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.