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.

Friday, February 27, 2009

It Takes Two to Tango

I don't usually get ticked off about stuff I pick up from Kevin, because as a fellow Family doc, he usually gets it. This time I'm afraid he missed the boat.

The topic is racial disparity in colon cancer screening. Apparently a study showed that in an all-Medicare population (ie, one in which access was not an issue) whites are still more likely to receive colonoscopy than black or Hispanic patients.

Kevin jumps to the standard conclusion:
...physicians need to be vigilant in offering the same treatment options and screening tests to minority patients.
Two words: Puh. Leeze.

I am hypervigilant about offering appropriate screening recommendations to all my patients regardless of race, gender, age and brand of sneaker. What I find -- and what the quoted article itself explicitly acknowledges -- is a huge variability in the ACCEPTANCE of my recommendations:
The researchers said that a combination of socioeconomic, healthcare access, and cultural factors likely explain the disparity in colorectal cancer screening, with the relative importance of each factor varying by race.
No one wants a colonoscopy. I do my best, equally with everyone, to talk them into it. Many remain reluctant. How is this my fault?

My reaction here is similar to my thoughts upon reading all those studies about how we doctors aren't doing a good enough job telling our patients to quit smoking. Researchers survey smokers and ask them things like,
  • Did your doctor tell you to stop smoking?
  • Would you stop smoking if your doctor told you to?
How many patients are going to answer truthfully:
  • Hell yes, every time I walk in the door he's up my ass about quitting.
  • Don't matter what no one says; I'll quit when I'm good and ready and not until then.
Of course not. You're going to get something more like:
  • Why no; I don't remember him saying anything about it at all.
  • Certainly. I have great respect for my doctor and would take his suggestions very seriously.
Conclusion: Bad doctor. You need to spend more time talking to your patients about smoking cessation.

It takes two to tango. I can "recommend" until I'm blue in the face. My powers of persuasion are pretty darn good, but patients have a responsibility here too. Although I'd love to see more direct studies of patient attitudes and specific ways to address them, I will settle for the acknowledgment that we doctors aren't necessarily to blame for these kinds of observed disparities.


At Fri Feb 27, 12:17:00 PM, Blogger AnneBethMN said...

bravo! Well put!

At Fri Feb 27, 01:11:00 PM, Anonymous Anonymous said...

A while back I was reading something about how difficult it is to get Latino women to discuss breast self exams or to have mammograms. Apparently there is a cultural issue that makes it very inappropriate for them to discuss this part of their body with anyone.

I don't have any citation for this, but in this situation I am not really sure that persuasion factors in. I don't know you are supposed to be able to trump somebody's belief system.

At Fri Feb 27, 02:55:00 PM, Anonymous Anonymous said...

Just wondering.... can you offer fecal occult blood testing to patients who refuse to get a colonoscopy? In Canada the standard for colon cancer screening is FOBT for everyone every 2 years, except for those who have a positive family history or had a previous polyp taken out, in which case they go straight to colonoscopy. Seems like FOBT might be a good alternative for anyone too squeamish for a colonoscopy because if it comes back positive you have some leverage to convince them to get that colonoscopy, and at least it's better than nothing.

At Fri Feb 27, 03:22:00 PM, Blogger #1 Dinosaur said...

Canuck: You're completely right. The problem is that people also don't want to deal with shit (literally) which they have to do for FOBT.

At Fri Feb 27, 03:43:00 PM, Blogger Pam said...

This topic of "disparity" makes me crazy! I have been a nurse 32 yrs I have seen MD bend over backwards myself included... it is about personal responsibility !!! not race,color,creed PLEASE stop blaming everyone except the person

At Fri Feb 27, 03:43:00 PM, Blogger Jessica said...

You'll do more for your patients (especially the African Americans) by checking their (inevitably low) Vitamin D 25(OH) levels and ramping them up to optimal levels (at the cost of $4/month, no RX required).

Patients are more likely to get a blood test than a colonoscopy (I'm not saying that is a proven fact- I'm reasonably assuming thats the case).

And, by optimizing D levels, you can actually PREVENT colon cancer rather than just detect it.

It's the same with slammograms...I mean Mammograms.

Get an optimal D level (70-90ng/mL) and reduce the incidence of breast cancer by 2/3.

How about we do what we can to prevent it rather than merely detect it?

The data is out there.

At Fri Feb 27, 03:58:00 PM, Anonymous Anonymous said...

As a non-compliant patient myself, I can state with absolute certainty that patients often do not get the tests their doctors recommend, particularly colonscopies.

My father died of colon cancer because he didn't want to get the test, even though he knew he probably had colon cancer. By the time his symptoms required an ER visit, the cancer had spread to his liver. So with that history do you think I or my sisters have had a colonscopy?

At Fri Feb 27, 04:30:00 PM, Blogger DocV said...

Amen! Preach it Brother! I am getting pretty damn tired of it being my fault if my patients chose to continue to smoke, dip, not perform oral hygiene, and so forth.

I have also noticed that the ones that doen't listen to me are also the ones that don't listen to you. Then they get pissy if I don't want to do certain procedures because their Ha1c is 14 or their INR is off the charts.

At Fri Feb 27, 04:49:00 PM, Anonymous Anonymous said...

Thanks~~~I am so flippin' sick of being blamed for pt's poor choices. I Juanita would rather die than lose a breast to a mastectomy, and D'Wayne would rather risk colon CA than be "queer", and if Billy-Bob isn't sure that them ciggarettes REALLY cause cancer---so be it. Pattie, RN

At Fri Feb 27, 06:47:00 PM, Anonymous Anonymous said...

Actually, Dr. D., you are wrong when you say categorically "No one wants a colonoscopy." 32 years ago I was diagnosed with ulcerative colitis, but it's been in remission for the past 15 or so years. Just this past week, I've had all the usual lovely symptoms of a flare-up, and I went to see my gastroenterologist (amazingly, still the same one my mom took me to when I was 12!) and I definitely wanted him to give the nod to scheduling a colonoscopy within days. (I was due for my every-three-years colonoscopy sometime this August anyway.) And of course he agreed it was necessary/appropriate, and now I have I think my 30th or so colonoscopy scheduled for next week. I am both eager to get a accurate assessment of the state of my flare-up so my doc can prescribe the best way to deal with it (abdominal pain is no fun!), and to be certain that it's nothing more nefarious that a UC flare-up (altho' my doc today did confirm what I already knew: that it's highly unlikely that I've developed colon cancer in the 2.5 years since my last, unremarkable colonoscopy.)

I'm totally weird in that I actually enjoy getting a colonoscopy, b/c I know from my vast experience that I don't really feel the colonoscopy itself, just those wonderful drugs!

Even the prep, which is the most unpleasant part of the whole process, I have down to a dealable-with science, since I forgo that nasty "Golightly" and use the traditional prep that I first used in the early 1970's: eat lightly for a few days, then the day before, pop a handful of Dulcolax and swig 8 oz. of Citrate of Magnesia, drink tons of clear liquid (Fresca is my favorite), and then on the morning of the colonoscopy, have a sufficient number of close encounters with the Dreaded Apparatus until, um, the waters run clear.

Kensington MD

At Sat Feb 28, 08:00:00 AM, Blogger ER's Mom said...

Dino - have the patient use the TP from wiping to smear on the take-home FOBT cards. Much more sanitary.

Just something I tell my patients.

ER's Mom

At Sat Feb 28, 02:28:00 PM, Anonymous Anonymous said...

I'm a latina woman and I've never heard of the cultural issue that makes it inappropriate for us to discuss our breasts. I guess that shows that there are different cultures within the latino community.

At Sun Mar 08, 03:02:00 PM, Anonymous Anonymous said...

Have you noticed that half the articles in the Annals of Family Medicine are these kind of surveys? And most of them conclude that we're not doing enough of what we think we're doing already to Nanny our patients into lifestyle compliance?

At Mon Mar 09, 11:13:00 PM, Blogger Cori said...

I've had two colonoscopies in one year's time at the ripe old age of 23. People need to suck it up and do what their doctors recommend unless there is a damn good reason not to (and "I don't want to" isn't a good enough one; as if anyone wants to do any of it!).

At Fri Jul 10, 08:40:00 AM, Anonymous Anonymous said...

Thank you all for your comments. As a Primary Care doc in a poor part of town, I can't tell you how frustrated I get trying to explain over and over to patients the importance of screening (mammo, colonosc, etc).

What kills me is the thought late at night of some patient who never listens to me can sue me at any time because they choose to not follow my recommendations. I could have a malpractice suit because I didn't go to the patients house, handcuff them, drive them to the radiologists and get a mammo?

It just sickens me... and I'm new to medicine!


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