“The medical arena, like society at large, is permeated with self-interest,” says Dr. Michael Kirsch writing on MDWhistleblower, a website whose name pretty much tells you where he’s coming from.
Like us, he’s a big supporter of comparative effectiveness research, which means comparing different treatments for a given illness and compiling a body of knowledge from which doctors and patients can choose the best option for a given case. And in the case of colonoscopy, an invasive procedure whose benefits vs. risk we’ve addressed before, this expert has a boatload of doubt.
As described by Gary Schwitzer on HealthNewsReview.org, Kirsch’s essay “Is Colonoscopy the Best Colon Cancer Screening Test?” manages to address “medical conflicts of interest, comparative effectiveness research, the medical arms race, medical marketing and more,” all within a few hundred words.
Kirsch starts by describing the absolute adoration his profession has for the latest medical tool or technology, and how this lust is ripe for conflict of interest. “In medicine, every heath care reform, new medicine, new medical device or revised medical guideline is at some constituency’s expense,” he says. “Recognizing and dismantling conflicts of interests is one of our greatest challenges and threats. ”
Practitioners and medical facilities love new medical developments not only for their therapeutic potential, but because they can be used to market somebody’s practice or hospital. “Large medical institutions will spend mightily for the latest high-tech robotic laser shooting burger-flipping tumor ray gun, even if (especially if) the competitor across the street already has one,” Kirsch writes. That, he says, is a “model of overtesting and overtreatment,” and leads to a “culture of excess.”
In the case of his field, gastroenterology, Kirsch is clear. Age 50, he says, is when “we pounce upon you to scour your colon to remove cancers-in-waiting. While we champion this test, and sincerely believe in its worth, it is not ideal.”
If the benefit is possible diagnosis of potential cancer, here, according to Kirsch, are some drawbacks:
- the pre-colonoscopy cathartic cocktail;
- discomfort (it’s not always painless);
- risk of complications (like a perforated bowel);
- high rate of negative results;
- loss of a day’s wages;
- the need for a driver to bring you home.
So when comparative effectiveness research finds a better test, Kirsch wonders if gastroenterologists will defend colonoscopy against it, and claim that the research behind the new development is flawed. “Gastroenterologists have successfully prevailed against CAT colonography, a competing test which examines the entire colon for polyps using a CAT scan,” he points out.
Unlike a colonoscopy, which involves inserting a probe in the rectum and snaking up through the bowel, a CAT scan is not invasive-it takes pictures (cross-section X-rays) while the patient lies motionless on the table.
Right now, colonoscopy is winning the match because patients who choose the CAT scan option still have to swallow that gacky laxative before the test, and if polyps are discovered, they can’t be removed-patients have to undergo another treatment. So colonoscopy has the advantage now because nearly all polyps discovered can be removed during the test.
But, Kirsch writes, “If radiologists perfect the technique of performing a CAT colonography without any required laxatives, then the scales may tip in their favor.”
And he believes that both colonoscopy and CAT colonography will lose favor while he’s still practicing medicine. “Colonoscopy,” he suggests, “will still be performed, but only when some kinder and gentler screening test indicates that an individual has a high probability of harboring polyps. It will no longer be wielded in a buckshot fashion. The number of colonoscopies being performed will be decimated.”
“When that happens,” he concludes with refreshing honesty, “it will not be good news for the Kirsch family. But, it will be greater good news for everyone else’s family.”