• EGD, Training and Credentialing of Family Physicians In (Position Paper)

    Overview and Justification

    Esophagogastroduodenoscopy (EGD) is an endoscopic procedure that is useful for the diagnosis and treatment of conditions of the upper gastrointestinal (GI) tract. It is a tool that many family physicians use to assist with diagnosing esophageal, gastric, and duodenal pathologies, some of which can only be diagnosed with direct visualization. In fact, for the diagnosis of upper GI tract inflammations, ulcers, and neoplasms, the sensitivity and specificity of EGD are greater than those of radiographic studies.1

    For many years, family physicians have demonstrated the ability to learn EGD and perform the procedure safely and effectively in institutional and office settings.2-5 Their complication rates compare favorably with others in the GI literature.6-9 Performing EGD increases family physicians’ knowledge of the anatomy and physiology of the upper GI tract and their ability to detect significant upper GI pathology. As physicians are under increasing pressure to work in the most efficient and cost-effective manner possible to make accurate diagnoses and develop efficacious treatment plans, EGD is a useful tool in the family physician's armamentarium.

    Because family physicians practice in all regions, including rural and underserved areas, their ability to perform EGD improves patients’ access to care. Patients also benefit from more rapid diagnosis and treatment, as well as enhanced continuity of care. In addition, family physicians may find that the benefits of performing upper GI endoscopy include increased patient satisfaction, better working relationships with gastroenterologist colleagues, improved understanding of the pathology in individual cases, and a greater comfort level with chosen treatments.    

    Section I - Scope of Practice for Family Physicians

    Esophagogastroduodenoscopy can be a natural extension of the comprehensive care provided in a family medicine practice. 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 GI disorders, knowing when EGD is required is one aspect of their role.

    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, individuals must assess the appropriateness of performing EGD in their practice. As with all clinical procedures, family physicians should consider the safety, purpose, and potential outcomes of an EGD so that it can be performed in an appropriate setting.

    EGD is safe and rarely causes significant physical stress for the patient. However, IV sedation does carry a measurable risk and significant post-procedure observation is required. Physicians who perform in-office procedures requiring IV sedation should be able to provide the same level of care that is available in an outpatient or hospital GI lab. This includes appropriate personnel trained in resuscitation and airway management during both the procedure and recovery, as well as telemetry, pulse oximetry, and end-tidal CO2 monitoring. Family physicians performing EGD may need to obtain privileges to provide moderate sedation in accordance with state regulations and/or hospital or facility requirements.

    The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) recommends that patients being considered for endoscopy in the office setting should be evaluated according to the American Society of Anesthesiologists (ASA) physical status classification system.10 The guidelines state that patients who have an ASA score of III (i.e., severe systemic disease, such as chronic obstructive pulmonary disorder [COPD] or poorly controlled diabetes11) should be further assessed to determine the impact of their specific health condition(s) on the risk of anesthesia and the endoscopic procedure in the office setting.10 According to SAGES, patients who have an ASA classification of IV should not undergo an in-office endoscopic procedure.

    Section II - Clinical Indications

    There are numerous indications for EGD, as noted on the list of indications for GI endoscopy from the American Society for Gastrointestinal Endoscopy (ASGE) (Table 1).

    Table 1. ASGE Guidelines for GI Endoscopy and for EGD

    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 unsuccessful.
    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.

    EGD is generally indicated for evaluating:

    1. Upper abdominal symptoms that persist despite an appropriate trial of therapy.
    2. Upper abdominal symptoms associated with other symptoms or signs suggesting structural disease (e.g., anorexia and weight loss) or new-onset symptoms in patients older than 50 years of age.
    3. Dysphagia or odynophagia.
    4. Esophageal reflux symptoms that persist or recur despite appropriate therapy.
    5. Persistent vomiting of unknown cause.
    6. Other diseases in which the presence of upper GI pathology might modify other planned management. Examples include patients who have a history of ulcer or GI bleeding who are scheduled for organ transplantation, long-term anticoagulation or nonsteroidal anti-inflammatory drug therapy for arthritis, and those with cancer of the head and neck.
    7. Familial adenomatous polyposis syndromes.
    8. For confirmation and specific histologic diagnosis of radiologically demonstrated lesions:
    9. For confirmation and specific histologic diagnosis of radiologically demonstrated lesions:
      • Suspected neoplastic lesion.
      • Gastric or esophageal ulcer.
      • Upper tract stricture or obstruction.  
    10. GI bleeding:
      • In patients with active or recent bleeding.
      • For presumed chronic blood loss and for iron deficiency anemia when the clinical situation suggests an upper GI source or when colonoscopy does not provide an explanation.
    11. When sampling of tissue or fluid is indicated.
    12. Selected patients with suspected portal hypertension to document or treat esophageal varices.
    13. To assess acute injury after caustic ingestion.
    14. To assess diarrhea in patients suspected of having small-bowel disease (e.g., celiac disease).
    15. Treatment of bleeding lesions such as ulcers, tumors, vascular abnormalities (e.g., electrocoagulation, heater probe, laser photocoagulation, or injection therapy).
    16. Removal of foreign bodies.
    17. Removal of selected lesions.
    18. Placement of feeding or drainage tubes (e.g., peroral, percutaneous endoscopic gastrostomy, percutaneous endoscopic jejunostomy).
    19. Dilation and stenting of stenotic lesions (e.g., with transendoscopic balloon dilators or dilation systems using guidewires).
    20. Management of achalasia (e.g., botulinum toxin, balloon dilation).
    21. Palliative treatment of stenosing neoplasms (e.g., laser, multipolar electrocoagulation, stent placement).
    22. Endoscopic therapy of intestinal metaplasia.
    23. Intraoperative evaluation of anatomic reconstructions typical of modern foregut surgery (e.g., evaluation of anastomotic leak and patency, fundoplication formation, pouch configuration during bariatric surgery).
    24. Management of operative complications (e.g., dilation of anastomotic strictures, stenting of anastomotic disruption, fistula, or leak in selected circumstances).

    EGD is generally not indicated for evaluating:

    1. Symptoms that are considered functional in origin (there are exceptions in which an endoscopic examination may be done once to rule out organic disease, especially if symptoms are unresponsive to therapy or symptoms recur that are different in nature from the original symptoms).
    2. Metastatic adenocarcinoma of unknown primary site when the results will not alter management.
    3. Radiographic findings of:
      • Asymptomatic or uncomplicated sliding hiatal hernia.
      • Uncomplicated duodenal ulcer that has responded to therapy.
      • Deformed duodenal bulb when symptoms are absent or respond adequately to ulcer therapy.

    Sequential or periodic EGD may be indicated for:

    1. Surveillance for malignancy in patients with premalignant conditions (e.g., Barrett's esophagus, polyposis syndromes, gastric adenomas, tylosis, or previous caustic ingestion).

    Sequential or periodic EGD is generally not indicated for:

    1. Surveillance for malignancy in patients with gastric atrophy, pernicious anemia, fundic gland or hyperplastic polyps, gastric intestinal metaplasia, or previous gastric operations for benign disease.
    2. Surveillance of healed benign disease, such as esophagitis and gastric or duodenal ulcer.

    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 can obtain EGD training through a family medicine residency or a post-residency fellowship. The Society of Teachers of Family Medicine (STFM) Group on Hospital Medicine and Procedural Training includes EGD on its list of recommended advanced procedures that are within the scope of family medicine and require focused training (in residency or fellowship) in order for residents to be able to perform them independently by graduation.12 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 EGD as one of the more complex or advanced procedures for which training may be offered to interested residents in some family medicine residencies.13

    Other options for obtaining EGD training include preceptorship, self-study resources, and CME activities or conferences. The AAFP and its chapters have provided hands-on CME opportunities focused on clinical procedures for decades. In fact, the first national course in EGD for family physicians was sponsored by the AAFP in 1989. Other organizations also offer procedural skills training through accredited CME activities and conferences. Any training approach should develop both the cognitive skills involved in knowing when to perform EGD and how to properly interpret and manage findings, and the technical skills involved in safely performing the procedure. EGD training should also address how to recognize and promptly treat procedure-related complications.

    Section IV - Testing, Demonstrated Proficiency, and Documentation

    The amount of EGD experience needed to gain and maintain proficiency is user dependent and related to local credentialing and privileging guidelines. Core cognitive and motor skills recommended for achieving competence in the performance of EGD are listed in Tables 2 and 3.

    Table 2. Core Cognitive Skills Necessary to Demonstrate Proficiency in EGD

    1. Patient evaluation

    2. Assessment of indication and risk

    3. Informed consent

    4. Patient preparation

    5. Airway assessment and sedation management

    6. Anatomy and landmark recognition

    7. Recognition of findings

    8. Integration of findings into management plans

    9. Knowledge of diagnostic techniques and therapeutic devices

    10. Detailed report generation and communication

    11. Adverse event recognition and management

    12. Knowledge of surveillance intervals

    Reprinted with permission from ASGE Training Committee, Kwon RS, Davila RE, et al. EGD core curriculum. VideoGIE. 2017;2(7):162-168. 

    Table 3. Core Motor Skills Necessary to Demonstrate Proficiency in EGD

    1. Correctly holding the endoscope

    2. Use of endoscope controls and buttons

    3. Intubation of the esophagus

     4. Advancement and navigation

    5. Tip deflection

     6. Pyloric intubation

    7. Advancement into the duodenal second portion

    8. Withdrawal

    9. Mucosal inspection including advanced imaging techniques

    10. Retroflexion in the stomach

    11. Biopsy and tissue sampling

    12. Therapeutic interventions

    Reprinted with permission from ASGE Training Committee, Kwon RS, Davila RE, et al. EGD core curriculum. VideoGIE. 2017;2(7):162-168. 

    After the completion of upper GI endoscopy, appropriate documentation of the procedure is necessary for continuing care of the patient, medicolegal reasons, and billing. Documentation can be performed by dictating or typing a complete report or by using an endoscopy report template that includes the appropriate indications, medications, findings, and pathology. This type of documentation is also helpful when additional clinical privileges are requested and in clinical studies on EGD.

    Section V - Credentialing and Privileges

    Family physicians should document all significant training and experience so that this information can be reported in an organized fashion.14 It is the AAFP’s position that clinical privileges should be based on the individual physician's documented training and/or experience, demonstrated abilities, and current competence, and, whenever possible, be evidence based.15 This perspective 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 anti-competitive intent or purpose.”16

    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 standards state, “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].17 All of the criteria should be "consistently evaluated for all practitioners holding that privilege” [MS.06.01.05].17

    According to the American Association for Primary Care Endoscopy (AAPCE), "credentialing should not be limited to specific medical specialties.”18 The AAPCE also states, “Credentialing should be based upon demonstrated proficiency rather than a specified number of procedures performed during training.”  

    Once a hospital determines the experience it will require to qualify for a privilege, it must confirm current competence. The AAFP believes this can be efficiently and fairly achieved through a requirement for references. The reference should have firsthand knowledge of the applicant’s ability to perform EGD competently. The reference’s attestation to competence affirms that the applicant’s training and experience have been adequate for the procedure and individual under review. If, after reviewing references, the hospital still has questions about an individual’s competence, a period of proctoring to observe performance may be appropriate.

    This process protects patients and, when uniformly applied, provides a fair mechanism for a hospital to grant a particular privilege. Artificial and arbitrarily high experience requirements should not be created as barriers to the privileging of family physicians. When a minimum volume threshold is required in specific privileging instances, it should be evidence based. If there are not sufficient data, a consensus opinion of experts from within the specialty may be necessary until an evidence-based recommendation becomes available.15 For example, the AAPCE states that if a hospital chooses to require a specific number of procedures during training, the requirement should not exceed 35 EGDs.18

    Table 4 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. This list should be reviewed by the department chair or a designee. Active privileges are renewed every one to two years by the authority of the department chair.

    Table 4: Recommended Steps for Applying for GI Endoscopy Privileges

    1. Become thoroughly familiar with the hospital’s bylaws and processes related to credentialing and privileging. Be cooperative yet persistent during the privileging process.
    2. Review the privileging policy statements 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 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) 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.
    10. Be prepared, if necessary, to discuss the criteria for credentialing proposed by the ASGE in Alternative Pathways to Training in Gastrointestinal Endoscopy.19 It is the AAFP’s position that the ASGE's stance is not supported by clinical evidence and may reasonably be interpreted as more aligned with competitive marketplace concerns than patient access to quality care.

    Section VI - Miscellaneous Issues

    A. Public health implications

    Little is known concerning the public health implications of family physicians performing EGD. However, it is known that patients, particularly in rural areas, often have better access to family physicians than to other specialists. Improved access to EGD can lead to more efficient diagnosis and treatment, as well as greater patient convenience.

    B. Current research agenda

    Research concerning EGD in primary care has predominantly comprised case series and descriptive studies that have shown family physicians can safely, accurately, and effectively perform EGD.

    Although the findings from this type of research are helpful, evidence is needed from randomized controlled trials and other more powerful study designs. The AAFP supports the need to conduct and publish research regarding the performance of EGD by family physicians. In particular, research is needed to document benefits and harms of the procedure, patient preferences, costs and savings, utilization, and alternatives.

    C. Relationships with other organizations

    AAFP policy states, “The AAFP seeks 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.”20 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 EGD.

    Section VII - References

    1.     Lee SH, Park YK, Cho SM, et al. Technical skills and training of upper gastrointestinal endoscopy for new beginners. World J Gastroenterol. 2015;21(3):759-785.

    2.     Rodney WM, Hocutt JE Jr, Coleman WH, et al. Esophagogastroduodenoscopy by family physicians: a national multisite study of 717 procedures. J Am Board Fam Pract. 1990;3(2):73-79.

    3.     Rodney WM, Weber JR, Swedberg JA, et al. Esophagogastroduodenoscopy by family physicians phase II: a national multisite study of 2,500 procedures. Fam Pract Res J. 1993;13(2):121-131.

    4.     Pope JB, Mayeaux EJ Jr, Harper MB. Effectiveness and safety of esophagogastroduodenoscopy in family practice: experience at a university medical center. Fam Med. 1995;27(8):506-511.

    5.     Pierzchajlo RP, Ackermann RJ, Vogel RL. Esophagogastroduodenoscopy performed by a family physician. A case series of 793 procedures. J Fam Pract. 1998;46(1):41-46.

    6.     Runser LA, Short MW. Esophagogastroduodenoscopy by a family physician: a case series demonstrating health care savings. Mil Med. 2007;172(8):888-891.

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

    8.     Hedayati-Vala F. GI endoscopy in rural communities: experience of a rural family physician in British Columbia. BCMJ. 2008;50(6):300-303.

    9.     ASGE Standards of Practice Committee, Ben-Menachem T, Decker GA, et al. Adverse events of upper GI endoscopy. Gastrointest Endosc. 2012;76(4):707-718.

    10.    Society of American Gastrointestinal and Endoscopic Surgeons. Guidelines for office endoscopic services (reviewed and approved November 2008). Accessed February 1, 2022. https://www.sages.org/publications/guidelines/guidelines-for-office-endoscopic-services/

    11.    American Society of Anesthesiologists (ASA). ASA physical status classification system. Accessed February 1, 2022. https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system

    12.    Kelly BF, Sicilia JM, Forman S, et al. Advanced procedural training in family medicine: a group consensus statement. Fam Med. 2009;41(6):398-404.

    13.    Council of Academic Family Medicine (CAFM). CAFM consensus statement for procedural training in family medicine residency. Accessed February 1, 2022. https://afmrd.socious.com/d/do/966

    14.    American Academy of Family Physicians. Privileges, documentation of training and experience (reviewed and approved 2017). Accessed February 1, 2022. https://www.aafp.org/about/policies/all/privileges-documentation.html

    15.    American Academy of Family Physicians. Privileging policy statements (reviewed and approved 2018). Accessed February 1, 2022. https://www.aafp.org/about/policies/all/privileging-policy-statements.html

    16.    American Medical Association. Patient protection and clinical privileges H-230.989 (reaffirmed 2019). Accessed February 1, 2022. https://policysearch.ama-assn.org/policyfinder/detail/on%20patient%20protection%20and%20clinical%20privileges%20?uri=%2FAMADoc%2FHOD.xml-0-1620.xml

    17.    The Joint Commission. 2022 Comprehensive Accreditation Manual. Joint Commission Resources; 2022.

    18.    American Association for Primary Care Endoscopy. Credentialing for gastrointestinal endoscopy: policy of the American Association for Primary Care Endoscopy. AAPCE; 2009.

    19.    American Society for Gastrointestinal Endoscopy. Alternative pathways to training in gastrointestinal endoscopy. Accessed February 1, 2022. https://www.asge.org/docs/default-source/education/training/f3cf9361-c650-47a1-9634-442ed63ec1d9.pdf?sfvrsn=4e234b51_4

    20.    American Academy of Family Physicians. Clinical procedural skills, support (reviewed and approved July 2021). Accessed February 1, 2022. https://www.aafp.org/about/policies/all/procedural-skills.html

    (August Board 2002) (JULY 2022 BOD)