Better outcome takes time

‘How long do you take to perform this procedure / operation?’ - a question that I am frequently asked by patients and relatives in Singapore. Why? I wondered. To gauge the complexity of the procedure or to plan how much time to set aside to accompany the patient? Or it is really used to gauge how good the doctor is?  The shorter the time, the better the doctor. Is that a good indicator?

Let us take colonoscopy as an example. Colonoscopy has been shown to be an important and effective preventive procedure for colorectal cancer (CRC). It has been shown that endoscopists who take a longer time to withdraw the scope during endoscopy achieve a higher rate of adenoma polyp detection. (Adenoma polyp, if left untreated, will evolve into colon cancer over time.) Several studies have been done to look at which processes constitute good colonoscopy practice. However, few have been carried out to look at what parts of the practice affects patient outcome. For example, does the type of endoscopist and the setting where the procedure is performed influence patient outcome?

A recent study from University of Toronto studied individuals in Ontario diagnosed with CRC between 2000 and 2005 (Gastroenterology 2011; 140: 65 -72). The researchers determined how many of these individuals with cancer had had complete colonoscopies 7 to 36 months before the diagnosis. These patients were defined as having developed a post colonoscopy colorectal cancer (PCCRC). The researchers then determined if endoscopist factors, such as volume of endoscopy, polypectomy and completion rate, specialization and setting where the procedure was carried out, were associated with PCCRC. A total of 14,064 patients had had a colonoscopy within 36 months. Of these, 1260 (8.95%) had developed a PCCRC. Patients with a proximal cancer were more likely to have a PCCRC than patients with distal cancer. Non-surgeon and non-gastroenterologist endoscopist is associated with PCCRC. When the colonoscopy is performed in a non-hospital based setting, it is associated with PCCRC. Patients undergoing colonoscopy performed by an endoscopist with a completion rate of ≥ 95% were less likely to have a PCCRC than those patients who had colonoscopy by an endoscopist with a < 80% completion rate. For proximal PCCRC, endoscopists with a polypectomy rate ≥ 30% were less likely to have patients with PCCRC. The volume of colonoscopies performed by an endoscopist had no influence on the PCCRC rate.

To me, the study shows that the training of the endoscopist and how meticulously he performs the procedure will impact significantly on the outcome. To be meticulous you cannot be hurried. If you do not want to be hurried, you will take more time to complete the task.

My standard answer to the question ‘How long do you take to perform this procedure / operation?’ is “It will take as long as it is necessary to do a good job”. I will, howeve,r tell the patient a time range but I cannot be precise about how long the procedure will take.

I have had patients who moved onto a different doctor because ‘my time’ is longer than the other doctor’s. A patient has rights and the choice is his / hers.