Today, I was asked for the first time, by someone who isn’t my patient, as to whether they should have a colonoscopy. This is, a fibre-optic camera inserted into their large bowel, preceded by powerful laxatives, sometimes accompanied by a hypnotic sedative and followed by, I imagine a smattering of wind.
I found the question interesting for a number of reasons, first, you might ask – if someone is scheduled to have such a potentially invasive investigation, surely there must be a good reason; it isn’t like a matter of taste;
‘Waiter, I’ll take the Chablis, oh dash, I’ll go for the Shiraz.’
Presumably, when someone is facing such a dilemma it is a matter of scientific judgement, or, at least something more concrete than a whim;
‘Mr Kafka, we have noticed that your red blood cell indices are a little low and that, combined with your recent bouts of diarrhoea have led us to conclude a colonoscopy would be an appropriate investigation.’
But no, from my understanding, the preceding history is of a vague, non-specific pain in their abdomen which has been investigated by multiple blood tests, ultrasound and CT.
The colonoscopy is really the next step in a logical process of ‘test until we find something.’
It is this approach that has me worried.
After all, no one is entirely normal.
All investigations and analyses are based on statistics, the normal population and in the case of radiological and endoscopic investigations, the skills (and sometimes focus/attention) of the operator.
Every couple of years I encounter a patient who asks for an excludogram – a test that can confirm they don’t have something – anything wrong. In general, the request is a ‘whole body scan’ – with the impression being that a) such a scan exists and b) I can easily arrange it.
‘Mrs Simpson, your whole-body scan was normal, you are in a state of complete (physical) wellbeing. Cheerio!’
It sounds daft when you hear it in this context, in reality, when an individual is faced with the demon of disease, a little like GK Chesterton’s allusion to God – when people are faced with an unanswerable question, they won’t take no answer, they will take any answer – this is behind the multi-billion-dollar alternative medicine marketplace.
‘Your tongue suggests black-bile, here, take these panda bone capsules, one a day for six weeks.’
It is also akin to the value of a map.
If you have a destination, a map is useful to help guide you, otherwise, as a tool, it is quite useless – if you don’t know where you are and where you want to go.
Back to the question… Should I have a colonoscopy?
I guess, when you look at it, there could be several possibilities. The most worrying of course, and the one which many people fear – do I have bowel cancer?
There has been a national screening programme running in the UK for the past decade which is dependent on people over the age of 60 sending-off a sample of stool for analysis – we call this faecal occult blood (or, FOB) testing.
When people are healthy, there shouldn’t be any blood in the stool. Sometimes this is accompanied by abnormalities in the blood screen – showing anaemia or a low iron (or its surrogate marker, ferritin) level.
A colonoscopy can detect a variety of abnormalities – including cancer, many of which are treatable, particularly if detected early.
As an investigation of the bowels it is very good and usually safe, but, we don’t send everyone for this test as not only are there not enough endoscopists – clinicians who wield the scope, it is likely that undertaking scopes in the population at large would yield many false positives – people being diagnosed with cancer when they don’t have anything wrong, as well as the risk of harm from the procedure – one in every three thousand people scoped can experience bowel perforation – a potentially serious complication.
To be honest, I don’t want to go into too many details about endoscopy as I am not an expert – you can find lots of information at this website.
What I am more of an expert at is working-out the rights and wrongs of tests.
And this is the point.
If a doctor proposes you have an investigation or not – invasive, painful, embarrassing or whatever, there should be a good reason for this.
As I have written before, the vast majority of clinicians – doctors, nurses, therapists and pharmacists care deeply about their patients and would never consider a treatment or test which could cause harm.
Different people have different interpretations of risk – others do not adequately perhaps consider a patient’s preferences.
What this comes-down to is the original questions.
‘Should I have a colonoscopy?’
My answer is truly, I don’t know, as I am not your doctor and I don’t have the whole picture.
What I can say with certainty is, if you are asking me the question, or you are not entirely sure whether a camera, CT, MRI or operation is right for you, you haven’t asked enough questions.
This leads to a mantra of patient safety.
Patients (and staff, and anyone for that matter), should be feel confident and adequately empowered to ask their doctor or nurse or therapist why.
Why do you think I need a CT?
Why don’t you think I need a CT?
You get the idea.
The days of the doctor sending an unquestioning patient for tests and treatments is over.
Empowered patients, who are informed, who share in their health care and treatment are those who are partnering in safe care and, if your doctor is unwilling to provide an adequate explanation, ‘I want you to have the test because I want you to have the test,’ then, my recommendation is to look beyond that individual who I am sure would not be satisfied with that approach were they the patient.
PS I am quite good at these non-answers; something they teach us in medical school!