Now Wait Just A Dadgum Minute

Posted on February 10, 2009
Filed Under General Rationing Issues, Guidelines, Abuse of, Wonkonian Rationing |

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Attention, shoppers.

The January 19 edition of the American Medical News describes a research study which DrRich would have written about sooner if it did not make him personally so uncomfortable. But in the interest of keeping his devoted readership fully informed on issues of relevance, DrRich has steeled himself, and is now prepared to discuss the matter.

According to the AMANews, Dr Felix Leung, MD, a professor of medicine at the David Geffen School of Medicine in Los Angeles, published a paper in the December, 2008 Journal of Family Practice describing his results when he presented the offer to 483 patients to perform their colonoscopies without using sedation!  Dr. Leung reports that 145 patients actually agreed to give no-sedation colonoscopy a try, and of these, 112 were able to complete the procedure. The conclusion of his paper is that no-sedation colonoscopy is feasible, and that since jettisoning the requirement for sedation reduces the resources necessary for performing the procedure (in Dr. Leung’s lab, for instance, it eliminated the need for two registered nurses), it is a real cost saver. Therefore, no-sedation colonoscopy is an option that perhaps soon should become “more widely considered.”

There is no indication in this report that physicians at the Geffen School are, as benefactors of Mr. Geffen, in more general ways seeking to discover new singing talent capable of hitting those really high notes.

As one whose own doctor has been pressing him for several years to just go ahead and get his colonoscopy, being well beyond the age where the guidelines begin prescribing such things, DrRich finds this research study objectionable on a very personal (not to mention visceral) level.

DrRich was already suspicious. He has suspected for years that his friends the gastroenterologists must have struck a deal with their rivals the radiologists, whereby a certain, relatively high percentage of patients having colonoscopy are told, after the procedure, “We just weren’t able to get past the hepatic flexure - some tricky anatomy there - so we’re going to have to send you for a radiology procedure to finish up the examination.”  In other words, DrRich wonders whether these two specialties have reached a tacit understanding (in order to take the edge off the guideline wars now taking place over the most appropriate screening test for colon cancer), by which a good proportion of patients wind up having both tests. (Admittedly, an alternate, and even more likely, explanation is that DrRich is just manufacturing excuses to avoid having his own screening procedure(s).)*

But this new study takes colonoscopy a step too far. DrRich trusts that most of his readers will find the notion of having no-sedation colonoscpy as (literally) gut-wrenching as he does. So the very idea is bad enough.

Of course, one can conceive of legitimate reasons for studying no-sedation colonoscopy. Perhaps, one might postulate, sedation adds some risk to the procedure. Or maybe sedation reduces the ability of the patient to inhale, exhale, or shift positions at just the right time to aid the physician in maneuvering the colonoscope. For reasons such as these, which postulate that sedation might impact the safety or efficacy of the test, it would be legitimate to do a research study on no-sedation colonoscopy.

But Dr. Leung’s research was conducted for a different reason. He works for the Veterans Administration, and the VA cut back on his nursing support to the extent that he either had to stop performing colonoscopy, or do it without offering sedation.  He chose option B, and for the benefit of posterity elected to tabulate and publish his results.

This research study, which was accepted and published by a peer-reviewed medical journal, did not ask a question about safety or effectiveness. Instead, it asked the question: How much out-of-the-ordinary pain and suffering will patients tolerate in the interest of performing elective medical procedures more cheaply?  And the answer was that 23% were willing to tolerate quite a bit.

As a result of this study, Dr. Leung and at least some of the experts interviewed by the AMANews feel that no-sedation colonoscopy now should be made more generally “available” within our healthcare system. Such a result, of course, will save the healthcare system a lot of money, for at least two reasons. First, it will save money on the cost of administering sedation during the hundreds of thousands of colonoscopies that are supposed to be performed each year. Second, it will save money when 77% of those patients either refuse the procedure, or are simply unable to tolerate it.

But more generally, Dr. Leung’s study sets new standards for what is acceptable as legitimate medical research. Among other things, it is an example of the research we might expect when all healthcare institutions are, like the VA, run by the government. (If this “study” had been conducted at Guantanamo, by now there would have been a general public uproar about it.)

But far more importantly, Dr. Leung’s groundbreaking study should open the door for countless other studies examining the willingness of American patients to tolerate pain and suffering far beyond current standards of care, in order to save the system some money.

DrRich can think of several reasonably funny and fairly snide examples of such studies, but he is too distressed at the moment to write them down. So talk among yourselves.

*DrRich hastens to point out that his own doctor is one of those evil retainer practitioners, and therefore is not subject to pay-for-performance checklists, and so DrRich is not jeopardizing his doctor’s standing as a medical practitioner by “temporizing” on his submission to certain guideline-prescribed procedures.  On the other hand, for all of you readers whose doctors are paid by Medicare or the health insurance companies, DrRich must insist that you get your colonoscopy the moment the guidelines say so, both in order to preserve your doctor’s professional viability, and also to fulfill your sacred obligation as a patient to accede to those evidence-based recommendations, handed down by certified experts, which will best optimize results across the collective.

Comments

9 Responses to “Now Wait Just A Dadgum Minute”

  1. Hal Dall, MD on February 11th, 2009 1:50 am

    How long until the “Guidelines” MANDATE no sedation for colonoscopies, with appropriate insurance company and gov’t input? After all, Dr. Leung works for the VA, the “Best Healthcare system in The Land TM”.

    (I have learned from DrRich, even when he defers his full dicussion to a future post.)

  2. pee cee on February 14th, 2009 5:20 pm

    I think the VA is on to something. Just a couple of weeks ago, a large study demonstrated the pain reduction efficacy of crying cum tear production. Pretty soon patients will be mandated to cry during their no sedation colonoscopies, and as a therapeutic “treatment”, they will be charged a co-pay for so doing.

    How clever! Get rid of nurses, charge the patient for suffering, and voila! Reduced costs (lower respiratory complications to boot).

    You should write the guideline….

  3. Doc on February 16th, 2009 10:28 pm

    I’m just waiting for the “Mr. Wizard home colonoscopy kit” to be standard of care, per the HMO’s.

  4. Z on February 17th, 2009 4:33 pm

    Yes, obviously a post by someone who has never had a colonoscopy. Earlier this year I had my 4th colonoscopy. Midazolam makes me a space cadet, plus I didn’t want to waste the rest of the day, so I requested no sedation. My GI guy was a little hesitant at first, but decided to use a pediatric scope (and offered to shoot me full of dope if I felt any discomfort). The result: no pain, essentially no discomfort and the ability to watch the monitor throughout the procedure (gives a new meaning to having one’s head up one’s arse).

    If you have avoided a colonoscopy for reasons of fear or embarrassment (which is what it seems like from the post), just go do it. And no more silly posts…..

  5. Guiac on February 17th, 2009 5:16 pm

    Of course Dr. Rich fails to point out that the radiologists must be besides themselves with joy at this latest revelation. Another victoy for virtual CT colonoscopy and additional dollars in their pockets. Then again when the government decides to allow foreign competitors to read the CT scans abroad in India they might not be so happy.

  6. DrRich on February 17th, 2009 5:32 pm

    Z,

    Congratulations for being among the fortunate 23%. If, by some odd chance, you seek employment, you might try contacting one of the big insurers. They will probably appreciate the opportunity to hire voices of experience who can encourage reluctant patients to go ahead and give the no-sedation colonoscopy a try.

    You can use me as a reference, since based on your pep talk I will now schedule my exam (with sedation - no need to tell your prospective employers that the real reason I’m having it now is not so much because you shamed me into it, but because I want to get it in while the guidelines still say sedation is OK).

    But please don’t ask me to give up on silly posts. To say what I’m thinking without injecting some irony, humor, or yes, silliness would be just too painful (though I’d still rather do that than have a no-sedation colonoscopy).

    Rich

  7. DrRich on February 17th, 2009 5:37 pm

    Guiac,

    Nice handle.

    Radiologists come in two species - those who read the results of studies, and those who stick tubes and catheters in people to make x-rays, then read the results of studies.

    The former are gravely endangered and ought to take up plumbing immediately, since one man’s signature on a single piece of paper (though, realistically, it will more likely be a 1,000 page document) can render them jobless overnight. The latter are less endangered, until somebody figures out that one really doesn’t need 8 years of post-college training to stick tubes in people. (Of course, when that happens, lots of specialists will be looking to join the ranks of plumbers.)

    Rich

  8. never again on May 31st, 2009 11:57 am

    I hope they do mandate no sedation, as long as if the patient NEEDS it and/or requests it, they can get this drug and pay for it out of pocket. This is an unnecessary step which adds major expense and risk to what would otherwise be a mildly uncomfortable procedure.

  9. Gary on July 9th, 2009 7:11 pm

    I’m a pharmacist, for what it’s worth, and have seen lots of colonoscopies under sedation and have interviewed way too many patients who had really awful experiences with the creepy partial amnesia often caused by Versed. If you want sedation, pay for propofol. When my arm was twisted to get a colonoscopy, the nice young GI doc listened to me bitch about the problems with Versed, the high cost of propofol (offered it to me for free) then told me I could get the exam unsedated,, with propofol at a no-cost professional courtesy, or with painkiller only. I told her that unsedated was my choice and the exam was a breeze. Unsedated is safer and it makes the doc do a better exam because they have to go slowly or the unsedated patient will slap them. Unfortunately my exam was positive and I now need yearly exams. They will all be unsedated.

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