Many patients complain after an esophagogastroduodenoscopy or a colonoscopy that the gastroenterologist did not discuss the results of the procedure with them. Consequently, the patients feel neglected, leaving them with a negative opinion of their doctor. Most of the time, the culprit in this situation is the administered sedative, particularly midazolam (Versed; Roche Laboratories, Nutley, NJ, U.S.A.). Our objective is to address this important issue and to suggest a strategy to maintain a positive patient–physician relationship after endoscopic procedures in which intravenous sedatives are administered.
Midazolam is a water-soluble benzodiazepine that is available for intravenous injection. This medication is relatively short acting. Per the Physician’s Desk Reference, 1 the central nervous system depressant effects are dependent on the dose, route of administration, and presence of other medications. The half-life of midazolam is 1.8 to 6.4 hours (mean, 3 hours).
The use of midazolam is extremely popular for gastrointestinal endoscopy. Gastroenterologists favor midazolam for two reasons. First, the patients are relaxed and comfortable immediately after its intravenous administration. Second, midazolam is known to cause a transient anterograde amnesia, which is advantageous because the patient does not remember the discomfort that may be associated with an esophagogastroduodenoscopy or colonoscopy.
On the other hand, anterograde amnesia caused by midazolam is what often causes the strained patient–physician relationship after the procedure. Many physicians diligently explain the results and the plan to the patients immediately or shortly after the procedure. Often, the patient calls hours later to ask the doctor what he or she found. One week later during a follow-up office or clinic visit, the patient arrives visibly disturbed, saying “You never talked to me after the procedure.” Some may even say, “Why did you cancel the procedure?” (after it was completed, of course).
Following are real instances that illustrate extremely common patient–physician postprocedure interactions. The first example is a 24-year-old patient with Crohn’s disease who had no history of dementia or Alzheimer’s disease. Midazolam was used as the sedative for the colonoscopy. The gastroenterology fellow later conducted a lengthy discussion with the patient, who appeared to be completely alert. The patient returned to his room on the medical floor from the endoscopy suite. The physician visited the patient 4 hours later and had an additional extensive discussion about the results of the colonoscopy and future plans. The patient conversed rationally and appropriately. The next day while rounding with the chief of gastroenterology, the patient had an angry and annoyed look on his face and said, “I feel abandoned; no one talked to me about the procedure; no one shared the plan with me.” The fellow felt offended, having spent an excess of 1 hour with the patient and thinking that she had established an excellent patient–doctor relationship. Almost certainly the midazolam was responsible for these reactions.
The second example is a patient who had no history of drug use, dementia, or Alzheimer’s disease. The patient underwent a colonoscopy for evaluation of anemia. Midazolam was used as the sedative for the procedure. One hour later, the physician discussed the procedure, results, and plan. The patient indicated that he understood everything that was discussed with him. The following day, the patient asked why the procedure was canceled and whether it was to be rescheduled for the next day.
A third example concerns a 22-year-old man who experienced anterograde amnesia for more than 2 days after an esophagogastroduodenoscopy. The amnesia was prolonged to the point at which the physicians thought a neurologist or a computed tomography scan was required to rule out another cause. The effects of the midazolam reversed only on the 3rd day.
A better relationship is established when the practitioner makes certain to tell the patient the following before the procedure: “You are receiving midazolam and other medications that will most likely make you not remember this procedure even a few hours after it is finished. Many patients complain that the doctor does not talk to them after the procedure; however, this can be caused by the medication. I would like you to call me or see me in the office next week to discuss the results and plans.” We also recommend having a prepared written document for the patient before the endoscopy to discuss the effects of midazolam and to address this problem. This will help eliminate many dissatisfactions patients have and improve the patient–doctor relationship.
Suggested procedure before colonoscopy or esophagogastroduodenoscopy when using midazolam (or other equivalent intravenous sedation):
- Instruct the patients verbally that they will be administered a sedative called midazolam, which will potentially cause them to forget the procedure and what occurs for a few hours after the procedure.
- Inform them that when they go home they may think that the physician did not speak to them after the procedure and that this is caused by the midazolam, which has an amnestic effect. A more lengthy discussion about the results may be conducted when they are alert, 24 to 72 hours later. Therefore, it is imperative that an appointment or a phone call is made to discuss the results a few days postprocedure.
SUGGESTED PROCEDURE AFTER COLONOSCOPY OR ESOPHAGOGASTRODUODENOSCOPY
- A prepared written document about the potential effect of midazolam, highlighting the anterograde amnesia and the need for a follow up visit or phone call a day or two later.
- If a family member accompanies the patient (most patients should have an escort home), be sure to remind them to tell the patient that a lengthy discussion about the results would be conducted in a couple of days, either by phone or when warranted, when the patient has recovered from the effects of the sedation.
- Although there are theoretical contraindications to discussing the results with friends or relatives, if the patient specifically requests or permits that this be done, it should be respected. With such permission, a brief summary of the endoscopic findings and any recommended change in treatment can be written for the relative to hand to the patient at a later date. If the patient prefers the discretion, then the summary and the changes should still be written and handed to the relative to give to the patient in a sealed envelope.
Efrat Z. Lobel, M.D.
Burton I. Korelitz, M.D.
Chief of Gastroenterology; Lenox Hill Hospital; New York, New York
1. Physician’s desk reference, 55th ed. Montvale, NJ: Medical Economics Company, Inc., 2000.