See also:
Obstetrics Privileges
Rural Practice: Family Medicine Graduate Medical Education Training for Rural Practice (Position Paper)
Colposcopy (Position Paper)
Overview and Justification
Worldwide, cervical cancer claims around 190,000 lives annually, and is the third most common cause of cancer-related death.1,2 In the United States, rates decreased from 14.2 new cases per 100,000 women in 1973 to 7.8 cases per 100,000 women in 1994, but despite the decrease, cervical cancer still remains the 10th leading cause of cancer death among women.3 As a result, it is estimated that over 2 million women annually will undergo colposcopy.4
Studies show that access to health care is an important predictor of cancer screening. The availability of physicians to provide screening could significantly decrease the mortality rate.5 The five-year survival rate is as high as 92 percent when cervical cancers are detected at an early stage.6
Although the Papanicolaou smear (Pap Smear) has become the standard method of screening, it fails as a definitive test to rule out disease. The false-negative rate of the Pap smear ranges from 1.5% to as high as 80%.7 The most likely scenario for false-negatives is that the critical areas on the cervix have not been sampled or the laboratory fails to identify abnormal cells on the smear due to sampling error or the presence of inflammation or excessive blood. The patient may also contribute to the false-negative rate by douching or having intercourse prior to the examination. Whatever the reason, if the Pap smear is underestimated, the patient may be erroneously triaged to observation or repeat cytologic surveillance rather than to a diagnostic test such as colposcopy.
While the Pap smear is the commonly used test for cervical cancer screening, colposcopy is the diagnostic test to evaluate patients with abnormal Pap smears.8 Colposcopy is a procedure that examines lower genital tract tissue under magnified illumination after the application of 3 to 5 percent acetic acid. A green filter highlights vascular patterns.
Neither cytologic sampling nor colposcopic examination alone provide definitive answers. If abnormal tissue is present, it is the histologic result that provides the basis for treatment or observation. Colposcopic-directed biopsies to confirm lower genital tract disease have become common procedure for many physicians, including family physicians. They are also performed by nurse practitioners, and physician assistants.
Studies show that access to health care is an important predictor of cancer screening. The availability of physicians to provide screening could significantly decrease the mortality rate.5 The five-year survival rate is as high as 92 percent when cervical cancers are detected at an early stage.6
Although the Papanicolaou smear (Pap Smear) has become the standard method of screening, it fails as a definitive test to rule out disease. The false-negative rate of the Pap smear ranges from 1.5% to as high as 80%.7 The most likely scenario for false-negatives is that the critical areas on the cervix have not been sampled or the laboratory fails to identify abnormal cells on the smear due to sampling error or the presence of inflammation or excessive blood. The patient may also contribute to the false-negative rate by douching or having intercourse prior to the examination. Whatever the reason, if the Pap smear is underestimated, the patient may be erroneously triaged to observation or repeat cytologic surveillance rather than to a diagnostic test such as colposcopy.
While the Pap smear is the commonly used test for cervical cancer screening, colposcopy is the diagnostic test to evaluate patients with abnormal Pap smears.8 Colposcopy is a procedure that examines lower genital tract tissue under magnified illumination after the application of 3 to 5 percent acetic acid. A green filter highlights vascular patterns.
Neither cytologic sampling nor colposcopic examination alone provide definitive answers. If abnormal tissue is present, it is the histologic result that provides the basis for treatment or observation. Colposcopic-directed biopsies to confirm lower genital tract disease have become common procedure for many physicians, including family physicians. They are also performed by nurse practitioners, and physician assistants.
SECTION I - Scope of Practice for Family Physicians
It is the position of the American Academy of Family Physicians that clinical privileges should be based on the individual physician’s documented training and/or experience, demonstrated abilities and current competence. This general policy would of course apply to privileges in all areas.9 The AAFP also advocates the development of specific patient-centered practice policies which focus on what should be done for the patient rather than who should do it. When policies 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.10
The American Medical Association’s (AMA) policy on staff privileges states that 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. Personal friendships, antagonisms, jurisdictional disputes, or fear of competition should not play a role in making these decisions.11
The Joint Commission on Accreditation of Health Care Organizations (JCAHO) defines the following four criteria for establishing and maintaining a qualified and competent medical staff: (1) current licensure; (2) relevant training or experience; (3) current competence; and (4) ability to perform the privileges requested.12
It is well established that performance of colposcopy is within the scope of family medicine. Recent Academy statistics show that 31.5% of Active AAFP members perform this procedure in the office setting.13
Interspecialty conflicts can produce tension in professional relationships. General consensus guidelines by recognized societies and organizations could help reduce this. However, conflicts and physician credentialing difficulties will only be solved by recognition that physicians’ practices are determined only by training, experience and competency, not by the type of specialty training.
The American Medical Association’s (AMA) policy on staff privileges states that 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. Personal friendships, antagonisms, jurisdictional disputes, or fear of competition should not play a role in making these decisions.11
The Joint Commission on Accreditation of Health Care Organizations (JCAHO) defines the following four criteria for establishing and maintaining a qualified and competent medical staff: (1) current licensure; (2) relevant training or experience; (3) current competence; and (4) ability to perform the privileges requested.12
It is well established that performance of colposcopy is within the scope of family medicine. Recent Academy statistics show that 31.5% of Active AAFP members perform this procedure in the office setting.13
Interspecialty conflicts can produce tension in professional relationships. General consensus guidelines by recognized societies and organizations could help reduce this. However, conflicts and physician credentialing difficulties will only be solved by recognition that physicians’ practices are determined only by training, experience and competency, not by the type of specialty training.
SECTION II - Clinical Indications for Colposcopy
Evaluation of an abnormal Pap smear is the primary indication for colposcopy. There is no authoritative document or consensus panel report that explicitly details the indications for colposcopy; however, examination of the cervix is recommended at any time magnified illumination of the lower genital tract is desired.
The following are generally considered to be the most specific indications for colposcopy:
The following are generally considered to be the most specific indications for colposcopy:
- Evaluation of the abnormal Pap smear.
- Evaluation of abnormal-appearing tissue in the vagina, on the cervix or vulva, perineum, perianal area or male genitalia.
- Evaluation of the abnormal-appearing cervix, even if cervical cytology is normal.
- Evaluation of patients with in-utero exposure to diethylstilbestrol (DES).
- Evaluation of child abuse and rape cases.
- A high-risk history for cervical cancer, such as a male partner who has had previous or current sexual partners who developed cervical cancer.
- Follow-up examinations after treatment for HGSIL or lower genital tract cancer.
SECTION III - Training Methodology
A joint task force of the AAFP and the American College of Obstetricians and Gynecologists (ACOG) developed Recommended Curriculum Guidelines for Family Medicine Residents: Maternity and Gynecologic Care. These core guidelines, which include colposcopy as a recommended skill, are intended to aid residency directors in developing curricula and to assist residents in identifying areas of necessary training.14 A 2002 survey of residency program directors shows that 94.1% of family medicine residency programs are currently teaching colposcopy.15
The AAFP sponsors introductory colposcopy continuing medical education (CME) courses at the Scientific Assembly. In addition, the AAFP offers a freestanding Colposcopy Update & Review Course, which is immediately preceded by a Women’s Health in Primary Care course. The AAFP maintains a registry of accredited courses and has published a comprehensive monograph, including syllabus, video and atlas, which was written and edited by family physicians. Family physician authors continue to publish articles on colposcopy in peer-reviewed journals.
A curriculum in colposcopy must provide both cognitive and psychomotor skills. The cognitive experience may be achieved from programmed texts such as the AAFP Colposcopy Self-Study CD-ROM, the AAFP Colposcopy Syllabus and Video Tape, or online CME from the American Society of Colposcopy and Cervical Pathology (ASCCP). Numerous colposcopy courses are also taught through various organizations and institutions.
In the ideal situation, the learner would continue a lifelong learning curve that would incorporate participation at intermediate and advanced level colposcopy courses and membership in societies actively involved in developing practice guidelines and developing standards for colposcopic excellence based on evidence-based literature and outcomes data.
The AAFP sponsors introductory colposcopy continuing medical education (CME) courses at the Scientific Assembly. In addition, the AAFP offers a freestanding Colposcopy Update & Review Course, which is immediately preceded by a Women’s Health in Primary Care course. The AAFP maintains a registry of accredited courses and has published a comprehensive monograph, including syllabus, video and atlas, which was written and edited by family physicians. Family physician authors continue to publish articles on colposcopy in peer-reviewed journals.
A curriculum in colposcopy must provide both cognitive and psychomotor skills. The cognitive experience may be achieved from programmed texts such as the AAFP Colposcopy Self-Study CD-ROM, the AAFP Colposcopy Syllabus and Video Tape, or online CME from the American Society of Colposcopy and Cervical Pathology (ASCCP). Numerous colposcopy courses are also taught through various organizations and institutions.
In the ideal situation, the learner would continue a lifelong learning curve that would incorporate participation at intermediate and advanced level colposcopy courses and membership in societies actively involved in developing practice guidelines and developing standards for colposcopic excellence based on evidence-based literature and outcomes data.
SECTION IV - Testing, Demonstrated Proficiency and Documentation
The AAFP believes the use of clinical proctoring is an important peer review tool for physicians seeking privileges in hospitals and healthcare organizations. The AAFP supports the development of proctoring programs, with appropriate medical staff bylaws provisions, to evaluate the clinical competency of new medical staff members and existing medical staff members who request new privileges. The AAFP strongly believes that proctoring requirements apply equally to all medical staff members, regardless of specialty, and that family physicians proctor family physicians whenever possible.16
Definitions of Clinical Proctoring
Proctoring is an objective evaluation of a physician's clinical competence by a proctor who represents, and is responsible to, the medical staff. Initial applicants seeking privileges or existing medical staff members requesting new or expanded privileges are proctored while providing the services for which privileges are requested. In most instances, a proctor acts only as a monitor to evaluate technical and cognitive skills of another physician. A proctor does not directly participate in patient care, has no physician-patient relationship with the patient being treated, does not receive a fee from the patient, and represents and is responsible to the medical staff.
The terms proctorship and preceptorship are sometimes used interchangeably. However, a preceptorship is different in that it is an educational program in which a physician acquires additional skills, and the preceptor has primary responsibility for the patient's care.
There are three types of proctoring: prospective, concurrent, and retrospective. Prospective proctoring is a review by the proctor of either the patient's chart or the patient personally before treatment. This type of proctoring may be used if the indications for a particular procedure are difficult to determine or if the procedure is particularly risky. Concurrent proctoring is when the proctor actually observes the physician's work. This is usually used for invasive procedures so that the medical staff has first-hand knowledge necessary to satisfy itself that the physician is competent. Retrospective proctoring involves a retrospective review of patient charts by the proctoring physician. Retrospective review is usually adequate for proctoring of noninvasive procedures.17
Proctoring Guidelines for Bylaws Provisions
Definitions of Clinical Proctoring
Proctoring is an objective evaluation of a physician's clinical competence by a proctor who represents, and is responsible to, the medical staff. Initial applicants seeking privileges or existing medical staff members requesting new or expanded privileges are proctored while providing the services for which privileges are requested. In most instances, a proctor acts only as a monitor to evaluate technical and cognitive skills of another physician. A proctor does not directly participate in patient care, has no physician-patient relationship with the patient being treated, does not receive a fee from the patient, and represents and is responsible to the medical staff.
The terms proctorship and preceptorship are sometimes used interchangeably. However, a preceptorship is different in that it is an educational program in which a physician acquires additional skills, and the preceptor has primary responsibility for the patient's care.
There are three types of proctoring: prospective, concurrent, and retrospective. Prospective proctoring is a review by the proctor of either the patient's chart or the patient personally before treatment. This type of proctoring may be used if the indications for a particular procedure are difficult to determine or if the procedure is particularly risky. Concurrent proctoring is when the proctor actually observes the physician's work. This is usually used for invasive procedures so that the medical staff has first-hand knowledge necessary to satisfy itself that the physician is competent. Retrospective proctoring involves a retrospective review of patient charts by the proctoring physician. Retrospective review is usually adequate for proctoring of noninvasive procedures.17
Proctoring Guidelines for Bylaws Provisions
- If evidence of sufficient experience is lacking, initial appointees to the medical staff and all existing medical staff members requesting new privileges should be subject to a period of proctoring, regardless of specialty.
- In departmentalized hospitals, each department should proctor its own new members or existing members who are requesting new privileges. For example, just as the family medicine department should recommend privileges for its members directly to the credentials committee without obtaining the approval of other departments, the department should also perform the proctoring for those privileges. If there is no suitable proctor within the department, the department will select a proctor from the medical staff. In departmentalized hospitals, each department should proctor its own new members or existing members who are requesting new privileges.
- In non-departmentalized hospitals, proctoring responsibilities should be assigned by the medical executive committee. The proctor should have similar qualifications and be in the same specialty as the applicant.
- The proctor should be impartial and have documented training and/or experience, demonstrated abilities, and current competence in the service or procedure that is the subject of the proctoring and should be a member of the hospital's medical staff. Occasional service as a proctor should be required for all medical staff members by the medical staff bylaws. If no suitable proctor is available on the medical staff (as may occur in rural hospitals), the hospital should obtain a proctor from another institution or training program. The hospital should pay the expenses incurred in obtaining that proctor.
- The proctor's duty is to observe, evaluate, and report to the department chair or medical executive committee. In the event a proctor finds it necessary to move beyond observation and evaluation and to intervene in a case, the hospital should agree in writing to indemnify the proctored physician for any damages that might occur from following the proctor's orders. (The medical executive committee should get written confirmation of this from the hospital's insurance carrier.) Likewise, the hospital should agree to indemnify a proctor for any damages resulting from a claim of battery.
- The proctor should prepare a written report describing the cases proctored and evaluating the applicant's performance. The report should be submitted by the department chair to the medical executive committee. In addition to the report, the department chair should recommend to the executive committee that the physician either (1) continue to exercise the clinical privileges initially granted, (2) be required to extend the proctoring period, or (3) have privileges restricted or terminated in accordance with the bylaws. The decision of the department should be based on the physician's performance during the proctorship period.
- The proctoring report should remain confidential and should be handled as other medical staff peer review information. The medical staff, through the Board of Trustees, should determine where the files will be kept, who will have access, when and in what format; the procedure for physicians to appeal the reports or question the proctor who wrote them; and policy on retention of proctoring reports.18
SECTION V - Credentialing and Privileges
The process for credentialing and delineation of family medicine privileges varies among organizations. Before applying for colposcopy privileges, the documentation of training, experience and current competence should be in order. The following are guidelines that will help with the credentialing process:19
- Collect letters of recommendation from past instructors, preceptors, those who have monitored your clinical performance, and colleagues who have worked with you throughout the years.
- Assemble case reports including data about the number and types of cases, treatment outcomes, etc.
- Assemble documentation records maintained during your family medicine residency.
Complete documentation, case reports, and letters of recommendation should be in order at the time of application for medical staff privileges. It is important that a copy of each document be submitted in the event that the original documents are lost or misplaced. Ongoing documentation of clinical experiences should be maintained.19
The AAFP recommends the establishment of family medicine departments in all hospitals departmentalized by specialty. The department of family medicine should have all the rights, duties, and responsibilities comparable to other specialty departments of the medical staff. It should have the right to recommend directly to the appropriate committee those privileges which fall within the scope of family medicine. The assent or approval of any other department should not be required.20
The AAFP believes that the department of family medicine should establish and use a core privileging process based on criteria developed by the department. Core privileges within the department of family medicine should reflect the core curriculum and training offered in accredited family medicine residency programs. Criteria for privileges outside of the core should be pre-established by the department of family medicine in consultation with other appropriate clinical departments. Recommendations for privileges outside the family medicine core may then be considered by the department of family medicine according to the criteria jointly established by the relevant clinical departments. In all cases, clinical review of a physician should be done in the department where the privilege originated.20
Some privilege problems arise because other specialists do not understand the scope of family medicine. In addition to providing other specialists with general information about family medicine, specific issues include:
The AAFP recommends the establishment of family medicine departments in all hospitals departmentalized by specialty. The department of family medicine should have all the rights, duties, and responsibilities comparable to other specialty departments of the medical staff. It should have the right to recommend directly to the appropriate committee those privileges which fall within the scope of family medicine. The assent or approval of any other department should not be required.20
The AAFP believes that the department of family medicine should establish and use a core privileging process based on criteria developed by the department. Core privileges within the department of family medicine should reflect the core curriculum and training offered in accredited family medicine residency programs. Criteria for privileges outside of the core should be pre-established by the department of family medicine in consultation with other appropriate clinical departments. Recommendations for privileges outside the family medicine core may then be considered by the department of family medicine according to the criteria jointly established by the relevant clinical departments. In all cases, clinical review of a physician should be done in the department where the privilege originated.20
Some privilege problems arise because other specialists do not understand the scope of family medicine. In addition to providing other specialists with general information about family medicine, specific issues include:
- Clinical privileges should be considered on the basis of each individual physician’s documented training and/or experience, demonstrated abilities and current competence.
- Overlap occurs among many specialties.
- Clinical privileges are not the exclusive province of one department.
- A vital part of a family physician’s training includes when to consult and when to refer patients.
- Continuity of care is a primary objective of family medicine and this objective is consistent with quality patient care.
- Family physicians are supported by the AAFP in their efforts to obtain privileges for which they are qualified.
SECTION VI - Miscellaneous Issues
Quality assurance of didactic and procedural training is important and can be fostered through the AAFP prescribed credit mechanisms using expert physicians within the AAFP.
The public health implication of expanding family physicians’ use of colposcopy is improved access to timely care for patients. Reducing the incidence of cervical cancer should emphasize primary prevention by risk-factor identification and patient education in addition to secondary prevention by identification of dysplastic lesions at the time of colposcopy.
The financial implications of family physicians performing colposcopy are uncertain. Identification of disease at an earlier stage, improved compliance with follow-up regimens because of continuity of care issues, an increased knowledge and attention to risk factors and patient satisfaction would all appear to be favorable in reducing the overall costs to society.
The main educational research objectives should include a clear definition of competency-based measures required for performance of colposcopy and analysis of outcomes that compares the clinical practices of all specialties.
The public health implication of expanding family physicians’ use of colposcopy is improved access to timely care for patients. Reducing the incidence of cervical cancer should emphasize primary prevention by risk-factor identification and patient education in addition to secondary prevention by identification of dysplastic lesions at the time of colposcopy.
The financial implications of family physicians performing colposcopy are uncertain. Identification of disease at an earlier stage, improved compliance with follow-up regimens because of continuity of care issues, an increased knowledge and attention to risk factors and patient satisfaction would all appear to be favorable in reducing the overall costs to society.
The main educational research objectives should include a clear definition of competency-based measures required for performance of colposcopy and analysis of outcomes that compares the clinical practices of all specialties.
SECTION VII - Data Sources
- Rohan T, Burk R, Franco E. Toward a reduction of the global burden of cervical cancer. Am J Obstet Gynecol 2003;189(4):S37-9.
- American College of Obstetricians and Gynecologists. ACOG practice bulletin: cervical cytology screening;102(2):417-27.
- American Academy of Family Physicians. Screening for cervical cancer: recommendations and rational. Am Fam Phys 2003. Retrieved April 2004 from http://www.aafp.org/afp/20030415/usx.html.
- Schiffman M, Solomon D. Findings to date from the ASCUS-LSIL triage study. Arch Pathol Lab Med 2003;127(8):946-9.
- Campbell R, Ramirez A, Perez K, Roetzheim R. Cervical cancer rates and the supply of primary care physicians in Florida. Fam Med 2003;35:60-4.
- Saslow D, Runowitz C, Solomon D, Moscicki A, Smith R, Eyre H, Cohen C. American Cancer Society guideline for the early detection of cervical neoplasia and cancer. CA Cancer J Clin 2002;52:342-62.
- Olaniyan O. Validity of colposcopy in the diagnosis of early cervical neoplasia – a review. Afr J Reprod Health 2002;6(3):59-69.
- Mayeaux E, Newkirk G. Introduction to colposcopy. Retrieved April 2004 from http://lib-sh.lsuhsc.edu/fammed/atlases/colpoat.html.
- American Academy of Family Physicians. Position on hospital privileges for family physicians. Retrieved April 2004 from http://www.aafp.org/online/en//home/policy/policies/p/privileges.html.
- American Academy of Family Physicians. AAFP policy on the joint development of clinical policies with other organizations. Retrieved December 2003 from http://www.aafp.org/online/en//home/clinical/clinicalrecs/clinpracguide.html.
- American Medical Association. Staff privileges E-4.07. In: AMA policy compendium. Chicago, IL: American Medical Association; 1998.
- Joint Commission on Accreditation of Healthcare Organizations. 2002 hospital accreditation standards. Oakbrook Terrace, IL: Joint Commission on Accreditation of Health Care Organizations; 2002.
- American Academy of Family Physicians. Survey on procedural skills training. Leawood, KS: American Academy of Family Physicians; 2002.
- American Academy of Family Physicians-American College of Obstetricians and Gynecologists. Recommended curriculum guidelines for family practice residents: maternity and gynecologic care. Retrieved April 2004 from http://www.aafp.org/online/en/home/aboutus/specialty/rpsolutions/eduguide/maternitygyn.html.
- American Academy of Family Physicians. Survey on procedural skills training: family practice residency programs. Leawood, KS: American Academy of Family Physicians; 2002.
- American Academy of Family Physicians. Clinical proctoring, AAFP position. Retrieved April 2004 from http://www.aafp.org/online/en/home/policy/policies/c/clinicalproctor.html.
- American Academy of Family Physicians. Clinical proctoring, definitions of clinical proctoring. Retrieved April 2004 from http://www.aafp.org/online/en/home/policy/policies/c/clinicalproctor.html.
- American Academy of Family Physicians. Clinical proctoring, proctoring guidelines for bylaws provisions. Retrieved April 2004 from http://www.aafp.org/online/en/home/policy/policies/c/clinicalproctor.html.
- American Academy of Family Physicians. Protocol for handling hospital privileges problems for family physicians who are medical staff members. Retrieved December 2003 from http://www.aafp.org/online/en//home/practicemgt/privileges/assistancepriv/protocol.html.
- American Academy of Family Physicians. Position on family medicine departments and privileges. Retrieved December 2003 from http://www.aafp.org/online/en//home/policy/policies/p/privileges.html.
(B1998) (2004)