Anyone who has read my work knows that articles like the one written in the New York Times on Sunday by Elisabeth Rosenthal will immediately get a response out of me. If you haven’t read it, here’s the link.
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 of 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 integrity of our healthcare system.
Shirie Leng, MD is a practicing anesthesiologist at Beth Israel Deaconess Medical Center in Boston. She blogs regularly at medicine for real, where an earlier version of this post appeared.