Esophagogastroduodenoscopy (EGD) is an endoscopic procedure that is useful for the diagnosis and treatment of conditions of the upper gastrointestinal (GI) tract. For all upper GI problems except esophageal and gastric motility abnormalities, EGD can often be substituted for radiologic studies. In fact, for the diagnosis of mucosal abnormalities, the sensitivity and specificity of EGD are greater than those of radiographic studies.1
Family physicians have demonstrated the ability to learn EGD and to perform the procedure safely and effectively in institutional and office settings. Their complication rates compare favorably with others in the GI literature.2-5 Performing EGD increases a family physician's knowledge of the anatomy and physiology of the upper GI tract, and his or her 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 areas, including rural and underserved areas, their ability to perform EGD improves patients' access to care. Patients also benefit from more rapid diagnosis and treatment, and enhanced continuity of care. In addition, family physicians may find that the benefits of performing upper GI endoscopy including increased patient, better working relationships with their gastroenterologist colleagues, improved understanding of the pathology in individual cases, and a greater comfort level with chosen treatments.
Esophagogastroduodenoscopy can be a natural extension of the comprehensive care provided by a family physician. 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 a family physician’s 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, each must assess the appropriateness of performing EGD 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. For many family physicians who perform EGD, economics may favor a GI lab setting over the office setting. The physician must also consider specific patient factors (e.g., the urgency and timing of the procedure) and preferences regarding outpatient EGD.
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 for assistance and observation, and may include oximetry monitoring and telemetry.
In Guidelines for Office Endoscopic Services, 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.6,7 The guidelines state that patients who have an ASA score of III (i.e., one or more moderate to severe systemic diseases, such as chronic obstructive pulmonary disorder [COPD] or acute myocardial infarction [MI]) 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. According to SAGES, patients who have an ASA classification of IV should not undergo an in-office endoscopic procedure.
There are numerous indications for EGD. The list of indications for GI endoscopy from the American Society for Gastrointestinal Endoscopy (ASGE) includes specific indications statements for EGD (Table 1).
Table 1. ASGE Guidelines for GI Endoscopy and for EGD
GI endoscopy is generally indicated:
GI endoscopy is generally not indicated:
GI endoscopy is generally contraindicated:
EGD is generally indicated for evaluating:
I. GI bleeding:
Sequential or periodic EGD may be indicated for:
Sequential or periodic EGD is generally not indicated for:
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.
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.8 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.9
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.
The AAFP recommends that family physicians document all significant training and experience so that this information can be reported in an organized fashion.10 Recommended requirements for demonstration of proficiency and documentation in EGD are listed in Table 2. The amount of continuing EGD experience needed to maintain proficiency has not been extensively studied.
Table 2. Demonstration of Proficiency and Documentation in EGD
The learner shall demonstrate adequate clinical knowledge regarding the following:
The learner shall demonstrate technical and clinical skills as he or she does the following: (Since the procedure cannot be completed without all of these steps, possession of the entire skillset is required.)
If administering conscious sedation, the learner shall demonstrate that he or she has performed conscious sedation during the past 24 months, with cases reviewed for choice of drug, interval, dosage, and outcome.
The learner shall demonstrate proficiency in post-procedure steps through the following:
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 a complete report or by using an endoscopy report form that allows notation by circling 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.
Adapted from American Academy of Family Physicians. Esophagogastroduodenoscopy: a syllabus for the family physician interested in performing this technique. Leawood, Ks.: American Academy of Family Physicians; 1999.
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.11 The AAFP also advocates the development of specific patient-centered practice policies that focus on what should be done for the patient rather than who should do it.12 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.13
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].14 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].14
According to the American Association for Primary Care Endoscopy (AAPCE), "Credentialing should not be limited to specific medical specialties.”15 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 competency. The AAFP believes this can be efficiently and fairly achieved through a requirement for references. The reference should have first-hand knowledge of the applicant’s ability to perform EGD competently. The reference’s attestation to competency affirms that the applicant’s training and experience have actually been adequate for the particular 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.
The process just described protects patients and, when uniformly applied, provides a fair mechanism for a hospital to grant a particular privilege, such as EGD. Artificial and arbitrarily high experience requirements should not be created as barriers to the privileging of family physicians. If a volume threshold to demonstrate competence is established, it should be evidence based. If the literature does not support a specific volume threshold, one should be established by the consensus of a multidisciplinary group of physicians that includes family physicians. 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.15
Table 3 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 his or her designee. Active privileges are renewed every one to two years by the authority of the department chair.
Table 3: Applying for GI Endoscopy Privileges
A. Public health implications
Little is known concerning the public health implications of family physicians performing EGDs. 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 efficent 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 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."16 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.
(August Board 2002) (2017 COD)