Colonoscopy (Position Paper)

Colonoscopy is an indispensable part of modern medical practice and is 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 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

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.^1,3,4 Joint Commission (JC) requires this, as stated in its “Comprehensive Accreditation Manual for Hospitals":^5,6

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.

1. 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 the following are included in the criteria:

2. Each of the criteria used are consistently evaluated for all practitioners holding that privilege.

The American Medical Association (AMA) holds a similar position. Regarding Staff Privileges E-4.07 “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.”⁷

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:

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.^5,14

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.

Skills for performing colonoscopy are most often acquired during three years of family medicine residency training. Another possible route to acquiring colonoscopy 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 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.

Although the number of procedures performed in training is sometimes recommended as a mechanism 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.^1,13 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.²¹ However, this recommendation was based on expert opinion, not scientific data.¹³

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.

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.^5,16,19,20

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. However, this is not consistent with JC and AMA credentialing criteria. Both 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 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

In addition to in-hospital colonoscopy, office colonoscopy may be considered as a safe and cost-effective alternative.^5,11 Because of the equipment expense, however, 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 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 with these requirements, as well as with state licensing or regulatory standards.

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

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 both professional and legal precedence to support granting of such privileges.²⁶ 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.

(B2000) (2008)