Letters
Downloaded from www.ajronline.org by 190.181.185.46 on 10/16/15 from IP address 190.181.185.46. Copyright ARRS. For personal use only; all rights reserved
The Clean
Colon:
Whose
for
Editor’s note-The Journal erred in failing to solicit a response from Roscoe Miller when the letter from Leonard Berlin. (AJR 130:403, 1978) was received. We present further discussion of the issue. in his letter [1], Berlin two articles suggested
completely
misunderstood
he cites [2, 3]. He implies the
responsibility
for
by citing
achieving
the thrust my articles
a
clean
is dictated
by the radiology
department,
that I
the
well
meaning
but
not
always
well
“to
ration
that
(aside
the
from
be the radiologist.
most
interested
party
the patient-victim
informed
The
requesting
to good
bowel
and his physician) physician’s
office
to
but
one-namely,
the
radiologist
or
office staff.” [5]. Berlin speaks of the cost of the radiologist sibility
for
patient
preparation.
In our
taking
department
enema
bag is about
$2.00.
prepa-
cost
increase
to the
patient.
There
been
in the overall
cost to patients
as a result
inadequate
nondiagnostic
barium
and repeat
trained
is ample
evidence
that 25%
of carcinomas
According
to Berlin’s
figures,
this
could
result
the instructions he
and equipment. enema
For
on the x-ray
prepared
receives
his
by the radiologist
barium
enema,
a day
possibly
when
makes the appointment.
This may well need to be tailored
individual
as those
us.”
men!
printing
patient,
such
with
inflammatory
he
to the
bowel
dis-
for a strong with
“Don’t [1].
effort
a clean
that
radiologists
worry
about
preparing
I agree
public
to obtain
Berlin that
your
radiologists
as “partners
colon. should
should
of good
just
present
health”
[1];
tell
not
colon,
their
leave
it
themselves
as partners
with
for the With
clean
the
resulting
colon
should
marked
and
does
decrease
lie with
the exam-
in nondiagnostic
and
repeat barium enemas, there can be a great decrease in the overall cost of this examination. This will also result in a substantial increase in diagnostic accuracy and a saving of the radiologist’s time. Roscoe E. Miller Indiana
University
School
Indianapolis,
of Medicine Indiana
46202
REFERENCES 1 . Berlin L: The clean colon: whose responsibility? Am J Roentgenol 103:430, 1978 2. Miller RE: The barium enema in the high-risk carcinoma patient. Radiology 123 :813-814, 1977 3. Miller RE: The clean colon. Gastroenterology 70:289-290,
of fewer examina-
are missed
on the initial barium enema and that most are due to retained fecal material [2]. With clean colons, we can most assuredly reduce the nondiagnostic and repeat barium enema rate by 20%.
needs before
two
sibility
tions. There
tables
the cleansing
substantial
reductions
enemas
charge
cathartics,
our patients, we must properly instruct them and not leave that instruction to the attending physician. We must also take the responsibility of supervising and performing that patient’s cleansing enema [7]. The surgeon, the endoscopist, the angiographer all take the responsibility for the preparation of their patients; so must the gastrointestinal radiologist. Legally, and morally, we can no longer avoid this responsibility. The respon-
This bag can be used
have
the
decreased hospitalization, colonic carcinoma earlier.
special
given
patient
to the
has to
for the administration of the barium enema itself. Therefore the total increase in cost of assuming complete responsibility for the instruction and preparation of the patient, including the cleansing enema, can be reduced to less than 55 cents including the cost of 2,000 ml of tap water. This expense has been absorbed by the radiology department and has not resulted in any
without
we have
or
to
cost of the brochure is less than 13 cents, technician time (5 mm) to administer the cleansing enema is about 40 cents, and the disposable
15 years
patient,
the responthe
can be done
over
I agree
has been
his
saving in dollars from and mortality by finding
This
sibility
notoriously inadequate in giving proper instructions. It is, therefore, further suggested that all patients who are to have a barium enema examination should receive their instructions from a knowledgeable, interested party, which reduces our selection
total
including
ease. Like it or not, a lawyer will hold any examiner of the colon responsible for patient preparation, for the type of procedure done, for keeping abreast of the relevant medical literature, and for adequately examining the entire colon from the anus to the appendix [3]. It should be evident that for any examination in which 5-15 years of life is at stake, there is no room for anything less than an attempt at excellence [3]. This includes the respon-
referring physician.” [3]. This concept has also been endorsed by the colonoscopist Rose [5], who states: “Patients will comply with intelligent instructions. Both verbal and supplemental written well thought out and clearly presented instructions are necessary. It is suggested
A common
not
‘
‘ ‘
to
yearly.
enema,
A real waste of money is Berlin’s suggestion that ‘we place advertisements in newspapers and magazines explaining why it is important to prepare the colon and how cleansing may be accomplished in a patient’s own home or private surroundings.” Such advertisements a few weeks or 10 years before the patient has the need for a barium enema would be worthless. The
help insure compliance, all patients are given written instructions and an explanation of the entire procedure.” [3]. This instruction booklet was written by the radiology department. We take the responsibility for seeing that both inpatients and outpatients are instructed properly. The thrust of these articles is to take the responsibility of instructing the patient away from the attending physician and put it where it belongs, on the radiologist-the one who will do the examination. The examiner must take responsibility for proper patient preparation and execution, as is done by the angiographer and the endoscopist. This aspect of the examination (preparation) can no longer be delegated
enemas
barium
table.
be
and,
barium
air-contrast
enormous morbidity,
of
colon
an
is about $99.00; an annual projected savings of nearly $7 million coud be achieved nationwide. This would be in addition to the
taken away from the patient. Neither I nor others [41 implied or suggested that this be done. Careful reading of our articles will show that we intimately involve the patient in this process. The preparation
useless
70,000
Responsibility?
1976 4.
Vasilas
cleansing
in saving
182
A,
Batillas
facility.
J,
Sibal
J AppI
AC:
Radiol
Establishment
6 : 75-76,
of
1977
a colon
LETTERS 5.
Rose
RA:
1977 6. Miller
Preparation
RE: Cancer
for
barium
and the clean
JAMA
enema.
colon
.
J AppI
Radio!
238:27,
70,000, which would save us $7 million. Although we must constantly strive to improve methods and techniques, I have
5:109-
serious doubts that we shall ever significantly reduce our miss” rate in barium enemas or in any other radiographic procedure. Even if fecal matter is totally absent, we shall never be able to do away with blind areas, overlapping walls, thickened folds, spasm and sphinctors, and other phenomena which from time tQ time cause us to simply overlook a lesion.
111, 1976 7. Miller
RE: The
‘ ‘
cleansing
enema.
Radiology
117:483-485,
Downloaded from www.ajronline.org by 190.181.185.46 on 10/16/15 from IP address 190.181.185.46. Copyright ARRS. For personal use only; all rights reserved
1975 Reply I fully agree with Miller that achieving a clean colon prior to the performance of a lower gastrointestinal series increases
diagnostic accuracy, given to the patient
that the instructions for bowel preparation should be formulated by the radiologist, and that good preparation can be accomplished without special
tables and equipment. However, I reiterate my suggestion that we should inform the public, through advertising, that accurate
barium enema examinations depend on good tion. People can more effectively be educated they’re they’re
183
calm, relaxed, ill or, at the
and well, rather least, anxious.
bowel preparaat home when
than in a hospital when Of course a magazine
advertisement tions prepared
cannot and should not replace specific instrucby the radiologist which are given to the patient a day or two before the examination, but I strongly believe that such instructions will be more effective and meaningful if the patient has a prior awareness of the subject. The radiologist does indeed have expanding liability in relation to his patients [1]. He owes every patient who comes to him for a barium enema the duty of explaining carefully and persuasively what steps are to be taken to achieve proper bowel preparation. But to hold the radiologist responsible if a colon
I take
convictions, Roscoe
quality
‘ ‘
subject,
I recommend
Smith’s
book
‘
[3] on the nature
of radio-
logic errors and “misses.” Garland [4] has pointed out that all diagnostic examinations are subject to error to about the same degree, because of what he terms the “human equation.” Thus I cannot accept Miller’s assurance that simply by better cleaning out the colon, we can reduce the number of repeat enemas by
exception
with
Miller’s
statement
a lawyer
that
no Miller
of
matter how has devoted
valid those convictions many yeaxs toward
gastrointestinal
radiology,
and
may be. improving
he
has
the
justifiably
earned the respect and admiration of the entire radiologic community. While there may be some disagreement on minor issues, there is no disagreement with the concept he has succeeded in teaching all of us: ‘There is no room for anything less than an attempt at excellence.” Leonard Berlin ‘
University
lesion is missed due to the patient’s refusal or failure to follow instructions is as illogical as holding a doctor responsible for
lung cancer in a patient who ignored his doctor’s advice to quit smoking. Radiologists have no greater obligation to clean out their patients’ colons than any other doctor has to personally administer prescribed medication. Miller correctly states that about 25% of carcinomas are missed on the initial barium enema, but I believe he is incorrect when he attributes most of these misses’ to retained fecal material. The most common causes of error, according to published reports enumerated elsewhere [2], are due to human failure, not to technical factors. To those interested in the
great
holds us responsible for the barium enema. No lawyer holds any radiologist to any standard! The only standards to which nadiologists adhere are those set down by their own consciences and by their professional peers. The courts in all states have said repeatedly that a doctor must simply possess and apply that degree of skill and knowledge equal to that of the reasonably well qualified physician [5, 6]. No court in the land requires a doctor to necessarily be correct, to guarantee a good result, or to agree with or abide by everything written in the medical literature. Raising the spectre of a malpractice suit and instilling a fear of lawyers are not appropriate means to promulgate one’s
of Illinois,
Abraham Skokie
Lincoln Valley
School of Medicine Community Hospital Skokie, Illinois 60076
REFERENCES 1
.
Berlin L: The radiologist: doctor’s doctor tor?AmJRoentgenol 128:702, 1977
2. Berlin
L: Does the “missed” tute malpractice? Radiology
3.
Smith
Error
MJ:
Springfield, 4.
Garland
and
Ill., Thomas, LH:
On
the
or patient’s
radiographic diagnosis 123 : 523-527, 1977
Variation 1967
in Diagnostic
scientific
evaluation
doc-
consti-
Radiology. of
diagnostic
procedures.
Radiology 52 :309-328, 1949 5. Berlin L: Whither goest the doctor’s duty? 151 :342-343, 1977 6.
Berlin
L: Doctors
55:165-172,
1978
have
a right
to make
mistakes.
Illinois
Med
Med
Econ
J
Downloaded from www.ajronline.org by 190.181.185.46 on 10/16/15 from IP address 190.181.185.46. Copyright ARRS. For personal use only; all rights reserved
The Clean
Colon:
Whose
for
Editor’s note-The Journal erred in failing to solicit a response from Roscoe Miller when the letter from Leonard Berlin. (AJR 130:403, 1978) was received. We present further discussion of the issue. in his letter [1], Berlin two articles suggested
completely
misunderstood
he cites [2, 3]. He implies the
responsibility
for
by citing
achieving
the thrust my articles
a
clean
is dictated
by the radiology
department,
that I
the
well
meaning
but
not
always
well
“to
ration
that
(aside
the
from
be the radiologist.
most
interested
party
the patient-victim
informed
The
requesting
to good
bowel
and his physician) physician’s
office
to
but
one-namely,
the
radiologist
or
office staff.” [5]. Berlin speaks of the cost of the radiologist sibility
for
patient
preparation.
In our
taking
department
enema
bag is about
$2.00.
prepa-
cost
increase
to the
patient.
There
been
in the overall
cost to patients
as a result
inadequate
nondiagnostic
barium
and repeat
trained
is ample
evidence
that 25%
of carcinomas
According
to Berlin’s
figures,
this
could
result
the instructions he
and equipment. enema
For
on the x-ray
prepared
receives
his
by the radiologist
barium
enema,
a day
possibly
when
makes the appointment.
This may well need to be tailored
individual
as those
us.”
men!
printing
patient,
such
with
inflammatory
he
to the
bowel
dis-
for a strong with
“Don’t [1].
effort
a clean
that
radiologists
worry
about
preparing
I agree
public
to obtain
Berlin that
your
radiologists
as “partners
colon. should
should
of good
just
present
health”
[1];
tell
not
colon,
their
leave
it
themselves
as partners
with
for the With
clean
the
resulting
colon
should
marked
and
does
decrease
lie with
the exam-
in nondiagnostic
and
repeat barium enemas, there can be a great decrease in the overall cost of this examination. This will also result in a substantial increase in diagnostic accuracy and a saving of the radiologist’s time. Roscoe E. Miller Indiana
University
School
Indianapolis,
of Medicine Indiana
46202
REFERENCES 1 . Berlin L: The clean colon: whose responsibility? Am J Roentgenol 103:430, 1978 2. Miller RE: The barium enema in the high-risk carcinoma patient. Radiology 123 :813-814, 1977 3. Miller RE: The clean colon. Gastroenterology 70:289-290,
of fewer examina-
are missed
on the initial barium enema and that most are due to retained fecal material [2]. With clean colons, we can most assuredly reduce the nondiagnostic and repeat barium enema rate by 20%.
needs before
two
sibility
tions. There
tables
the cleansing
substantial
reductions
enemas
charge
cathartics,
our patients, we must properly instruct them and not leave that instruction to the attending physician. We must also take the responsibility of supervising and performing that patient’s cleansing enema [7]. The surgeon, the endoscopist, the angiographer all take the responsibility for the preparation of their patients; so must the gastrointestinal radiologist. Legally, and morally, we can no longer avoid this responsibility. The respon-
This bag can be used
have
the
decreased hospitalization, colonic carcinoma earlier.
special
given
patient
to the
has to
for the administration of the barium enema itself. Therefore the total increase in cost of assuming complete responsibility for the instruction and preparation of the patient, including the cleansing enema, can be reduced to less than 55 cents including the cost of 2,000 ml of tap water. This expense has been absorbed by the radiology department and has not resulted in any
without
we have
or
to
cost of the brochure is less than 13 cents, technician time (5 mm) to administer the cleansing enema is about 40 cents, and the disposable
15 years
patient,
the responthe
can be done
over
I agree
has been
his
saving in dollars from and mortality by finding
This
sibility
notoriously inadequate in giving proper instructions. It is, therefore, further suggested that all patients who are to have a barium enema examination should receive their instructions from a knowledgeable, interested party, which reduces our selection
total
including
ease. Like it or not, a lawyer will hold any examiner of the colon responsible for patient preparation, for the type of procedure done, for keeping abreast of the relevant medical literature, and for adequately examining the entire colon from the anus to the appendix [3]. It should be evident that for any examination in which 5-15 years of life is at stake, there is no room for anything less than an attempt at excellence [3]. This includes the respon-
referring physician.” [3]. This concept has also been endorsed by the colonoscopist Rose [5], who states: “Patients will comply with intelligent instructions. Both verbal and supplemental written well thought out and clearly presented instructions are necessary. It is suggested
A common
not
‘
‘ ‘
to
yearly.
enema,
A real waste of money is Berlin’s suggestion that ‘we place advertisements in newspapers and magazines explaining why it is important to prepare the colon and how cleansing may be accomplished in a patient’s own home or private surroundings.” Such advertisements a few weeks or 10 years before the patient has the need for a barium enema would be worthless. The
help insure compliance, all patients are given written instructions and an explanation of the entire procedure.” [3]. This instruction booklet was written by the radiology department. We take the responsibility for seeing that both inpatients and outpatients are instructed properly. The thrust of these articles is to take the responsibility of instructing the patient away from the attending physician and put it where it belongs, on the radiologist-the one who will do the examination. The examiner must take responsibility for proper patient preparation and execution, as is done by the angiographer and the endoscopist. This aspect of the examination (preparation) can no longer be delegated
enemas
barium
table.
be
and,
barium
air-contrast
enormous morbidity,
of
colon
an
is about $99.00; an annual projected savings of nearly $7 million coud be achieved nationwide. This would be in addition to the
taken away from the patient. Neither I nor others [41 implied or suggested that this be done. Careful reading of our articles will show that we intimately involve the patient in this process. The preparation
useless
70,000
Responsibility?
1976 4.
Vasilas
cleansing
in saving
182
A,
Batillas
facility.
J,
Sibal
J AppI
AC:
Radiol
Establishment
6 : 75-76,
of
1977
a colon
LETTERS 5.
Rose
RA:
1977 6. Miller
Preparation
RE: Cancer
for
barium
and the clean
JAMA
enema.
colon
.
J AppI
Radio!
238:27,
70,000, which would save us $7 million. Although we must constantly strive to improve methods and techniques, I have
5:109-
serious doubts that we shall ever significantly reduce our miss” rate in barium enemas or in any other radiographic procedure. Even if fecal matter is totally absent, we shall never be able to do away with blind areas, overlapping walls, thickened folds, spasm and sphinctors, and other phenomena which from time tQ time cause us to simply overlook a lesion.
111, 1976 7. Miller
RE: The
‘ ‘
cleansing
enema.
Radiology
117:483-485,
Downloaded from www.ajronline.org by 190.181.185.46 on 10/16/15 from IP address 190.181.185.46. Copyright ARRS. For personal use only; all rights reserved
1975 Reply I fully agree with Miller that achieving a clean colon prior to the performance of a lower gastrointestinal series increases
diagnostic accuracy, given to the patient
that the instructions for bowel preparation should be formulated by the radiologist, and that good preparation can be accomplished without special
tables and equipment. However, I reiterate my suggestion that we should inform the public, through advertising, that accurate
barium enema examinations depend on good tion. People can more effectively be educated they’re they’re
183
calm, relaxed, ill or, at the
and well, rather least, anxious.
bowel preparaat home when
than in a hospital when Of course a magazine
advertisement tions prepared
cannot and should not replace specific instrucby the radiologist which are given to the patient a day or two before the examination, but I strongly believe that such instructions will be more effective and meaningful if the patient has a prior awareness of the subject. The radiologist does indeed have expanding liability in relation to his patients [1]. He owes every patient who comes to him for a barium enema the duty of explaining carefully and persuasively what steps are to be taken to achieve proper bowel preparation. But to hold the radiologist responsible if a colon
I take
convictions, Roscoe
quality
‘ ‘
subject,
I recommend
Smith’s
book
‘
[3] on the nature
of radio-
logic errors and “misses.” Garland [4] has pointed out that all diagnostic examinations are subject to error to about the same degree, because of what he terms the “human equation.” Thus I cannot accept Miller’s assurance that simply by better cleaning out the colon, we can reduce the number of repeat enemas by
exception
with
Miller’s
statement
a lawyer
that
no Miller
of
matter how has devoted
valid those convictions many yeaxs toward
gastrointestinal
radiology,
and
may be. improving
he
has
the
justifiably
earned the respect and admiration of the entire radiologic community. While there may be some disagreement on minor issues, there is no disagreement with the concept he has succeeded in teaching all of us: ‘There is no room for anything less than an attempt at excellence.” Leonard Berlin ‘
University
lesion is missed due to the patient’s refusal or failure to follow instructions is as illogical as holding a doctor responsible for
lung cancer in a patient who ignored his doctor’s advice to quit smoking. Radiologists have no greater obligation to clean out their patients’ colons than any other doctor has to personally administer prescribed medication. Miller correctly states that about 25% of carcinomas are missed on the initial barium enema, but I believe he is incorrect when he attributes most of these misses’ to retained fecal material. The most common causes of error, according to published reports enumerated elsewhere [2], are due to human failure, not to technical factors. To those interested in the
great
holds us responsible for the barium enema. No lawyer holds any radiologist to any standard! The only standards to which nadiologists adhere are those set down by their own consciences and by their professional peers. The courts in all states have said repeatedly that a doctor must simply possess and apply that degree of skill and knowledge equal to that of the reasonably well qualified physician [5, 6]. No court in the land requires a doctor to necessarily be correct, to guarantee a good result, or to agree with or abide by everything written in the medical literature. Raising the spectre of a malpractice suit and instilling a fear of lawyers are not appropriate means to promulgate one’s
of Illinois,
Abraham Skokie
Lincoln Valley
School of Medicine Community Hospital Skokie, Illinois 60076
REFERENCES 1
.
Berlin L: The radiologist: doctor’s doctor tor?AmJRoentgenol 128:702, 1977
2. Berlin
L: Does the “missed” tute malpractice? Radiology
3.
Smith
Error
MJ:
Springfield, 4.
Garland
and
Ill., Thomas, LH:
On
the
or patient’s
radiographic diagnosis 123 : 523-527, 1977
Variation 1967
in Diagnostic
scientific
evaluation
doc-
consti-
Radiology. of
diagnostic
procedures.
Radiology 52 :309-328, 1949 5. Berlin L: Whither goest the doctor’s duty? 151 :342-343, 1977 6.
Berlin
L: Doctors
55:165-172,
1978
have
a right
to make
mistakes.
Illinois
Med
Med
Econ
J
