Monday, March 18, 2013

Too Many Scopes

Colonoscopy is overdone in this country.  This is an observable fact.  I see patients every single day who get scoped every 2-3 years for no discernible reason.  I see inpatient 90 year olds who present with "GI bleed" (really just a little coffee ground emesis from dehydration/mild peptic ulcer disease) who end up getting black tubes snaked through their mouth and anus before they are returned to the nursing home from whence they came.  This happens constantly.  A study from Archives of Internal Medicine elucidates this phenomenon:
The colonoscopists with percentages significantly above the mean were more likely to be surgeons, graduates of US medical schools, medical school graduates before 1990, and higher-volume colonoscopists than those with percentages significantly below the mean.
A large percentage of colonoscopies performed in older adults were potentially inappropriate: 23.4% for the overall Texas cohort and 9.9%, 38.8%, and 24.9%, respectively, in patients aged 70 to 75, 76 to 85, or 86 years or older.
I post about this because, although the main problem with rampant, out of control healthcare expenditure in this country occurs at the macro-level via the health-industrial complex of hospitals, Big Pharma, the insurance carriers and the medical device industry, it doesn't excuse unscrupulous physicians acting like greedy assholes and the role individual doctors play in driving up costs.  Whether it's cardiologists performing unwarranted cardiac stent procedures or general surgeons taking out robin's egg blue gallbladders, we have to be able to shine the light on such behavior and shame those who betray basic medical ethics. 


Anonymous said...

Totally agree. It's also a risky test for some patients. Even just in the prep.


Paracelsus said...

Medical ethics - an issue in dire need of review this days. By way too many doctors.

Well put, sir.

Josh said...

I saw this study too and agree the problem is there. As a surgeon who does routine screening endoscopies, I really try and do the right thing in this regard.

However, let me play devil's advocate and describe a scenario I see a little more than I like:

A 75-100 year old patient comes in and says, "Dr. ___ (PCP) said I need a colonoscopy. I sure do love Dr. ___." Now I invariably take the time to talk with the patient about why he/she might not need a colonoscopy, but there are hazards with several of these arguments on a micro level.

First, even though official recommendations say not to screen people older than 75, most otherwise fairly healthy people over 75 do not think too highly of this recommendation. They want the scope.

Also, many come in saying "I had one about 3-7 years ago at another hospital, said I had some polyps he took out, no I don't have any records" - how do you interpret this? How many polyps? What types? Was it 3 years or 7 years? Often I will just do the scope because I don't want to get sued.

Finally, "If Dr. ___ says I need one, then I should get one." What am I REALLY supposed to do? Dr. ___ sends me quite a few good referrals on a regular basis. The patient has trust in him/her - I am the outsider [esp. being new in the community]. This patient WILL get a colonoscopy, by me or someone else, so I will occasionally acquiesce.

These are hard things to elicit from some giant database. Could I fight harder in these situations? Sure. But the day is full of fights, and sometimes I get tired.

JD said...

My grandfather actually died because of an unnecessary colonoscopy that resulted in complications and an unsuccessful surgery to save his life. This is an interesting take - never thought about physicians driving up costs in this way, more think of their impact on the hospital's costs - such using a more expensive implant that produces the same results as a less expensive option.

Anonymous said...


This is true, but as a colorectal surgeon, I see the opposite much more commonly... Patients who never had a scope at age 50, and come in with symptoms at age 60-70, and have a rip-roaring colon cancer.

The vast majority of adults in the US still don't get appropriate screening. It's a balance. Don't do too much or too little.