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Cost Effective Management of Colon and Rectal Disease

A few years ago when I worked in Denver, Dr. Ben Eiseman, who was a world renowned surgical educator at the University of Colorado Medical School asked me to collaborate with him on a book on Cost Effective Surgery. The purpose of his book was to outline protocols and management techniques to various surgical specialists. I was asked to author a chapter on Colon and Rectal Diseases. The book never came to light as we both got busy in our careers but I never forgot those many talks I had with Dr. Eiseman about cost effectiveness.

What do I mean by Cost Effective Surgery? It is much more than just providing care for the least amount of money. Being cost-effective is quick and timely attention to medical complaints, making sure that the problem is dealt with by the most qualified medical provider who integrates data from clinical research with his/her clinical skills as a doctor.

Unfortunately in the past 24 years, I have seen many examples of cost-ineffective management of colon and rectal problems.

When I was teaching surgery residents and medical students at the University of Colorado I would often give a lecture on proctology discussing the signs and symptoms of common problems such as hemorrhoids. I would outline a plan to manage familiar complaints like rectal bleeding or anal pain. I was surprised how sparsely attended my lectures were. This observation is shared by colon and rectal surgeons across the country. When asked, my students and residents would tell me they knew the subject well and it was not worth their time to attend lectures about a subject so mundane.

I have also lectured on proctology to physicians already in practice. At these lectures the same degree of indifference was noted. Some would tell me the subject was not interesting or that it was something they were already familiar with. Interestingly, it was not uncommon for the same doctors to refer me a patient with ‘hemorrhoids’ but the patient would actually have a cancer.

I can give other examples of cost-ineffective care. Recently a patient came to see me with an anal fissure. She had a several month history of anal pain with bleeding. Her primary care doctor saw her for a few visits over 3 months for what he thought were hemorrhoids. Her anal pain and bleeding did not improve with the suppositories he gave her. Mystified, he sent her to a gastroenterologist but since our county has few such GI specialists, she had to wait a few months. She was finally seen and the specialist sent her to a general surgeon. He knew surgery was necessary but that meant having to divide the patient’s internal anal sphincter. He was worried and reluctant since he had seen few fissure patients. The surgeon referred the patient to me - she had fissure surgery. The patient has recovered and is pain free and happy. What did this cost the patient – many visits to her primary care, a long wait followed eventually with a consult with a gastroenterologist and a general surgeon? There is also a great cost to the insurance company. It would have been more cost-effective if the patient had seen a colon and rectal surgeon sooner.

This scenario is all too common.

A few years ago, a patient with an anal fistula was sent to a popular general surgeon for surgery. The surgeon operated on the patient’s fistula four times over 6 months. The patient still had anal pain and a foul discharge. She got tired of being told to be patient and that healing would eventually occur. She found me on the Internet, came for one consult, and I performed surgery just once. Her fistula is cured and she is overjoyed.

Once I was sent a man with a right colon cancer. Apparently he had been bleeding a little and he was sent to a gastroenterologist for colonoscopy. The wait to see this gastroenterologist was over 3 months. At the consultation colonoscopy was recommended but he had to wait another 2 months since the gastroenterologist had a waiting list. The patient had the colonoscopy but since his preparation was inadequate – there was a lot of retained stool – the procedure was abandoned and he was asked to return in a month to repeat the scope. Now close to 6 months passed – he had colonoscopy successfully but a right colon cancer was found. He was referred to me for surgery. I could have seen the patient many months ago for his colonoscopy and surgery saving him this delay in diagnosis.

In Sonoma County many doctors have merged their practices so you will find primary care doctors in the same group as surgeons. While that is necessary for financial reasons, a new trend is emerging. Doctors that used to refer patients to me no longer do so now. Instead these doctors are referring colorectal problems to general surgeons in their medical group - keeping the patients in their system increases profits to that medical group. These patients end up having their problem inefficiently managed and in some cases inappropriately managed. When these general surgeons have a complication, I end up seeing the patient. I think this kind of practice is wasteful - many wasted medical visits would have been avoided if the patient had been sent to a colorectal specialist in the first place.

Sometimes a patient knows about me but cannot come to me because I am not an “in-network” provider or because I do not participate with their insurance. The patient begins a long journey with the “in-network” doctors. In Denver some Kaiser patients who could not see me for cancer surgery ended up with a colostomy. To get the best result sometimes you have to pay a little extra.

I hope to provide that little 'extra' to patients who come to see me. I try my best to provide timely care for significant colon and rectal problems.

Doctors and patients wonder how I can see patients so soon.

When I worked in Canada in socialized medicine, patients had to wait 6 months to see me in consultation. My surgery list was over one year long. I never took a day off like so many of my American colleagues. However if a patient had severe symptoms or cancer I would see them immediately and bump my waiting list.

In the 10 years I worked in Denver, I became the busiest colon and rectal surgeon there. I saw over 100 new consults a month and my waiting list again grew several months long. Yet when a patient presented with severe pain or bleeding, I tried to see the patient within a few days. I wouldn't allow my office staff to make that patient suffer a long wait.

How am I practicing cost-effective surgery? My pledge is to see patients without long delays. I will continue to try to educate patients and their doctors about the services I offer so they don’t have to lose time spent with the wrong type of doctor and so their problem can be corrected right away.

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