Laurel R. Fisher, MD

 

A 53-year-old woman was referred for surveillance colonoscopy. She is a current smoker with a history of chronic kidney disease, chronic obstructive pulmonary disease, atrial fibrillation, and two diminutive hyperplastic polyps found on average-risk screening colonoscopy 3 years previously. Her prep at the time was excellent and she was advised to return in 10 years for follow-up. She has taken the day off work, arranged for a driver, is prepped, and is on your schedule for a colonoscopy for a “history of polyps.” Is this an appropriate referral and how should you handle it?

Most of us have had questionable referrals on our endoscopy schedules. While judgments can vary among providers about when a patient should undergo a procedure or what intervention is most needed, some direct-access referrals for endoscopy are considered inappropriate by most standards. In examining referrals for colonoscopy, studies have shown that as many as 23% of screening colonoscopies among Medicare beneficiaries and 14.2% of Veterans Affairs patients in a large colorectal cancer screening study are inappropriate.^1,2 A prospective multicenter study found 29% of colonoscopies to be inappropriate, and surveillance studies were confirmed as the most frequent source of inappropriate procedures.^3,4 Endoscopies are performed so frequently, effectively, and safely that they can be readily scheduled by gastroenterologists and nongastroenterologists alike. Open access has facilitated and expedited needed procedures, providing benefit to patient and provider and freeing clinic visit time for more complex consults. But while endoscopy is very safe, it is not without risk or cost. What should be the response when a patient in the endoscopy unit appears to be inappropriately referred?

The first step is to determine what is inappropriate. There are several situations when a procedure might be considered inappropriate, particularly when we try to apply ethical principles.

1. The performance of the procedure is contrary to society guidelines. The American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, and American College of Gastroenterology publish clinical guidelines. These documents are drafted after rigorous research and literature review, and the strength of the recommendations is confirmed by incorporation of GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology. Such guidelines allow gastroenterologists across the country to practice confidently in a manner consistent with the current available data and the standards of care for the GI community. A patient who is referred for a procedure for an indication that does not adhere to – or contradicts – guidelines, may be at risk for substandard care and possibly at risk for harm. It is the physician’s ethical responsibility to provide the most “good” and the least harm for patients, consistent with the ethical principle of beneficence.

Guidelines, however, are not mandates, and an argument may be made that in order to provide the best care, alternatives may be offered to a patient. Some circumstances require clinical judgments based on unique patient characteristics and the need for individualized care. As a rule, however, the goal of guidelines is to assist doctors in providing the best care.

2. The procedure is not the correct test for the clinical question. While endoscopy can address many clinical queries, endoscopy is not always the right procedure for a specific medical question. A patient referred for an esophagogastroduodenoscopy (EGD) to rule out gastroparesis is being subjected to the wrong test to answer the clinical question. Some information may be obtained from an EGD (e.g., retained food may suggest dysmotility or the patient could have gastric outlet obstruction) but this is not the recommended initial management step. Is it reasonable to proceed with a test that cannot answer the question asked? Continuing with the endoscopy would not enhance beneficence and might be a futile service for the patient. Is this doing the best for the patient?

 

3. The risks of the procedure outweigh the benefits. Some procedures may be consistent with guidelines and able to answer the questions asked, but may present more risk than benefit. Should an elderly patient with multiple significant comorbidities and a likely limited life span undergo a follow-up colonoscopy even at an appropriate interval? The principle of nonmaleficence is the clear standard here.

4. The intent for doing the procedure has questionable merit. Some patients may request an EGD at the time of the screening colonoscopy just to “check,” regardless of symptoms or risk category. A patient has a right to make her/his own decisions but patient autonomy should not be an excuse for a nonindicated procedure.

In the case of the 53-year-old woman referred for surveillance colonoscopy, the physician needs to consider whether performing the test is inappropriate for any of the above reasons. First and foremost, is it doing the most good for the patient?

On the one hand, performing an inappropriately referred procedure contradicts guidelines and may present undue risk of complication from anesthesia or endoscopy. Would the physician be ethically compromised in this situation, or even legally liable should a complication arise during a procedure done for a questionable indication?

On the other hand, canceling such a procedure creates multiple dilemmas. The autonomy and the convenience of the patient need to be respected. The patient who has followed all the instructions, is prepped, has taken off work, arranged for transportation, and wants to have the procedure done may have difficulty accepting a cancellation. Colonoscopy is a safe test. Is it the right thing to cancel her procedure because of an imprudent referral? Would this undermine the patient’s confidence in her referring provider? Physicians may face other pressures to proceed, such as practice or institutional restraints that discourage same-day cancellations. Maintenance of robust financial practices, stable referral sources, and excellent patient satisfaction measures are critical to running an efficient endoscopy unit and maximizing patient service and care.

Is there a sensible way to address the dilemma? One approach is simply to move ahead with the procedure if the physician feels that the benefits outweigh the medical and ethical risks. Besides patient convenience, other “benefits” could be relevant: clinical value from an unexpected finding, affirmation of the patient’s invested time and effort, and avoidance of the apparent undermining of the authority of a referring colleague. Finally, maintaining productive and efficient practices or institutions ultimately allows for better patient care. The physician can explain the enhanced risks, present the alternatives, and – perhaps in less time than the ethical deliberations might take – complete the procedure and have the patient resting comfortably in the recovery unit.

An alternative approach is to cancel the procedure if the physician feels that the indication is not legitimate, or that the risks to the patient and the physician are significant. Explaining the cancellation can be difficult but may be the right decision if ethical principles of beneficence are upheld. It is understood that procedures consume health care resources and can present an undue expense to society if done for improper reasons. Unnecessary procedures clutter schedules for patients who truly need an endoscopy.

Neither approach is completely satisfying, although moving forward with a likely very safe procedure is often the easiest step and probably what many physicians do in this setting.

Is there a better way to approach this problem? Preventing the ethical dilemma is the ideal scenario, although not always feasible. Here are some suggestions to consider.

Reviewing referrals prior to the procedure day allows endoscopists to contact and cancel patients if needed, before the prep and travel begin. This addresses the convenience aspects but not the issue regarding the underlying indication.

The most important step toward avoiding inappropriate referrals is better education for referring providers. Even gastroenterologists, let alone primary care physicians, may struggle to stay current on changing clinical GI guidelines. Colorectal cancer screening, for example, is an area that gives gastroenterologists an opportunity to communicate with and educate colleagues about appropriate management. Keeping our referral base up to date about guidelines and prep and safety recommendations will likely reduce the number of inappropriate colonoscopy referrals and provide many of the benefits described above.

Providing the best care for patients by adhering to medical ethical principles is the goal of our work as physicians. Implementing this goal may demand tough decisions.

 

Dr. Fisher is professor of clinical medicine and director of small-bowel imaging, division of gastroenterology, University of Pennsylvania, Philadelphia.

References

1. Sheffield KM et al. JAMA Intern Med. 2013 Apr 8;173(7):542-50.

2. Powell AA et al. J Gen Intern Med. 2015 Jun;30(6):732-41.

3. Petruzziello L et al. J Clin Gastroenterol. 2012;46(7):590-4.

4. Kapila N et al. Dig Dis Sci. 2019;64(10):2798-805.

 

A 53-year-old woman was referred for surveillance colonoscopy. She is a current smoker with a history of chronic kidney disease, chronic obstructive pulmonary disease, atrial fibrillation, and two diminutive hyperplastic polyps found on average-risk screening colonoscopy 3 years previously. Her prep at the time was excellent and she was advised to return in 10 years for follow-up. She has taken the day off work, arranged for a driver, is prepped, and is on your schedule for a colonoscopy for a “history of polyps.” Is this an appropriate referral and how should you handle it?

Most of us have had questionable referrals on our endoscopy schedules. While judgments can vary among providers about when a patient should undergo a procedure or what intervention is most needed, some direct-access referrals for endoscopy are considered inappropriate by most standards. In examining referrals for colonoscopy, studies have shown that as many as 23% of screening colonoscopies among Medicare beneficiaries and 14.2% of Veterans Affairs patients in a large colorectal cancer screening study are inappropriate.^1,2 A prospective multicenter study found 29% of colonoscopies to be inappropriate, and surveillance studies were confirmed as the most frequent source of inappropriate procedures.^3,4 Endoscopies are performed so frequently, effectively, and safely that they can be readily scheduled by gastroenterologists and nongastroenterologists alike. Open access has facilitated and expedited needed procedures, providing benefit to patient and provider and freeing clinic visit time for more complex consults. But while endoscopy is very safe, it is not without risk or cost. What should be the response when a patient in the endoscopy unit appears to be inappropriately referred?

The first step is to determine what is inappropriate. There are several situations when a procedure might be considered inappropriate, particularly when we try to apply ethical principles.

1. The performance of the procedure is contrary to society guidelines. The American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, and American College of Gastroenterology publish clinical guidelines. These documents are drafted after rigorous research and literature review, and the strength of the recommendations is confirmed by incorporation of GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology. Such guidelines allow gastroenterologists across the country to practice confidently in a manner consistent with the current available data and the standards of care for the GI community. A patient who is referred for a procedure for an indication that does not adhere to – or contradicts – guidelines, may be at risk for substandard care and possibly at risk for harm. It is the physician’s ethical responsibility to provide the most “good” and the least harm for patients, consistent with the ethical principle of beneficence.

Guidelines, however, are not mandates, and an argument may be made that in order to provide the best care, alternatives may be offered to a patient. Some circumstances require clinical judgments based on unique patient characteristics and the need for individualized care. As a rule, however, the goal of guidelines is to assist doctors in providing the best care.

2. The procedure is not the correct test for the clinical question. While endoscopy can address many clinical queries, endoscopy is not always the right procedure for a specific medical question. A patient referred for an esophagogastroduodenoscopy (EGD) to rule out gastroparesis is being subjected to the wrong test to answer the clinical question. Some information may be obtained from an EGD (e.g., retained food may suggest dysmotility or the patient could have gastric outlet obstruction) but this is not the recommended initial management step. Is it reasonable to proceed with a test that cannot answer the question asked? Continuing with the endoscopy would not enhance beneficence and might be a futile service for the patient. Is this doing the best for the patient?

 

3. The risks of the procedure outweigh the benefits. Some procedures may be consistent with guidelines and able to answer the questions asked, but may present more risk than benefit. Should an elderly patient with multiple significant comorbidities and a likely limited life span undergo a follow-up colonoscopy even at an appropriate interval? The principle of nonmaleficence is the clear standard here.

4. The intent for doing the procedure has questionable merit. Some patients may request an EGD at the time of the screening colonoscopy just to “check,” regardless of symptoms or risk category. A patient has a right to make her/his own decisions but patient autonomy should not be an excuse for a nonindicated procedure.

In the case of the 53-year-old woman referred for surveillance colonoscopy, the physician needs to consider whether performing the test is inappropriate for any of the above reasons. First and foremost, is it doing the most good for the patient?

On the one hand, performing an inappropriately referred procedure contradicts guidelines and may present undue risk of complication from anesthesia or endoscopy. Would the physician be ethically compromised in this situation, or even legally liable should a complication arise during a procedure done for a questionable indication?

On the other hand, canceling such a procedure creates multiple dilemmas. The autonomy and the convenience of the patient need to be respected. The patient who has followed all the instructions, is prepped, has taken off work, arranged for transportation, and wants to have the procedure done may have difficulty accepting a cancellation. Colonoscopy is a safe test. Is it the right thing to cancel her procedure because of an imprudent referral? Would this undermine the patient’s confidence in her referring provider? Physicians may face other pressures to proceed, such as practice or institutional restraints that discourage same-day cancellations. Maintenance of robust financial practices, stable referral sources, and excellent patient satisfaction measures are critical to running an efficient endoscopy unit and maximizing patient service and care.

Is there a sensible way to address the dilemma? One approach is simply to move ahead with the procedure if the physician feels that the benefits outweigh the medical and ethical risks. Besides patient convenience, other “benefits” could be relevant: clinical value from an unexpected finding, affirmation of the patient’s invested time and effort, and avoidance of the apparent undermining of the authority of a referring colleague. Finally, maintaining productive and efficient practices or institutions ultimately allows for better patient care. The physician can explain the enhanced risks, present the alternatives, and – perhaps in less time than the ethical deliberations might take – complete the procedure and have the patient resting comfortably in the recovery unit.

An alternative approach is to cancel the procedure if the physician feels that the indication is not legitimate, or that the risks to the patient and the physician are significant. Explaining the cancellation can be difficult but may be the right decision if ethical principles of beneficence are upheld. It is understood that procedures consume health care resources and can present an undue expense to society if done for improper reasons. Unnecessary procedures clutter schedules for patients who truly need an endoscopy.

Neither approach is completely satisfying, although moving forward with a likely very safe procedure is often the easiest step and probably what many physicians do in this setting.

Is there a better way to approach this problem? Preventing the ethical dilemma is the ideal scenario, although not always feasible. Here are some suggestions to consider.

Reviewing referrals prior to the procedure day allows endoscopists to contact and cancel patients if needed, before the prep and travel begin. This addresses the convenience aspects but not the issue regarding the underlying indication.

The most important step toward avoiding inappropriate referrals is better education for referring providers. Even gastroenterologists, let alone primary care physicians, may struggle to stay current on changing clinical GI guidelines. Colorectal cancer screening, for example, is an area that gives gastroenterologists an opportunity to communicate with and educate colleagues about appropriate management. Keeping our referral base up to date about guidelines and prep and safety recommendations will likely reduce the number of inappropriate colonoscopy referrals and provide many of the benefits described above.

Providing the best care for patients by adhering to medical ethical principles is the goal of our work as physicians. Implementing this goal may demand tough decisions.

 

Dr. Fisher is professor of clinical medicine and director of small-bowel imaging, division of gastroenterology, University of Pennsylvania, Philadelphia.

References

1. Sheffield KM et al. JAMA Intern Med. 2013 Apr 8;173(7):542-50.

2. Powell AA et al. J Gen Intern Med. 2015 Jun;30(6):732-41.

3. Petruzziello L et al. J Clin Gastroenterol. 2012;46(7):590-4.

4. Kapila N et al. Dig Dis Sci. 2019;64(10):2798-805.

 

A 53-year-old woman was referred for surveillance colonoscopy. She is a current smoker with a history of chronic kidney disease, chronic obstructive pulmonary disease, atrial fibrillation, and two diminutive hyperplastic polyps found on average-risk screening colonoscopy 3 years previously. Her prep at the time was excellent and she was advised to return in 10 years for follow-up. She has taken the day off work, arranged for a driver, is prepped, and is on your schedule for a colonoscopy for a “history of polyps.” Is this an appropriate referral and how should you handle it?

Most of us have had questionable referrals on our endoscopy schedules. While judgments can vary among providers about when a patient should undergo a procedure or what intervention is most needed, some direct-access referrals for endoscopy are considered inappropriate by most standards. In examining referrals for colonoscopy, studies have shown that as many as 23% of screening colonoscopies among Medicare beneficiaries and 14.2% of Veterans Affairs patients in a large colorectal cancer screening study are inappropriate.^1,2 A prospective multicenter study found 29% of colonoscopies to be inappropriate, and surveillance studies were confirmed as the most frequent source of inappropriate procedures.^3,4 Endoscopies are performed so frequently, effectively, and safely that they can be readily scheduled by gastroenterologists and nongastroenterologists alike. Open access has facilitated and expedited needed procedures, providing benefit to patient and provider and freeing clinic visit time for more complex consults. But while endoscopy is very safe, it is not without risk or cost. What should be the response when a patient in the endoscopy unit appears to be inappropriately referred?

The first step is to determine what is inappropriate. There are several situations when a procedure might be considered inappropriate, particularly when we try to apply ethical principles.

1. The performance of the procedure is contrary to society guidelines. The American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, and American College of Gastroenterology publish clinical guidelines. These documents are drafted after rigorous research and literature review, and the strength of the recommendations is confirmed by incorporation of GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology. Such guidelines allow gastroenterologists across the country to practice confidently in a manner consistent with the current available data and the standards of care for the GI community. A patient who is referred for a procedure for an indication that does not adhere to – or contradicts – guidelines, may be at risk for substandard care and possibly at risk for harm. It is the physician’s ethical responsibility to provide the most “good” and the least harm for patients, consistent with the ethical principle of beneficence.

Guidelines, however, are not mandates, and an argument may be made that in order to provide the best care, alternatives may be offered to a patient. Some circumstances require clinical judgments based on unique patient characteristics and the need for individualized care. As a rule, however, the goal of guidelines is to assist doctors in providing the best care.

2. The procedure is not the correct test for the clinical question. While endoscopy can address many clinical queries, endoscopy is not always the right procedure for a specific medical question. A patient referred for an esophagogastroduodenoscopy (EGD) to rule out gastroparesis is being subjected to the wrong test to answer the clinical question. Some information may be obtained from an EGD (e.g., retained food may suggest dysmotility or the patient could have gastric outlet obstruction) but this is not the recommended initial management step. Is it reasonable to proceed with a test that cannot answer the question asked? Continuing with the endoscopy would not enhance beneficence and might be a futile service for the patient. Is this doing the best for the patient?

 

3. The risks of the procedure outweigh the benefits. Some procedures may be consistent with guidelines and able to answer the questions asked, but may present more risk than benefit. Should an elderly patient with multiple significant comorbidities and a likely limited life span undergo a follow-up colonoscopy even at an appropriate interval? The principle of nonmaleficence is the clear standard here.

4. The intent for doing the procedure has questionable merit. Some patients may request an EGD at the time of the screening colonoscopy just to “check,” regardless of symptoms or risk category. A patient has a right to make her/his own decisions but patient autonomy should not be an excuse for a nonindicated procedure.

In the case of the 53-year-old woman referred for surveillance colonoscopy, the physician needs to consider whether performing the test is inappropriate for any of the above reasons. First and foremost, is it doing the most good for the patient?

On the one hand, performing an inappropriately referred procedure contradicts guidelines and may present undue risk of complication from anesthesia or endoscopy. Would the physician be ethically compromised in this situation, or even legally liable should a complication arise during a procedure done for a questionable indication?

On the other hand, canceling such a procedure creates multiple dilemmas. The autonomy and the convenience of the patient need to be respected. The patient who has followed all the instructions, is prepped, has taken off work, arranged for transportation, and wants to have the procedure done may have difficulty accepting a cancellation. Colonoscopy is a safe test. Is it the right thing to cancel her procedure because of an imprudent referral? Would this undermine the patient’s confidence in her referring provider? Physicians may face other pressures to proceed, such as practice or institutional restraints that discourage same-day cancellations. Maintenance of robust financial practices, stable referral sources, and excellent patient satisfaction measures are critical to running an efficient endoscopy unit and maximizing patient service and care.

Is there a sensible way to address the dilemma? One approach is simply to move ahead with the procedure if the physician feels that the benefits outweigh the medical and ethical risks. Besides patient convenience, other “benefits” could be relevant: clinical value from an unexpected finding, affirmation of the patient’s invested time and effort, and avoidance of the apparent undermining of the authority of a referring colleague. Finally, maintaining productive and efficient practices or institutions ultimately allows for better patient care. The physician can explain the enhanced risks, present the alternatives, and – perhaps in less time than the ethical deliberations might take – complete the procedure and have the patient resting comfortably in the recovery unit.

An alternative approach is to cancel the procedure if the physician feels that the indication is not legitimate, or that the risks to the patient and the physician are significant. Explaining the cancellation can be difficult but may be the right decision if ethical principles of beneficence are upheld. It is understood that procedures consume health care resources and can present an undue expense to society if done for improper reasons. Unnecessary procedures clutter schedules for patients who truly need an endoscopy.

Neither approach is completely satisfying, although moving forward with a likely very safe procedure is often the easiest step and probably what many physicians do in this setting.

Is there a better way to approach this problem? Preventing the ethical dilemma is the ideal scenario, although not always feasible. Here are some suggestions to consider.

Reviewing referrals prior to the procedure day allows endoscopists to contact and cancel patients if needed, before the prep and travel begin. This addresses the convenience aspects but not the issue regarding the underlying indication.

The most important step toward avoiding inappropriate referrals is better education for referring providers. Even gastroenterologists, let alone primary care physicians, may struggle to stay current on changing clinical GI guidelines. Colorectal cancer screening, for example, is an area that gives gastroenterologists an opportunity to communicate with and educate colleagues about appropriate management. Keeping our referral base up to date about guidelines and prep and safety recommendations will likely reduce the number of inappropriate colonoscopy referrals and provide many of the benefits described above.

Providing the best care for patients by adhering to medical ethical principles is the goal of our work as physicians. Implementing this goal may demand tough decisions.

 

Dr. Fisher is professor of clinical medicine and director of small-bowel imaging, division of gastroenterology, University of Pennsylvania, Philadelphia.

References

1. Sheffield KM et al. JAMA Intern Med. 2013 Apr 8;173(7):542-50.

2. Powell AA et al. J Gen Intern Med. 2015 Jun;30(6):732-41.

3. Petruzziello L et al. J Clin Gastroenterol. 2012;46(7):590-4.

4. Kapila N et al. Dig Dis Sci. 2019;64(10):2798-805.