Worldwide, it is estimated that there are 528,000 new cases of cervical cancer each year and that 266,000 women die from teh disease.1 In the United States, the National Cancer Institute (NCI) estimates that 1,200 new cases of cervical cancer will be diagnosed in 2015, and that 4,100 women will die from the disease.2 Currently, the five-year survival rate for localized cervical cancer is 91.5%; the overall (i.e., all stages combined) five-year survival rate is approximately 67.8%.3 Cervical cancer was once one of the most common causes of cancer death among U.S. women, but since the 1980s, the cervical cancer death rate in the United States has decreased by more than 50%.4
Studies show that access to health care is an important predictor of cancer screening. In the United States, pap tests are ordered or provided in approximately 29.4 million physician office visits each year, and it is estimated that more than 3 million women get unclear or abnormal results.5,6
Colposcopy is the diagnostic test indicated for evaluating patients with abnormal Pap test results. 7During the procedure, features of the cervical epithelium are examined under magnified illumination after the application of normal saline, 3% to 5% dilute acetic acid, and Lugol iodine solution in successive steps.7 A green filter highlights vascular patterns.
Neither cytologic sampling nor colposcopic examination alone provides definitive answers. If abnormal tissue is present, it is the histologic result that provides the basis for treatment or observation.
Use of colposcopy-directed biopsies to confirm lower genital tract disease has become common practice for many physicians. It is recognized that performance of colposcopy, in both inpatient and outpatient settings, is within the scope of family medicine, and data from a 2014 member census show that 15.6% of American Academy of Family Physicians (AAFP) members perform this procedure in the office setting.8
It is the position of the AAFP that clinical privileges should be commensurate with the individual physician’s documented training and/or experience, demonstrated abilities, and current competence.9 This policy applies to privileges in all areas. The AAFP also maintains the position that all physicians should be paid for performing all clinical services for which they have documented training and/or experience, demonstrated abilities and current competence to perform.10
The AAFP also advocates the development of explicit patient-centered clinical practice guidelines that focus on what should be done for patients rather than who should do it.11 When clinical practice guidelines address the issue of who should provide care, then recommendations for management, consultation, or referral should emphasize appropriate specific competencies, rather than a clinician’s specialty designation.
The American Medical Association’s policy on staff privileges states that “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.”12
The Joint Commission requires hospitals or credentialing entities to establish a process that provides fair and equal treatment to all applicants. The “credentialing and privileging process involves a series of activities designed to collect, verify, and evaluate data relevant to a practitioner’s professional performance. These activities serve as the foundation for an objective, evidence-based decisions regarding appointment to membership on the medical staff. And recommendations to grant or deny initial and renewed privileges. In the course of the credentialing and privileging process, an overview of each applicant’s licensure, education, training, current competence, and physical ability to discharge patient care responsibilities is established.”13
The following, however, are generally considered to be the most specific indications for colposcopy14,15:
The AAFP’s recommended curriculum guidelines for family medicine residents are intended to help family medicine residency directors develop curricula and to help residents identify areas of needed training. The curriculum guideline on women’s health and gynecologic care lists colposcopy as a skill that family medicine residents should demonstrate the ability to independently perform or appropriately refer.16 A curriculum in colposcopy must impart cognitive and psychomotor skills.
Ideally, the family physician will continue a lifelong learning program that incorporates participation in intermediate and advanced colposcopy courses, which are offered by the American Society of Colposcopy and Cervical Pathology (ASCCP) and other organizations and institutions. Membership in societies that are actively involved in developing evidence-based practice guidelines and standards for colposcopy may also be beneficial.
The AAFP recommends that family physicians document all significant training and experience so that it is recorded and can be reported in an organized fashion. Such documentation should include at a minimum all procedural skills, intensive/critical care experiences, treatment of major illnesses, and other significant training and experiences.17 Further, procedural skills and professional competency can be effectively evaluated. Clinical proctoring is an important peer review tool for physicians seeking privileges in hospitals and health care organizations including colposcopy. Please see the Academy’s position paper on Clinical Proctoring for additional information.18
As is already established, the AAFP holds that all physicians on the medical staff should have the opportunity to practice medicine in their health care organizations, and should be granted clinical privileges commensurate with their documented training and/or experience, demonstrated abilities, and current competence.19 The AAFP believes that any hospital departmentalized by specialty should establish a department of family medicine that has the right to recommend privileges that fall within the scope of family medicine directly to the appropriate committee.20 Please see the AAFP’s policy on Family Medicine Departments and Privileges for additional information.
The process for credentialing and delineation of family medicine privileges varies among organizations. Before applying for colposcopy privileges, the applicant should do the following:
The applicant should include complete documentation, case reports, and letters of recommendation with the application for colposcopy privileges. To avoid losing original documents in the course of the review, he or she should submit copies, not originals.
Some problems with privileges arise because other specialists do not understand the scope of family medicine. Family physicians on the medical staff—or within the hospital’s family medicine department, if there is one— should provide general information about family medicine to other specialists. They should also communicate the following points:
It is important for family physicians to receive high-quality didactic and procedural training in colposcopy.
Primary prevention through risk-factor identification and patient education is as important in reducing the prevalence of cervical cancer as secondary prevention by identification of dysplastic lesions at the time of colposcopy.
Whether the performance of colposcopy by family physicians saves money and resources at the societal level is unknown, although it would seem to have several favorable results:
Productive areas for educational research on colposcopy privileging include improved definition of the competency-based measures required for performance of colposcopy and analysis of outcomes in family medicine compared with other specialties.
(B1998) (2015 July BOD)
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Colposcopy (Position Paper)