While I consider myself to be an ethical practitioner, I am not perfect, and neither is the medical profession.
I will present a recurrent ethical dilemma to my fair and balanced readers and await their judgment.
Our gastroenterology practice, like all of our competitors, has an open access endoscopy option. This permits a physician to refer a patient to us for a colonoscopy, without the need for an initial office visit.
Patients can also schedule procedures themselves, such as a screening colonoscopy, without a physician referral, if allowed by their insurance carriers. These patients enjoy the convenience of bypassing an office visit. We agree that an office consultation should not be required for routine screening procedures or to evaluate minor gastrointestinal symptoms.
Of course, if a patient wants to see us in the office in advance—and some do—we are happy to do so. I enjoy these pre-op visits which allows me to develop some measure of rapport with the patient and to discuss the upcoming endoscopic adventure, before the patient is naked with an IV dripping into his arm.
When these open access procedures are scheduled, we carefully screen patients on the phone to verify that bypassing an office visit does not pose any safety risks for the patient. We do not want to meet a patient for the first time for a screening colonoscopy, who is on kidney dialysis and uses an oxygen tank.
Here's the rub. There are times when I meet an open access patient who is prepped and primed for a colonoscopy that is not necessary. In the most recent example, I greeted a patient who was poised to have a colonoscopy because there was a prior history of colon polyps. However, according to current professional guidelines, the patient didn't need the exam for a few more years. I was meeting this patient for the first time. She had taken a day off of work and had a driver with her. She had enjoyed the delight of the gentle cathartic agent that colonoscopy patients imbibe with gustatory pleasure on the prior evening. She believes, of course, that the procedure is necessary as her physician had recommended it.
What should my response, if any, to her be?
One of the pitfalls of open access is that we can never screen patients as carefully as we do during an advance office visit. Should we halt a procedure that an internist has requested even if we may not believe the procedure is of medical necessity? Should we be willing to serve as technicians for referring doctors in the same manner that radiologists serve their colleagues? When we order a CAT scan, for example, the procedure is always done whether it's needed or not.
I sit in judgment now awaiting your verdict. May it be as probing and enlightening as a colonoscopy.
This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.