Flexible Sigmoidoscopy Should Be Encouraged

“Flexible Sigmoidoscopy Should Be Encouraged”

I would like to comment on the two reports from Baltimore on the subject of colonoscopy as a screening tool (“Symptoms not enough to predict women’s colorectal CA,” and “Colonoscopy screening: specialists walk the talk,” the Medical Post, Nov. 4, 2003).

One was a large retrospective study done by Dr. Radhika Srinivasan of the University of Pennsylvania Medical Centre in Philadelphia.

Dr. Srinivasan said most symptoms of colorectal cancer are poor predictors for the presence of the disease. Since colon cancer can occur without any symptoms, Dr. Srinivasan recommends screening colonoscopy for men and women over the age of 50.

The second study was by Dr. Prem Chattoo of St. Vincent’s Hospital in Manhattan, New York. His study showed 70% of gastroenterologists older than 50 years have had a routine screening colonoscopy, compared to about 15% of patients age 50-plus in the general population.

This finding is not surprising. We know screening for colorectal cancer saves lives. But the ideal method of screening remains controversial. Dr. Chattoo’s finding suggests the general public and the referring physicians are still not convinced an asymptomatic person over 50, with no risk factors, needs to undergo screening colonoscopy.

In Canada, my impression is the percentage of asymptomatic patients, at average risk for colorectal cancer undergoing screening colonoscopy, is probably less than 15%. Although colonoscopy remains the gold standard for screening, it is not without disadvantages.

There is a fair amount of waiting before a patient can get in for a consultation. Then there is more waiting before the patient gets a procedure. In the meantime, the patient wonders whether he has cancer or not.

Colonoscopy is as good as the skill and patience of the operator. There is a small risk of bleeding and perforation. Some patients react adversely to sedatives used during the procedure.

Endoscopy time in a hospital setting is at a premium and takes up a significant amount of hospital resources. There is a fair amount of inconvenience to patients and their families before and after the procedure (bowel prep, taking time off work, getting a ride to and from hospital, etc.). There is a great amount of anxiety about the procedure and waiting for the results.

It is estimated colonoscopy costs our health-care system about $1,000 per procedure. Eighty-five per cent of colonoscopies are usually normal and 95% of colonoscopies do not show any cancer.

Gastroenterologists and other GI endoscopists (I used to be one) are keen on promoting colonoscopy as a screening procedure. But somehow, either there is a credibility gap or there is failure in communication. Or there is no convincing argument that screening colonoscopy is as good as screening mammography or Pap smear.

What about symptomatic patients? Do all patients with lower GI symptoms need colonoscopy? Are there other tools that can be used safely and appropriately?

Flexible sigmoidoscopy is a good instrument for symptomatic patients under the age of 40 or even 50 if their symptoms are hemorrhoidal in nature. Patients younger than 40 have an incidence of colorectal cancer anywhere from 1% to 6%. Overall, for an average risk patient the lifetime risk for developing colorectal cancer is 5%.

Flexible sigmoidoscopy has many advantages. It is being underused and undervalued by many endoscopists and physicians. It is safer than colonoscopy. It is easy to perform in an office setting and does not require hospital resources. It is highly sensitive within the distance.

It is a good test for younger patients especially those who have symptoms related to the ano-rectal area. It is a good test for older patients at low risk for colorectal cancer. It is a useful test for reducing the waiting list for colonoscopies. It will make room for symptomatic patients who really need colonoscopy on an urgent basis for whom sometimes it is impossible to find a spot.

Most endoscopists find it easier to book patients for colonoscopy in a hospital than to do a flexible sigmoidoscopy in an office. This is quite a natural process as most endoscopists spend more time in hospital looking after sick patients.

Besides, to buy and maintain a flexible sigmoidoscope in an office requires a fair amount of investment for equipment and staffing. Naturally, the overhead goes up. Hence there is no incentive for physicians to set up a system in the office.

I have been doing flexible sigmoidoscopy in my office for the last 13 years or so. I think flexible sigmoidoscopy should be encouraged and promoted as a good test for many patients. Better fee schedule for the procedure would certainly help. —Dr. Noorali Bharwani, Medicine Hat, Alta.

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Captivating Venezia (Venice)

I first read about Venice (Venezia), Italy when I was in high school in Tanzania. We were reading William Shakespeare’s Merchant of Venice. I never thought that one day I would get a chance to visit Venice, described by some to be the most beautiful and the most captivating city in the world.

It was last summer, we arrived at Venezia Santa Lucia train station on a Wednesday at 4.00 p.m. We had left Geneva at 9.05 a.m. So it was a long day. But traveling first class with prior reserved seats made the journey very comfortable.

As soon as we came out of the platform, we were approached by several “hotel agents”. We had booked our hotel which was supposed to be a walking distance from the railway station. But, in which direction? As we tried to make our way through these agents, a middle-aged man stopped us and said he was there to help us (i.e. tourists).

We gave the name of our hotel and he gave us the direction. The hotel was on the other side of the Grand Canal. As we came out, we could see the hotel from the railway station. But we had to carry our luggage and walk over a bridge which had lots of steps! I knew it would take more than five minutes to get there.

Venice is one of the most unusual places on earth. It is divided by a 1.8-mile-long waterway called the Grand Canal (Canal Grande). The canal is a magical highway – never fades. It divides the city in two and is crossed by three bridges.

Along the banks of the canal are the palazzi, or palaces, which were built by wealthy merchants and their families. Most of these were built between the 12th and 18th centuries. The owners decorated these palaces as a dazzling display of their power and wealth.

No cars, taxis, motorcycles or trucks are permitted within the city of Venice. If you arrive in a wheeled vehicle to Venice then you have to leave your vehicle in a parking lot on the outskirts of the city. From there you enter Venice by boat or on foot.

Venetians use boats instead of cars to travel through the town, because there are more waterways than walkways. There are water taxis and water buses. Instead of streets, there are 120 canals. There are traffic lights as well. And there is water police, enforcing law and order and traffic control. Docks and bridges connect the canals to the land.

Water bus, water taxi or gondola drops you off to the landing point nearest your destination then you have to walk. There is lot of walking to do.

To build houses and office buildings is not easy. First, you have to drive wooden poles, called pilings, deep into the firm clay of the lagoon. Then timbers are attached to the pilings and buildings are constructed over them.

What did we do?

Out of our three weeks in Europe, we had kept two nights for Venice. That came down to one evening and one full day. We knew that would not be enough. But we wanted to have a glimpse of the city and see what it is all about – how do people travel and work and live in this unusual city.

After we checked-in in our hotel, we decided to explore the surrounding areas by foot. The canal is like a busy highway during the day time. As the darkness arrives, the city gives an aura of romance as reflected lights twinkle on the water. There are multitudes of shops and restaurants catering to the tourists who flock this place like birds. Of course, nothing is cheap. Even pizza is expensive!

Next day, after breakfast, we were offered free water taxi (compliments of Murano Gallery) to visit the island of Murano and the Murano glass factory. We took up the offer and spent couple of hours at the gallery. Glass is a true Venetian specialty, made for centuries (since 1291) on the island of Murano. The furnaces were moved away from the city as a fire precaution.

There were eye popping, breathtaking colorful glass pieces from very small to giant size glasses, stemware, bowls, vases, chandeliers and other artifacts. No photographs were allowed inside the gallery. Nothing there was within my prize range! The sales person, who gave us a guided tour, was very persuasive. But we resisted the temptation.

From Murano, we took a water taxi to San Marco square. It was full of tourists. It is a beautiful open space. We took a stroll around the square and saw many monuments which have played important role in the development of Venice. The important monuments are: a 15th century Torre dell’Orologio (Clock Tower) and its zodiac clock, the beautiful Libreria Sansoviniana (Sansoviniana Library) and two columns near the waterfront, topped by the lion of St. Mark and St. Theodore with his crocodile emblem.

We took a day pass for the water bus and did some more site seeing of our own. There are many guided water-taxis and walking tours available. For example, Casanova and the Age of Decadance focus on the life and times of Casanova. A time of illegal gambling parlors, of masked courtesans and spies, of corruption and political intrigue.

Other tours show you the Jewish Ghetto and life of Marco Polo. Rialto and Merchant of Venice and Venice Ghost Walk, where the ghosts of the past and present day will keep you company as your guide will tell the stories as you walk along the dimly lit deserted streets of Venice – as your shadows get longer, you can hear the foot steps coming behind you!

We managed to cover a lot of Venice walking and using the water bus pass – very economical way to do it if you go with your family. It was a hot day. After a brief afternoon rest at the hotel we took a Grand Canal Boat Tour at 5.30 pm (there is another one at night at 9 pm). That was great fun – maximum of eight people in a luxurious motor boat lasting 70 minutes. It takes you through the Grand Canal and some lesser known canals.

As the darkness fell, we went on our walk along the canal near the railway station. They are open till late in the evening.

After a good night’s sleep, it was time to pack and walk to the railway station. Our next stop was Florence. We felt we needed more time to enjoy this beautiful and unusual city. A day and a half was worth it but not enough! One day, we hope to go back.

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Headshave for Docs for Cancer

Missed a spot.

For some it’s a fashion statement, for others a genetic inevitability. But when Dr. Noorali Bharwani went bald recently, it was all for a good cause. The general surgeon from Medicine Hat, Alberta, volunteered to have his head shaved at Relay for Life, a Canadian Cancer Society fundraiser in the city this spring. Dr. Bharwani held his event, which he called “Docs for Cancer”, during the all night relay run. Stylist Debbie Bullman of the Hair Palace salon donated her time and talents to crop his locks. By asking for pledges, from anyone wanting to watch him be shorn, he managed to raise more then $2 200.00 from an audience of about 300 people. Prior to this, Dr. Bharwani had raised in excess of over $12 000.00 over three years for the Cancer Society through a “Jail and Bail” event. He said he hopes his “Docs for Cancer” idea catches on and other physicians adopt the idea in their communities to show that doctors care.

Click here for photo album of the event!

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Quick Q & A with The Medical Post

The Medical Post November 19, 2002

Quick Q & A with Dr. Noorali Bharwani – a general surgeon in Medicine Hat, Alta.

What is your least favourite medical procedure that you regularly perform?
Not a medical procedure but part of it: filling insurance forms.

What book are you reading?
Jacalyn Duffin’s History of Medicine: A Scandalously Short Introduction.

What illness do you most fear getting?
Hepatitis or AIDS.

What do you think is the most exciting field of science at the moment?
Medical genetics.

What is the least enjoyable job you’ve ever had?
Working as a stock boy at a supermarket in London, England, while waiting for my General Medical Council registration.

What do you do when you need to clear your mind?
Watch a comedy show, go on a treadmill or meditate.

What is the best piece of advice you’ve ever been given?
“Be an optimist but have plan B ready.”

What is your greatest fear?
To die before my children enter university.

What vice do you have that you hide from patients?
My short fuse – if that is a vice!

What is your biggest extravagance?
My office building.

What talent do you envy in others?

What is your favourite meal?
My wife’s vegetable soup.

What do you say to someone who says “doctors have it made”?
Try going through a medical school and residency program, then come and talk to me.

What do you think is the greatest political danger to the medical profession?
Politicians do not understand that medicine is an imperfect science with many promises and expectations which cannot be satisfactorily delivered without adequate funding, manpower, equipment and infrastructure.

What’s your junk-food weakness?
Chocolate chip peanut butter cookies from Tim Hortons! Our hospital Tim Hortons is out of bounds for me, so I am going through withdrawal symptoms.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!