Sunday, January 25, 2009

The First Secret of Medicine

In Medicine as in life, everything old at one point in time becomes new again. This month there was a flurry of interest in an study from the Journal of Family Practice in December 2008 that reported that up to one third of people who need colonoscopy (and we all need colonoscopy or an alternative at some point to screen for colon cancer) can have it done wide awake with no sedation if given the choice. Now I know that most of you, just hearing about this and visualizing a long tube being pushed up your rectum would question the sanity of anyone choosing to have the test done while awake and alert. However, as a former gastroenterologist, and someone who, twenty years ago using equipment that is not as good as the equipment today, did about half of all my colonoscopies with no anesthesia, I sit back with smug self satisfaction as I look at these reports.

Colonoscopy is a medical procedure where a long, flexible, tubular instrument called the colonoscope is used to view the entire inner lining of the colon (large intestine) and the rectum. It can be uncomfortable and in the United States is usually done with some type of anesthesia. In recent years the anesthesia for the test has become more sophisticated and has thus required the involvement of an anesthesiologist or a nurse anesthetist. Of course, whenever I say “sophisticated” in the course of this blog my reading audience can substitute the word “expensive” as we do pay for that sophistication. It turns out that around the world the standard way to do this test is without anesthesia and it is only in the United States that most experts who do this procedure use anesthesia routinely.

Whenever I have been on the receiving end of the colonoscope and had this test done I have always had it performed with no anesthesia. I know that having the test done without any medication to dull my senses makes the test safer as well as less expensive. While safe, the test does have rare complications. The most common is perforation of the bowel which is puncturing the wall of the colon or rectum. In American Medical News, in their report on the study about colonoscopy done on a person who is awake, Ricardo Hahn, M.D. of the University of Southern California was quoted as saying “You cannot perforate the bowel of an awake patient. They will get off the table and smack you.” This may also be a reason that many physicians in this country want to sedate patients. They don’t want to be smacked! If you stay awake for the procedure, it also makes the logistics of having it done much easier. You don’t need anyone to drive you home as you are able to drive yourself home. You can also discuss what the doctor is seeing and doing during and immediately after the exam and remember what is said to you.

One of the secrets of medicine is that doctors are people. They make mistakes and they are not all above average. There are many who are excellent but they may have not slept well the night before your procedure, they may have a mild illness of their own or they may just be unlucky that day. The doctor may be excellent at the procedure and not as good at communicating the results. I want to be awake to watch them, to talk to them and to interact with them in a way that will make the procedure being done on me the safest and most effective it can be. I say all this even though I have great faith in my doctors. While I know that there are many procedures that require sedation, colonoscopy is not one of them so I welcome this new, old trend. If you have it done this way, make sure that the bill that is generated reflects the fact that you didn’t receive the drugs and that you didn’t have the services of an anesthesiologist. While not always the case, in this instance cheaper can be safer and better even if more uncomfortable.