I think it is worth responding clearly to multinational insurance companies’ comments at the Public Account Committee (PAC). Although some of these arguments sound convincing on paper, they do not hold up in actual clinical practice.
Utilisation Rates Are Not Clinical Judgement: Let’s be clear: percentages/statistics are not how medical decisions are made. You cannot look at a “higher scope rate” and conclude overuse without knowing the patients behind those numbers.
A 35-year-old with so-called stomach pain is not comparable to a 60-year-old with similar symptoms. Same symptom label, completely different risk profile. Clinical medicine is based on risk, not averages. Using utilisation data to judge individual clinical decisions is simply not valid.
Combined Scopes Are Being Unfairly Labelled: The idea that doing both gastroscopy (OGDS) and colonoscopy as over-scoping is an oversimplification. There are clear, guideline-supported situations where both are appropriate, such as abdominal pain/bloating, iron deficiency anaemia, occult GI bleeding, weight loss, persistent mixed upper and lower GI symptoms, older patients with non-specific but concerning symptoms.
In these cases, doing both in one session is often the most efficient and appropriate approach. It reduces repeated procedures, avoids repeated sedation, and actually speeds up diagnosis.
Calling this “overuse” without clinical context is misleading.
Stomach Pain Isn’t A Diagnosis And It Cannot Be Localised Reliably: One point that keeps being overlooked: abdominal pain is not a specific symptom.
For example, upper abdominal pain does not automatically mean stomach disease. It can come from the stomach/duodenum, biliary system, pancreas, small bowel, colon, or sometimes referred pain from elsewhere.
Even experienced clinicians cannot reliably pinpoint the source based on location alone. This is exactly why investigation is sometimes broader.
In patients with non-specific or overlapping symptoms, it is not unusual or inappropriate to perform both OGDS and colonoscopy to avoid missing pathology.
That is not overuse but recognising diagnostic uncertainty.
Inaccurate Comparison Of Gastric Polyp Removal Rates: Comparing polypectomy rates between hospitals or countries without pathology and clinical context is not meaningful.
You need to know the patient population, helicobacter pylori rates, acid suppressors use, referral bias (secondary and tertiary hospitals tend to get more clinically significant cases, therefore more positive findings), and histology results.
Some gastric polyps are completely benign. Others have dysplastic or malignant potential and must be removed or sampled.
In addition, in some centres, the biopsy’s code is labelled as gastric part/polyp (e.g. the actual biopsy sample might be taken from gastric mucosa rather than gastric polyp, leading to higher percentages of gastric polyp removal on paper).
Stool Tests Aren’t A Substitute For Colonoscopy In Symptomatic Patients: Fecal Immunochemical Test (FIT) is useful, but let’s not misuse it. It is meant for asymptomatic, average-risk screening, not for patients who already have symptoms.
A negative stool test does not reassure you. It does not rule out significant diseases. International guidelines are very clear on this. So the idea of “do stool test first for everyone” is simply not evidence-based.
Screening Isn’t The Same As Diagnosis: This is where a lot of arguments fall apart. Screening is for healthy people. Diagnostic work-up is for symptomatic patients.
They are not interchangeable pathways. Applying screening logic to symptomatic patients is not good practice—it risks missed or delayed diagnosis.
Doctors Do Follow Guidelines: The suggestion that clinicians are not following guidelines is frankly not fair. Most gastroenterologists work within ACG, ESGE, BSG, AGA, and Asia-Pacific consensus guidelines.
But guidelines are not rigid boxes. They are frameworks that still require clinical judgement. Because patients don’t read algorithms before they present.
The Real Issue Is Balance, Not ‘Too Many Scopes’: Yes, unnecessary procedures should be avoided. No disagreement there. But the opposite problem is just as important: under-investigation and missed diagnosis.
If you push too hard on reducing utilisation without clinical nuance, you don’t eliminate waste, but you increase diagnostic risk.
Cost matters. Every health care system has to manage it. But once cost becomes the main filter for whether a patient gets investigated, you move away from medicine and towards rationing. That is not quality improvement. Clinical indication must always come first.
There is nothing wrong with questioning health care utilisation. But it has to be done properly. You cannot take population-level statistics and use them to judge individual clinical decisions without context.
Appropriateness in gastroenterology depends on symptoms, risk profile, clinical findings, and guideline-based judgement. Not averages, benchmarks, or simplified interpretations of incomplete data.
The author is a consultant physician, gastroenterologist and hepatologist. This article was reproduced from the author’s original Facebook post with permission.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.
