Colonoscopy (Position Paper)
Colonoscopy is an indispensable part of modern medical practice and one of the most commonly used invasive medical procedures. Like other endoscopic procedures, it has become “despecialized” in recent years and is now performed by physicians in many specialties, including family physicians.1 Colonoscopy is essential in diagnosing a variety of conditions, but it is most commonly used in the prevention and detection of colon cancer.
Family physicians have demonstrated the ability to learn colonoscopy and to perform the procedure safely and effectively. Because family physicians practice in all areas, including rural and underserved areas, their ability to offer colonoscopy improves access to care for many needy populations. Making this service readily available also helps reduce the inconvenience to patients who might otherwise have to wait weeks or travel long distances to see a specialist for the procedure.2
The performance of colonoscopy is within the scope of family medicine, as evidenced by the following:
- In 2011, 2.6% of family physicians across the United States reported performing colonoscopy in their hospital practices, and an additional 5.1% said they perform colonoscopy with consultation only, demonstrating that in many locations mechanisms exist for family physicians to be privileged in this procedure.1
- In rural areas, an average of 6.7% of family physicians perform colonoscopy.3 One geographic area in Texas reported a rate as high as 42% among physicians who graduated from family medicine residencies since 1990.4
- Results of the 2009 American Academy of Family Physicians (AAFP) Practice Profile II Survey indicate that 5.7% of family physicians reported performing colonoscopy in their offices.5
- According to a 2004 study, 48% of family medicine residency program offered training in colonoscopy, and 18% reported actually training one or more residents in the procedure.6
Colonoscopy can be a natural extension of the total care provided by a well-trained family physician. Patients with gastrointestinal disorders are commonly seen by family physicians, and such complaints are often first reported to a family physician. Family physicians are trained to diagnose, treat, manage and appropriately refer patients with gastrointestinal disorders. Thus, part of a family physician’s role is to know when patients require endoscopy.7,8
Studies indicate that family physicians who perform colonoscopy compare favorably with gastroenterologists and general surgeons when observable factors such as the cecal intubation rate, the time required to complete the procedure, and the rate of complications are used to determine technical competency in colonoscopy.9-14
Benefits to the patient of having his or her family physician perform the colonoscopy include less fragmentation of care, patients’ comfort in having colonoscopy done by a physician they know and trust, decreased travel time, decreased cost to the patient, fewer (often redundant) lab tests, and high patient satisfaction.15 Rural patients particularly benefit from these factors because of their distance from urban referral centers.2
The provision of colonoscopy by family physicians also has community implications. Endoscopic procedures constitute a major portion of the clinical care provided by many hospitals. Rural hospitals, in order to continue providing this care, need physicians who can perform colonoscopy. The survival of small hospitals may hinge on the presence of family physicians who can provide modern endoscopic care, among other issues.
Circumstances in Which Diagnostic Colonoscopy is Generally Not Indicated
- Chronic, stable irritable bowel syndrome
- Chronic abdominal pain
- Acute diarrhea
- Routine follow-up of inflammatory bowel disease (except dysplasia/cancer surveillance in chronic ulcerative colitis)
- Upper gastrointestinal tract bleeding or melena with a demonstrated upper gastrointestinal tract source
- Metastatic adenocarcinoma or unknown primary site in the absence of colonic signs or symptoms when it will not influence management
Conditions Increasing the Risk of Colonoscopy
- Fulminant colitis
- Known or suspected perforation
- History of radiation therapy for abdominal or pelvic cancer
- History of abdominal or pelvic malignancy
- Extensive adhesions from prior abdominal surgery
- Bleeding dyscrasias
- Anticoagulant therapy
- History of complications with anesthesia or intravenous conscious sedation
- Known history of diverticulosis/diverticulitis
- Unstable cardiorespiratory condition
- Early post-colectomy period
- Uncooperative patient
Possible Complications of Colonoscopy
- Respiratory depression
- Cardiac arrhythmias or ischemia
- Transient bacteremia
- Postpolypectomy syndrome
- Drug reaction
Family physicians most often aquire skills for performing colonoscopy during their three years of family medicine residency training. Another possible route to acquiring the needed skills is through preceptorship by another physician who already has such training and privileges. Established experience in flexible sigmoidoscopy examination is helpful in developing colonoscopy skills. For those family physicians already skilled at flexible sigmoidoscopy, there are courses, seminars, and other extended opportunities to learn colonoscopy. These courses usually include the use of models, patients, and extensive didactic instruction, including slide and/or video programs.
The acquisition of the psychomotor skill involved in performing colonoscopy should be coupled with development of the cognitive skills involved in knowing when to perform the procedure and how to properly interpret findings and pathology reports. Any program that includes endoscopy training should provide both. It is equally important to teach the recognition of the contraindications to colonoscopy, the possible complications, and their proper management as laid out in tables 1 through 3 above.16,17
Advanced Cardiac Life Support (ACLS) training and certification may be required for hospital privileges because of the use of intravenous (IV) conscious sedation. Even if ACLS certification is not required, it is recommended, so that the physician performing colonoscopy is prepared for an anesthetic or cardiopulmonary complication.
Although the number of procedures performed in training is sometimes recommended as a criterion for credentialing, numbers alone do not demonstrate quality of outcomes. There is no scientific data correlating the volume of colonoscopies performed with the acquisition of competence.18 The American Society for Gastrointestinal Endoscopy (ASGE) recommends that physicians perform a minimum of 140 diagnostic colonoscopies and 30 snare polypectomies before competency can be assessed, but the organization does acknolwedge the importance of using "objective criteria of skill, rather than an arbitrary number of procedures performed" in the granting of endoscopic privileges.19
Based upon recent studies, the AAFP has determined that the standard of fifty (50) cases as the primary operator be used as a basis for determination of basic competency.20-22
Family physicians seeking colonoscopy privileges would do well to document their training and experience. This should include keeping a record of patients' operative reports (including the items listed in Table 4), a record of experience and training (including items listed in Table 5), and a competence-based evaluation or recommendation from their residency program or faculty instructors.
Content of Procedure Notes
- Patient identification or code
- Date of procedure
- Name of hospital/location of procedure
- Patient's age
- Patient's history of prior colonoscopy, including any problems associated with previous procedures
- Clinical indication for colonoscopy
- Description of procedure
Suggested Documentation of Colonoscopy Experience
- Number of procedures performed during training and practice
- Outcome data, including complication rate
- Letters from instructors, preceptors, and proctors documenting training, experience, demonstrated abilities, and current competence
- Letters from previous hospitals documenting experience and outcomes
- Documentation that potential complications from the procedure and medications have been discussed with the patients, that alternative diagnostic tests and their advantages and disadvantages compared with endoscopy were discussed, and that informed consent has been obtained.7
The amount of continuing colonoscopy experience needed to maintain proficiency has not been extensively studied. As mentioned above, however, researchers have reported that family physicians performing endoscopic procedures have outcomes comparable to, or exceeding, those of other specialists.9-14
Current policies and procedures for credentialing family physicians in colonoscopy vary markedly from site to site. In hospitals with departments of family medicine where other family physicians perform colonoscopy, the department should privilege its own members. In hospitals where it is not usual for family physicians to perform colonoscopy, there may be no mechanism for family medicine credentialing in this or other invasive procedures. In these institutions, completion of a residency in gastroenterology may be stated as a prerequisite for obtaining colonoscopy privileges. Such requirements run counter to the positions of the AAFP, the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO), and the American Medical Association (AMA) credentialing criteria.
It is the position of the American Academy of Family Physicians (AAFP) that clinical privileges should be based on the individual physician's documented training and/or experience, demonstrated abilities and current competence, and not on the physician’s specialty.23
The JCAHO requires this, as it makes clear in its Hospital Accreditation Standards 2013:
The decision to grant or deny a privilege(s), and/or to renew an existing privilege(s), is an objective, evidence-based process. …
The hospital, based upon recommendations by the organized medical staff and approval by the governing body, establishes criteria that determine a practitioner’s ability to provide patient care, treatment, and services within the scope of privilege(s) requested. Evaluation of all of the following are included in the criteria:
- Current licensure and/or certification, as appropriate, verified with the primary source
- The applicant’s specific relevant training, verified with the primary source
- Evidence of physical ability to perform the requested privilege
- Data from professional practice review by an organization(s) that currently privileges the applicant (if available)
- Peer and/or faculty recommendation
- When renewing privileges, review of the practitioner’s performance within the organization
All of the criteria used are consistently evaluated for all practitioners holding that privilege. (MS.06.01.05)24
The AMA holds a similar position. Regarding staff privileges, AMA Policy E-4.07 says this:
The mutual objective of both the governing board and the medical staff is to improve the quality and efficiency of patient care in the hospital. Decisions regarding hospital privileges should be based upon the training, experience, and demonstrated competence of candidates, taking into consideration the availability of facilities and the overall medical needs of the community, the hospital, and especially patients. Privileges should not be based on numbers of patients admitted to the facility or the economic or insurance status of the patient. Personal friendships, antagonisms, jurisdictional disputes, or fear of competition should not play a role in making these decisions. Physicians who are involved in the granting, denying, or termination of hospital privileges have an ethical responsibility to be guided primarily by concern for the welfare and best interests of patients in discharging this responsibility.25
In addition, AMA policy H-230.998 on Hospital Privileges says, "Our AMA believes that clinical departments of family practice should be established where appropriate with duties comparable to any other specialty department of the medical staff."26
“Community need” is often cited as a reason to withhold colonoscopy privileges from family physicians practicing in environments shared with subspecialists. In such environments, gastroenterologists may not perceive a community need for family physicians to provide this service. This approach is not consistent with Joint Commission or AMA credentialing guidelines either, however.
Family physicians moving to new practice sites who plan on performing colonoscopy would do well to extensively research the site’s policies and procedures regarding privileges for colonoscopy. They should obtain these privileges before moving to the new practice site. This approach would be particularly helpful if the family physician is to be the first to request these privileges in an environment where gastroenterologists alone hold such privileges.
The following is a list of items to consider when applying for hospital privileges to perform colonoscopy:27
- Carefully study the language of the hospital privileges policy, and make sure you understand the process by which the privileges are granted.
- Prepare a brief resume describing your educational background including college, medical school, and board certification/recertification. Include dates of hospital affiliations, state and national medical societies, professional honors, awards, and elected offices or committee chair positions. Describe any prior hands-on proctorship experiences.
- Describe the years of practice and your record in providing high-quality health care for a variety of cases. This should include the number of colonoscopies performed, your cecal intubation rate, and your complication rate.
- List all accredited CME courses you have taken that pertain to colonoscopy. Also include any self-study of gastrointestinal disease, such as atlases, articles, etc.
- Include a summary letter from your residency or state chapter of the American Academy of Family Physicians that supports these privileges as being within the scope of family practice.
- Cite pertinent AAFP policies, including these:
A. "The AAFP affirms that all physicians on the medical staff should … be granted clinical privileges commensurate with their documented training and/or experience, demonstrated abilities and current competence." (Privileges. http://www.aafp.org/online/en/home/policy/policies/p/privilege.html. Accessed January 31, 2013.)
B. The AAFP believes that adequate training [in colonoscopy] 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.
C. "Endoscopic competence is determined and verified by evaluation of performance under clinical conditions rather than by an arbitrary number of procedures." (Colonoscopy Privileging. http://www.aafp.org/online/en/home/policy/policies/c/colonoscopyprivileging.html. Accessed January 31, 2013.)
D. Endoscopic competence should be demonstrated by any physician seeking privileges for the procedure.
E. Privileges should be granted for each specific procedure for which training has been documented and competence verified. The ability to perform any one endoscopic procedure does not guarantee competency to perform others
F. Endoscopic privileges should be defined by the institution granting privileges and reviewed periodically with due consideration for performance and continuing education.
- Indicate that the AAFP strongly believes that all medical staff members should realize that there is overlap between specialties and that no one department has exclusive “rights” to privileges.28
- Highlight AMA Policy E-407: Staff Privileges, quoted above.25
- Highlight JCAHO Standard MS.06.01.05, ("The desicion to grant or deny a privilege(s) and/or to renew an existing privilege(s), is an objective, evidence-based process,"), a portion of which is quoted above.24
- Identify to the appropriate hospital committee a physician on staff who has colonoscopy privileges and is willing to proctor you.
- Provide evidence of your ability to obtain malpractice insurance coverage. If your malpractice coverage includes surgical assisting, or if you are doing obstetrics, you should not have to increase your “insurance class.”7
- Describe your plan for quality assurance. This should mean tracking your cases, and providing the data to your department chair after a period of six to 12 months.
- Establish a plan for continuing medical education, such as attendance at gastrointestinal conferences or board reviews, the annual meetings of the American College of Gastroenterology or the American Gastroenterology Association, or Digestive Disease Week.
- Express your willingness to work with the hospital to provide any information it believes is missing or incomplete.
- If necessary, indicate that legal opinion and precedent have determined liability regarding the granting and/or failure to grant privileges for procedures based on factors other than the experience and competency of the physician in question. A legal opinion on privileges for endoscopy submitted to the AAFP in 1993 stated the following:
A. Hospitals and peer review participants risk liability under state law if they base credentialing decisions solely on whether or not a physician has obtained specialty certification.
B. The Council on Ethical and Judicial Affairs of the AMA has issued the opinion that competitive factors must be disregarded in making decisions about credentials and privileges.
C. There is no evidence that only board-certified gastroenterologists are “qualified” to perform endoscopic procedures.
D. Hospitals violate the “Medicare Conditions for Participation” if they base credentialing decisions solely on specialty board certification.
E. Hospitals and peer review participants risk loss of federal and state immunity from liability by basing credentialing decisions solely on whether or not a physician has obtained specialty
Some family physicians may find office colonoscopy to be considered a safe and cost-effective alternative to in-hospital colonoscopy.5,7 Because of the equipment expense, however, this may be too costly an option, especially for solo practitioners. Practices that offer office colonoscopy, need to maintain monitoring equipment and emergency supplies. These should include a pulse oximeter, a blood pressure cuff (preferably automated), an electrocardiogram monitor, oxygen, and a “crash cart,” with both naloxone (Narcan) and flumazenil (Romazicon) to reverse narcotic and benzodiazepine effects, if necessary. Consideration should also be given to meeting JCAHO or other accreditation inspection and licensing standards for this equipment.
Since some health insurance companies now require that colonoscopy be performed in a hospital or licensed outpatient facility, family physicians should determine whether their practices are in compliance
The research agenda relating to colonoscopy by family physicians should focus on these major areas:
- Quality assurance. Initiate ongoing case review programs/studies to monitor the endoscopic outcomes of family physicians performing colonoscopy, and compare these outcomes with those of other specialties.
- Training methods, including cognitive and procedural aspects. Address questions concerning the learning curve. For continuing quality improvement purposes, research is needed to determine the relationship significance, if any, between the number of procedures performed and demonstrated proficiency and maintenance of skills.
In an ideal world, the specialty societies would work together to improve patient care by disseminating technology and educating all physicians. Unfortunately, other groups have in the past been unwilling to work cooperatively with the AAFP on endoscopy issues. In such situations, the AAFP has had no choice but to develop its own educational programs. In situations where other specialty organizations are willing to partner with the AAFP, the AAFP welcomes the chance to work toward improved patient care by increasing the education of its members.
1. American Academy of Family Physicians. Provision of selected services and procedures in hospital practices of family physicians (as of April 2011). In Facts About Family Medicine. Kansas City, MO: American Academy of Family Physicians; 2008. http://www.aafp.org/online/en/home/aboutus/specialty/facts/17.html. Accessed January 30, 2013.
2. Carr KW, Worthington JM, Rodney WM, et al. Advancing from flexible sigmoidoscopy to colonoscopy in rural family practice. Tenn Med. 1998;91(1):21-26.
3. American Academy of Family Physicians. Member census data collected July 2010 through January 2012.
4. Young RA, Byrd AN. Practice patterns of rural Texas physicians trained in a full-service family practice residency program. Tex Med. 1999;95(2):64-68.
5. American Academy of Family Physicians. Practice Profile Survey II. Kansas City, MO: American Academy of Family Physicians; 2009.
6. Wilkins T, Jester D, Kenrick J, et al. The current state of colonoscopy training in family medicine residency programs. Fam Med. 2004;36(6):407-11.
7. Musallam LS. Privileges, credentialing, and liability. Prim Care. 1995;22(3):491-8.
8. Brandt LJ, Daum F, eds. Clinical Practice of Gastroenterology. Vol 2. Philadelphia, Pa: Current Medicine; 1999.
9. Harper MB, Pope JB, Mayeaux EJ Jr, et al. Colonoscopy experience at a family practice residency: a comparison to gastroenterology and general surgery services. Fam Med. 1997;29(8):575-579.
10. Pierzchajlo RP, Ackermann RJ, Vogel RL. Colonoscopy performed by a family physician. A case series of 751 procedures. J Fam Pract. 1997;44(5):473-480.
11. Hopper W, Kyker KA, Rodney WM. Colonoscopy by a family physician: a 9-year experience of 1048 procedures. J Fam Pract. 1996;43(6):561-566.
12. Kolber M, Szafran O, Suwal J, Diaz M. Outcomes of 1949 endoscopic procedures: performed by a Canadian rural family physician. Can Fam Physician. 2009;55(2):170-5.
13. Xirasagar S, Hurley TG, Sros L, et al. Quality and safety of screening colonoscopies performed by primary care physicians with standby specialist support. Med Care. 2010;48(8):703-9.
14. Wilkins T, LeClair B, Smolkin M, et al. Screening colonoscopies by primary care physicians: a meta-analysis. Ann Fam Med. 2009;7(1):56-62. Erratum in: Ann Fam Med. 2009;7(2):181.
15. Nijjar UK, Edwards JA, Short MW. Patient satisfaction with family physician colonoscopists. J Am Board Fam Med. 2011;24(1):51-6.
16. Robinson R. Colonoscopy. Prim Care. 1995;22(3):399-409.
17. Mahajan RJ, Barthel JS, Marshall JB. Appropriateness of referrals for open-access endoscopy. How do physicians in different medical specialties do? Arch Intern Med. 1996;156(18):2065-9.
18. Ackermann RJ. Performance of gastrointestinal tract endoscopy by primary care physicians. Lessons from the US Medicare database. Arch Fam Med. 1997;6(1):52-8.
19. American Society of Gastrointestinal Endoscopy; Eisen GM, Baron TH, Dominitz JA, et al. Methods of granting hospital privileges to perform gastrointestinal endoscopy. Gastrointest Endosc. 2002;55(7):780-3.
20. Eckert LD, Short MW, Domagalski JE, et al. Assessing colonoscopy training outcomes using quality indicators. J Grad Med Educ. 2009;1(1):89-92.
21. Short MW, Kelly KM, Runser LA. Colonoscopy by a family physician: a case series demonstrating health care savings. Mil Med. 2007;172(10):1089-92.
22. Bittner JG 4th, Marks JM, Dunkin BJ, et al. Resident training in flexible gastrointestinal endoscopy: a review of current issues and options. J Surg Educ. 2007;64(6):399-409.
23. American Academy of Family Physicians. Privileges. [Policy statement]. http://www.aafp.org/online/en/home/policy/policies/p/privilege.html. Accessed January 30, 2013.
24. Joint Commission on Accreditation of Healthcare Organizations. Hospital Accreditation Standards 2013. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations 2012.
25. American Medical Association. E-4.07 Staff Privileges [Policy statement]. Available online through the AMA policy finder. http://www.ama-assn.org/ama/pub/about-ama/our-people/house-delegates/policyfinder.page(www.ama-assn.org). Accessed January 31, 2013.
26. American Medical Association. H-230.998 Hospital Privileges [Policy statement]. Reaffirmed by CMS Report 6-A-10, Chicago; 2000. Available online through the AMA policy finder. http://www.ama-assn.org/ama/pub/about-ama/our-people/house-delegates/policyfinder.page(www.ama-assn.org). Accessed January 31, 2013.
27. Rodney WM. How to apply for GI endoscopy privileges. Memorandum to the American Academy of Family Physicians Commission on Continuing Medical Education. 6th draft. June 29, 1994.
28. American Academy of Family Physicians. Privilege Overlap [Policy statement]. http://www.aafp.org/online/en/home/policy/policies/p/privilegeoverlap.html. Accessed January 31, 2013.
29. Smith, Gill, Fisher & Butts, Attorneys. Opinion letter to the AAFP, July 20, 1993.
(B2000) (2013 COD)