A colleague of mine who is a family physician in Arlington, Texas, let’s call him Dr. Smith, was sued several years ago for medical malpractice.
His patient had reached the age where routine screening for colorectal cancer is recommended. Dr. Smith performed flexible sigmoidoscopies (flex sigs) in his office, which is a procedure where the physician looks inside the large intestine for pre-cancerous polyps with a flexible fiber-optic scope. It requires no anesthesia and the patient can leave the office with no assistance as soon as the procedure is finished.
Over the past decade, the major medical societies have published guidelines that listed several acceptable approaches to screening patients for colorectal cancer including flex sigs, colonoscopy, and testing stool for hidden blood. According to the guidelines, all these approaches meet the standard of care.
Dr. Smith performed a flex sig on this particular patient and found no evidence of cancer. About two years later, this patient developed symptoms in his abdomen and was eventually discovered to have colon cancer in the far right side of his colon. He ultimately died of the cancer, but before he died he sued Dr. Smith claiming a colonoscopy should have been performed.
Supporters of colonoscopy believe it is the best approach for colon cancer screening, which makes sense to many people. A colonoscope is longer than a sigmoidoscope, so the doctor can see the entire colon. The sigmoidoscope only goes about half way, which means it only sees the left side of the colon, though cancers can occur anywhere.
As common sensical as colonoscopy sounds, why isn’t it recommended for everybody? First, the guideline writers realized that some patients either don’t prefer a colonoscopy or shouldn’t have one for medical reasons. Unlike the other approaches, colonoscopy requires IV sedatives to perform comfortably, which some patients can’t tolerate. Because of the sedation, a colonoscopy has a higher risk of serious side effects, though the absolute number is low.
Also, the evidence that screening prevents deaths from colon cancer is actually the strongest for fecal blood testing and flex sigs. There are no randomized clinical trials proving colonoscopies save lives or that they are better than other approaches.
Several studies have been published questioning the value of colonoscopy. They report on the outcomes of many patients who did and didn’t receive the procedure. They found that deaths from left-sided cancers were reduced by about 70%, but deaths from right-sided cancers were not reduced at all.
The important take-home point of the current literature on colon cancer screening is that in spite of early detection, not all colon cancers are curable. Also, the current best evidence is that colonoscopies add no value to flex sigs. Gastroenterologists have always assumed right- and left-sided pre-cancerous lesions behave the same. The best current evidence is this assumption is wrong.
What this means for local insurance plans and the employers who sponsor them is they are paying around $2,000 for a screening test that is probably no more effective than a $500 test. The difficult question for them is do they want to continue paying the extra cost under the unproven hope that a few of their employees destined to develop right-sided colon cancers will have their lives extended by a colonoscopy? Should taxpayers pay for screening colonoscopies for seniors on Medicare or are flex sigs sufficient?
In the process of the lawsuit, the plaintiff produced expert witnesses who claimed colonoscopies were superior to flex sigs. The fact that Dr. Smith followed national guidelines carried absolutely no weight. Malpractice law only asks about the habits of local physicians, even if those habits have no proof of effectiveness or they don’t conform to national recommendations. Dr. Smith made the wrenching choice to settle the case while not admitting fault.
Even though there is now evidence that a colonoscopy wouldn’t have prevented his patient’s death, Dr. Smith’s malpractice insurance company can’t get a refund. Lawyers say that lawsuits are about settling disputes, not discovering scientific truths. The settlement money is long gone.
Dr. Smith doesn’t care about that. For the rest of his professional life, every time he fills out a malpractice insurance form, a hospital privilege application, or any other document where bureaucrats look over his shoulder, he will have to relive the injustice. He would much rather have his reputation back.