My meaning behind the “Sherlock” comment is that we can tell based on history and physical whether the underlying problem is a serious physical problem or functional 99% of the time.

Yeah, it’s a weird thing–and much of medicine is that way as well with us doing that “Sherlock”: type assessment before we even touch a patient, (Good medical records help as well). My tolerance for shriekieng has decreased over the years so I employ our anesthesiologists more often.

Patients tend to need proof that they don’t have an ulcer, cancer, Crohn’s or other worrisome conditions causing symptoms and primary care providers accept nothing less than an EGD or colonoscopy to assess this which helps my bottom line, but makes my satisfaction with my specialty diminish. Not sure if this is related to malpractice risk or not. For what it’s worth, I set up a lot of endoscopies which are are very low yield in order to get patients and PCPs off my back. Sad but true.

Yeah, I hear you. Usually I can tell who is going to have problems with a procedure within about 5 seconds of walking in to the room. I’ve learned some weird Jedi mind tricks though so nearly everyone does OK. I almost think I can sometimes talk a patient out of their pain to some extent.

In any event, I have learned a tremendous amount about pain and perception of pain doing this. People who want to undergo colonoscopy with no sedation do fine. These are some of my favorite patients. The technique is no changed much, but I do warn them that a they’ll feel a “big cramp” when going around a flexure etc.

Patients that are obviously extremely anxious and say I want to be OUT!!!” are always trouble. Even if the procedure is as smooth as can be, we may have to close some doors because of shrieking.(Standard sedation is fentanyl and versed, BTW) They rarely remember anything, but in the interest of my eardrums and emotional health, I am involving our anesthesiologists more and more, mainly for patients I see in clinic with anxiety etc on chronic bentos. Of course that’s an extra 800+ charge for a routine procedure, but only for selected patients right now.

Back to the topic after my digression, pain appears to have a “YUGE” (to quote our president) supratentorial component. If you want to undergo colonoscopy without sedation you can and you’ll do fine. That’s a maxim I’ll stand by.

Steve