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Thursday March 14 8:00-11:00PM (eastern time)
Friday March 15 7:00-10:00PM
Saturday March 16 7:00-10:00PM
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An INFORMED Doctor Discusses Colonoscopy
Pamela A. Popper, President
Wellness Forum Health
I invest a lot of time in preparing my weekly newsletters and videos. My goal is to encourage people to become more careful when making decisions about any health-related topic. The best way to do this is by looking at data concerning risks and benefits and then considering this data in view of your personal values and risk tolerance.
The medical system is remarkably resistant to doing this for many reasons. One is the time involved. Unlike issuing instructions which can take only a minute or two, discussions that involve nuance can take between 20 and 45 minutes. Another reason is the time needed to prepare for these discussions. For example, I’ve spent almost 28 years developing decision tools for everything from dietary supplements to surgical procedures. Thousands of hours have been spent on this endeavor. For doctors who work in institutions, time to do this is simply not available. Last but not least, we know that informed people consume less healthcare services, which makes informed decision-making a rather bad business model for medical institutions, which is one of the reasons institutions don’t invest in it.
In spite of the general incompetence and dismissiveness in medicine to day, there are some bright spots. Like Alison Huffstetler, a family practice doctor in Fairfax Virginia. She recently co-authored an article that looked at potential harms from colonoscopy, and discussed her approach to talking with patients about it in an article posted on MedPage.
Here are excerpts from her article:
“In my average day of clinical care, I offer patients 4 options for colorectal cancer screening. It took me at least 4 years to caress my monologue into a dialogue that does not result in an eyes-glazed-over look due to information saturation.
“Our dialogue results in shared decision-making – that shared decision-making is based on the best available evidence and values of the person in front of me. The recommended screening options for colorectal cancer include colonoscopy, flexible sigmoidoscopy, CT colonography, and stool-based tests such as FIT. The risks of colonoscopy cited by the USPSTF in their 2021 update are 17.5 serious bleeding events and 5.4 perforations per 10,000 colonoscopies. We review the benefit of colonoscopy; identification of precancerous lesions and a longer interval for repeat if findings are normal.”
She then discusses the article she co-authored about risks, which was a systematic review to look at harms related to the use of colonoscopy for screening purposes. This review was different from others regarding the same topic in two important and specific ways:
· The review looked only at harms reacted to population screening with colonoscopy and excluded procedures performed for diagnostic purposes and for those patients considered to be at high risk of colorectal cancer.
· Individuals were followed for 30 days after screening and included patients who had polypectomies while having the procedure.
The review included six studies and 467,139 screening colonoscopies. The incidence of harm was higher than had reported in previous reviews, and ranged from 16.4 to 36.9 serious bleeding events and 7.62 to 8.50 perforations per 10,000 colonoscopies.
Dr. Hufstetler says that “…all medical interventions pose risks and that the job of clinicians is to balance these risks with the benefits, consistent with the patients’ personal values. Serious bleeding and perforations are not uncommon after colonoscopies and should be explicitly communicated to patients. Screening should still take place and patients often choose colonoscopy. However, communicating accurate, timely, and realistic risk is essential to shared decision-making.”
Amen to that. If all doctors engaged in these types of discussions, our medical system would be much safer, medical expenses would be much lower, and people like me would not hear “If I’d known then what I know now…I would have made a different decision” dozens of times every year.
It is the nature of my work that a lot of what I write and speak about sounds negative. I often discuss facts that patients are not told; the financial incentives that persuade people to do nefarious things; flaws in the system that seem to get worse instead of better; and practitioners who ignore the preponderance of the evidence. But it is important sometimes to focus on the positive – there are good people doing good things out there. Hopefully this will inspire you to be one of them.
Huffstettler AN, Fraiman J, Brownlee S, Stoto MA, Lin KW. “An Estimate of Severe Harms Due to Screening Colonscopy: A Systematic Review” JABFM 2023 May;36(3):493-500
Alison Huffstetler MD. Screening for colorectal cancer in average risk individuals can cause harm. MedPage July 5 2023
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Special Note
My non-profit, Make Americans Free Again (MAFA), is committed to both representing practitioners who are in trouble with licensure boards right now, and to long-term regulatory reform. Misbehavior of licensure boards is not new; it has just escalated during the last three years. Resolving this will take a lot of money, determination, and time.
Until this systemic problem is resolved, all practitioners – both licensed and unlicensed – are at risk of being investigated by licensure boards. In some cases, investigations can lead to criminal prosecutions.
Our lawyers have prevented licensure revocation for many doctors and restored the licenses of several, often without the usual practice restrictions the state likes to impose. MAFA’s executive staff has a long history of successfully fighting restrictions on the practices of unlicensed professionals in several states and winning some of those battles as well.
Email pampopper@msn.com for more information and an application.