Thursday, April 22, 2010

Seventy Five Percent of Primary Care Doctors Provide Sub-Standard Colon Cancer Screening Care

A recent article found that primary care doctors the United States are providing sub-standard care when it comes to colon cancer screening. In the Journal of General Internal Medicine, researchers found that 25% of primary care doctors used in office stool testing to screen for colon cancer. Specifically, doctors do a rectal exam and then swipe the rectal contents off their gloves onto a stool testing card. A positive test result indicates the presence of blood, which can be invisible to the naked eye.

The in office stool testing has not been the standard of care for at least a decade. More importantly, it also misses 95% of advanced colon / rectal cancers. The study found that doctors most likely to do the in office stool testing were those in solo practice.

To confuse matters even further, another fifty percent of doctors did both in office stool testing as well as home testing. This means that essentially 75 percent of primary care doctors are using the wrong screening test.

If one is to screen for colon cancer correctly and wishes to use stool card testing, then it must be done by the patient at home, not in the office by the doctor.

If the stool test revealed occult blood, the recommended follow-up is a colonoscopy. A repeat stool test is not suggested. A sigmoidoscopy is also not recommended for a positive stool test result.

Disappointingly, 17.8% of doctors recommend repeating the stool test. If the second stool test was normal, 28.8% recommended no further workup. This is not only wrong, but now falsely assures the patient that everything is fine. Researchers found doctors most likely to recommend a repeat stool test were those who graduated from medical school before 1978, who were not board-certified, and who were in solo practice.

Though this study surveyed doctors from September 2006 to May 2007 and researchers noted that there was slight improvement in colon cancer screening from 2000, (more doctors did not choose sigmoidoscopy after a positive stool test) the results are still quite disturbing.

The correct options for colon cancer screening for Americans at average risk for colon cancer beginning at age 50 include the following:

Fecal occult blood testing (FOBT) -- stool testing which is done at home, not in the office. Done annually.
above with flexible sigmoidoscopy every 5 years
colonoscopy every 10 years

The authors of the article were too kind when they subtitled their article “serious deviations from evidence based recommendations”. In 2000, when a colleague of mine and I during residency polled our twenty two other family medicine residents and interns, every one correctly knew that in office stool testing was not the standard of care.

The article concludes that “many physicians are continuing to use inappropriate implementation methods [and that] intensified efforts to inform physicians of recommended technique and promote the use of systems for tracking test completion and follow-up are needed.” In other words, if we continue educating doctors perhaps one day they will all do what the standard of care has been for the past 10 years!

Why is this study important?

The only people that can make the healthcare system better is doctors. When we fail, patients get inadequate care.

When healthcare reform proponents recommend patients be given more financial responsibility to get medical care, I wonder if they are too naive. The belief is that the public will choose more prudently when they have more monetary skin in the game. As a result, the thought is that as healthcare becomes more like other markets, consumer goods, purchasing other services, that the healthcare system will be more efficient and drive costs down further.

While I understand that patients should have some cost-sharing, this alone won’t fix the healthcare crisis. Consumer driven healthcare advocates fail to realize that the degree of information needed to make patients truly smart consumers requires a medical degree and training.

Do we expect that patients should be able to recite what are the correct screening modalities for colon cancer screening when doctors can’t do it consistently now even though guidelines have been around for years?

Will patients choose only board-certified doctors or choose quality of medical care based on bedside manner? The correct answer is they should find doctors who have both qualities. If one must choose between the two, patients should opt for board-certification over bedside manner.

This research suggest that perhaps it might be better to find a doctor not in solo practice. Is it possible that doctors are smarter and up to date on the latest research findings because of conversations that occur between patients? Are two heads better than one?

Otherwise, patients have a difficult, but not impossible responsibility to educate themselves. That is why I wrote my book so if our healthcare system truly becomes consumer driven at least there is an easy reference to get everyone up to speed.

You might need to pick up a copy for your own doctor to read.

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