A patient came to the office and refused to see me, although
I was quite willing to see him. I’ll
present the scenario followed by the patient’s reason he took an abrupt
U-turn. Then, if you are inclined, you
may offer your own advice and comment.
I performed a colonoscopy on this patient and found a large
polyp in the upper part of the large intestine, or colon. The upper part of the colon, or right side of
the colon, has been receiving a lot of press in gastroenterology in recent
years. Medical studies have observed
that cancers in this region are more easily missed for reasons that don’t need
to be explained here. For this reason,
gastroenterologists are particularly vigilant when examining this region.
The polyp was large and somewhat hidden behind a fold of
tissue. I suspected that this was a
benign lesion. I removed the polyp using
one of the gadgets in our bag of tricks, but knew at the time that I had left
some polyp tissue behind. I was unable
to remove the entire lesion because of its tricky location. In addition, because the polyp seemed to be
embedded in the wall of the colon, I wasn’t certain that I could safely remove
the remaining fragment without causing a complication. First, do no harm.
The Large Intestine - Where Polyps Hang Out
I advised the patient to return to the office in 3 weeks so
that we could review the options. In
the meantime, the pathology report from the specimens confirmed that the polyp
was benign, but pre-cancerous. The
remaining polyp tissue would have to be removed. Our practice has a No Polyp Left Behind
policy.
There are 2 options that make sense.
- Have a surgeon remove the R side of the colon, which would guarantee safe and complete removal of residual polyp in one session.
- Refer the patient to an expert colonoscopist at one of our nearby teaching institutions. There are advanced techniques and skills that could complete the task that I left unfinished without surgery. This is certainly easier to go through than an operation, but there is a lower probability that all of the polyp will be removed in one session. Therefore, future colonoscopies would be needed to reexamine the site to verify that it is clean. Colonoscopies have risk and inconvenience. This approach, in my view, affects quality of life as for a long period of time, the patient has concern about polyp tissue left behind.
Discussing these two options, with their respective risks
and benefits, is a long conversation. I
would anticipate many questions from the patient and any family member who
might be present.
The patient came to the office at the appointed time, but
then balked when he was asked for his $40 co-payment, as required by his
insurance company. Of course, we have
nothing to do with setting co-payment rates.
While I have respect for the sum of $40, I think it can be argued that
this is not excessive for receiving a full presentation of medical options from
a physician on how best this patient can prevent colon cancer from
developing.
He left the office.
How should I react? Should I call
him and provide a ‘free office visit’ on the phone for 15 minutes so he doesn’t
have to fork over the forty? I make
dozens of phone calls to patients every week, but these are generally to
resolve simple issues. If during one of
these calls, I decide that a phone call is not appropriate for resolving the
issue, then I ask the patient to make an appointment. While a patient might think, for example,
that I can diagnose and treat diverticulitis on the phone, I prefer a hands on
approach here.
Should I write to my PPP (petulant
polyp patient) and advise him that he needs to see me face to face as the issue
is more than a phone call can handle?
What if I do so and he doesn’t show up. If a
few years from now, the lesion turns malignant, then will this be my fault? When does my responsibility end and his
begins?