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Colonoscopy (Position Paper)
Family physicians have demonstrated the ability to learn and safely and effectively 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
SECTION I - Scope of Practice for Family Physicians
MS.4.15 The decision to grant or deny a privilege(s), and/or to renew an existing privilege(s), is an objective, evidenced-based process.
- 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
E-4.07 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. 8
The performance of colonoscopy is within the scope of family medicine, evidenced by the following:
- 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.10
- In rural areas, an average of 5.7% of family physicians perform colonoscopy. One geographic area in Texas reported a rate as high as 42% among physicians who graduated from family medicine residencies since 1990.11
- On the 1998 AAFP Practice Profile Survey, 1,163 family physicians reported performing colonoscopy in their offices.12
- Twenty-six percent of family medicine residency programs provide training in colonoscopy.13
SECTION II - Clinical Indications
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.2,13
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, and fewer (often redundant) lab 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.
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
SECTION III - Training Methods
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 the recognition of the contraindications to colonoscopy, 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.15,17
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 physicians are prepared for an anesthetic or cardiopulmonary complication.
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 arrythmias or ischemia
- Transient bacteremia
- Postpolypectomy syndrome
- Drug reaction
SECTION IV - Testing, Demonstrated Proficiency and Documentation
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.25, 26, 27
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), keeping 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 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
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.5,16,19,20
SECTION V - Credentialing and Privileges
“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 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:22
- Carefully study the language of the hospital privileges policy, and understand the process by which the privileges are granted.
- 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.
- 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 “reach-the-cecum” 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.
- Include a copy of the “American Academy of Family Physicians Policy on Gastrointestinal Endoscopic Training,” which includes the following points.23
- Gastrointestinal endoscopy should be performed by physicians with documented training and/or experience, and demonstrated competence in the procedures.
- Training in endoscopy includes clinical indications, diagnostic problem solving, mechanical skills acquired under direct supervision and prevention and management of complications.
- Endoscopic competence is determined and verified by evaluation of performance under clinical conditions rather than by an arbitrary number of procedures.
- Endoscopic competence should be demonstrated by any physician seeking privileges for the procedure.
- 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.
- 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.25
- Highlight the AMA clinical privileges policy from the “AMA Policy Compendium.”
- Highlight the JCAHO clinical privileges policy from its “Comprehensive Accreditation Manual for Hospitals.”
- Identify to the appropriate hospital committee a physician on staff with colonoscopy privileges who 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.”5
- 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 and the American Gastroenterology Association, and the Digestive Disease Week.
- Express your willingness to work with the hospital in order to provide any information it believes is missing or incomplete.
- If necessary, indicate that legal opinion and precedence 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:
- 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.
- 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.
- There is no evidence that only board-certified gastroenterologists are “qualified” to perform endoscopic procedures.
- Hospitals violate the “Medicare Conditions for Participation” if they base credentialing decisions solely on specialty board certification.
- 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.5,26
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 with these requirements, as well as with state licensing or regulatory standards.
SECTION VI - Future Issues
- 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.
- 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.
- Ackermann RJ. Performance of gastrointestinal tract endoscopy by primary care physicians. Lessons from the US Medicare database. Arch Fam Med. 1997;6(1):52-58.
- 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.
- American Academy of Family Physicians. Facts about family practice, 1996. Kansas City, Mo: American Academy of Family Physicians; 1996.
- Guide for the use of American College of Physicians Statements on Clinical Competence. Health and Public Policy Committee. Ann Intern Med. 1987;107(4):588-589.
- Musallam LS. Privileges, credentialing, and liability. Prim Care. 1995;22(3):491-498.
- Joint Commission on Accreditation of Healthcare Organizations. Comprehensive accreditation manual for hospitals: the official handbook. Oakbrook Terrace, Ill: Joint Commission on Accreditation of Healthcare Organizations; 2008.
- American Medical Association. Hospital Privileges H-230.998 Reaffirmed: Sunset Report,A-001, Chicago, Ill.
- American Medical Association. Staff Privileges E-4.07 Chicago, Ill: American Medical Association; 1994.
- American Academy of Family Physicians. Practice Profile Survey I. Kansas City, Mo: American Academy of Family Physicians; 1999.
- 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.
- American Academy of Family Physicians. Practice Profile Survey II. Kansas City, Mo: American Academy of Family Physicians; 1998.
- 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.
- American Academy of Family Physicians. Facts about family practice. Kansas City, Mo: American Academy of Family Physicians; 1993.
- Brandt LJ, Daum F, eds. Clinical practice of gastroenterology. Vol 2. Philadelphia, Pa: Current Medicine; 1999.
- Robinson R. Colonoscopy. Prim Care. 1995;22(3):399-409.
- Vennes JA, Ament M, Boyce HW Jr, et al. Principles of training in gastrointestinal endoscopy. American Society for Gastrointestinal Endoscopy. Standards of Training Committees. 1989-1990. Gastrointest Endosc. 1992;38(6):743-746.
- 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):2065-2069.
- 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.
- 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.
- Rodney WM. How to apply for GI endoscopy privileges. Memorandum to the AAFP CoCME. 6th draft. June 29, 1994.
- 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.
- Tudor JM, Jr. Hospital privileges in gastrointestinal endoscopy. Memorandum to US Hospitals. July, 1993.
- American Academy of Family Physicians. 1992-1993 Compendium of AAFP positions on selected health issues. Kansas City, MO: American Academy of Family Physycians; 1993;67.
- Smith, Gill, Fisher & Butts, Attorneys. Opinion letter to the AAFP, July 20, 1993.
- Johnson L, Short M, Domagalski J, Jaboori K. Colonoscopy by a family physician: a case series assessing quality indicators in 800 procedures Department of Family Medicine, Madigan Army Medical Center 2007
- Short M, Kelly K, Runser L. Colonoscopy by a Family Physician: A Case Series Demonstrating Health Care Savings. Military Medicine Vol. 172, October 2007
- Bittner J, Marks M, Dunkin B, Richards W, Onders R, Mellinger J. Resident Training in Flexible Gastroinstentinal Endoscopy: A Review of Current Issues and Options, Journal of Surgical Education 2007