Patients should question their colonoscopy preparation

Recently I wrote about my aggravation when staff at Salem Gastroenterology Associates (SGA) , the only place in town that does colonoscopies, brushed off my questions about their two day clear liquid diet preparation for the procedure.

I'd emailed a mention of the post to the SGA nursing staff, saying that I hoped they'd reconsider both their colonoscopy prep protocol and how they respond to patient concerns.

Yesterday I got a phone call from Zoe Wendolowski, who I believe is the nursing head honcho (probably her real job title is more formal).

We had a thoroughly enjoyable lengthy conversation that likely would have gone on even longer if I wasn't getting the Demanding Walk Look from the family dog. I came away feeling that if everyone at Salem Gastroenterology Associates is as pleasant and sociable as Zoe, the patient care there must be excellent.

She invited me to consider SGA for my next colonoscopy -- which is supposed to be in a couple of years -- and I told her that I'd be pleased to do that. But I'm still concerned about their atypical colon prep schedule.

Having worked in the health planning/policy area for fifteen years, I dredged up some memories of early enlightening experiences -- when I'd just started working as a research associate in the Oregon medical school's Family Practice Department.

One of the faculty members there was big on treatment protocols. Basically, flow charts to guide a doctor's decision making process. I told Zoe about the time I observed several experienced family physicians sitting around a conference table discussing urinary tract infections.

It turned out that each of them had a different way of handling this common problem. They argued for their own way of doing things; I can't remember if a consensus ever emerged.

So medicine isn't a science -- not in the sense of physics, where doing this generally causes that with remarkable precision (except in the quantum realm, where probabilities rule).

This is why patients should feel free to question what a doctor wants to do. And physicians should respond openly and non-defensively. Reasons should be given, not the sort of "just because" that I got from Salem Gastroenterology Associates.

I reiterated to Zoe what I wrote to the SGA doctor who was going to do my colonosocopy: the Mayo Clinic, Massachusetts General Hospital, and plenty of other highly respected medical centers typically use a one-day colon prep schedule, so why does your clinic believe a two-day liquid diet is called for?

Until I get a good answer to that question, I'll continue to wonder about Salem Gastroenterology Associates' approach to colonoscopies. Zoe said that they conduct research on the effectiveness of this screening procedure, which is great.

But I told her that they needed to also ask themselves whether they're doing some things just because that's the way it's always been done -- which isn't the best way to practice medicine.

President Obama is calling for more emphasis on comparative effectiveness research. For example, a question dear to my heart (and organs underneath) is whether a one-day colonoscopy prep is as effective, from both a patient and physician perspective, as a two-day prep.

Given that a one-day prep is so common, I suspect there's quite a bit of research to support that approach. However, if Salem Gastroenterology Associates can prove otherwise, they should do so.

If not, SGA may just be a quirky exception to a reasonable typical rule.

This is common in medical practice. There are large variations in how often certain procedures are performed in different parts of the country, as well as varying areas of the world.

Doctors get into habits. Often there isn't any reasonable reason for doing things a particular way other than "this is how we've always done it." As the story mentioned above said: 

At this time, however, comparative effectiveness research enters very little into most of our healthcare experiences. Clinicians still generally make decisions based on often limited research, professional guidelines, and their own experience. They don't have any other options: Comparative effectiveness research exists for only about 30 percent of medical treatments, experts say.

"We know macro answers, like whether surgery helps reduce heart attacks," says Jed Weissberg, associate executive director for quality and performance improvement for the Permanente Federation, the umbrella organization representing physician groups at Kaiser Permanente, which has been a pioneer in this area. "But we don't know answers to precise questions, like for different groups of patients, which drugs or which surgeries work best."

So don't have a my doctor knows best attitude. Question. Do your own research. Become friends with Google. Don't be afraid to ask "Why?"

I told Zoe that everyone agrees the colonoscopy prep -- cleansing the bowel -- is the worst part of the procedure. If it isn't necessary to almost double the time someone is on a liquid diet, why do it?

There may a good reason Salem Gastroenterology Associates typically uses a two-day prep. I just haven't heard it yet.

Comments

[Roxanne]

I agree with you. As patients we should do a research for an added knowledge about our disease or medication.

[tucson]

I have no idea why Salem Gastroenterology requires(ed) a two day prep. One day is sufficient. The colonoscopy procedure is no big deal and the drug commonly used to put you to sleep (propophol) for the prodedure has little hangover effect.

The hassle is the day before when you have to cleanse the bowel and stay on a clear liquid diet. It is a day of projectile diarrhea. The toilet is your constant companion and your friends keep their distance. The dog is fightened.

I had surgery on Tuesday for a tumor (villious adenoma neoplasm) in my rectum. I had been noticing some blood on my stool (aka shit) and went to a gastroenterologist who ordered a colonoscopy on Dec. 2. As a result of this examination I was referred to a colo-rectal surgical specialist.

He was able to remove the growth, which he said was quite large. Pathology studies were negative. He said it was almost certain that this thing would have become malignant had it been allowed to remain much longer.

Colo-rectal cancer is insidious. Sometimes you don't have any symptoms until the situation is serious or fatal. While diet and lifestyle can help, anyone can get cancer. Anyone. Even if you live on organic produce and drink a gallon of green tea every day. I suggest if you are over 50 you have a colonoscopy. About 50% of the U.S. population in their 50's and 60's have pre-cancerous polyps which may remain benign, or not.

A colonoscopy is a small price to pay to avoid having your colon removed and going around with a bag on you abdomen for the rest of your life which is not good for scoring chicks at the beach... "Nice bod on that dude, but I don't think I can deal with that shit bag slapping against me while we're doing it."

[Blogger Brian]

tucson, you offered up some great advice -- about getting a colonoscopy if someone is 50 or older. It isn't as bad as people expect. And getting colon cancer is a whole lot worse, for sure.

I'm going to have a repeat colonoscopy fairly soon, as a small polyp was found and removed two years ago, and the doctor wanted to check things again in early 2011. I'm not looking forward to it, but I'm not dreading it either, having survived my first colonoscopy just fine.

[mom4kids]

You need to do a two day prep to get cleaned really well. If you don't get clean the doctor can not see the flat cancer. I had colon cancer at 36 years old. The two day prep is what I do I am still not clean. Maybe I should ask the doctor if I can do a 3 day?