Monday, December 31, 2007

Hate to End the Year on a Rant, But...

I was going to post a list of new year's resolutions. One of the things that was almost on my list was to try not to be so peevish.

Then some of my pet peeves started crawling into my mind, and before long I was making a list of pet peeves. Somebody please smack me.

Fear not, I won't foist either my so-called resolutions or my list of pet peeves on anyone today, but I do need to vent about something on the pet peeve list. Let's call it Pet Peeve #5: being told what to do as a physician by an insurance company.

Because there is already a brilliant post about this topic on the well-written blog Counting Sheep, I will try to be as concise as possible on this particular subject.

You have two choices.

See that long, black thing I'm holding in the picture on the side bar at right?

Behind Door #1, someone is going to snake a device similar to that, but longer and larger in caliber, up into your rectum and all the way through your colon after giving you a dose or two of unpredictable, unreliable sedatives with unpleasant side effects such as grogginess, uneasiness, nausea, vomiting, and itching. The person operating the black scoping thing is trying to make sure you don't have an ugly polyp (see above) or anything life-threatening in your colon, but because you're half awake, you sometimes tense and buck, making it hard for him or her to pass the scope through, hard to find lesions in all the recesses, and hard to watch over any ill effects the sedatives might be wreaking on your system. When you come to, you feel groggy and perhaps queasy, and you might have vague recollections of a big tube being snaked up through you, causing some abdominal cramping...

Behind Door #2, someone is going to snake a device similar to the scope at right, but longer and larger in caliber, up into your rectum and all the way through your colon after someone gives you a small, calculated dose of a drug that removes any awareness of the discomfort associated with the procedure. This drug can actually make it easier for the person operating the scope to pass it (and detect those life-threatening problems) because you are totally relaxed. Someone highly trained to protect you from this drug's possible side effects is giving it to you and watching over your breathing and your vital signs. You wake up quickly, feeling refreshed and nausea-free, probably surprised that it's all over, and you will probably be ready to go home soon.

Let me guess - you'd rather take Door #2, right?

Oh, oops, I lied. You don't have two choices, actually. That is, if your health insurance is covered by Aetna, Humana, or WellPoint. Sorry. You get Door #1.

Call me uncharitable, but right now I think any insurance carrier who's making these medical judgments without anesthesia training, or any medical training at all, should first be required by law to undergo the prize behind Door #1 before imposing such regulations on doctors and patients. Happy New Year to you too.


Bardiac said...

Um... weirdly, before I got to reading, and just saw the picture, it struck me as a rather beautiful picture in a fractally sort of way.

Not so much now.

T. said...

That's actually a very fascinating testament to the process of perceiving and defining beauty! Neat!

The New Year has officially arrived over here in Manila. Happy New Year, Bardiac! :)

Eric, AKA The Pragmatic Caregiver said...

Not to be...contentious....

But use of Diprivan is almost *unheard of* in our area; I seriously can't think of the last time someone other than the mentally incapacitated was scoped with anything other than benzos, perhaps with a little fentanyl. It's *very much* a northeast thing to have an anesthesiologist for a colonoscopy.

I agree that sedation depth improves the likelihood of a complete visualization, but please don't operate under the assumption that this is standard of care throughout the country.


Patty said...

And I, thankfully, got door #2. Whew! (I'm in California, in case Eric is curious.) The only thing that I hated about the whole ordeal was the night before and that wonderful "beverage" I was blessed to drink. ;-)

My brother, who lives in Germany, had the procedure (as well as the one down the throat) with nothing. He was so miserable and said it was the worst experience ever. Poor guy. And he says he has to do it again soon.

T. said...

Hi, Eric!

You're not being contentious at all. I appreciate the visit and the perspective.

I am well aware of the vast regional differences in anesthesia practice and agree this may not qualify for "standard of care." But I also think anesthesia providers need the choice and judgment left to THEM, without being curtailed by folks who aren't in the trenches doing it every day, which is what I assume about insurance company bureaucrats.

What can I say - when it's my turn, I really want what Patty had!


P.S. I really enjoyed your post on the virtues of Fruit-Eze. :)

T. said...

I copied this quote from an anonymous commenter on Terry's blog (Counting Sheep) because I thought it really got the point:

"the principle of the matter here is critically important for everyone. we cannot allow the insurance companies to dictate medical care...i can’t tell you how many patients ‘wake up’ from versed/fentyanyl claiming that they had no anesthesia what so ever."

Anonymous said...

I live in Dallas and had a colonoscopy done at Baylor hospital. I had United Healthcare at the time. I don't know what they gave me but I have absolutely no memory of the procedure. My GI doc said I had a lot of discomfort and they had to give me additional pain meds but they found nothing (yeah!) and I felt pretty normal when I woke up.

I guess its only a matter of time before some insurance company decides that epidurals are not medically necessary for childbirth and won't be covered.....

Eric, AKA The Pragmatic Caregiver said...

Yeah, I'm *so* not defending the morons at my insurance company (who, thanks to careful plan design on our firm's part, years ago, have very limited UR provisions in our certificate) as supreme arbiters of medical care. They're losers, they suck grandly, and I tend to go with the theory that I do what *my doctor* wants to do, and we can endlessly argue about the money with the insurer later. If having an anesthesiologist was indicated, or there was a technical reason for a little milky white stuff, I'd be starting my own IV yellin' BRING IT or sweet-talking said anesthesiologist for the cheap thrill of a little bonus Versed up front.

I've been scoped (endo and colon) with just a splash of Versed, and honestly didn't find it horrific. The worst part was waking up in a room with 11 other people farting their colons out. They *REALLY* should offer you a little something for that particular indignity.

Most people (myself sort of included - I'm our group administrator, so I get to pick our plan) don't *really* get to design their own healthcare financing strategy and therefore get to play by UR rules someone else set up. I agree that the Diprivan is *nice*, but "necessary" seems . . . a bit of a reach, especially given that some reports put the rates in NYC as 6X the country as a whole.

Out of curiousity, given the average duration of a colonoscopy and the complexity of Diprivan usage in that setting, if someone said "hey, even though this isn't strictly indicated for my procedure, I don't want scoped without the creamy goodness of propofol. What's this gonna cost me if I just hand over a Visa card?", how much are they in for? My guess is that it's more than a little Botox, substantially less than a whole-body screening CT. If people *want* this, why not make it like nitrous at the dentist - ie, not paid for by insurers, but an affordable luxury for the inclined?

As for the Fruit-Eze....yeah, I'm consistently amazed about what I blog about. It's been a little less-frequently-updated than I hoped - there's been a few crises in 2007 (I've learned more about electrophysiology, arthrocentesis, osseous mets, steatohepatitis, retroperitoneal lymphadenopathy and angina than I ever planned to).

I would *like* to do a new blog to chronicle my journey with my mom (I rarely blog about her - it's usually about my FIL Cal), but I can't see people wanting to read a snarky, sarcastic trip through the horror of recurrent breast cancer written by someone who tells the *most offensive cancer jokes ever*.

Anyway, back to poop. F-E is great stuff, though and it's genuinely delicious. It's no Miralax, but it's a useful part of a comprehensive program. I suppose it supplies enough fiber that you might be able to avoid this whole scoping thing entirely. ;0)


T. said...

I'm not sure that anyone I've read, including Terry over at Counting Sheep, has claimed that Propofol is medically necessary for colonoscopy. What we have claimed is that it is in many ways anesthetically superior in terms of comfort for the patient and titrability for the provider - as she puts it, "100% reliable endpoints."

Epidurals for labor aren't medically necessary either, one could argue, but it seems most insurance companies cover them. But not all. I'd like to see those folks push something the size of watermelon out through their nether regions.

Your descriptions of recovery room noises made me laugh out loud! I think you *should* start an irreverent blog about a medical journey. It might be refreshing.

Anonymous said...

I had a colonoscopy with Diprivan yesterday and it was a much better experience than I expected. Details at I wasn't aware of this whole controversy until I went looking today to see if the depression I feel is an aftereffect of the medication. But even if it is I wouldn't do it any other way. I'm a survivor of sexual abuse and could only tolerate the procedure on two conditions--not having to give myself an enema beforehand and not being aware of anything during the procedure.

I'm in small town South Carolina but I think the difference may be I went to a general surgeon who did the procedure at a hospital rather than to a gastroenterologist who did the procedure in his/her office.

T. said...

PamSC, I'm truly glad the anesthetic was able to diminish or even minimize the discomfort of the procedure for you.

Thank you for sharing your experiences. It's surely helpful to many others to know they're not alone.

gelci72 said...

Just wanted to share this excerpt from an email I received from a gastroenterologist:

"As a gastroenterologist practicing 19 years, I had previously had patients tell me they weren't returning for their follow-up colonoscopies when I was using Versed/Valium and Demerol/Fentanyl over five years ago (before I started using Diprivan)...Now, with the prospect of the return to the Stone Age, thanks to [the insurance companies], patients will once again have the displeasure of being half-awake (or half-asleep, for optimists) for their colonoscopies, have the opportunity to vomit post-procedure, have to be on the endoscopy table and recovery room stretcher for longer periods of time, have polyps and cancers potentially missed as they thrash about on the table, and not follow-up with such a pleasurable procedure when they are next due."

Just some more food for thought, from an experienced practitioner...

Anonymous said...

Well, I'm in a quandry. I am considering having a colonoscopy and I WANT (will only have the procedure if I can have) total recall and nearly no impact on "state of consciousness". The standard meds here are an IV combination of Versed and Fentanyl. Ok, scratch the Versed (TOTAL amnesia and no recollection of ANYTHING). But I'm concerned that just the Fentanyl alone will put me "too much under". I am considering doing this with nothing at all (well, perhaps two oral Percocet, which I know has NO perceptable effect on my state of consciousness but does provide some pain relief). But I'd really like to hear from an anesthesiologist as to what medication regime would work best for me and still give me minimal discomfort. Note, I am NOT a masochist and do not want ANY discomfort, but if push comes to shove, I'll take full memory and total awareness and cognizance over discomfort. That's a personal choice, it's mine, I'm going that way, now what medication regime best accomplishes that goal?

T. said...

The best suggestion I have would be for you to convey your wishes directly and openly to the person providing sedation or anesthesia for you. Because people can react to drugs in such different ways, it's not really possible to claim one "best" regimen that can be predictably satisfactory for every patient.

Anonymous said...

I had a colonoscopy today was given versed and demerol. Dont remember anything when I came around in recovery I was told that I did not tolerate the veresed and demerol and had to be give propofol. I cant remember anything except thinking I was dreaming of being hurt. Glad its over with. Would want propofol next time without the versed. Not a fan of not remembering everything that was said to me. I am told I was awake and talking before the propofol. Thank god I remember nothing.

Anonymous said...

I have had two colonoscopies done with Diprivan, and would not do it any other way!


I agree that it sounds safer to do it with anesthesia than without.