense? I will admit that my current EMR, called Epic, is more physician-friendly than prior competitors, but it remains a formidable adversary.  And it’s not a fair fight.  You might be a great chess player, but odds are that you will not vanquish a computer adversary armed with artificial intelligence. I have a competitive advantage over many other physician contestants in the battle of Man vs Machine.   I can type well and can do so while maintaining eye contact with the patient.   You must think I am a magician or a savant.   While this may be true, the birth of my advanced digital skills started decades ago.   (As an aside, digital competence is essential for gastroenterologists.) During college, I worked as a secretary