American College of Physicians: Internal Medicine — Doctors for Adults ®

Thursday, June 25, 2015

Is office colonoscopy ethical?

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.

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Blogger PGYx said...

I think the right thing to do is to explain your reasoning to the patient and delay the test until indicated. Most patients do not want an unnecessary test and really, insurance should not pay for an unnecessary test. Peace of mind is a nice idea, but all procedures carry some risk and also cost money. One of the reasons reimbursements for procedures have declined is that too many doctors do tests when they are not clearly indicated.

As a physician who gets referrals for electrodiagnostic testing, however, I understand the pressure to do what the referring doctor has ordered. Not doing so may result in him/her choosing not to refer to you in the future. In a perfect world you could have this conversation with the referring physician and come to a mutual agreement. I do think this is worth a try, although neither you nor the referring doctor will be reimbursed for time spent discussing the best plan.

In the real world, however, the referring doc (who may have a bit of a chip on his shoulder as primary care docs often feel looked down upon, and definitely bear a greater proportion of the medical administrative burden than specialists) may view this as you questioning his judgment and/or condescendingly correcting him. I would like to think all doctors eagerly assimilate new information to improve the quality of care they deliver, but experience suggests some doctors would not appreciate you sharing your expertise as much as I certainly would.

Still, our first priority is the patient. If you do not feel the test is indicated at this time, then you must document your reasoning, ideally share it with the referring doctor, and not perform that test.

June 26, 2015 at 1:30 PM  

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

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Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

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Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

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Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

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John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

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Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

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Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

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MD Whistleblower
Michael Kirsch, MD, FACP, 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.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

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Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

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The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

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Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

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Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

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Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
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