A gastroenterologist dishes on unnecessary colonoscopies

We gastroenterologists are regularly summoned to bring light into dark places. We are the enlightened ones who illuminate anatomical shadows. Sure, we have tunnel vision, but we like to believe that we can think broadly and creatively as well.

We are the scope doctors.

We are commonly consulted by primary care physicians and hospitalists to perform colonoscopies, upper endoscopies (EGDs) of the esophagus and stomach and other gastrointestinal delights. We deliver a probing element to patient care.

We are called to serve as technicians — plumbers, if you will — although we actually have cognitive knowledge of our specialty. Yes, we can think. Often, we have tension over what we are asked to do and what we think we should do.

Do I think that every procedure I am asked to do is medically necessary? Of course not. Before you target me for investigation and professional censure, realize that every physician in America and beyond would fall under indictment. Indeed, a legal defense often offered by accused individuals is that they have been unfairly and selectively targeted. For example, if a company’s human resource officer puts an employee on warning for habitual tardiness, her case may be weakened if others who commit the same offense are left alone.

So, before you throw me in the dock for pulling the procedure trigger prematurely, I will depose physicians across the land to respond to the following interrogatory.

  • Have you ever prescribed an antibiotic that was not medically essential?
  • Have you ever admitted an individual to the hospital who could have been safely treated as an out-patient?
  • Has every CT scan you ordered been medically essential?
  • Has every cardiac stent you have placed been in accordance with best practices?
  • Do you consistently practice evidence based medicine?
  • Has every batch of chemotherapy you prescribed been reasonably shown to improve patients’ lives?

My point is that the system is riddled with overdiagnosis and overtreatment and it won’t be easy to clean the rot out. While physicians have responsibility here, they are not exclusively culpable. Indeed, no player at the table has clean hands.

I wish that physicians who consult me would ask more often for my head and not just for my hands. Typically, we are asked specifically to do a colonoscopy or some other procedure. We usually acquiesce in the same manner that radiologists perform every x-ray test that they are asked to do, whether it is needed or not. If you order an ultrasound of the gallbladder, it will be done even if it makes no medical sense. (Good doctors consult regularly with radiologists in advance so the correct radiology exam can be arranged. Radiologists, who can also think, find these conversations to be useful and refreshing. In my case, they have often spared my patient from the wrong test. Referring physicians order a colonoscopy in the same manner that they order a chest x-ray. They expect that the test will be done on demand. A scope, however, unlike an x-ray, has risk of harm and should not be blithely done.

Medicine is not a math problem that has a single solution. Just because I might not advise a colonoscopy that another physician has requested, doesn’t mean the procedure is a wrong choice. There’s nuance and judgment in the medical world. Of course, if a procedure would be reckless or idiotic, then we keep our scope securely holstered.

On those occasions when my opinion is being sought, I consider a few issues before greasing up the scope.

  • Is the scope essential to the patient’s care?
  • Is there a safer alternative to answer the clinical question?
  • When should the procedure occur? (We are often asked to do routine procedures on very sick hospital patients that should be deferred until after the patient is discharge and has recovered.)
  • Has the patient provided informed consent to proceed?

Do you want my advice or don’t you? Or, am I just a tool using tools?

Michael Kirsch is a gastroenterologist who blogs at MD Whistleblower.

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  • MarylandMD

    I can’t imagine a weaker defense of gastroenterologists who perform unnecessary procedures. Do you really think my prescribing an antibiotic in borderline cases is remotely similar to your performing an unnecessary endoscopy? Really?

    The “everyone else is doing it” argument wouldn’t take you far in even a medical ethics 101 class.

    • MKirschMD

      @MarylandMD:disqus , Of course, there is a parallel between an unnecessary procedure and an antibiotic. Both are unnecessary and are ordered by physicians for reasons unrelated to the medical issue. I think you are overly casual about unneeded antibiotic use in the country. I surmise that the costs of unnecessary antibiotics, in the hospital and out-pt, and the costs of their complications would be rather staggering. Have you seen cases of C. diff from unnecessary antibiotics? Additionally, I did not offer the ‘everyone else is doing it’ as a defense. I merely point out that overdiagnosis and overtreatment are widespread phenomena that reaches every medical specialty.

      • MarylandMD

        Sure, they are identical, except that the risk to the patient of an unnecessary colonoscopy is greater than the risk of a single course of antibiotic, the cost of an unnecessary colonoscopy to the patient and the insurance is much much greater that the cost of an antibiotic, and the profit to the provider writing an antibiotic is nil and the profit to you for an unnecessary colonoscopy is a boat payment. So, yes, other than those things, they are exactly the same. Sure, I get it now.

        I understand quite well the cost of antibiotic resistance, but I take responsibility for my part in the problem and I do my best to use them judiciously. And if I did use them inappropriately I would never, ever claim that it would be OK because you did unnecessary colonoscopies or a local cardiologist put in unnecessary stents.

        This is partly the reason why we have such a messed up system: doctors rationalize their bad behavior by claiming that the other specialties down the hall are doing the same thing.

        So the next time you jam a scope in a patient without an appropriate indication, don’t blame me or anybody else. Just look in the mirror and have a talk with that doctor. Own your part of the problem and fix it.

        • MKirschMD

          @Maryland, you are attacking me for points I have not made. I’ll try again. Did you read my comment to you above carefully? I recognize that an unnecessary liver transplant is more consequential than an unnecessary wart removal. I also clearly expressed in my above comment that I do not excuse my errors and excess because ‘everybody does it’. While there is a spectrum of overtreatment, the sin is the same and we all commit it at times.

          • MarylandMD

            No, the “sin” is not the same. You are creating false equivalences. And while you claim you are not excusing yourself, it is hard to read your original post and not see at least a shred of rationalization.

          • MKirschMD

            Theft is theft regardless of the value of the purloined item.

        • rtpinfla

          Not sure I interpret this as “everyone else is doing it so it must be OK”. Rather, I think a better interpretation is, “If everyone, including me, is doing it, what is the bigger issue that allows this?” You can’t tell me every single GI doctor is a greedy unethical maniac shoving scopes up everyone’s backside to pay for their yacht, yet most of them (the honest ones) will tell you there is not always a good indication for the scope they are doing.
          That question about the bigger question is an important question raised here and can be applied equally to any of the examples: antibiotics, tests, procedures, take your pick.

  • rtpinfla

    As an Allergist I am often consulted to evaluate coughs. Most patients want to get skin tested to find out what allergy is causing them to cough. A fair number (maybe 50%) are clearly a reflux cough and I don’t need to perform any sort of test. I used to explain their condition and why they don’t need any further testing, prescribed Prilosec, gave them a handout I made up about this kind of cough, and ask to see them in follow up in a few weeks.
    The result? Usually a request for the patient’s medical records from the Allergist down the street.
    Now I order a full allergy test panel ($600) to show them they are not allergic to anything. I also perform a rhinoscopy ($100) to look at their voicebox and take a picture to show them the irritation there that is driving the cough. Then I prescribe a PPI. Now, instead of seeking care from another allergist, that patient thinks I am a genius. An added bonus? I put about $700 extra in my pocket.
    For these patients, both tests are completely unnecessary. However, if I don’t perform them I lose patients. After they leave they tell their friends and their primary doctors (my referral base) that I don’t know what I am doing and was a total jerk who did nothing except recommend some crappy over the counter pills. If I do all the tests I am a genius and I make an extra $700 testing that added nothing to what I knew from the history. That choice has become much easier over time.

    • Hannah

      If patients were paying their own medical bills, of course, the situation would be absolutely reversed: they’d be happy to be diagnosed for the least possible cost.

      Incentives get so screwed up when Person A is paying for goods and services from Person B, using Person C’s money.

      • SarahJ89

        Not so. I have good insurance and would MUCH prefer a doctor who spares me testing and explains why. Much.

      • SarahJ89

        Also, I’m *really* clear on the fact that I pay for my insurance and therefore I’m paying for my care indirectly. Not hard to connect those dots, really.

        • Guest

          You “pay” the same whether you get thousands of dollars worth of “free” tests or whether you get sent home with nothing.

          Most people take all the “free” stuff they can grab, they feel that they “deserve” it because they pay for insurance. If your car insurance included all the “free” car washes you wanted, would you just get one every fortnight, or two or three a week?

          It’s just like, going into an all-you-can-eat seafood night, how many people would really limit themselves to one small plate of salad and a bread roll?

          No, most people turn into greedy-guts when they can take as much as they want and not have it cost any more. ESPECIALLY when they’re on Medicaid and not paying a dime for anything. FREE CHEESE, man. Gimme dat free cheese.

    • commentator

      Wow, doesn’t seem like you have much integrity. You could spend a little more time with the patient to educate them and engage them in a plan that doesn’t start with expensive testing. Your experience really uncovers a lack of skill in working with patients to ensure they get the right care. These skills can be acquired. I have had great success in talking patients out of unnecessary testing

      • rtpinfla

        In the past I have taken an inordinate amount of time trying to explain these issues to these patients. Just this week I spent 40 minutes explaining why a patient’s rash was not an allergy and she didn’t need any testing, just to wait it out and treat it. Her response? “No, it’s gotta be the mold”. To tell her anything else was clearly futile. Yep I am testing her to mold so she can see for herself that she isn’t reacting to it- in this case it’s a blood based test, I don’t make a dime by the way. Keep in mind I also specifically addressed the fact that her symptoms occurred regardless of mold exposure In fact, I still do try to avoid unnecessary testing when a patient is open to the discussion. When I saw enough patients bash me in person then online and simply go down the street for the test that they think they need I changed my approach. It may be a Faustian bargain but I at least the patient leaves satisfied and I can still go over the testing and hopefully get them to the right conclusion.
        If, you in fact have NEVER ordered an X-ray, lab test, or prescribed an antibiotic that probably wasn’t necessary, then congratulations. Please let me know when your next seminar is scheduled so I can learn how you do it.

        • commentator

          I have no idea why my comment was deleted. Who is trying to stifle valid discussion? I maintain that if you have decided to order unnecessary tests as a common practice, you have sketchy integrity. I don’t make it a practice to order tests that I know are not necessary. There are times where a patient may insist on a test and its not certain if its needed or not, then ordering it could be a valid step. I am an ED doc and get a number of patients who insist on unnecessary tests but find if I take a few minutes to explain, most of the time they are ok with a stepwise approach. And I don’t have a ongoing relationship. No letters of complaint. I find that people want to be respected as intelligent decision makers and when presented with a rationale they can understand, they are appreciative.

          • rtpinfla

            Not sure why you were deleted either. But to clarify, I do not perform these tests as common practice- just the patients that refuse, for whatever reason, the accept the diagnosis. These are the patients that come that are referred to an allergist because they have often been told that they have allergies by their co workers, neighbors, and often their primary doctors. They steadfastly refuse to believe otherwise. It’s not a question of my integrity at all. These tests are tools to get the patient to a therapeutic partnership. Once they see where the problem is, I can usually get their “buy in” and see that, yes, maybe I do know what I’m talking about after all. If I can get them there without all the testing, I am just as happy.
            You say “most” of your patients are OK with a stepwise approach, that means not all of them are OK with it. (Just like what I experience, in fact) What do you do those that just refuse to accept your diagnosis even after you’ve outlined your rationale?
            Again, if you’ve never ordered a head CT, ankle film, or wrote for a Z pak when you knew it wasn’t really necessary then you clearly have a gift you need to share with the rest of the world. If your colleagues do it? Do you call them out for their lack of integrity?

    • May Wright

      “Now I order a full allergy test panel ($600) to show them they are not allergic to anything. I also perform a rhinoscopy ($100) to look at their voicebox and take a picture to show them the irritation there that is driving the cough. Then I prescribe a PPI. Now, instead of seeking care from another allergist, that patient thinks I am a genius. An added bonus? I put about $700 extra in my pocket.
      “For these patients, both tests are completely unnecessary.”

      And people wonder why healthcare makes up such a large part of America’s GDP, and why healthcare costs and insurance costs are spiraling out of control?

      • rtpinfla

        100% correct. I would like to see health insurance that is modeled after car insurance where only major issues are covered. Hannah hits it right on the head.
        A patient that paid 100% out of pocket for my evaluation and recommendation would be grateful that I could solve their problem without unnecessary expense. Since most patients don’t have any financial incentive they want the full court press. In their eyes I am withholding medical care.

        • SarahJ89

          It’s hard for me to believe people want to waste their time, endanger their bodies and just put up with a lot of annoyance that testing brings.

          You know, there really are a whole lot of us out here who avoid seeing doctors because we really hate all that stuff. You just don’t see us. I’d love a doc who’d keep it simple and stop with all this technology.

          • rtpinfla

            Hard to believe but true. Often those people are grateful and relieved after I do these tests so, at least from a peace of mind standpoint, it’s worth it (I do very low risk procedures).
            Occasionally they get mad at me when the test is negative and it’s just further proof I don’t know what I’m doing.

  • Cameo

    THANK YOU. Finally some HONESTY in the medical field. And, the government wonders why MEDICARE is abused?
    I appreciate good doctors; but realize they are also “businessmen”. I do NOT allow “why not” procedures on my person. I remain finely turned to my body and mind and diligently stay aware and take time to educate myself on ALL health issues. Colonoscopies are are BIG BUCKS for gastroenterologists and the sad, “sick” system at the risk of ordinary people.

  • drjoekosterich

    Every piece like this which talks about the problems of over diagnosis and over treatment is part of the solution. Thanks.