Colonoscopy by coercion? How often might this occur?

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When my recent blog post about HealthDay failing to challenge a researcher’s claim that universal pancreatic cancer screening was ready for prime time was re-posted on MedPageToday, an interesting comment was left on that site.

It’s an anonymous comment, the person identified only as a 61-year old RN. As with any online comment, it’s not verified. It’s only one comment. But it makes me wonder how often this might occur. 61-year old RN wrote:

“My neighbor and her husband just received letters from the Gastroenterologist, informing each of them that they must have a colonoscopy or else he would not provide any future care for them and would not be held responsible for the consequences. Her husband, an attorney, thought the wording of this letter actually sounded like a threat. I fail to see why people should be coerced into having certain diagnostic tests and not be offered information about other testing options. Threatening with “have this test or else” seems pretty strong to me. My coworker just had a colonoscopy and ended up in the hospital for 3 days due to fever, elevated white count, abnormal CT scan, and severe abdominal pain. The overall consensus when she went home was that she may have sustained a tear to her colon from the test. Suffice it to say, she’ll think pretty hard before she agrees to another such exam.”

Based on recent research, perhaps most notably the DECISIONS study, we know that the quantity and quality of shared decision-making encounters in US health care is not what it could/should be. But we are curious how often instances like the above alleged coercion might actually take place.

Please leave a comment if you can add to this discussion.

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Please note, comments are no longer published through this website. All previously made comments are still archived and available for viewing through select posts.

Gregory D. Pawelski

November 10, 2010 at 12:20 pm

Treatment by coercion vividly catches my attention. Picture Carl Sagen, the late astronomer, with his distinct voice, saying “you have millions and millions of microscopic cancer cells inside your body and when they become billions and billions, that’s when a tumor develops.”
The medical oncologist told my wife and me this and his forceful statement that my wife needed chemotherapy. This was seven months after having a metastatic tumor surgically excised and no tumor markers or any other signs that indicated any cancer within her system. Consensus of ovarian cancer guideline development is that chemotherapy should be started no later than eight weeks after surgery. Chemotherapy for recurrent ovarian cancer should be reserved for symptomatic recurrence of disease.
Shared decision-making information would have indicated whether to treat with the assumption of microscopic disease or wait until there were indicators of further disease. We wanted the later, but after getting that stern warning about millions and millions and billions and billions, it would scare the bejesus out of anyone!
However, that was before I learned that cancer doctors had the financial incentive to select chemotherapy treatment, as opposed to non-treatment, and select certain forms of chemotherapy over others because they receive higher reimbursement.
Typically, doctors give patients prescriptions for drugs that are then filled at pharmacies. But medical oncologists buy the chemotherapy drugs themselves, often at prices discounted by drug maufacturers trying to sell more of their products and then administer them intravenously to patients in their offices.
Not only do the medical oncologists have complete logistical, administrative, marketing and financial control of the process, they also control the knowledge of the process. The result is that the medical oncologist selects the product, selects the vendor, decides the markup, conceals details of the transaction to the degree they wish, and delivers the product on their own terms including time, place and modality.
The practice creates a potential conflict of interest for these doctors, who must help cancer patients decide whether to undergo chemotherapy or not or to continue if it is not proving to be effective and which drugs to use. I’m sure instances of coercion take place quite often.

Michael Kirsch, MD

November 10, 2010 at 4:38 pm

I am a gastroenterologist and I suspect that the vignette is an aberration. I suspect that the gastroenterologist has had some collisions with the medical liability system.


November 11, 2010 at 7:01 am

The doctor I go to has stated that if I do not have the required exams at set time frames, that he will not continue to provide services including refill of perscriptions. I suspect it is a combination of generating revenue an also possibly litigation concerns, but think these concerns could simply be my signing a letter that I have been advised of the need for the exams and have refused to have them when required in his view.
I also face a new annual fee to see my primary care doctor of 75$ he says he needs for administrative costs not covered by insurance. I called my insurance company and they told me that my insurance costs should cover his expenses unless I go to him for a lot of forms such as school forms, etc. I require none of the services mentioned by the insurance company over the past 6 years I have been going to him. I called them with this information and was told to pay up or find a new doctor. Finding a new doctor. I understand the problems in primary care and also know of the shortage, but looks to me like the doctors are starting to do everything they can to boost income and in doing so, are driving me toward supporting full government takeover.

Rick Evans

November 15, 2010 at 4:20 am

On NPR health economist Uwe Reinhardt advocated passing health reform as an economic stimulus.
Think of these coercions … um … nudges as stimulative sparks; your patriotic contributions to the fastest growing part of our economy.

Kate Murphy

November 15, 2010 at 2:33 pm

I wonder why these two family members were patients of the gastroenterologist. If they were there just for routine average-risk colorectal cancer screening, then they certainly should be able to choose a personal screening method based on risks and benefits.
The problem is that if they chose fecal occult blood testing (FOBT) or CT colonography (virtual colonoscopy) and had an abnormal result, they would then need a colonoscopy follow-up, which this doctor appears unwilling to provide.
I also wonder if he was providing follow-up exams at recommended intervals, which would range fro 3 years for advanced adenomas to 10 years for normal exams. Evidence is that many gastroenterologists are scoping repeat patients at shorter intervals, adding to the risk of bleeding or perforation.
Since both individuals got the letter, screening seems more likely than important surveillance of diseases like ulcerative colitis — where it would make sense for a doctor to urge regular colonoscopies to watch for developing cancer.
Not having all the information makes it tough to praise the doctor for protecting his patients, if somewhat clumsily, or criticize him abusing their right to make their own medical choices.
Patients always have the right to say no. Doctors who don’t want to work with a no, still have the ethical responsibility not to abandon patients, but help them find other care.
Did this doctor offer that?

R. A. Suzor

March 10, 2011 at 4:15 pm

I found this blog post because I was searching for the answer to my question “what is my doctor talking about?”
I had a semi-annual exam yesterday and, as always, did the ritual colonoscopy dance (why I should have it, etc.). I again, as always, declined. I usually sign his form acknowledging our discussion and that’s the end of it. This time my doctor surprised me by saying he’ll have to write a letter to my insurance company stating I refused the test and that they will not pay him because of it.
I was perplexed and just said okay. What I wondered later on my way home was, what aren’t they going to pay for? The test I’m not going to have? The exam I did just have? His new boat? (Spring is around the corner.) Treatment if eventually necessary?
So, I ended up trying a search to see if anyone else has heard of such a thing or if maybe I was under anesthesia and dreamt the whole business.

Gary Schwitzer

April 20, 2011 at 8:01 am

Coercion is almost the cornerstone of cervical and breast cancer screening. Try declining a pap test or mammogram – it is accepted that all women MUST have cancer screening. Of course, cancer screening, ethically and legally, is always elective – as it carries risk to the healthy body. It should be OUR decision, but is rarely viewed that way. I know this means many American women who decline testing are virtually locked out of all health care and denied the Pill.
Your doctors have decided to make screening a “requirement” for birth control pills – to coerce women into not only ANNUAL pap testing, but other completely unnecessary gyn and breast exams – & to FORCE women into elective cancer screening. BC has nothing to do with cancer screening. The Pill – your medical history and a blood pressure test is all that’s clinically required (confirmed by all of your medical associations)…but your doctors routinely DENY women reliable BC UNTIL they agree to their unrelated/unnecessary & potentially harmful demands. If that doesn’t amount to coercion, I don’t know what does!
See” Women after birth control get unneeded pelvic exams” also, “Questioning the value of the routine pelvic exam” and comments made by Dr Carolyn Westhoff. Dr Robert Hatcher from the “Managing Contraception” site had some harsh words for these his name plus pelvic and birth control and it should appear…
Fortunately, our doctors do not recommend routine pelvic, rectal, recto-vaginal or breast exams at any age in asymptomatic women. They don’t help, but lead to biopsies, unnecessary procedures and even surgery.
It has always amazed me that the Govt and medical profession still think it’s fine to tell women a “happy screening story” and then demand screening – they make decisions for us and accept risk on our behalf, but don’t accept responsibility for negative outcomes.
The truth behind these screening tests is in stark contrast to the spin…cervical screening harms FAR more than it helps…fewer than 0.45% of women are helped, and we’ll never know for sure anyone is helped, as there are no randomized controlled trials for pap testing – we also know other factors are at least partly responsible for the fall in the death rate – which was happening before screening started…more hysterectomies, fewer women smoking, having fewer children, better condoms and as Dr Gilbert Welch suggests in his book, “Over-diagnosed”, better hygiene and less STD.
The numbers are also quite small – this cancer was always rare.
Lifetime risk of cc is 0.65%… So, fewer than 0.45% are helped (being generous) 0.20% get false negatives and may be disadvantaged by the incorrect “normal” result (false reassurance and delay seeing a Dr for symptoms) PLUS, the hidden downside – FALSE POSITIVES – to “perhaps” help fewer than 0.45% of women, we send 95% of American women and 77% of Australian women at some stage for colposcopy and usually some sort of biopsy – almost all are false positives. That is HUGE over-detection and results in huge over-treatment. Some women are left with health problems after unnecessary procedures – especially cone biopsies and LEEP. Infertility, high risk pregnancy, miscarriages, premature babies, cervical stenosis/scarring, more c-sections and psych issues.
VERY few women are giving informed consent for pap testing – we’re basically herded into testing with zero respect for our rights and health. Coercion is the norm in the States and still happens in this country. (although I doubt many GP’s would be foolish enough to refuse a woman reliable birth control to coerce her into testing)
The harms are made worse by over-screening and by inappropriate screening – women under 30 don’t benefit from pap tests, but produce lots of false positives. Sadly, testing does not bring down the tiny death rate in young women, these very rare cases tend to be false negatives. See: “Cervical cancer screening” in “Australia Doctor” 2006 by Assoc Prof Margaret Davy, Director, Gyn-Oncology, Royal Adelaide Hospital and Dr Shorne (on line) Also, research by Dr Angela Raffle – 1 in 3 pap tests are “abnormal” (false positives) in young women also,”1000 women need regular testing for 35 years to save one woman from cervical cancer” British Medical Journal;2003 (Commentary: “Why I’ll never have another smear test” by A Saybourn in the “Guardian” newspaper) Annual and 2 yearly testing is OVER-screening which increases the risk of a false positive for NO additional benefit. Finland has the lowest rates of cc in the world and sends the fewest women for biopsies – they offer 5 yearly testing from age 30 – 5 to 7 tests in total. (the referral rate is still high at 35%-55%, but the best you’ll do with this unreliable test)
Preventing access to BC means unplanned pregnancies, abortions, ectopic pregnancies, miscarriages, social/emotional/financial issues …all FAR greater risks to our health. I have always declined testing – as a low risk woman, it was an easy decision.
Mammograms – a more difficult decision, but I have also decided to pass….thankfully, after criticizing Breast Screen’s brochures as inadequate and misleading, the Nordic Cochrane Institute produced a great summary for us, “The risks and benefits of mammograms” appears at their website.
Honesty and respect are rare in women cancer screening – demands, shaming, guilt, name-calling (women who don’t screen are often called uneducated, irresponsible, silly etc) pressure, scare campaigns, harassment, opportunistic screening is encouraged, which is basically ambushing women in unrelated medical consults, misleading/manipulative “information”/statistics and coercion are the norm – all to reach screening targets.
Australian doctors (and NZ and until recently, UK) doctors also receive undisclosed financial incentives from the Govt when they reach screening targets for pap tests. IMO, a clear conflict of interest…
Sadly, cervical and breast cancer screening is more about politics, profits and power and has little to do with our health. I see it as a great threat to our health, happiness and rights.