National screening guidelines for colon cancer have expanded in recent years to include a number of options. Although no single procedure has emerged as the screening of choice, colonoscopy is increasing in frequency because of greater likelihood of detecting early lesions and for patient comfort. To meet this important public health challenge, communities must have adequate numbers of physicians capable of performing colonoscopy. Increasing numbers of family physicians are trained to perform colonoscopy, with nearly 2,000 practicing this procedure in communities throughout the United States.
Hospital governing boards, with the input of their medical staffs, must determine who should be granted colonoscopy privileges at their institutions. The basis for such decisions is a review of the education, training, experience and current competence of the practitioner applying for the privilege. Where family physicians meet the institution’s privileging criteria for colonoscopy, they should be granted this privilege. This decision should be based solely on the candidate’s ability to meet established criteria, and not be improperly blocked or derailed by the opposition of other specialists or competitors on the medical staff.
The American Academy of Family Physicians (AAFP) believes that adequate training can consist of documented education in an ACGME-approved residency program which prepares residents to practice colonoscopy; continuing medical education courses which provide didactic and procedural training; and/or precepted experience focused on colonoscopy.
The amount of experience that should be required to hold privileges in colonoscopy is often a matter of contention. There is no scientific data correlating the volume of colonoscopies performed with the acquisition of competence. It is clear that individual practitioners have varying levels of manual dexterity and prior experience with flexible sigmoidoscopy and acquire skills at different rates. Studies indicate that family physicians who perform colonoscopy compare favorably with gastroenterologists and general surgeons when observable factors (such as the “reach-the-cecum” rate, the time required to complete the procedure, and the rate of complications) are used to determine technical competency in colonoscopy.1
The AAFP has performed a national survey of its members who have been granted colonoscopy privileges in US hospitals. The data from this survey indicate that hospitals have granted privileges to family physicians whose experience ranges from five colonoscopies to more than 150. Of those surveyed, 61 percent had received hospital privileges having performed less than 55 colonoscopies. A review of the literature and available data provide no basis for believing individuals at the low end of this experience range should not hold colonoscopy privileges. Nevertheless, specialty societies have sometimes promulgated “privileging guidelines” putting forth high number requirements for experience which are arbitrary and self-serving.
Once a hospital determines the experience it will require to qualify for a privilege, it must confirm current competency. The AAFP believes this can be efficiently and fairly achieved through a requirement for references. The reference should have first-hand knowledge of the applicant’s ability to perform colonoscopy competently. The reference’s attestation to competency affirms that the applicant’s training and experience have actually been adequate for the particular individual under review. If after reviewing references, the hospital still has questions about an individual’s competence, a period of proctoring to observe performance may be appropriate.
The process just described protects patients and, when uniformly applied, provides a fair mechanism for a hospital to grant a particular privilege such as colonoscopy. Hospital credentialing committees, medical executive committees, and governing boards should resist pressure to create artificial and arbitrarily high experience requirements as barriers to the privileging of family doctors to perform colonoscopy. (2003) (2009 CoD)