Colonoscopy (Position Paper)

Overview and Justification

Colonoscopy is an indispensable part of modern medical practice and one of the most commonly used invasive medical procedures. It is essential in diagnosing a variety of conditions, but it is most commonly used in the prevention and detection of colorectal cancer, the third most common cancer in men and women in the United States.1 Of cancers that affect both men and women, colorectal cancer is the second leading cause of cancer mortality in the United States, causing approximately 50,000 deaths each year.2,3,4 Colonoscopy screening is associated with a reduced risk of colorectal cancer mortality.5

Gastrointestinal complaints are often first reported to a family physician. Since family physicians are trained to diagnose, treat, and, if necessary, appropriately refer patients who have gastrointestinal (GI) disorders, knowing when colonoscopy is required is one aspect of a family physician’s role. Like other endoscopic procedures, colonoscopy has become “despecialized” in recent years and is now performed by physicians in many specialties.

Family physicians have demonstrated the ability to learn colonoscopy and to perform the procedure safely and effectively. Because family physicians practice in all areas, including rural and underserved areas, their ability to perform colonoscopy improves patients’ access to care.6 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. Patients also benefit from more rapid diagnosis and treatment, and enhanced continuity of care.

Section I - Scope of Practice for Family Physicians

Colonoscopy can be a natural extension of the comprehensive care provided by a family physician. According to the American Academy of Family Physicians (AAFP) Member Census (as of December 31, 2017), 2 percent of AAFP members perform colonoscopy in their practice.7 Family physicians choose a personal scope of practice based on factors that include their training experiences, their practice interests, and the needs of their patient populations. Therefore, each family physician must assess the appropriateness of performing colonoscopy in his or her practice. The physician should consider his or her training and level of comfort with the procedure, the expertise of staff members, the set-up of the office, local standards of care, economic implications, and privileging requirements.

Adenoma detection rate (ADR), which is defined as the proportion of a physician’s screening colonoscopies that detect one or more adenomas, is the primary quality measure in colonoscopy.8,9 The American Society for Gastrointestinal Endoscopy (ASGE)/American College of Gastroenterology (ACG) Task Force on Quality in Endoscopy recommends a minimum ADR target of 25% or greater in a population of men and women 50 years or older who are undergoing screening colonoscopy.8 The recommended ADR target is 30% or greater for screening colonoscopy in men 50 years or older and 20% or greater for screening colonoscopy in women 50 years or older.8 Studies have shown that trained primary care physicians who perform colonoscopy can meet established quality targets and perform the procedure safely and effectively.10,11 For example, in a 2015 study, family physicians performing colonoscopy had an ADR of 38.15% for men older than 50 years and 25.96% for women older than 50 years.12 In addition, studies have shown that primary care physicians who performcolonoscopy compare favorably with gastroenterologists and general surgeons when other observable factors, such as cecal intubation rate, the time required to complete the procedure, and the rate of complications, are used to determine technical competence.6,10-

Both limited capacity for endoscopy and an insufficient number of physicians who perform colonoscopy contribute to suboptimal colorectal cancer screening rates, particularly in underserved populations.12,18,19 Geographic proximity (travel time to or physical distance from a health care provider) has also been identified as a barrier to colorectal cancer screening and a cause of poorer outcomes for patients in rural areas.20 The quality, safety, and efficacy indicators for colonoscopies performed by primary care physicians meet or exceed the benchmarks established by the ASGE/ACG Task Force on Quality in Endoscopy and compare favorably with subspecialists.11,12 Therefore, increasing the number of trained family physicians who perform colonoscopy has the potential to improve colorectal cancer screening rates and access to care, and to reduce both colorectal cancer incidence and later-stage diagnosis.12,18,19,21 Benefits to the patient of having his or her family physician perform a colonoscopy include less fragmentation of care; increased patient comfort in having the procedure done by a familiar, trusted physician; decreased travel time; decreased cost to the patient; fewer lab tests; and high patient satisfaction.22

The provision of colonoscopy by family physicians also has community implications. Endoscopic procedures constitute a major portion of the clinical care provided by many hospitals and outpatient clinical settings. In order to continue providing this care, rural hospitals and outpatient clinical settings need physicians who can perform colonoscopy. The presence of family physicians who can provide modern endoscopic care may be one key factor in the survival of small hospitals and outpatient clinical settinings.

Section II - Clinical Indications

Colonoscopy is the most commonly used colorectal cancer screening test in the United States.23 The U.S. Preventive Services Task Force (USPSTF) recommends screening adults for colorectal cancer starting at age 50 years and continuing until age 75 years.4 This recommendation applies to individuals “who are at average risk of colorectal cancer and who do not have a family history of known genetic disorders that predispose them to a high lifetime risk of colorectal cancer (such as Lynch syndrome or familial adenomatous polyposis), a personal history of inflammatory bowel disease, a previous adenomatous polyp, or previous colorectal  cancer.”4The USPSTF does not recommend specific screening approaches, instead providing information about the effectiveness, strengths, limitations, and considerations for various screening tests, including colonoscopy, so that physicians can make informed decisions with individual patients.

The AAFP’s clinical preventive service recommendation for colorectal cancer screening in adults’ states: “The AAFP recommends screening for colorectal cancer with fecal immunochemical tests, flexible sigmoidoscopy, or colonoscopy starting at age 50 years and continuing until age 75 years. The risks, benefits, and strength of supporting evidence of different screening methods vary.”24 Under the Choosing Wisely campaign—a national effort to reduce waste in the health care system and avoid unnecessary or harmful tests and treatment, the American Gastroenterological Association (AGA) advises that individuals at average risk for colorectal cancer who undergo screening colonoscopy should have the exam every 10 years, beginning at age 50 years and continuing until age 75 years.25 Patients at higher risk may need more frequent screening.

The list of indications for GI endoscopy from the American Society for Gastrointestinal Endoscopy includes specific indications for colonoscopy (Table 1).

Table 1. ASGE Guidelines for GI Endoscopy and for Colonoscopy

GI endoscopy is generally indicated:

  1. If a change in management is probable based on results of endoscopy.
  2. After an empirical trial of therapy for a suspected benign digestive disorder has been unsuccesful.
  3. As the initial method of evaluation as an alternative to radiographic studies.
  4. When a primary therapeutic procedure is contemplated.  

GI endoscopy is generally not indicated:

  1. When the results will not contribute to a management choice.
  2. For periodic follow-up of healed benign disease unless surveillance of a premalignant condition is
        warranted.

GI endoscopy is generally contraindicated:

  1. When the risks to patient health or life are judged to outweigh the most favorable benefits of the procedure.
  2. When adequate patient cooperation or consent cannot be obtained.
  3. When a perforated viscus is known or suspected.

Colonoscopy

Colonoscopy is generally indicated in the following circumstances:

        A.    Evaluation of an abnormality on barium enema or other imaging study that is likely to be
               clinically significant, such as a filling defect and stricture.

        B.    Evaluation of unexplained GI bleeding:

                1.   Hematochezia.
                2.   Melena after an upper GI source has been excluded.
                3.   Presence of fecal occult blood.

        C.    Unexplained iron deficiency anemia.

        D.    Screening and surveillance for colonic neoplasia:

                1.    Screening of asymptomatic, average-risk patients for colonic neoplasia.
                2.    Examination to evaluate the entire colon for synchronous cancer or neoplastic polyps in a
                       patient with treatable cancer or neoplastic polyp.
                3.   Colonoscopy to remove synchronous neoplastic lesions at or around the time of curative
                      resection of cancer followed by colonoscopy at 1 year and, if normal, then 3 years, and, if
                      normal, then 5 years thereafter to detect metachronous cancer.
                4.   Surveillance of patients with neoplastic polyps.
                5.   Surveillance of patients with a significant family history of colorectal neoplasia.

        E.    For dysplasia and cancer surveillance in select patients with long-standing ulcerative or
               Crohn's colitis. For evaluation of patients with chronic inflammatory bowel disease of the colon,
                if more precise diagnosis or determination of the extent of activity of disease will influence
                management.

        F.    Clinically significant diarrhea of unexplained origin.

        G.   Intraoperative identification of a lesion not apparent at surgery (e.g., polypectomy site, location
              of a bleeding site).

        H.   Treatment of bleeding from such lesions as vascular malformation, ulceration, neoplasia, and
               polypectomy site.

        I.    Intraoperative evaluation of anastomotic reconstructions typical of surgery to treat diseases of
              the colon and rectum (e.g., evaluation for anastomotic leak and patency, bleeding, pouch
              formation).

        J.    As an adjunct to minimally invasive surgery for the treatment of diseases of the colon and
              rectum.

        K.    Management or evaluation of operative complications (e.g., dilation of anastomotic strictures).

        L.    Foreign body removal.

        M.    Excision or ablation of lesions.

        N.    Decompression of acute megacolon or sigmoid volvulus.

        O.    Balloon dilation of stenotic lesions (e.g., anastomotic strictures).

        P.    Palliative treatment of stenosing or bleeding neoplasms (e.g., laser, electrocoagulation,
               stenting).

        Q.    Marking a neoplasm for localization.

Colonoscopy is generally not indicated in the following circumstances:

        A.    Chronic, stable, irritable bowel syndrome or chronic abdominal pain; there are unusual
                exceptions in which colonoscopy may be done once to rule out disease, especially if
                symptoms are unresponsive to therapy.
        B.    Acute diarrhea.
        C.    Metastatic adenocarcinoma of unknown primary site in the absence of colonic signs or
               symptoms when it will not influence management.
        D.    Routine follow-up of inflammatory bowel disease (except for cancer surveillance in chronic
               ulcerative colitis and Crohn's colitis).
        E.    GI bleeding or melena with a demonstrated upper GI source.

Colonoscopy is generally contraindicated in:

        A.    Fulminant colitis.
        B.    Documented acute diverticulitis.

Reprinted with permission from Early DS, Ben-Menachem T, Decker GA, et al; ASGE Standards of Practice Committee. Appropriate use of GI endoscopy. Gastrointest Endosc. 2012;75(6):1127-1131.

Section III - Training Methodology

Family physicians most often acquire skills for performing colonoscopy during their family medicine residency training. The Society of Teachers of Family Medicine (STFM) Group on Hospital Medicine and Procedural Training includes colonoscopy on its list of core procedures for family medicine that all residents must have exposure to and be given the opportunity to be trained to perform independently by graduation.26 A task force of Council of Academic Family Medicine (CAFM) member organizations and experienced faculty and program directors published a consensus statement for procedural training in family medicine residency that includes colonoscopy as one of the more complex or advanced procedures for which training may be offered to interested residents in some family medicine residencies.27

The AAFP believes that adequate training can consist of documented education in an Accreditation Council for Graduate Medical Education (ACGME)-approved residency program that prepares residents to practice colonoscopy; continuing medical education (CME) courses that provide didactic and procedural training; and/or precepted experience focused on colonoscopy.28

Any training approach should develop both the cognitive skills involved in knowing when to perform colonoscopy and how to properly interpret and manage findings, and the technical skills involved in safely performing the procedure. Colonoscopy training should also address how to recognize and promptly treat procedure-related complications (Table 2).

Table 2. Possible Complications of Colonoscopy

  • Bleeding
  • Perforation
  • Respiratory depression
  • Bradycardia
  • Hypoxemia
  • Hypotension
  • Cardiac arrhythmias or ischemia
  • Transient bactermia
  • Postpolypectomy electrocoagulation syndrome
  • Bloating
  • Abdominal pain or discomfort

Information from ASGE Standards of Practice Committee, Fisher DA, Maple JT, et al. Complications of colonoscopy. Gastrointest Endosc. 2011;74(4):745-752.

Because of the use of intravenous (IV) conscious sedation, Advanced Cardiac Life Support (ACLS) training and certification may be required by hospitals or outpatient clinical settings for colonoscopy privileging. Even if ACLS certification is not required, it is recommended so that the physician performing a colonoscopy is prepared for an anesthetic or cardiopulmonary complication.

Section IV – Testing, Demonstrated Proficiency, and Documentation

Although the number of procedures performed in training is sometimes recommended as a criterion 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. It is clear that individual physicians have varying levels of manual dexterity and prior experience with flexible sigmoidoscopy and acquire skills at different rates.

Based on its review of available evidence, the AAFP has determined that the standard for determining a family physician’s basic competence in colonoscopy should be 50 procedures performed as the primary operator.29-31 The American Association for Primary Care Endoscopy (AAPCE) concurs, stating that if a hospital or outpatient clinical setting chooses to require a specific number of procedures during training, the requirement should not exceed 50 colonoscopies.32 The amount of continuing colonoscopy experience needed to maintain proficiency has not been extensively studied.

The AAFP recommends that family physicians document all significant procedural skills training and experience so that this information can be reported in an organized fashion.33 This includes keeping a record of the procedure note for each patient (Table 3), a record of colonoscopy experience and training (Table 4), and an evaluation of competence or recommendation from a residency program or faculty instructor(s).

Table 3. Suggested Content of Procedure Note

  • Patient identification or code
  • Date of procedure
  • Location of procedure (name of hospital or outpatient clinical setting)
  • 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. Suggested Documentation of Colonoscopy Experience

  • Number of procedures performed during training and in practice
  • Outcomes data, including complication rate
  • Letters from instructors, preceptors, and proctors documenting training, experience, demonstrated
        abilities, and current competence
  • Letters from hospitals and outpatient clinical settings documenting experience and outcomes

Section V - Credentialing and Privileges

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.34 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. It is the position of the 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.35 The AAFP has a policy that specifically addresses colonoscopy privileging.

The AAFP’s position is in line with the policies of other organizations with influence on credentialing and privileging:

  • The American Medical Association (AMA) policy on patient protection and clinical privileges states, in
        part, “Concerning the granting of staff and clinical privileges in hospitals and other health care
        facilities, the AMA believes: (1) the best interests of patients should be the predominant
        consideration; (2) the accordance and delineation of privileges should be determined on an
        individual basis, commensurate with an applicant's education, training, experience, and
        demonstrated current competence. 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.”36
  • The Joint Commission's standards also require that the decision to grant or deny privileges, and/or
        to renew existing privileges, must be an objective, evidence-based process in which there are no
        barriers to granting privileges for a given activity to more than one clinical specialty. The Joint
        Commission Comprehensive Accreditation and Certification Manual for 2017 states, “Credentialing
        involves the collection, verification, and assessment of information regarding three critical
        parameters: current licensure; education and relevant training; and experience, ability, and current
        competence to perform the requested privilege” [MS.06.01.03].37 All of the criteria regarding
        licensure, education, training, and current competence should be "consistently evaluated for all
        practitioners holding that privilege” [MS.06.01.05].37         

Lack of community need may be cited as a reason to withhold colonoscopy privileges from family physicians who practice in environments shared with subspecialists. However, this approach is not consistent with AAFP, AMA, or Joint Commission privileging policies.

Family physicians moving to a new practice site who plan on performing colonoscopy would benefit from researching the policies and procedures of their chosen site regarding privileges for colonoscopy and obtaining these privileges before actually moving to the new practice site, if possible. This approach is particularly advisable if a family physician is the first to request colonoscopy privileges in an environment in which gastroenterologists alone hold such privileges.

Table 5 lists recommended steps for family physicians applying for GI endoscopy privileges. Privileges for invasive procedures are usually granted provisionally with the requirement that the physician submit progress reports at designated intervals (e.g., three months, six months, one year). In a hospital departmentalized by specialty, the family medicine department should monitor these progress reports for department members and make recommendations for advancement from provisional privileges to active privileges. To ensure continuous monitoring of quality, physicians may be required to submit an annual census of all invasive procedures that lists any complications that arise.

Table 5. Applying for GI Endoscopy Privileges

  1. Become thoroughly familiar with the hospital or outpatient clinical setting’s bylaws and processes
        related to credentialing and privileging. Be cooperative yet persistent during the privileging process.
  2. Review the privileging resources available from the AAFP.
  3. Prepare a brief curriculum vitae (CV) that describes educational background, including college,
        medical school, residency, board certification, and recertification. List affiliations with hospitals,
        outpatient clinical settings, and state/national medical societies, including the duration of these
        affiliations. List any professional honors, elected offices, or committee chair positions.
  4. State the number of years in practice and describe provision of high-quality care for a variety of
        complicated cases. A physician can point to a record of exemplary service as evidence of professional
         excellence.
  5. Describe all completed CME courses on GI endoscopy and GI-related self-study (e.g., atlases,
        articles). In addition, be able to demonstrate an ongoing commitment to relevant continuing
        medical education.
  6. Obtain and include a summary letter from a residency or AAFP chapter stating that the requested
        privileges are within the scope of the specialty of family medicine.
  7. State the number of rigid sigmoidoscopies, flexible sigmoidoscopies, colonoscopies, and/or upper GI
        endoscopies performed. Include a log that lists procedures by date, patient age and sex, and
        indication. Provide diagnostic findings and prominently highlight a low rate of complications. 
  8. If required, describe any hands-on proctorship experience(s) and/or identify someone who is willing
        to serve as a proctor. A hands-on proctorship is not necessarily a prerequisite for physicians who
        have equivalent training and experience in GI endoscopy.
  9. Provide evidence of your ability to obtain malpractice insurance coverage.

Section VI – Miscellaneous Issues

A.    Current research agenda

The AAFP supports the need to conduct and publish research regarding the performance of colonoscopy by family physicians. This research should focus on the following major areas:

  • Quality assurance: Ongoing case review programs/studies to monitor the outcomes of colonoscopies
        performed by family physicians should be initiated, and these outcomes should be compared with
        those of other specialties.
  • Training methods, including cognitive and procedural aspects: Questions concerning the learning
        curve for colonoscopy should be addressed. For continuing quality improvement purposes, research
        is needed to determine the relationship significance, if any, between the number of colonoscopies
        performed and demonstrated proficiency and maintenance of skills.

B. Relationships with other organizations

AAFP policy states, "The AAFP should seek to work collaboratively with other specialty societies, when appropriate, concerning issues of procedure skills, including but not limited to: training, privileging and credentialing, and joint political action."38 Unfortunately, in the past, some specialty societies have been unwilling to work cooperatively with the AAFP on endoscopy issues. In such situations, the AAFP has had no choice but to develop its own educational programs. It would be ideal if the AAFP and other specialty organizations could work together to improve patient care by disseminating information to educate all physicians. The AAFP welcomes opportunities to partner with other groups that have members who perform colonoscopy.

Section VII – References

1.     Centers for Disease Control and Prevention. Colorectal cancer statistics.
        https://www.cdc.gov/cancer/colorectal/statistics/index.htm(www.cdc.gov). Accessed April 6, 2018.

2.     American Cancer Society. Cancer facts & figures 2018.
        https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annualcancer-(www.cancer.org)
        facts-and-figures/2018/cancer-facts-and-figures-2018.pdf(www.cancer.org).  Accessed April 6, 2018.

3.      American Cancer Society. Colorectal cancer facts & figures 2017-2019
https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/colorectalcancer-facts-and-figures/colorectal-cancer-facts-and-figures-2017-2019.pdf (www.cancer.org) Accessed April 6, 2018.

4.      U.S. Preventive Services Task Force. Final recommendation statement. Colorectal cancer:
        screening.
https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/colorectal-cancer-screening2(www.uspreventiveservicestaskforce.org). Accessed April 6, 2018.

5.     Baxter NN, Warren JL, Barrett MJ, Stukel TA, Doria-Rose VP. Association between colonoscopy and colorectal cancer mortality in a US cohort according to site of cancer and colonoscopist specialty. J Clin Oncol. 2012;30(21):2664-2669.

6.     Kolber MR, Wong CK, Fedorak RN, Rowe BH, APC-Endo Study Physicians. Prospective study of the quality of colonoscopies performed by primary care physicians: the Alberta Primary Care Endoscopy (APC-Endo) Study. PLoS One. 2013;8(6):e67017.

7.     American Academy of Family Physicians. AAFP Member Census, December 31, 2017. Table 12: Clinical procedures performed by physicians at their practice.
https://www.aafp.org/about/the-aafp/family-medicine-facts/table-12(rev).html. Accessed April 6, 2018.

8.     Rex DK, Schoenfeld PS, Cohen J, et al. Quality indicators for colonoscopy. Gastrointest Endosc. 2015;81(1):31-53.

9.     Corley DA, Jensen CD, Marks AR, et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med. 2014;370(14):1298-1306.

10.   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.

11.   Wilkins T, LeClair B, Smolkin M, et al. Screening colonoscopies by primary care physicians: a meta-analysis. Ann Fam Med. 2009;7(1):56-62. Erratum in: Ann Fam Med. 2009;7(2):181.

12.   McClellan DA, Ojinnaka CO, Pope R, et al. Expanding access to colorectal cancer screening: benchmarking quality indicators in a primary care colonoscopy program. J Am Board Fam Med. 2015;28(6):713-721.

13.   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.

14.   Kolber M, Szafran O, Suwal J, Diaz M. Outcomes of 1949 endoscopic procedures: performed by a Canadian rural family physician. Can Fam Physician. 2009;55(2):170-175.

15.   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.

16.   Xirasagar S, Hurley TG, Sros L, et al. Quality and safety of screening colonoscopies performed by primary care physicians with standby specialist support. Med Care. 2010;48(8):703-709.

17.   Newman RJ, Nichols DB, Cummings DM. Outpatient colonoscopy by rural family physicians. Ann Fam Med. 2005;3(2):122-125.

18.   Haas JS, Brawarsky P, Iyer A, et al. Association of local capacity for endoscopy with individual use of colorectal cancer screening and stage at diagnosis. Cancer. 2010;116(12):2922-2931.

19.   Soneji S, Armstrong K, Asch DA. Socioeconomic and physician supply determinants of racial disparities in colorectal cancer screening. J Oncol Pract. 2012;8(5):e125-134.

20.   Aboagye JK, Kaiser HE, Hayanga AJ. Rural-urban differences in access to specialist providers of colorectal cancer care in the United States. A physician workforce issue. JAMA Surg. 2014;149(6):537-543.

21.   Ananthakrishnan AN, Hoffmann RG, Saeian K. Higher physician density is associated with lower incidence of late-stage colorectal cancer. J Gen Intern Med. 2010;25(11):1164-1171.

22.   Nijjar UK, Edwards JA, Short MW. Patient satisfaction with family physician colonoscopists. J Am Board Fam Med. 2011;24(1):51-56.

23.   Klabunde CN, Joseph DA, King JB, White A, Plescia M. Vital signs: colorectal cancer screening test use—United States, 2012. MMWR Morb Mortal Wkly Rep. 2013;62(44):881-888.

24.   American Academy of Family Physicians. Clinical preventive service recommendation. Colorectal cancer screening, adults. https://www.aafp.org/patient-care/clinicalrecommendations/all/colorectal-cancer-adults.html. Accessed April 6, 2018.

25.   Choosing Wisely®. Colonoscopy. When you need it and when you don’t.
http://www.choosingwisely.org/wp-content/uploads/2018/02/Colonoscopy-AGA.pdf(www.choosingwisely.org). Accessed April 6, 2018.

26.   Nothnagle M, Sicilia JM, Forman S, et al. Required procedural training in family medicine: a consensus statement. Fam Med. 2008;40(4):248-252.

27.   Council of Academic Family Medicine (CAFM). Consensus statement for procedural training in family medicine residency. https://afmrd.socious.com/d/do/966. Accessed April 6, 2018.

28.   American Academy of Family Physicians. Colonoscopy privileging (reviewed and approved 2014). https://www.aafp.org/about/policies/all/colonoscopy-privileging.html. Accessed April 6, 2018.

29.   Eckert LD, Short MW, Domagalski JE, et al. Assessing colonoscopy training outcomes using quality indicators. J Grad Med Educ. 2009;1(1):89-92.

30.   Short MW, Kelly KM, Runser LA. Colonoscopy by a family physician: a case series demonstrating health care savings. Mil Med. 2007;172(10):1089-1092.

31.   Bittner JG 4th, Marks JM, Dunkin BJ, et al. Resident training in flexible gastrointestinal endoscopy: a review of current issues and options. J Surg Educ. 2007;64(6):399-409.

32.   American Association for Primary Care Endoscopy. AAPCE Policy on Credentialing for Gastrointestinal Endoscopy. Leawood, Ks.; 2009.

33.   American Academy of Family Physicians. Privileges, documentation of training and experience (reviewed and approved 2017).
http://www.aafp.org/about/policies/all/privilegesdocumentation.html. Accessed April 6, 2018.

34.   American Academy of Family Physicians. Privileges in family medicine departments (reviewed and approved September 2017). https://www.aafp.org/about/policies/all/privilegesfamily.html. Accessed April 6, 2018.

35.   American Academy of Family Physicians. Privileging policy statements (reviewed and approved 2017). http://www.aafp.org/about/policies/all/privileges.html. Accessed April 6, 2018.

36.   American Medical Association. Patient protection and clinical privileges H-230.989 (reaffirmed 2009).
https://policysearch.ama-assn.org/policyfinder/detail/patientprotectionandclinical?uri=%2FAMADoc%2FHOD.xml-0-1620.xml(policysearch.ama-assn.org)

37.   The Joint Commission. Joint Commission Comprehensive Accreditation and Certification Manual for 2017. Oak Brook, Ill.: Joint Commission Resources; 2017.

38.   American Academy of Family Physicians. Procedural skills, interspecialty support in clinical procedures (reviewed and approved 2016).
http://www.aafp.org/about/policies/all/proceduralskills.html. Accessed April 6, 2018.

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