The colonoscopy saga aired liberally in the press over the past few months has also brought to light a long-standing dilemma of how to use tightly allocated resources in the most cost effective way.
The general practitioner initiated so-called survey of patients does disservice to the word survey.
It was a collection of selected anecdotal reports of patients, not all of whom had passed through the Dunedin Gastroenterology Department, over a period of many years.
A number (10 of 33) did not have a confirmed cancer diagnosis.
To be fair, any proper survey needs to include a randomly selected group, including the good and the bad.
Knowing how many patients were considered for inclusion and over precisely what period of time is a basic requirement for a meaningful survey.
Agreed, some of those reported had an unacceptably slow progress through the system, but there are many possible reasons for that.
Audit of problem cases is a valuable exercise, yielding most benefit when reported promptly, case by case.
Delayed analysis aired through the press often introduces distracting factors.
Most people are aware of the fact that colorectal cancer (CRC) is common in New Zealand.
Colonoscopy is still the gold standard in its investigation and diagnosis.
However, symptoms of CRC are usually very non-specific, and include change in bowel habit, bleeding from the bowel, abdominal pain and weight loss.
It is neither feasible nor necessary to investigate everyone among the many hundreds in the population with any of these symptoms.
In a situation of resource constraint, patients have to be prioritised as to whether they will have a colonoscopy or not.
Great care is required to choose those who are most likely to benefit from the procedure.
In Otago, the colonoscopy review panel, made up of of gastroenterologists and surgeons, makes this decision.
Besides the above symptoms, the panel also considers the patient's age, family and past history, as well as other possible individual factors.
Despite all this information, the process is not perfect, bearing in mind that many patients with CRC do not have typical, or any, symptoms until very late in the disease.
Resources for Gastroenterology at Dunedin Hospital have been stretched for at least 25 years.
Staff have had to make do with the full knowledge that they often cannot meet high public and general practitioner expectations associated with the knowledge that early investigation improves the outlook in CRC.
Staffing has been below recommended levels, and now that this has at last been recognised, finding the appropriate staff has been slow and difficult.
The need to update and expand the facility has been deferred over at least 15 years.
This has not helped with staff recruitment.
All the junior staff trained as specialists in Dunedin over the past many years are now working overseas.
Some have returned to their home countries, while others emigrated to Australia.
Senior staff have worked very long hours under difficult circumstances.
In the ODT (17.2.10), it was noted that the Otago unit performed about half as many colonoscopies per head of population (37.33/10,000 population) compared with other centres in New Zealand (from 76.89/10,000 nationally to over 120/10,000 in some smaller boards, such as West Coast and Southland).
The article also stated that the rate of cancer diagnoses in patients presenting in Otago required less than half as many colonoscopies (5.1/cancer detected) than in other centres in NZ (10.8/cancer detected).
From these data, it seems evident that the number of cancers diagnosed per head of population in Otago is in fact a little better at 7.32 cancers/10,000 population compared with the national NZ average at 7.12.
Is this not what the aim of colonoscopy is all about in the population under investigation, finding cancers? Given their funding, staffing and facility restrictions, should the Otago doctors not be congratulated for focusing the limited resources allocated to them on the population of maximum return? It could also be asked whether other centres in NZ could perform many fewer colonoscopies to achieve a similar rate of CRC diagnosis.
While that may be true, the common aim is to expand the range of people who have a colonoscopy, especially well planned surveillance and screening programmes.
Although effective, these programmes (particularly screening) generally require many more colonoscopies per cancer diagnosed than in those with clear cancer symptoms.
Surveillance was discontinued in Otago and some other boards because of resource limitations.
Adequate resources are essential for the viability of any such programme.
Ultimately, is the death rate for patients registered as having CRC any different in Otago than in other NZ centres? The latest available Ministry of Health figures for 2001 to 2005 show that for each of those years Otago had a lower death rate for patients registered with a diagnosis of CRC than the mean for the country as a whole for every one of those years (averaging 1.9% fewer deaths per CRC diagnosis in Otago than the country average).
This may well reflect the fact that the proportion of CRCs diagnosed at an early stage (localised to the organ of origin, and thus more amenable to curative surgery) was greater in Otago (33.8%) than the national average (27.4%).
Although the ministry indicates that these figures may be an approximation, it would be perverse to point a finger at Otago when available official evidence indicates a consistent set of data which is in their favour.
The problem is to know who among referred patients has a tumour, and who does not.
The selection criteria are imperfect, but it would appear that the Otago doctors are closer to the mark with respect to prediction accuracy.
However, the fact that some patients were deferred or refused colonoscopies when initially referred is very regrettable, if a cancer is found at a later date.
It may point to the need to be able to expand the prioritisation process to include a few more patients, but that must be accompanied by more staff and more appropriate facilities.
For example, asymptomatic patients with significant family histories of CRC in first-degree relatives which occurred at a young age (less than 55 years) are known to benefit from surveillance.
The system in Otago and in a number of other boards in New Zealand is too stretched to accommodate such patients, despite recommendations for this in the national guidelines.
Selection on symptoms will always have an error rate.
Why is prioritisation of patients with any symptoms required? Why not colonoscope them all? Would this not lead to early treatment and prevent the evolution of premalignant polyps to cancers? Although theoretically feasible, this is neither possible nor beneficial to the population as a whole.
We need to spend our valuable health dollar responsibly.
In the United States, colonoscopies are performed for a wider range of indications than here, many of them on the worried well.
The US spends about 16% of its gross domestic product (GDP) on health care, a dominant proportion of this being spent on insured patients.
In that population, preventive programmes have been successful, but by no means perfect.
However, among the nearly 40 million uninsured in the US, the outlook is much worse.
Where do we fit in this scale? We spend about 8% of GDP, half the American figure on health, and our health outcomes are not all that different, and indeed better in most areas, when the total American population is considered.
Although the risks of colonoscopy are low, they are not zero, and some completely unnecessary deaths will occur if the procedure is performed for unwarranted indications.
We need to choose our colonoscopy patients carefully and fairly.
There is no perfect system.
CRC may be difficult to diagnose in some patients, with resulting poorer outcomes, even in an ideal medical setting.
This adds another dimension which is insidiously creeping into New Zealand: if you are insured, or have the money to pay, you can have your colonoscopy privately.
This is clearly the case for surveillance in many centres, despite the New Zealand guidelines recommending this for all patients with a significant family history.
Those with symptoms are investigated in both the public and private sectors, although the wait for a colonoscopy is usually longer in the public sector.
We do deserve better funding for colonoscopies in the public sector, and appropriate staffing and facilities to provide the service.
Colonoscopy is not an easy procedure.
Good training of expert staff is essential for a reliable service.
Expanding such a service takes time, a lot of collaboration within the health care team, and significantly, appropriate funding.
In the early 1980s, when Aussie Malcolm was minister of health, he told those of us who formed a medical audience at his talk at Dunedin Hospital: "You can talk until you are blue in the face.
You represent a vested interest.
When the population talks, we are politicians, we will listen."
What can you do to help? Demand a better health deal from our politicians, and support our dedicated colonoscopy staff in their difficult task of providing and, hopefully, improving their range of service in the public hospital system.
Prof Gil Barbezat is emeritus professor of medicine and consultant gastroenterologist. He is a former head of Dunedin's gastroenterology unit, a previous president of the NZ Society of Gastroenterology, and was on world gastroenterology committees. He does not perform colonoscopies.
