Colonoscopy Culture Clash: Why Am I Getting One When Canada Says Not So Fast?

Various colonoscopy prep options, none of them yummy (Courtesy of Dr. Ram Chuttani)

Various colonoscopy prep options, none of them yummy (Courtesy of Dr. Ram Chuttani)

My last thought before drifting off was: What am I doing here?

As the nurse hooked up the IV for my “conscious sedation” — a pain-killing, amnesia-inducing, anxiety-easing cocktail of fentanyl and Versed — I had checked my phone one last time and up popped this headline: “New Canadian recommendation against colonoscopy for routine screening of colorectal cancer.”

So why was I in the endoscopy suite on a recent Monday morning, my backside exposed in a hospital johnny?

Some background: I was supposed to get this routine colonoscopy when I turned 50 in 2014 but, like many people, I delayed — no family history and an emotionally tough year offered good excuses. When the year passed, I tried to procrastinate further, and asked my doctor about alternatives. “There are no real alternatives,” she told me. “If there were another good option, I would choose that for myself but I will be having my colonoscopy this year as well.”

As Dr. Ram Chuttani, chief of endoscopy at Beth Israel Deaconess Medical Center in Boston, put it: “Colonoscopy is still the gold standard.”

So, of course, I made the appointment, ate the low-fiber diet, complied with the clear liquid fast the day before and suffered through the prep. (Except I was unable, at 4:30 in the morning, gagging, to finish the full 16 ounces of prep mixture.) Like countless other middle-aged Americans, sitting on the toilet en route to a pristine colon, I thought: There’s got to be a better way.

Better In Canada?

Late last month, for the first time, Canadian medical professionals came out against colonoscopies for routine screening, saying that the evidence is lacking that this method is effective enough at preventing deaths from colon cancer.

“We recommend not using colonoscopy as a screening test for colorectal cancer,” the new guidelines, published in the Canadian Medical Association Journal, say, in a summary.

So, if colonoscopy is the gold standard here but not recommended there, what’s a patient to do? Maybe just acknowledge that different health systems, with different priorities and cost structures, end up promoting different flavors of medical care. What you should not do is nothing. If there’s one thing pretty much everyone agrees on: colon cancer kills, but it’s also largely preventable, so the best screening method is one that actually gets done.

The Canadian Task Force on Preventive Health Care, the group that wrote the new guidelines, cited two preferred colon cancer screening methods for low-risk, asymptomatic adults ages 50 to 74:

  • Fecal occult blood testing (FOBT), in which stool samples are analyzed for hidden traces of blood, every two years
  • Flexible sigmoidoscopy, which uses a scope to examine the lower part of the colon and rectum only, every 10 years (This procedure involves less prep than colonoscopy, no sedation, and in Canada it’s done by either a nurse practitioner or primary care doc, with no specialist needed)

In America, the U.S. Preventive Services Task Force, an independent panel of medical experts that issues guidelines, recommends a range of colon cancer screening methods for low-risk adults 50 to 74.

Dr. Albert Siu, chair of the U.S. Preventive Services Task Force, told me in an email that the main point of the guidelines is simply to encourage screening. Continue reading

Follow-Up: $1.6M Damages For Forced Colonoscopy, Enemas



Apparently, this is a country where you might find yourself unwillingly subjected to enemas and even a colonoscopy when certain police officers just can’t believe you’re not concealing drugs inside your body, and certain doctors go along with those police. But at least it’s also a country where you can then sue the heck out of everyone involved, and come away with major financial compensation.

We picked up this sorry tale in November: Report: N.M. Traffic Stop Turns Into Forced Enemas, Colonoscopy. To recap:

The New Mexico TV station KOB-TV Channel 4 reports that a man who was pulled over for failing to make a full stop at a stop sign was brought to a hospital and forcibly subjected to repeated anal probes, three enemas and ultimately a colonoscopy.

A drug-sniffing dog indicated a possible odor of drugs on the car seat, and a police officer thought the man, David Eckert, was “clenching his buttocks” when he got out of the car, and wanted his anal cavity searched for drugs, KOB-TV reports. At a nearby emergency room, a doctor refused to do the search, calling it unethical; Eckert was brought to another hospital, where doctors apparently raised no such objections.

Now for the update: The Los Angeles Times reports that though officials denied some claims in Eckert’s suit, a settlement agreement will give him $1.6 million in damages.

“The lawsuit continues against an assistant district attorney as well as hospital officials,” the LA Times reports. It does not specify what happened with the $4,539 bill the hospital sent to Eckert for services rendered, but I’m betting that’s off. And as for Eckert, the Times reports, he “said that he was ‘grateful to live in the United States.'”

One Man’s Sedation-Free Colonoscopy (And Why You Should Try It Too)

By David C. Holzman
Guest Contributor

I’m one of an elite group of American patients. Only about one percent of us undergo colonoscopy without sedation. The big secret: it doesn’t have to be painful. And it’s probably safer than with sedation.

Like most Americans, I was ignorant of all of this until about a month ago. In my imagination, a sedation-free colonoscopy would have been painful indeed, the device snaking up my GI tract, pushing against my insides as it resisted the twists and turns. Then my best friend, Greg, who has made several suggestions that have resulted in distinct improvements in my life, suggested forgoing the drugs, as he had recently done.

Gateway to the author's colon (Courtesy)

Gateway to the author’s colon (Courtesy)

It made sense. I could drive myself to and from the hospital, and I’d be able to work when I got home.

Greg had also told me that there’s a correlation of anesthesia with loss of memory later in life. Some googling revealed that this may be true in some cases. But despite that uncertainty, that made the unmedicated colonoscopy far more compelling.

It helped to learn that Dr. Douglas Horst, who would be doing the colonoscopy, did a number of them unsedated, and even more, that he called me to discuss it, putting my mind even more at ease. (He gets top grades on several different doctor evaluation websites.)

And overall, the discomfort was minimal, hitting maybe 3-max out of 10 on the pain-meter for seconds at a time here and there, and otherwise never going beyond 2 out of 10, comparable, perhaps, to a very mild cramp. I’d much rather have another colonoscopy than an upset stomach.

The Prep: Dystopian Poison

Far worse than the colonoscopy was the “prep.” Continue reading

Searching For The Best Colonoscopy In Town


All Martha Bebinger wants is a good colonoscopy. Don’t we all? But look at the lengths she has to go to in order to find out which doctors are good, who finds the polyps and what the actual cost of the procedure is. Her search shows that while everyone in health care talks about the importance of transparency, it’s not here yet. Here’s the top of Martha’s story:

Someday soon, you’ll need a routine medical test, perhaps an ultrasound or a mammogram, and you’ll obviously want the best. But the quality of health care tests and procedures can vary a lot depending on the doctor or hospital, and it’s not easy for patients to find information about quality.

Still, we’re all supposed to be choosing our care more carefully these days. So when I got a scribbled note from my doctor saying that it was time for a colonoscopy, I set out to find the best one in Boston.


I used to think a colonscopy is a colonoscopy, just one of those tests we have to get when we hit middle age. Then I met James Tracey, a gastroenterologist (GI) who does more than a thousand colonoscopies a year. He starts telling me about this running competition he has with other GI docs, one in particular at Hawthorn Medical Associates in North Dartmouth. It’s about who has the highest rate for finding polyps in patients during a colonoscopy.

“When he and I walk down the hall, it wouldn’t be uncommon for him to mention his percentage just to get me going,” Tracey says. “And of course that redoubles my effort that I’m not going to have that edge over me! I’m going to make my numbers as good as his.”

Tracey tells me some doctors in his practice find polyps in twice as many patients as others. Hold on, I think, this seems pretty important. I’m getting this not-so-pleasant test to look for adenomas, those polyps that can develop into colon cancer. So I ask Tracey, why is there such a big difference? He reminds me the colon is a five- to six-foot-long tube packed into the abdomen. Continue reading

Humor: Author Laura Zigman Does The Colonoscopy Prep Math

A supremely virtuous colleague of ours recently took some flak for mildly calling colonoscopy prep “nasty.” She was accused of possibly deterring some people who should get the procedure. So I can just imagine what those critics will say of the hilarious video above by the author Laura Zigman.

To forestall them, let us stipulate: Yes, it’s no fun to swig quarts of swampy liquid and stay within a few feet of a toilet for hours as your digestive system roto-tills itself clean. But the colonoscopy is an important screening tool, it saves lives, and colonoscopy prep is nothing, really nothing, compared to advanced colon cancer. So let’s just relax and enjoy it as Laura’s character explains colonoscopy-prep math:

“It’s how much of a disgusting liquid you drink, divided by how many hours before the test you stop eating solid food, multiplied by how many times you’ll go to the bathroom, divided by the square root of how many times you’ll gag, how many Preparation H cooling toilets you’ll need, and how long it will take before you cry ‘Uncle!’ and threaten not to complete the prep.”

And that’s only the beginning…If you’re a colonoscopy virgin, it might be best not to watch, but for seasoned veterans, the three-minute video will offer many a knowing chuckle — along with a pointed illustration of just how complex medical instructions can get.

Further reading: Oh, Joy! The Prospect of Laxative-Free Colonoscopies

A Colonoscopy Quest That Captures A Central Health Shopping Problem


In case you missed it on Healthcare Savvy, WBUR’s Martha Bebinger is on a mission worth watching: She’s trying to figure out how to decide where to get her next colonoscopy. And that’s no easy task, if you don’t want to passively accept your primary care doctor’s recommendation.

The trouble is not just the general lack of transparency in health care. It’s that as would-be smart patients, our toolboxes tend to lack even the most basic information: When we try to shop around, what should we be shopping for? What if we want more than basic patient satisfaction surveys? What if we want actual data about the performance of a particular practice or doctor?

Martha has made a substantial start on what may be a model for the rest of us as we become better health care consumers. Thus far, she has gathered a list of questions, and is asking for suggestions for more. They include:

•  What’s the doctor’s detection rate? One medical society (the American Society for Gastrointestinal Endoscopy) says a doctor should find a polyp in 25% of men and 15% of women (why the difference?), but I know that some physician groups around Boston say the average is 40-50% among docs who really look for polyps.

•  How much time does the doctor spend, on average, on the test? I think more is better, is that right?

•  How many colonoscopies does the doc do each year? The average, according to the ASGE, is 750. Again, more is better.

• What’s the doc’s error or complication rate per 1,000 patients? I do not want to see blood afterward, although if the doc finds and snips a polyp, I suppose I will.


Read the full post here, and if you know colonoscopies, please help Martha — and the rest of us — out.

Oh, Joy! The Prospect Of Laxative-Free Colonoscopies


Even now, weeks after my first colonoscopy, certain tastes and smells still trigger odd sensory flashbacks to the gallon of salty-swampy laxative liquid I had to glug to clean out my intestines before the procedure.

The taste didn’t seem so bad at first. I scoffed at all the whiners who have made the nastiness of colonoscopy prep so legendary. But near the end of the gallon, I found myself gagging and forced to suck on lollipops to help the swallowing along. Not that I’d ever skip the test. Colon cancer is too common and deadly, killing 50,000 Americans a year, and the effectiveness data on colonoscopies look good. Still, I couldn’t help wondering aloud: Does it really, truly have to be like this?

So even though the prospect of a laxative-free colonoscopy is years away, I can make no pretense of journalistic objectivity. I’m overjoyed to share this news: A new study out of Massachusetts General Hospital, following about 600 patients, suggests that a colonoscopy without the noxious preliminaries is feasible.

The point isn’t just to make life easier for people getting colonoscopies. It’s to help persuade them to get the test in the first place.

I did my due diligence: I asked the study’s leader, Dr. Michael Zalis, director of CT Colonography in the hospital’s imaging department, whether any potential financial conflicts needed to be disclosed — a start-up to develop laxative-free colonoscopies, that kind of thing? But no, no such disclosures, he said. The study was funded by the American Cancer Society, General Electric and the National Institutes of Health. Good enough — please sign me up for ten years from now.

A bit of background: Medical innovators had already invented the “virtual colonoscopy,” in which a patient’s innards are inspected using an abdominal CT scan rather than by inserting a long fiber-optic tube with a camera and a light on the end. But the patient still has to go through the colon-cleansing prep. The new study, just out in the May 15 Annals of Internal Medicine, takes the “virtual” one step farther: it uses software and a special contrast agent to make the colon cleanse virtual as well.

The point isn’t just to make life easier for people getting colonoscopies; It’s to help persuade them to get the test in the first place. Only about half of adults follow the recommendations for getting tested — which include universal testing for people over 50 — and surveys find that the nastiness of the prep is part of the problem.

Let me cut to the chase: If all goes well, I asked Dr. Zalis, how soon might the virtual cleansing be available? Conservatively speaking, he said, at least one more study is needed to confirm his team’s results, and that will probably take at least three years. Continue reading

Why I Love Colonoscopies (And You Should Too)


By Mary Mulkerin Donius
Guest Blogger

“Got a match? Yeah, your face and my, um, backside.”

That old insult comes to mind every time someone takes me aside to tell me they finally got a long-overdue colonoscopy or just scheduled one for a loved one. It happens all the time.

Ever since I was diagnosed and successfully completed eleven months of treatment for colorectal cancer at Massachusetts General Hospital, I feel like I’ve become a walking, talking reminder about the importance what The New York Times recently termed cancer’s “most unloved screening test.”

My face reminds friends, family members, colleagues and acquaintances to think about protecting their bottoms; it’s a role I’ve come to relish.

Just last month, a study in the New England Journal of Medicine proved what doctors have long suspected; that mortality is reduced by a whopping 53 percent in those who undergo colonoscopies and have pre-cancerous growths removed. It’s the strongest evidence yet that colonoscopies save lives. Despite the success of early detection and the steadily climbing cure rate of colorectal cancers in the past twenty years, only sixty percent of eligible adults get a colonoscopy, according to the American Cancer Society.

Okay, I’ll say it. That really bums me out.

March is Colorectal Cancer Awareness Month. With all due respect to the folks who work hard on the cause, you’d never know it. There’s no little ribbon or bracelet. It’s a tough disease to build a cute little symbol around, I’ll concede. Continue reading

One Doctor’s Quest to Change Medicine Through Song

For a long time, Dr. Mache Seibel says, he was a “closet guitarist.”

He is famed here in Massachusetts infertility circles as the pioneer who performed the state’s first in-vitro fertilization, and he also specializes in complicated menopause and its intersection with mental illness. He is a bona-fide member of the academic white coats, currently at the University of Massachusetts Medical School and a veteran of Harvard.

He writes songs about mammograms and stress incontinence, about junk food and swine flu and bacterial vaginosis

But if all he does is practice medicine, he figures he can reach only perhaps 20 patients a day — and he aims to reach millions with his health messages.

So no more closet for the guitar. In fact, Mache (pronounced Maish) Seibel approaches Lady Gaga in his eagerness to use music to gain attention — within the bounds of what’s acceptable for an M.D., of course, and with the lofty aim of promoting health.

He writes songs about mammograms and stress incontinence, about junk food and swine flu and bacterial vaginosis. He runs a Website at He makes CDs under the “HealthRock” label and composes “Stay Well” musical e-cards (“Get a light at the end of your tunnel. Get a colonoscopy.”) And this week, he even brought the guitar to the august halls of Massachusetts General Hospital, goading a full hall of obstetrics and gynecology staffers — some with the red eyes of the morning after a night shift — to clap along with his tunes.

Not that those staffers need to know more about health. For them, the message from Dr. Seibel’s “Grand Rounds” talk was different: They must change their mindset about communicating with patients. To wit: Continue reading

Will The Shift Against Cancer Screening Reach Colonoscopies?

Yes! I’m a little overdue for a colonoscopy, and I’d been hoping against hope that maybe the recent pendulum shift on cancer screening might get me off the hook entirely for a while. Debate continues, but lately you can just feel the weight of medical opinion tipping somewhat away from routine cancer screening procedures like PSA tests and mammograms.

So I was thrilled today to see this New York Times “Bloggingheads” debate between John Horgan of Scientific American (on the left, above) and George Johnson of The Cancer Chronicles, on the merits of colonoscopies. I’m not off the hook and neither are you; the colonoscopy guidelines haven’t changed.

But John Horgan cites a recent paper in the British Medical Journal that makes me feel a bit less delinquent. And he says quite ringingly: “Mark my words, we’re going to see a big revision on tests for colon cancer as well in the future. I think this is a major wave that is making its way through medicine right now, where we are — I hope — really beginning to question the value of routine screening of healthy people for cancer and other diseases.”

George Johnson has some excellent ripostes, pointing out that if our use of the testing is flawed, that doesn’t take away from the value of working on ways to “nip in the bud” debilitating diseases like cancer.