Healthcare Reform

Healthcare Reform

The Colonoscopy Chronicles-a Baby Boomer’s Guide to Colonoscopy-has so far focused on some of the medical nuts and bolts issues related to colon cancer screening, and colonoscopy in general. So today’s posting will be a bit of departure, as I will take this opportunity to editorialize about the healthcare topic of the day-Healthcare Reform. I propose that healthcare reform is necessary, and long overdue. I firmly believe that Congress will pass some form of reform, and it is my hope that it will be the reform that we want and need. Who would have thought that this would have been such a political tinderbox? Well, when you stop to consider it, perhaps it was predictable that healthcare debate would generate a visceral response from Americans. For one thing, many Americans earn their livelihood from the healthcare industry. It is estimated that healthcare comprises about 17% of our economy, thus it stands to reason that about one of every six Americans’ paychecks come from healthcare.

Another reason for the spirited debate that has occurred is that those Americans who are covered by healthcare insurance in one form or another fear, understandably, losing that coverage, or having their coverage seriously altered. Most studies have indicated that those who are covered are generally happy with their coverage and would not want to see it replaced. This is despite the fact that there is widespread agreement that there are serious flaws with the status quo.

Let’s face it, when those of us with health insurance receive the estimate of benefits letter from our insurance company, we see the initial charge by the provider or institution, and then we see how our insurer has negotiated a more favorable rate for us, and finally we see how much of this negotiated rate the insurance company will pay, and how much we are responsible for. This last number, our ultimate patient financial responsibility, is generally a far cry from the initial charge. This fact is not lost on patients, and the last thing they want to see is that they are now on the hook for the total charge. This potential hit to the pocket book is bound to provoke a powerful reaction.

Another reason people are loathe to see anything that compromises their health insurance coverage is the fact that most covered patients have significant choice in terms of choosing their doctor, and are afraid that this freedom would vanish under healthcare reform.

Finally, most of us have had either personal experience or have had a loved one experience a catastrophic injury or illness. We all know that without coverage we or someone close to us would have been devastated financially, on top of the effects of the illness.
So yes, it is completely understandable that those who currently have health insurance in one form or another are willing to fight to maintain the status quo-or at least some semblance thereof. American medicine-despite the potshots it takes in the media-has much to be proud of. American research in medicine and pharmacology has produced advances that were practically unthinkable. To put things into perspective, when I was a medical student in the early 1980’s, AIDS was first recognized. Within a matter of only a few years, the virus responsible for AIDS was identified, and treatments developed. Now, what was once a uniformly rapidly fatal disease has been transformed into what is largely a controllable chronic illness-all within an approximately 20 year time frame. This is not to say that we have cured HIV. I also recognize that there are huge numbers of patients that cannot afford antiviral drugs in order to keep the virus in check. But the point is, that the speed and effectiveness with which medicine has advanced is remarkable. Death rates from cancer are declining in America, and people are living longer than ever.

So, why does healthcare in America need reform? First of all, there are vast numbers of Americans who do not have healthcare insurance. While the estimates vary, most would agree that approximately 10-15% of Americans are not covered. What is not exactly clear is why these patients have no coverage. Most certainly, some of them simply cannot afford medical insurance due to a low income, but yet are not eligible for Medicaid-the government healthcare for the indigent. Still others are not able to afford healthcare insurance, not because of a substandard income, but because they have a pre-existing medical condition that makes their insurance rates impossibly expensive. Finally, there are many who can afford health insurance, but simply choose not to. Any meaningful reform in healthcare would have to address all of these underlying reasons for lack of healthcare insurance. Those who truly cannot afford insurance due to low income should get some form of subsidy. Those who have pre-existing conditions should not become healthcare pariahs. Those who can afford insurance but choose not to must be mandated in some way to purchase it.

In addition to reform ensuring that all Americans are covered, it must address the issue of runaway costs. Clearly, the rise in healthcare cost has oustripped rate of inflation. The reasons for this are complex, but certainly include massive profits by health insurance companies. When the insurers offer patients fewer services at a higher premium each year, and pay healthcare providers less each year, it doesn’t take a math genius to see that it is a recipe for steadily increasing profits for the insurers. United Healthcare, just to cite one example, earned nearly 5 billion dollars in profits in 2008, while Aetna earned about 1.5 billion in 2008 profits. No one begrudges them an opportunity to turn a profit, but the insurers must be regulated so they cannot cherry pick the healthier more profitable patients and refuse to cover the higher risk individuals.

Another reason for spiraling costs is the litigation-crazy society in America, and the constant threat that doctors will be sued for malpractice for any sort of negative patient outcome. Beleaguered doctors, fearing lawsuits, often resort to ordering tests that they know are unlikely to be fruitful just to cover the remote possibility that something could have been missed, or to mollify patients. This wasteful process results in huge, essentially worthless, healthcare expenditures. Reforming the malpractice laws could result in a system that no longer promotes this futile spending, yet still protects patients. Yet the current healthcare reform bills that are being proposed do nothing to promote malpractice reform. The trial lawyers have too strong a lobby, and they are not about to allow this source of windfall profits to slip through their fingers.

Finally, healthcare should be reformed because, despite the steadily rising costs, we really do not get our money’s worth-partly for reasons mentioned above. In addition, there have not been uniform standards for measuring outcomes and quality. Consumers deserve to know if their healthcare provider follows evidence based medicine, and deserves to know how they perform on a series of universally accepted benchmarks.

There you have it-it is hard to argue against the principles of universally available healthcare this is cost-effective, and promotes quality. The dilemma is in choosing the best path to get there. The reality is that these noble principles will be completely distorted once Congress takes out their toolbox and goes to work drafting a bill. The incredibly powerful special interests who donate millions of dollars to the politicians will really be the ones crafting these bills, and crowding out the interests of the public. The lobbyists that represent the hospitals, the pharmaceutical companies, and the insurance companies will see to it that their interests will be the first priority, and then let the chips fall where they may. They will come out the true winners in whatever reforms come about.

The losers? You guessed it-first and foremost John Q. Public. Sure, on the surface it may seem that there are some gains for the average citizen, but this will come at a gigantic cost in terms of higher taxes and higher public debt. The other big losers will be physicians. As the least powerful link in the healthcare food chain, their interests will be overshadowed by the big bullies on the block-big pharma, insurance, and the hospitals.

What about the “Public Option”? On the face of it, a public option sounds attractive: provide a competitor for the private insurers to let free market forces drive down prices for the consumer. As many have aptly pointed out, it would be one thing if this competition was fair, but it would hardly be a fair fight since the government run option would have gigantic competitive advantages-being subsidized by the taxpayer. What we really need is proper regulation and oversight of the existing private health insurance market. Private profit driven companies will not necessarily do the right thing for society-their principal responsibility is to the shareholder. But that doesn’t mean that every industry needs a government run competitor to force private industry into compliance-that’s what laws are for.

For example, automobile manufacturers knew full well that installing seat belts and headrests in automobiles would prevent injuries and death in car accidents. While the moral imperative would have been to install them, they did not, since it would cut into their profit. So what should the response of government be-to open up a government run automobile manufacturing company and produce cars with seat belts and headrests? Of course not!! Rather, the answer was to federally mandate that these safety measures be implemented by the existing manufacturers.

Creating a public option would entail the creation of a new entity that would bloat the already massive Washington beureucracy and cost the taxpayers beyond their wildest dreams. If the true aim is to achieve universal coverage, with cost reduction, and quality assurance, we can and should do it without a public option. For all of our sake, let’s hope Washington gets it right.

Here’s to good health!

Respectfully,

The Colonoscopy Chronicles

Virtual Colonoscopy-A Primer

Virtual Colonoscopy-What You Need to Know

Note: The Colonoscopy Chronicles attempts to provide information that is as accurate as possible. It is not intended as medical advice. You should consult your personal physician regarding your own medical condition.

So called “virtual colonoscopy” has generated a lot of buzz lately. This is probably because most of us baby boomers fancy ourselves as being a little “tech savvy”, and at the same time are at an age when we have to think about colon cancer screening. Thus, “virtual colonoscopy” would seem like the “perfect storm”- a way to do the right thing, and at the same time use sleek new technology to avoid the indignity of a conventional “optical”colonoscopy. Well, as they say, if it sounds too good to be true, it probably is!

Don’t get me wrong, virtual colonoscopy is definitely an excellent addition to the arsenal of tools we have available for colorectal cancer screening. However, it has to be placed in proper perspective. Virtual colonoscopy is also known as computerized tomographic colography(CTC). For sake of simplicity, I will refer to it as CTC the rest of the way. Well, for starters, what is CTC? Essentially, CTC is a CT scan of the abdomen and pelvis using specialized software that provides detailed images of the colon. A CT scan is a type of x-ray that involves placing the patient in a machine with a flat table, and a doughnut shaped ring that surrounds the area of the body being scanned. In order for CTC to be done properly, the patient has to take a laxative preparation prior to the procedure(just like for conventional colonoscopy). Furthermore, a small tube is placed into the patient’s rectum to inflate the colon with air for optimal results-sometimes a rather uncomfortable maneuver-since the patient is not given anesthesia.

I think you are getting the picture that virtual colonoscopy is not quite as virtual as you might have thought. It’s not like you just e-mail your information to the radiologist and you get a nice little printout of the results without ever having to step foot into the hospital!! The fact is, the aspect of conventional colonoscopy that tends to aggravate patients the most-the laxative cleanout-is still necessary with CTC.

OK, well then, let’s say it is not quite so virtual. But you’re still interested, because you like to be on the edge of technology. Due to your busy schedule, you don’t want to be sedated for a conventional colonoscopy, which would require that you do not work or drive for the remainder of the day. You want to come in, get your CTC, then head off to the health club and Starbuck’s-right? Understandable. But consider this-what if CTC shows a polyp-a potentially precancerous lesion that will need to be removed via conventional colonoscopy? There would be two options in this situation:
1-Proceed directly to conventional colonoscopy that same day(requiring that you have pre-arranged a ride home. Forget about Starbucks+health club)
2-Arrange conventional colonoscopy for a later date. The downside here is that you would have to repeat the laxative preparation prior to the conventional colonoscopy-again, the aspect that patient’s find the most distasteful.

Well, despite these somewhat confusing logistical issues, you are still fired up for the CTC. The next question to tackle is, how accurate is CTC? This is a question that I could discuss for hours, but I’ll try to distill it into a single sentence: CTC seems generally pretty accurate. It is up to about 95% accurate for discovering polyps greater than 10 millimeters(mm). While some studies have shown a significantly lower detection rate, I think that the bulk of the evidence is that CTC is quite accurate for detecting these larger polyps. Conventional colonoscopy is not 100% accurate for detecting polyps greater than 10 mm, but is more accurate than CTC. As far as detecting polyps less than 10mm, conventional colonoscopy is dramatically better. Does this matter? This is a subject of great debate. Clearly, polyps greater than 10mm are the ones more likely to contain cancer cells, or if not already cancerous, to transform into cancer. So clearly these polyps are more significant than polyps less than 10mm. However, a certain percentage of even these small polyps can contain cancer cells, or transform into cancer.

You, the unapologetic baby boomer, are still enthused about CTC, despite some of its imperfections. The next question is, what about the safety of the exam. CTC is extremely safe. There is radiation exposure involved, which should not be completely dismissed. Furthermore, the American Cancer Society guidelines for colorectal cancer screening(just updated in 2008) advise CTC every 5 years as opposed to every 10 years for conventional colonoscopy. The significance of this radiation exposure every 5 years in a person starting at age 50 and expected to live to at least 75 is not clear. On the other hand, assuming nothing is detected on CTC, the patient avoids the potential hazards of conventional colonoscopy-which, although rare, do exist-including risk of perforation, bleeding, and anesthetic risks.

Now, the quintessential question on a baby boomer’s mind-will insurance cover it? Aha, when the rubber meets the road, we want our technology, but do we want to pay for it? Although CTC has been endorsed by the American Cancer Society as an acceptable colorectal cancer screening alternative, Medicare and most third party payers will not cover screening CTC. This is not likely to change in the near future, since Medicare recently came out with their position-CTC will not be covered for screening. So, unless you are willing to pay out of pocket-it is likely that you will choose conventional colonoscopy- rather than CTC, since the cost of conventional colonoscopy is generally covered by Medicare and most third party payers.

If you choose to have a CTC to evaluate your colon, rather than conventional colonoscopy, I would suggest the following advice:

1. Go to a center that has a reasonable amount of experience in the CTC and a radiologist who has a special interest and training in the procedure

2. Make sure that the center where you do the CTC has a system in place to

a. Read the x-rays promptly
b. Have it arranged so that if a polyp or other abnormality is seen on CTC, you can be assured that a gastroenterologist is available to do a conventional colonoscopy the same day-so you do not have to go through the laxative cleanout process a second time. I would emphasize that you will have to have someone on standby to drive you home in case you should need to have the conventional colonoscopy.

It is worth having a frank, detailed discussion with your physician to see if CTC is a good option in your particular community, as the availability and quality of CTC may vary tremendously. Whether you choose virtual or conventional colonoscopy, make sure you get appropriate colon cancer screening so we can reduce the death rate from the number two cancer killer in America!

What’s the Best Anesthestic for Colonoscopy?

Anesthesia for Colonoscopy

Note: The Colonoscopy Chronicles attempts to provide information that is as accurate as possible. It is not intended as medical advice. You should consult your personal physician regarding your own medical condition.


Most patients are, predictably, worried about whether the colonoscopy will be painful. Virtually every colonoscopy done these days is performed under anesthesia to make the procedure comfortable. There are several types of anesthesia available. It is advisable to have a frank discussion with the physician performing the colonoscopy to be sure you understand this important aspect of the procedure, and to make sure you have realistic expectations of the anesthesia. For the sake of simplicity, I’ll break them down into two main categories:
1) Conscious sedation
2) Monitored Anesthesia Care(MAC)

Conscious Sedation

The vast majority of anesthesia used for colonoscopy is conscious sedation. This is generally administered by the physician doing the colonoscopy. Usually, it takes the form of two different medications, given into an intravenous line that has been inserted into the patient’s vein prior to the procedure. The two medications normally given are 1)a narcotic analgesic(painkiller)-usually Demerol(meperidine) or Sublimaze(fentanyl) 2)a benzodiazepine(sedative/hypnotic)-usually Versed(midazolam) or Valium(diazepam).

The physician generally gives a small starting dose, then small subsequent doses until the patient is sufficiently sedated. Then the physician will start the colonoscopy, giving repeated doses of the medicine as necessary during the procedure. The vast majority of physicians who perform colonoscopy are experienced administering conscious sedation, and know what it takes to keep the patient comfortable and safe during the procedure. These medications can provide extremely effective, safe sedation for colonoscopy, but must be administered by a physician who is well trained in their use. The most common serious adverse effect is respiratory depression(decreased breathing). Changes in blood pressure, heart rate, and heart rhythm can occur as well. In most centers, patients are closely monitored before, during, and after the anesthesia-using monitors that check the pulse rate, heart rhythm, oxygen level, and blood pressure. Reversal agents-drugs that can reverse the effect of the anesthetic drug-exist for meperidine, fentanyl, and versed. These are generally only given if the patient experiences a significant, persistent decrease in breathing or blood pressure that is felt to be anesthetic related. This is relatively rare. Most physicians advise that, following conscious sedation, the patient be accompanied home, and they may not drive until the following day. Your physician should give you specific instructions regarding restrictions of your activity following the anesthetic.

There are several issues regarding conscious sedation that bear discussing:

· Because this form of anesthesia is not deep anesthesia or general anesthesia, it is possible that the patient may have some discomfort during the procedure-usually quite minor, although in rare cases it can be severe. I try to be quite honest with my patients: There is about a 95-99% chance they will be totally comfortable throughout the procedure-but I cannot give them an ironclad guarantee. If they expect and demand a virtually 100% guarantee then I suggest they consider MAC anesthesia(discussed below).
· Versed, which is commonly given, can cause transient amnesia. The main practical consequence of this is that patients often forget the conversation with the physician in the recovery area after the procedure. It is a good idea to ask ahead of time that the physician write down the findings, and also discuss them with the person accompanying them to the procedure.
· It is sometimes difficult to achieve adequate sedation in certain patients-including those who are unusually anxious, or are on certain medications, such as narcotic painkillers, medication for anxiety, sleeping pills, or those who have a history of being difficult to sedate for other procedures in the past. Again, these are situations where MAC anesthesia may be considered.

Monitored Anesthesia Care(MAC)

MAC anesthesia is a somewhat generic term, but basically describes anesthesia services that are under the supervision of an anesthesiologist or registered nurse anesthetist. As you recall, I mentioned that in conscious sedation, the physician performing the procedure also supervises the sedation. In contrast, with MAC anesthesia, there is a separate physician or nurse whose sole job is to administer and monitor the anesthesia. The anesthesiologist may choose to use the same drugs that I mentioned in the section on conscious sedation. In addition, they have a wide variety of other medications available which they are trained to give. One of the most commonly used medications used in MAC anesthesia for colonoscopy is called Diprivan(propofol). Propofol is well suited to colonoscopy due to its rapid onset of action, and short duration. It can be given alone, or in combination with a painkiller and/or sedative-depending on the preference of the anesthesiologist. Like the medications mentioned above, propofol can decrease the breathing, and patients receiving it must be carefully monitored by the anesthesia specialist during the procedure. Depending on the amount given, patients can go into deep sedation or even general anesthesia from propofol. MAC anesthesia has the advantage of being more effective for the “hard-to-sedate” patients, and also allows the physician performing the colonoscopy to focus on the procedure and not the anesthesia.

There is currently some controversy about who is qualified to use propofol as an anesthetic agent. Some feel that only those trained specifically in anesthesia-such as anesthesiologist and registered nurse anesthetists-should give propofol. Others feel that Gastroenterologists and other physicians who perform colonoscopy can-with proper training-safely give the medication.
I, personally, do not administer propofol, but commonly have an anesthesiologist or nurse anesthetist available to administer it to my patients.

A few things to mention about MAC anesthesia.

· Because an anesthesia specialist will be used, there will be an additional fee involved. Your insurance company may or may not cover this fee-depending on your particular policy, and the details of your case. You may want to clarify this in advance if MAC anesthesia will be used.
· Anesthesia specialists may not be available at the particular center where your colonoscopy will be performed. If MAC anesthesia is something your physician deems necessary, he or she may have to schedule it at a particular center or hospital where an anesthesia specialist is available.

Conclusion

Colonoscopy is safer, and more comfortable than ever. Physicians performing the procedure generally take great care to make it a pleasant and safe experience for patients. Don’t let fear of being uncomfortable stop you from having this important test. Be a good consumer, and make sure to discuss any questions or concerns you have with your physician prior to the colonoscopy.

Laxative Cleanout for Colonoscopy

Laxative Preparation for Colonoscopy

Note: The Colonoscopy Chronicles attempts to provide information that is as accurate as possible. It is not intended as medical advice. You should consult your personal physician regarding your own medical condition.

In order to do a colonoscopy properly, the colon has to be completely clear of stool. This means that prior to the procedure, the patient has to take some sort of laxative preparation to cleanse the colon. As a general rule, this is the part of the entire process of colonoscopy that patients hate the most! I can’t tell you how many times patients have told me,”The procedure was easy, it’s just that prep that was tough”.

There are a huge variety of laxative preparations that have been used over the years. Each has its pros and cons-and none are perfect. Unfortunately, many of them can cause cramps and nausea, and they can be just downright nasty tasting. Some seem less effective than others and can leave some residual stool in the colon, which limits the effectiveness of the test. Others can lead to dehydration and electrolyte (sodium, potassium) abnormalities that can be dangerous. Some have even been associated with severe kidney damage.

I am not going to give you a comprehensive review of every colonoscopy prep available. But I will speak from personal experience about the ones I have prescribed in the in the past and the ones I currently use.

PEG Preps

There are a number of PEG preps on the market. The common denominator here is that the active ingredient is PEG(polyethylene glycol). PEG is a molecule that helps draw water into the lining of the intestine, which then flushes the intestinal contents out. These laxative preps also contain extra sodium and potassium to replace that which is often lost in this process. The PEG solutions are appealing for their safety, and effectiveness. They are of particular importance in patients with kidney failure or heart failure. Other types of preps may cause fluid and electrolyte disturbance that are particularly harmful in these conditions, whereas the PEG preps have much less chance of doing so. The downside of these solutions is that they taste lousy. They have a somewhat salty, sweet taste that can get on your nerves, especially when you have to drink such a large amount of it. Even though there are flavoring packets available for many of the solutions, they are still not particularly pleasant.

Despite these imperfections, I believe that PEG preps are generally the best currently available, and I recommend them for almost all my patients undergoing colonoscopy.

I’ll briefly review some of the PEG solutions available. The original PEG preps consisted of a four liter solution(almost 1 gallon). There are several of these that are still available, and are in common use today. These include: Golytely, Colyte, and NuLytely. The main advantage of the 4 liter solutions is price:they are about half the price of the 2 liter solutions. These cost in the $25-30 range.

Due to the fact that many people have trouble consuming 4 liters of a PEG solution over 4 hours, lower volume PEG solutions were developed. These include HalfLytely and MoviPrep. The HalfLytley involved taking two laxative pills followed by 2 liters of PEG solution. The MoviPrep consists of a one liter solution of PEG which is repeated as few hours later. The main disadvantage of these preps is the pricing, which is in the $50-60 range.

I have prescribed almost all of the above preps. I think that they are all basically safe and effective. Since the 2 liter solutions are easier to take, I favor them if the patient is willing and able to afford the additional cost. Of the two liter preps, I favor MoviPrep, since the dulcolax tablets in the HalfLytely can cause additional cramping. However, in fairness to the manufacturers of HalfLytley, at the time I was prescribing it, the recommended dose included 4 dulcolax tabs. This was recently changed to two, and I have not yet tried this new formulation-which was designed to reduce the crampiness.

Other Common Laxative Preps

While I generally do not use these preps, I will briefly discuss them.

Fleets Phosphosoda-This is a solution that has been around for many years, and is a fairly effective laxative. It became popular as a lower volume alternative to the 4 liter PEG solutions. Patients complained of its bad taste, and it could cause the usual cramps and nausea that the other preps caused. In 2006 the Food and Drug Administration reported that 21 cases of a rare form of kidney failure had been associated with this prep. Many physicians stopped using this form of prep following this report.

Pill Prep-The idea of replacing drinking up to a gallon of lousy tasting fluid with downing a few pills is very appealing. Unfortunately, there are several reasons why I don’t favor pill preps: 1) You need to take a large number of pills (32) 2)I find the cleanout to be less satisfactory than the PEG preps 3)The pills are made of essentially the same chemical contained in the Fleets Phosphosoda, and therefore may have the same potential for kidney damage

Odds and Ends

There are a million and one other ways to cleanse the colon, and I won’t get into every single one that is used. I will mention that your physician may recommend an enema(which is basically a small volume of liquid that is inserted into the rectum-designed to clear out the last few inches of the colon)-in addition to the laxatives you need to drink.

· Whatever prep you and your physician agree to use, make sure you understand the directions your physician gives you, and follow them carefully.
· Often the solution is more palatable if you chill it. Taking a bite or two of lemon sorbet in between drinking the PEG solution made it a little more tolerable.
· Remember, the better your cleanout, the better your physician can see inside your colon. This increases the chance of detecting abnormalities like polyps. So be an active partner in the process.

Remember, after you’ve finished your laxative cleanout-the worst is over!!

Next installment: Types of anesthesia used in colonoscopy

Where to Have Your Colonoscopy-and Happy Thanksgiving!

Note: The Colonoscopy Chronicles attempts to provide information that is as accurate as possible. It is not intended as medical advice. You should consult your personal physician regarding your own medical condition.

In our last post, we discussed who should perform your colonoscopy. As promised, we’ll now cover where you should have it done.

Your basic options are as follows:

Hospital Endoscopy Department
Ambulatory Surgery Center(ASC)
Physicians Office

So what’s your best bet? Sorry folks, this one is not as black and white as who should do your colonoscopy. You can have a safe, high quality experience at any of these three options. Here are a few factors to consider:

Safety: This is of utmost importance. Patients often have the perception that the hospital is “safer”. I don’t necessarily share this view. Certainly, the hospital has far more resources to care for acutely ill patients. The main “seconds to minutes” emergency that can result from colonoscopy is that of respiratory depression. This means decreased breathing, and drop in the blood oxygen level, related to the anesthesia. The key here is that the staff at the center where the procedure is being done need to know how to manage this situation properly.

At my center, which is an ASC, our staff is trained in Advanced Cardiac Life Support(ACLS) and we have a certified anesthesiologist present, who is an expert in managing respiratory emergencies. When patients ask me”Isn’t is safer to do the procedure at the hospital”, I sort of chuckle to myself, because to my way of thinking, I’d rather have an anesthesiologist two feet away from the patient in case of an airway emergency-like we have in my office-as opposed to having them come over from a different section of the building –as is often the case in the hospital. Therefore, I feel that a colonoscopy in our office/ASC is certainly just as safe as colonoscopy in the hospital. But this is not necessarily the case in every ASC or office. It is quite reasonable to be sure that wherever procedure is performed that there are staff who are trained and experienced in handling airway/respiratory emergencies. You have every right to ask about this in advance of your procedure.

One additional way you can check on a facility is to see if it is accredited. There are several organizations that evaluate outpatient facilities. The most prominent of these organizations are JCAHO(The Joint Commision on Accreditation) and AAAHC(American Association of Ambulatory Surgery Centers). In order to be accredited, a center has to go through a rigorous evaluation. This is not a rubber stamp process. Our center is AAAHC accredited, and the process was very impressive. The AAAHC evaluated all of our policies and procedures, and did thorough on-site inspection of our facility.


Cost: Once you’re comfortable with the safety aspects of the center where you’re going to have your colonoscopy, make sure you check out the cost! Some insurance carriers will specify where you should have the procedure; if you don’t use their “preferred” facility, it might cost you an exorbitant amount of money-so check this out well in advance of the procedure.

If your health insurance plan allows you a choice of location, you may want to do some cost comparison. Fees involved in colonoscopy may include: 1)The professional fee of the physician performing the colonoscopy 2)The professional fee of the anesthesiologist-if there is one involved(sometimes the physician doing the colonoscopy gives the anesthesia, and does not involve an anesthesiologist) 3)The facility fee that the hospital/ASC/office charges 4)If any biopsies are performed, there is an additional professional fee and facility fee involved.

You are well within your rights to ask what the costs of any of the above charges will be. The center where the procedure is being done should certainly be able to tell you what their charges are for the facility fee. Hospitals are generally have the highest facility fees, but this is highly variable. Don’t be surprised if you get quizzical looks when you ask about the pricing, since most facilities aren’t used to having this question asked by patients!

Physician Preference: The most important component of the colonoscopy is the experience and proficiency of the physician performing it. Your physician may have a preference for where you have the procedure done. It certainly makes sense to have the colonoscopy done at the venue where the physician is comfortable with the environment. You are certainly entitled to ask the physician why he or she prefers a particular location. If you have a strong preference for another location, you should discuss it with your physician.

Have a Happy Thanksgiving!

Who Should Do Your Colonoscopy?

Who Should Do Your Colonoscopy?

Note:While the information contained in The Colonoscopy Chronicles will be as accurate as possible, it is not intended as medical advice. You should consult your personal physician regarding your own medical issues.

Like most boomers-you want to research your procedure in advance. Logically, your first question may be:Who should do the procedure? In short, I would recommend a board-certified Gastroenterologist. This may seem like a bit of a “no-brainer”. After all, aren’t all colonoscopies performed by Gastroenterologists? No! We’ll talk later about what other physicians do colonoscopy.

The vast majority of colonoscopies in the United States are performed by Gastroenterologists. A Gastroenterologist is a physician specifically trained in the field of digestive diseases. The training generally consists of a four-year college program, followed by a four-year medical school, then a three year internship/residency in Internal Medicine, and finally a fellowship in Gastroenterology-usually for three years. During this fellowship, trainees learn in depth about digestive disorders, and also learn to perform endoscopic procedures-including colonoscopy.

Most physicians who complete their training in Gastroenterology become board-certified under the auspices of the American Board of Internal Medicine. Board certification in Gastroenterology means the physician has 1)completed an accredited training program in Internal Medicine, then passed the Internal Medicine Board Exam 2)completed an accredited training program in Gastroenterology, then passed the Gastroenterology Board Exam.



If colonoscopy is not performed by a Gastroenterologists, it would most likely be done by a surgeon or primary care physician-such as an Internist or Family Medicine specialist. It is relatively uncommon for primary care physicians to perform colonoscopy, but in some parts of the country that are underserved by Gastroenterologists, primary care physicians have learned to do the procedure out of necessity.


· Is it necessary for your physician to be a Gastroenterologist in order to perform your colonoscopy?
o No-but studies have shown that colonoscopies performed by non-gastroenterologists are five times more likely to miss colorectal cancer.

· Is it necessary for your Gastroenterologist to be Board Certified?
o No-but it indicates that they have met certain well accepted standards of training.


Comment: Gastroenterologists are generally your best bet-they have generally have the most extensive training and experience with colonoscopy. There are certainly many surgeons and primary care physicians who are well-trained, and highly competent.

I liken it to pitchers in major league baseball. They are generally all amazing athletes, and most of them were well-training in batting at one time, and most were excellent hitters in high school, or even college. However, since they specialize in pitching, they don’t have as many at bats as the position players, and don’t have as much time to take batting practice. Therefore, they generally are not as good hitters as the position players.

Make sure the physician performing your colonoscopy does them frequently. Most Gastroenterologists have performed thousands of colonoscopies. Make sure that their success rates and complication rates meet certain standards.
The success rate(measured by the frequency with which the physician is able to examine the entire colon) should be over 90%. It should be even higher(over 95%) for screening colonoscopies.
The physician’s track record for complications is another measure of competence. The rate of perforation should be lower than 1 in 500 cases-many experts have rates less than 1 in 1000.

Next….Where should you have your colonoscopy?

Welcome to the Colonoscopy Chronicles

Welcome to The Colonoscopy Chronicles-The Baby Boomers Underground Guide to Colonoscopy!

My goal is to entertain, inform, and most importantly to reduce the ridiculous number of deaths from colorectal cancer in America. While the information contained in The Colonoscopy Chronicles will be as accurate as possible, it is not intended as medical advice. You should consult your personal physician regarding your own medical issues.

Let's face it, us boomers are a different breed. We are the generation that won't accept ageing without a fight. When arthritis hampers our running regimen-do we give up running? No! We replace the joint! Unlike our parents' generation, we are more health-conscious. We are into better nutrition, more physical fitness, and we are sold on preventative health measures. We are more savvy about issues that affect our health, and when we see the doctor, we are far more informed than our predecessors.

So, we've all already had our screening colonoscopies at age fifty-right?

Ahh, just as I suspected! Many of you have managed to evade your initial screening colonoscopy. Kudos to those who have already done it. By walking you through the process, I hope to demystify the experience of the colonoscopy.

We'll keep it accurate and up-to-date,yet easy to understand, and hopefully add a little humor to the process! The Chronicles will discuss what's really on your mind, but what you may feel uncomfortable asking your physician.

Topics will include:

• Who should do your colonoscopy?
• Where should the procedure be done?
• What is the best laxative prep?
• What are the alternatives to colonoscopy?
• What type of anesthetic is best?
• How often should the procedure be done?
• What are the possible complications?
• What should I expect the day of the exam?

These topics will be presented from the standpoint of a physician who is in your age group, has performed over 15,000 colonoscopies, and who-incidentally-has had a colonoscopy himself!

I look forward to sharing the Chronicles with you.

Doctor Mike