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As long as you’re here…

June 4, 2013

OK all you loyal readers.  You know what I’m going to talk about.  Anyone who reads this blog for more than five minutes knows that articles like the one written in the New York Times on Sunday by Elisabeth Rosenthal are like crack for people like me.  If you haven’t read it here’s the link, but take your medication before reading:

Where do I start with this???  I’m going to let Ms. Rosenthal tell you about how many unnecessary colonoscopies we do.  I’ll let her tell you how much more it costs here than anywhere else.  I will address the anesthesia bit.  Let me tell you a little story.  When I was a baby anesthesiologist my hospital sent anesthesiologists “downstairs” to do anesthesia for GI procedures maybe once a week for a few hours.  This was in 2004 or so.  Now we send three board certified anesthesiologists to various GI units every day all day.  We do maybe 25 cases a day on average.  Now, some of this is due to the aggressive expansion of the advanced GI procedures unit as well as the addition of an outside private group that was recently folded into the greater hospital system.  It’s also because we’re there.  It’s no accident that as soon as we committed troops to the GI battle all of a sudden everybody needed anesthesia. 

The NYT article uses Dierdre Yapalater as an example, a healthy 60-something.  Putting aside the ridiculous cost for the overall procedure, she was billed $2,400 for anesthesia.  But she didn’t need anesthesia.  There is absolutely no reason for her to have an anesthesiologist involved for that case.  None.  Anesthesia care used to be limited to very sick patients, not because they are harder to sedate (they’re actually often easier) but to monitor them closely because of their tenuous physiologic status.  Now everybody is getting it.  Why did she get anesthesia, why did the anesthesiologist give it, why does insurance pay for it?

Another little story.  About 6 months ago there was a midazolam shortage.  Midazolam is a valium-like drug given intravenously for sedation, often used by nurses and non-anesthesia providers very safely, and frequently used in colonoscopies.  One of my hospital’s affiliates, which does a hundred colonoscopies a day, didn’t want their revenue stream interruped by this so instead of delaying these completely elective cases they asked my department to come give the anesthesia for all their cases until the midaz shortage was over.  So we sent 2 or 3 doctors over there everyday for a while to give propofol.  Increased the cost of each case by a couple of thousand bucks.  Why did we have to send fully-trained anesthesiologists over there?  Because the anesthesia lobby has been powerfully persuasive about limiting the use of some drugs to our docs only.  Propfol, the sedative used in the above example in place of midazolam, is a powerful drug but it’s use is not rocket science.  It has been used in other developed countries by non-anesthesia personnel safely for years. 

And even without propofol, the vast majority of colonoscopies can be done easily with midazolam and fentanyl.  An anesthesiologist is just not necessary.  Apologies to my colleagues.  Protecting our jobs looks great from our 4 bedroom houses in the suburbs, but not so great for the longevity and integrigy of our healthcare system.

  1. This is a little misleading. The vast majority of colonoscopies are done without anesthesia at our institution, and the ones who receive anesthesia are the patients with significant comorbidities. As much as we all hate going to the GI unit, we have to admit that our presence makes the complex procedures like ERCP safer for the patient. It’s not a question of protecting our jobs, because we still have plenty to do without GI.
    The ridiculous scam that should be quashed are the doctors making millions of dollars from “facility fees” (and from “concierge medicine” for the healthy wealthy, but that’s a whole other topic.) We as physicians should be better than that. Facility fees should cover the cost of running the facility, period.
    One difference between this country and the other countries that use less expensive, less invasive tests for colon cancer screening has to do with the litigation risk in the US if we do anything less than “the gold standard” and miss a cancer. Another difference is the huge number of healthcare dollars going to the bureaucracy and administration of the system, not just the insurance companies’ outrageous profits but also the expense each physician’s office incurs by needing so many extra employees to do the billing, coding, prior authorizations, referrals, appeals, ad nauseum. In the pre-managed care days of pure fee for service, my doctor’s office had a nurse and a receptionist and that was it. Insurance covered hospitalization, not routine care, in the same way that car insurance or homeowner’s insurance covers the big stuff, and not routine maintenance. Some paternalistic administrator got the bright idea that people would get more preventive care if they didn’t have to pay for it, and that would overall reduce the cost of health care. That experiment has clearly not worked, but has the system now metastasized too far out of control to be reined back in?

  2. I agree with all your points. I should have made clear that most colonoscopies are still done without anesthesia providers. But that is apparently not true everywhere. I have also found that since we’re always around the routine sometimes creeps into our case load. As far as the outside group that we provided anesthesia for, I have recently heard that patients are having trouble with their insurance companies over our services. The proceduralists make a lot of money off colonoscopies, but the anesthesia field is not immune to the temptations of this revenue stream.

  3. I am very disturbed by the thrust of your argument regarding anesthesia providers and colonoscopy. Am I to understand that the provision of anesthesia services for routine colonoscopy can only be seen as exploitative? In my community, no one wants to have a colonoscopy without sedation, and I for one feel very uncomfortable leaving “conscious” sedation up to GI docs and nurses. Now there’s a situation that is ripe for exploitation: poor airway and anesthesia preop; nurses muscled into giving higher and higher “midaz” doses until the threshold for general anesthesia has been crossed, with the inevitable emergent call to the anesthesia team (if one’s available) to rescue an errant GI procedure originally billed as conscious sedation. And in contrast to your “significant comorbidities” argument, a case can be made that a routine anesthesia presence obviates intraop problems including airway disasters and medical catastrophes. If anesthesiologists are in the patient safety business, why can’t their established use be seen as arising out of something other than the temptation of greed or “creep?”

    • Thank you so much for reading! A few comments. No one is suggesting that anyone have a colonoscopy with out sedation. I certainly wouldn’t want to. I’m just saying that for most people, a nurse is enough. Nurses usually have a protocol in place, including maximum doses for body weight, etc. and if the sedation is not adequate past this dosage anesthesia is brought in. No nurse would give so much midaz that the threshold for general anesthesia has been crossed. It’s actually not possible to do that with midazolam. Anesthesiologists are not in the patient safety business. Patient Safety officers are. Anesthesiologists are in the business of providing services to people who need them. Routine colonoscopies don’t need us.


  4. Dana Seidl, MD permalink

    I struggle with this question daily, though most of the cases we see I think benefit by anesthesia personnel involvement. All routine endoscopies on healthy patients in our community are performed in a physician owned GI center and the sedation performed by an employed or contracted CRNA, “supervised” by the GI doc. Our hospital and surgery center generally get the patients with significant comorbidities that the GI center folks don’t want to mess with. Airway and desaturation issues are common as are hemodynamic mini-crises. Personally, I’d rather be involved in sedation cases from the beginning – responding to stat calls (or code blue-ish situations) when something goes awry isn’t ideal patient care in my view.
    One of my main concerns, however, is that If feel we’re frequently doing a service for people where the endo procedure isn’t indicated, i.e., patients over 75 getting their first colonoscopy, frequent follow ups for benign polyps, etc. I don’t think I’ve done someone a favor by sedating them for a procedure done with questionable (or not justifiable) indications. There’s no question that doing colonoscopies on every patient is a money making proposition.Hey – who’s going to turn down free money and a chance to pay for their shiny GI office?
    As to hospital based sedation, unless the rules have changed, JACO puts the sole responsibility on credentialing nurses or physicians providing “conscious” sedation on the department chair of Anesthesiology. If I were in that position (never one of my aspirations) I’d be somewhat cautious in granting privileges to every applicant. I think I’d prefer to stick with people that know how to manage an airway or use pressor drugs.
    As to midazolam, it is difficult to oversedate with it by itself but frequently it’s accompanied by fentanyl or another narcotic. I remember when midazolam was almost pulled from the market in the 1980s when over 30 people died in GI suites after being administered the drug. Admittedly, this was before pulse oximetry but only action by the ASA saved a valuable drug for our use.
    Overall, I agree with your comments, but I’d rather see the focus on why so many endoscopies are done rather than why as a specialty we anesthesiologists are unnecessary. Personally, my preference is doing anesthetics for surgical procedures rather than enduring a day witnessing oral and ab-oral probing in a dark room. I sometimes feel like I’m on the crew of an alien spaceship doing what, you know, aliens do there on unsuspecting humans.

    • Dana – ironically I’m in that cold dark room all day today doing ERCPs! Absolutely, there are many procedures we do anesthesia for that have questionable utility, and not just in GI. I also struggle with this. The NYT article goes into a good deal of detail on this problem. Perhaps I do a dis-service by focusing on the anesthesia aspect. Interestingly, this post when syndicated on thehealthcareblog generated discussion concerning malpractice insurance. People see a connection there as well. Thanks for reading!

  5. Jackie sammartino permalink

    I’m a nurse. I would feel better having anesthesia around for any procedure I have.
    You are the experts.
    I actually had a nurse give me propofol and it
    Did not put me down ( no I’m not a drug addict) she had given me all she was allowed as far as dose. I had to go home in afib and return the next day to be cardioverted by anesthesia. I feel better having them around!!
    It’s worth the money to get the job done right.
    Ps. I haven’t had my colonoscopy yet but when I do I want anesthesia there !

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