On Requesting a Colonoscopy

It is interesting how things happen in Family Practice....I spend every day dealing with a plethora of human suffering, anxiety and disease.  

From one moment to the next, I can deal with anything from excising a tumour to counselling a suicidal teenager that wants to die because a girl has failed to notice him.  Each hour, I have to be on my game to deal with any and all aspects of Cardiology, Endocrinology, Orthopedics, Psychiatry, Obstetrics, etc., etc., and the list goes on.....

But the only thing that gives me anxiety, believe it or not, is having to refer a patient to a Gastroenterologist for a Colonoscopy in Calgary.  I have a growing list of patients - all of who need a colonoscopy - and none are going to get the procedure done in a reasonable amount of time.  Current wait lists are in excess of two years - no matter what lies "officials" state to the media and when confronted at an educational seminar.

The procedure for referring a patient to the Calgary Health Region can only be described as insanely stupid.  I write a detailed letter that includes my reasoning for the patient needing a colonoscopy...in several cases, I have included a reports of a Barium Enema SHOWING an obstructing abnormality in the colon....and the Radiologist commented in his report that a Colonoscopy is suggested....but the triage nurse in charge of access to Colonoscopy returns my note - unread - and insists that I check off one of 4 boxes on a stupid referral sheet.

They refuse the referral unless I can tell them what the patient's serum ferritin is.  The problem is that the patient has a chronic inflammatory disease - and his serum ferritin will be falsely elevated - which means that it will be normal even though he is chronically bleeding out of his gut.

But triage nurses in programs like Gastroenterology all too often have too little education to understand nuances like this...the referral is rejected unless I provide them with a serum ferritin and check off some of the boxes on their form.  My letter isn't read and it isn't appreciated.  An M.D. never reviews my letter...an issue which I believe falls far short of a minimal professional standard.

So - on behalf of my increasingly desperate patient -  I am going to lie through my teeth and check off every box there is on the stupid little form.  Some "nurse practitioner" will then see the patient and mindlessly follow a questionnaire algorithm to make the patient an appointment for a Colonoscopy.  

A nameless masked face hiding a Gastroenterologist will then step into a room with my terrified patient, tiredly mutter an incomprehensible string of reassurances while they instruct the nurse to push some Fentanyl and Midazolam...and then the patient will wake up in a cold room under fluorescent lights....be checked by a disinterested nurse and then told that they should "see their Doctor" - which is me.

The patient will then go home and suffer anxiety until they come to see me 2 weeks later - only to discover that the Calgary Health Region didn't bother to send me any kind of report.  My nurses will spend an hour trying to get a report faxed - and then I will receive a report that can say any of a number of things from "Cancer" to "Unremarkable" to "Biopsies are pending".  One time, the report was "lost" by the Region and I had to put the patient through the whole thing all over again!  Could not even find the name of the Gastroenterologist because he/she was a "fill in" that doesn't have a real office!

If  "biopsies are pending" is on the report....my nurses will then spend literally another couple of hours on the phone while juggling desperate patients, making triage decisions and juggling insurmountable paperwork.......to get a copy of the Pathology report.

The report can then say anything from "Celiac Disease" to "Cancer" to "Inflammation"....I will then try to contact the Gastroenterologist...only to discover that they don't actually have an office...or a nurse...or a secretary.....they just do colonoscopies from time to time when needed.

It will then be left to me to decide how to proceed with the patient.

It's a scary process - and it is getting worse for these patients!

It is sad that Gastroenterologists are allowing the esteem of their profession to suffer under the auspices of the Calgary Health Region.  Family Physicians  in the community are losing trust in our Gastroenterologists.  We are also losing trust in our Calgary Health Region.  As my Father-in-law likes to say, "It's so broke, you can't fix it".  But can we fix it?

Our Medical system is as close to "free" as any medical system can really get.  But the "costs" of our "free" system only become realized if you ever really need it!  We need to restructure our Health Care System from the bottom up, not the top down!  We need more "Indians" and less "Chiefs"!

Perhaps a new system being put together by our new Health Minister will be better...perhaps not!  All I know is that the increase in, so-called, "allied health care professionals" like nurse practitioners that replace what M.D.'s are supposed to do....is rotting our medical system from the inside.  For M.D.'s to assign many of their patient interaction responsibilities to Nurse Practitioners is an erosion of M.D. skills, esteem and trust!  

Gastroenterologists that don't actually interact with patients are allowing themselves to become mere technicians!  Medicine is a proud profession with a proud history and a proud foundation...to allow oneself to become relegated to a mere medical technician is something that requires a real wake up call!

I do everything I can to support the Specialists that I refer to...but they are increasingly overwhelmed - so they invent new punitive administrations to "manage the demand"....and in so doing, drastically deteriorate the quality of their work, their reputations and their profession!

We need to do better...but our extremely top heavy medical administration in Alberta has to be fixed first....I remain grudgingly optimistic......