Like nearly every gastroenterologist, we have an open access endoscopy system. This means that patients can be referred, or refer themselves, directly to our office for a a procedure without an office visit in advance.
Why do we do this? We offer it as a convenience, so patients do not need to make two visits to see us when it is clear that a procedure is necessary. For example, a referring physician doesn’t need our consultative advice for his 50-year-old patient with rectal bleeding. He just needs us to do a colonoscopy. We have a strict screening process in place to verify that these patients are appropriate for our one-stop colonoscopy program. If we have concerns about medical issues or potential informed consent capability, then we arrange for these patients to see us in advance.
However, no screening process is perfect. On occasion, someone shows up who we might have preferred to see in our office first. How should we handle these situations? We don’t automatically cancel the test, particularly after the patient and his driver have taken time off work, and the patient has already swallowed the delectable and satisfying colonoscopy prep.
We are meeting many of these folks for the first time, and they are often nervous. We get this. First, they are at a physician’s office for an intrusive medical test, always a relaxing activity. The doctor may be a stranger to him, another calming feature of the event. They become victims of intravenous needle assault, always a pleasure even from our ICU nursing veterans. They have been fasting and may have enjoyed the pleasure and delight of our colonoscopy cleansing cocktail. They are naked except for a gown that by design covers about 40 percent of their body’s surface area. Ready to sign up?
Open access endoscopy also raises potential ethical issues. On occasion, a patient arrives for a procedure that we may not feel he truly needs or needs now. Or, the patient is sent for one of our procedures, which may not be the best choice to address the patient’s symptoms. These are delicate issues, and I don’t have an idealized response to offer here. In the open access arena, we regard ourselves more as technicians than consultants. This is similar to when a doctor sends a patient for a CT scan; the study gets done regardless if it is medically appropriate, or the patient has had half a dozen of them over the past year. Radiologists don’t question the appropriateness of what we order. While patient care would be better served if radiologists offered their advice in advance, this is not how the game works. Of course, they are happy to have these conversations about our patients, but their default system is open access.
How would you handle this scenario? One of your best-referring physicians sends a patient for an open access colonoscopy. We interview him and realize he is two years early. He is prepped and took a day off of work. He has a driver with him. Do we tell the patient that he is two years early? Do we send the patient home? Do we say nothing? Do we contact the referring physician and point out his error?
As you craft your response to the above hypothetical scenario, remember that this is not an ethics seminar but is the real world. Real life is not as neat and tidy as we would like.
Michael Kirsch is a gastroenterologist who blogs at MD Whistleblower.
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