AAFP POSITION PAPER

Colonoscopy: Procedural Skills

Am Fam Physician. 2000 Sep 1;62(5):1177-1182.

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, and safely and effectively to perform colonoscopy. 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

Scope of Practice for Family Physicians

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.3,4 The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires this, as stated in its Comprehensive Accreditation Manual for Hospitals5,6:

  1. MS.2.15 Whatever mechanism for granting or renewal/revision of clinical privileges is used, there is evidence that the granting of clinical privileges is hospital-specific and based upon the individual's current competence.

  2. MS.2.15.1 Privileges are related to: MS.2.15.1.1 An individual's documented experience in categories or treatment areas of procedures.

  3. MS.2.15.3 When privilege delineation is based primarily on experience, the individual's credentials record reflects the specific experience and successful results that form the basis for granting of privileges.

The American Medical Association (AMA) holds a similar position.7,8 Regarding clinical privileges, the 1993 AMA Policy Compendium states, “The accordance and delineation of privileges should be determined on an individual basis, commensurate with an applicant's education, training and experience, and demonstrated current competence.” It also states that “In implementing these criteria, each facility should formulate and apply reasonable nondiscriminatory standards for the evaluation of an applicant's credentials, free of anticompetitive intent or purpose.”8

The performance of colonoscopy is within the scope of family practice, evidenced by the following:

  1. Approximately 1,440 family physicians across the United States perform colonoscopy in a hospital setting, demonstrating that in many locations mechanisms exist for family physicians to be privileged in this procedure.9

  2. In rural areas, an average of 5.7 percent of family physicians perform colonoscopy. One geographic area in Texas reported a rate as high as 42 percent among physicians who have graduated from family practice residencies since 1990.10

  3. On the 1998 AAFP Practice Profile Survey, 1,163 family physicians reported performing colonoscopy in their offices.11

  4. Twenty-six percent of family practice residency programs provide training in colonoscopy.12

Clinical Indications

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.5,13

Studies indicate that family physicians who perform colonoscopy compare favorably with gastroenterologists and general surgeons when observable factors (i.e., reach-the-cecum rate, time required to complete the procedure and rate of complications) are used to determine technical competency in colonoscopy.2,12

Benefits to the patient of having the 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 and fewer (often redundant) laboratory tests. Rural patients particularly benefit from these factors because of their distance from urban referral centers.2

There are also 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.

Training Methods

Skills for performing colonoscopy are most often acquired during three years of family practice residency training. Another possible route to acquiring colonoscopy skills is through preceptorship with a 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 video programs.

The acquisition of the psychomotor skill involved in performing colonoscopy should be coupled with 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.

The above discussion of training methods focuses on the “how” and “when” of performing colonoscopy. It is equally important to teach recognition of the contraindications to colonoscopy (Table 1), the possible complications and their proper management. Table 2 lists clinical situations that increase the risk of complications, and Table 3 lists complications that physicians performing colonoscopy should be able to recognize and manage.14,15

TABLE 1

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

TABLE 1   Circumstances in Which Diagnostic Colonoscopy Is Generally Not Indicated

View Table

TABLE 1

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

TABLE 2

Conditions Increasing the Risk of Complications in 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 postcolectomy period

Uncooperative patient

TABLE 2   Conditions Increasing the Risk of Complications in Colonoscopy

View Table

TABLE 2

Conditions Increasing the Risk of Complications in 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 postcolectomy period

Uncooperative patient

TABLE 3

Possible Complications of Colonoscopy

Bleeding

Cardiac arrhythmias or ischemia

Perforation

Transient bacteremia

Respiratory depression

Postpolypectomy syndrome

Bradycardia

Drug reaction

Hypoxia

Nausea/vomiting

Hypotension

Ileus

TABLE 3   Possible Complications of Colonoscopy

View Table

TABLE 3

Possible Complications of Colonoscopy

Bleeding

Cardiac arrhythmias or ischemia

Perforation

Transient bacteremia

Respiratory depression

Postpolypectomy syndrome

Bradycardia

Drug reaction

Hypoxia

Nausea/vomiting

Hypotension

Ileus

Advanced Cardiac Life Support (ACLS) training and certification may be required for hospital privileges because of the use of intravenous conscious sedation. Even if ACLS certification is not required, it is recommended so that physicians are prepared for an anesthetic or cardiopulmonary complication.

Testing, Demonstrated Proficiency and Documentation

Although the number of procedures performed in training is sometimes recommended as a mechanism for credentialing, numbers alone do not demonstrate quality of outcome. There are no scientific data correlating the volume of colonoscopies performed with the acquisition of competence.1,12 The American Society for Gastrointestinal Endoscopy (ASGE) recommends that physicians perform a minimum of 100 diagnostic colonoscopies and 20 snare polypectomies as a threshold for determining clinical competence.16 However, this recommendation was based on expert opinion, not scientific data.12

Family physicians seeking colonoscopy privileges should document their training and experience. This includes a record of patients' operative reports (Table 4), a record of experience and training (Table 5), and a competence-based evaluation or recommendation from their residency program or faculty instructors.

TABLE 4

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

Complications

TABLE 4   Content of Procedure Notes

View Table

TABLE 4

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

Complications

TABLE 5

Suggested Documentation of Colonoscopy Experience

Number of procedures 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

TABLE 5   Suggested Documentation of Colonoscopy Experience

View Table

TABLE 5

Suggested Documentation of Colonoscopy Experience

Number of procedures 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

Informed consent must also be obtained, with documentation that potential complications from the procedure and medications have been discussed with the patient. It is also important to document that alternative diagnostic tests and their advantages and disadvantages compared with endoscopy were discussed.5

The amount of continuing colonoscopy experience needed to maintain proficiency has not been extensively studied. However, researchers have reported that family physicians performing endoscopic procedures have outcomes comparable to, or exceeding, those of other specialists.5,1719

Credentialing and Privileges

Current policies and procedures for credentialing family physicians in colonoscopy vary markedly from site to site. In hospitals with departments of family practice 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 practice 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. However, this requirement is not consistent with JCAHO and AMA credentialing criteria. The latter require that privileges be based on criteria such as training, experience, demonstrated ability, current licensure and health status, rather than medical specialty.2,3

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. However, this approach is not consistent with JCAHO or AMA credentialing guidelines.

Family physicians moving to new practice sites who plan on performing colonoscopy should research the site's policies and procedures regarding privileges for colonoscopy and obtain these privileges before moving to the new 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 colonoscopy20:

  1. Carefully study the language of the hospital privileges policy and understand the process by which the privileges are granted.

  2. Prepare a brief resume describing your educational background, including college, medical school, residency and board certification/recertification. Include dates of hospital affiliations, state and national medical societies, professional honors, awards, elected offices or committee chair positions. Describe any prior hands-on proctorship experiences.

  3. Describe your years of practice and your record in providing high-quality health care in a variety of cases. This description should include the number of colonoscopies performed, your reach-the-cecum rate and your complication rate.

  4. List all accredited continuing medical education (CME) courses you have taken that pertain to colonoscopy and include any self-study of gastrointestinal disease, such as atlases, articles, etc.

  5. Include a summary letter from your residency or state chapter of the AAFP that supports these privileges as being within the scope of family practice.

  6. Include a copy of the AAFP Policy on Gastrointestinal Endoscopic Training, which includes the following points21:

    1. Gastrointestinal endoscopy should be performed by physicians with documented training and experience, and demonstrated competence in the procedures.

    2. Training in endoscopy includes clinical indications, diagnostic problem solving, mechanical skills acquired under direct supervision, and prevention and management of complications.

    3. Endoscopic competence is determined and verified by evaluation of performance under clinical conditions rather than by an arbitrary number of procedures.

    4. Endoscopic competence should be demonstrated by any physician seeking privileges for the procedure.

    5. 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.

    6. Endoscopic privileges should be defined by the institution granting privileges and reviewed periodically with due consideration for performance and continuing education.22

  7. 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.23

  8. Highlight the AMA clinical privileges policy from the AMA Policy Compendium.

  9. Highlight the JCAHO clinical privileges policy from its Comprehensive Accreditation Manual for Hospitals.

  10. Identify to the appropriate hospital committee a physician on staff with colonoscopy privileges who is willing to proctor you.

  11. 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.5

  12. 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.

  13. Establish a plan for continuing medical education, such as attendance at gastrointestinal conferences or board reviews, annual meetings of the American College of Gastroenterology and the American Gastroenterology Association, and Digestive Disease Week.

  14. Express your willingness to work with the hospital to provide any information it believes is missing or incomplete.

  15. If necessary, indicate that legal opinion and precedence have determined liability regarding the granting 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:

    1. 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.

    2. 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.

    3. There is no evidence that only board-certified gastroenterologists are qualified to perform endoscopic procedures.

    4. Hospitals violate the Medicare Conditions for Participation if they base credentialing decisions solely on specialty board certification.

    5. 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 certification.5,24

In addition to in-hospital colonoscopy, office colonoscopy may be considered as a safe and cost-effective alternative.5,10 Because of the equipment expense, this may be too costly an option for physicians, especially solo practitioners. If office colonoscopy is performed, monitoring equipment is needed. This should include a pulse oximeter, blood pressure cuff (preferably automated), electrocardiogram monitor, oxygen and a crash cart, with naloxone (Narcan) and flumazenil (Mazicon) 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.

Because 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 with these requirements and with state licensing or regulatory standards.

Future Issues

The research agenda relating to colonoscopy by family physicians should focus on these major areas:

  1. 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.

  2. Research training methods, including cognitive and procedural aspects. The learning curve issue needs to be addressed. 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.

Many training opportunities are available for family physicians to become qualified to perform colonoscopy. The ability of family physicians to perform this procedure will maintain and increase patient access to and quality and continuity of care. Hospital privileges can and should be sought by qualified family physicians, and there is professional and legal precedence to support granting of such privileges.24 Granting of colonoscopy privileges, like all privileges, must be determined solely on the basis of documented training, experience and current clinical competence of the individual physician. Research is needed to determine any relationship between the number of procedures performed and demonstrated proficiency and maintenance of skills. A collegial relationship between the AAFP and other specialties committed to quality colonoscopy should be established and maintained.

REFERENCES

1. Ackermann RJ. Performance of gastrointestinal tract endoscopy by primary care physicians. Lessons from the US Medicare database. Arch Fam Med. 1997;6:52–8.

2. Carr KW, Worthington JM, Rodney WM, Gentry S, Sellers A, Sizemore J. Advancing from flexible sigmoidoscopy to colonoscopy in rural family practice. Tenn Med. 1998;91:21–6.

3. American Academy of Family Physicians Facts about family practice, 1996 Kansas City, Mo: The Academy, 1996.

4. Guide for the use of American College of Physicians Statements on Clinical Competence. Health and Public Policy Committee. Ann Intern Med. 1987;107:588–9.

5. Musallam LS. Privileges, credentialing, and liability. Prim Care. 1995;22:491–8.

6. Joint Commission on Accreditation of Healthcare Organizations. Comprehensive accreditation manual for hospitals: the official handbook. Oakbrook Terrace, Ill.: The Commission, 1998.

7. American Medical Association. Department of Hospital Medical Staff Services Statements on delineation of hospital privileges. Chicago: The Association, 1991.

8. American Medical Association. Clinical privileges In: AMA policy compendium. Chicago: The Association, 1993.

9. American Academy of Family Physicians. Practice Profile Survey I. Kansas City, Mo.: The Academy, 1999.

10. Young RA, Byrd AN. Practice patterns of rural Texas physicians trained in a full-service family practice residency program. Tex Med. 1999;95:64–8.

11. American Academy of Family Physicians. Practice Profile Survey II. Kansas City, Mo.: The Academy, 1998.

12. Harper MB, Pope JB, Mayeaux EJ, Davis TJ, Myers A, Lirette A. Colonoscopy experience at a family practice residency: a comparison to gastroenterology and general surgery services. Fam Med. 1997;29:575–9.

13. American Academy of Family Physicians. Facts about family practice. Kansas City, Mo.: The Academy, 1993.

14. Brandt LJ, Daum F, eds. Clinical practice of gastroenterology. Vol 2. Philadelphia: Current Medicine, 1999.

15. Robinson R. Colonoscopy. Prim Care. 1995;22:399–409.

16. Vennes JA, Ament M, Boyce HW, Cotton PB, Jensen DM, Ravich WJ, et al. Principles of training in gastrointestinal endoscopy. American Society for Gastrointestinal Endoscopy. Standards of Training Committees, 1989–1990. Gastrointest Endosc. 1992;38:743–6.

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;156:2065–9.

18. Pierzchajlo RP, Ackermann RJ, Vogel RL. Colonoscopy performed by a family physician. A case series of 751 procedures. J Fam Pract. 1997;44:473–80.

19. Hopper W, Kyker KA, Rodney WM. Colonoscopy by a family physician: a 9-year experience of 1,048 procedures. J Fam Pract. 1996;43:561–6.

20. Rodney WM. How to apply for GI endoscopy privileges. Memorandum to the American Academy of Family Physicians CoCME. 6th draft. June 29, 1994.

21. Task Force on Procedures Training and credentialing of family physicians in EGD Procedural skills position paper Kansas City, Mo: American Academy of Family Physicians, 1995.

22. Tudor JM Jr. Hospital privileges in gastrointestinal endoscopy Memorandum to US Hospitals. July 1993.

23. American Academy of Family Physicians. 1992–1993. Compendium of AAFP positions on selected health issues. Kansas City, Mo.: The Academy, 1993:67.

24. Smith, Gill, Fisher & Butts, Attorneys. Opinion letter to the American Academy of Family Physicians, July 20, 1993.


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