Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Monday, April 23, 2007

That's Right; Blame Me

Yet another "educational" throwaway in today's mail exhorts me once again to encourage, urge and recommend colorectal cancer screening to my eligible patients.

Once more, I am reminded of the criteria for colorectal cancer screening (basically everyone over age 50 and certain individuals under age 50 with risk factors like polyps or a family history of polyps or colorectal cancer), the options for colorectal cancer screening (fecal occult blood testing, flexible sigmoidoscopy, double contrast barium enema, colonoscopy, or some combination of these) and the reasons why colorectal cancer screening is a good idea ("In Pennsylvania, 8,000 residents will be diagnosed with colorectal cancer and 2,970 will die of the disease this year.")

I know this. I do this. I urge, plead, encourage and exhort patients on a daily basis to undergo appropriate screening tests for colorectal cancer, breast cancer, osteoporosis, cervical cancer and prostate cancer, not to mention my urgings, pleadings, encouragement and exhortations for appropriate patients to receive pneumococcal polysaccharide vaccine (Pneumovax for patients over 65), annual flu vaccine, and diphtheria/tetanus booster vaccination (10 year intervals; one dose now to be replaced with a new combination that includes acellular pertussis antigen.) In addition, I regularly urge, plead, encourage and exhort my patients to stop smoking and begin excercising, to get enough sleep and to reduce alcohol intake.

I do my damndest. Really I do.

And yet, in boldface type on the front page of this American Cancer Society sponsored pamphlet provided courtesy of the Pennsylvania Medical Society, it says right there:
...90 percent of the patients who have not had colorectal cancer screening report that they would undergo screening if their doctor recommended it.
Cut me a fucking break!!

Think about how that kind of a survey is done. What do you expect a patient to say in response to a question like, "Would you undergo colorectal cancer screening if your doctor recommended it?"
"Hell no! Shove something up my butt? No way, Jose!"
No, of course not. Isn't it far more likely to hear something along the lines of:
"But of course if my doctor recommended it, I'd do it. I have great respect for my doctors and I would always do whatever they say."
If you're buying that, then you probably also believe that Stephen Colbert is a Republican.

I am sick and tired of having surveys shoved in my face saying that all I have to do is "recommend" something to my patients, as if the only reason screening guidelines fail is that I don't bother mentioning them. (The same thing holds for smoking cessation, by the way. "Surveys show" that -- according to patients -- the most important reason they stopped smoking was that their doctor told them to. Bullshit!! If that were true, none of my patients would smoke; I say something about it every time I see them.) I can recommend, urge, plead, encourage and exhort until I'm blue in the face, and not only will patients refuse to do what I suggest, they'll innocently refuse to remember I even said it when asked by a survey taker from the American Cancer Society.

I know it's my job to be adequately persuasive, and frankly, I'm damn good at it. But don't go telling me -- on the basis of patient reported surveys -- that I'm not trying hard enough.


At Mon Apr 23, 07:38:00 PM, Blogger Artemis said...

Ah, but those surveys fail to ask what patients actually REMEMBER what we talk to them (talk at them?) about at each visit. I have no doubt that you are making the recommended comments regarding screenings and quitting smoking and losing weight (and on and on...) -- but if you were to ask your patients at their next visit "Do you remember our discussion on ____?", the majority would admit they didn't.
Keep up the great work.

At Mon Apr 23, 09:39:00 PM, Blogger Judy said...

You're doubtless doing better than most docs -- and it must be terribly frustrating.

I'm a colon cancer survivor. It took me AND my mom's doc 18 months after my diagnosis to convince her that she needed a colonoscopy. Mom thought it was unnecessary because she had her annual FOB and periodic flexible sigmoidoscopy.

Unfortunately, nearly half of all colon cancers are too deep for flexible sigmoidoscopy to find them.

Fortunately, mom's cancer was caught at an even earlier stage than mine.

Now SHE nags people - for all the good it does. If a colon cancer survivor saying, "I wouldn't be here talking to you if I hadn't...." doesn't get the message across, I don't know how anyone can blame a physician for what his patients decline to do.

At Mon Apr 23, 10:56:00 PM, Anonymous Anonymous said...

Don't take is so personally. The American Cancer Society is a big business with a lot of well paid executives. They use reported surveys like this to justify their existence and attract donations. After all, someone has to keep reminding all those dumb ass doctors to do their job.

At Tue Apr 24, 04:21:00 PM, Anonymous Anonymous said...

And of course, it adds to the documentation we will have to do as part of pay-for-performance, I am sure and as our patients decline, our numbers go down and down and down... just like our reimbursement.

And just like the poor ER nurses who have more BS added to their lives by JCAHO.

At Tue Apr 24, 07:43:00 PM, Anonymous Anonymous said...

na-na-na-na-na! you can't maaaaaake me!

--your patient

At Tue Apr 24, 07:50:00 PM, Anonymous Anonymous said...

You know....

You could create a written contract with checkoff boxes for the screenings/tests recommended - and then have the patient sign to confirm that they were all discussed, recommended and offered - just like an auto repair estimate. Check it off as you discuss the recommendations. Give a computer/NCR copy to the patient.

Date, time, signature of the patient and voila!

You now have a statistically valid real time education, screening and compliance tool.

Just sayin' ;^)

At Wed Apr 25, 09:20:00 PM, Anonymous Anonymous said...

Ditto times 10 to the 3rd power. Insurance companies, JACHO (its another name now), and lawyers use the excuse that "if it wasn't documented, it didn't happen".

Come on now, there is also the idea of usual and customary practice. It is the usual and customary practice of mine to do what you do. I do not have to document it for every visit for the whole time I have cared for that patient. It only adds to the "noise" in EMRs in the notes.

At some time there has to be a movement toward patient responsibility in all this. It is THEIR responsibility to act on the information given to them. My documentation that I put a piece of paper in front of them and had them sign it, still will not protect me in a court of law!!! The plaintiffs lawyer will always tell a jury that "the patient didn't really understand what he was signing" or something to that effect.

At Mon Apr 30, 08:53:00 AM, Anonymous Anonymous said...

As a former market researcher for big pharma just remember that surveys are designed and manipulated to give the answer that the one funding wishes to get out.

At Tue May 08, 12:57:00 PM, Anonymous Anonymous said...

Okay, my new doc (first one I've had in over ten years) did recommend the 'scopy, and I said no....because my friend told me she was scheduled to get one and beforehand had to drink something awful that made her ill for a while. But...after reading about colon cancers, I'll say yes next time I'm in the doc's office. However, first I'll ask who'll be doing the scoping, what method, and how many of these has he done. AND when and how I'll learn the results.

At Wed May 09, 11:20:00 AM, Anonymous Anonymous said...

I'll be fifty in July. In January, my internist was already discussing screenings and tests that will be done at that magic age.

I'll get the colonoscopy. Just medicate the hell out of me - give me some Versed and I'll do anything you want! : D

It's the patient's responsibility to follow through with required screenings, and the doctor's responsibility is to explain why. Docs don't need to hand-hold the patient to the tests!

At Thu May 10, 02:38:00 PM, Anonymous Anonymous said...

It's interesting to see the md's point of view, how his industry appeals to his altruism and sense of responsibility to push screening procedures, even when there is no indication they save lives, or have a marginal effect, at best.

Most doctors don't understand statistics, and do what they are told, like good little wind-up dolls.

And patients, especially 'responsible' ones are gulled into thinking we have more knowledge or control than we actually do.


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