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:
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
Conditions Increasing the Risk of Colonoscopy
Possible Complications of Colonoscopy
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
Suggested Documentation of Colonoscopy Experience
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:
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
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:
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)
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Colonoscopy (Position Paper)