• 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. 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.

    Section I - Scope of Practice for Family Physicians

    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.

    Section II - Clinical Indications

    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:

    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:
      1. Suspected neoplastic lesion.
      2. Gastric or esophageal ulcer.
      3. Upper tract stricture or obstruction.  

    I. GI bleeding:

    1. In patients with active or recent bleeding.
    2. 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.
    • When sampling of tissue or fluid is indicated.
    • Selected patients with suspected portal hypertension to document or treat esophageal varices.
    • To assess acute injury after caustic ingestion.
    • To assess diarrhea in patients suspected of having small-bowel disease (e.g., celiac disease).
    • Treatment of bleeding lesions such as ulcers, tumors, vascular abnormalities (e.g., electrocoagulation, heater probe, laser photocoagulation, or injection therapy).
    • Removal of foreign bodies.
    • Removal of selected lesions.
    • Placement of feeding or drainage tubes (e.g., peroral, percutaneous endoscopic gastrostomy, percutaneous endoscopic jejunostomy).
    • Dilation and stenting of stenotic lesions (e.g., with transendoscopic balloon dilators or dilation systems using guide wires).
    • Management of achalasia (e.g., botulinum toxin, balloon dilation).
    • Palliative treatment of stenosing neoplasms (e.g., laser, multipolar electrocoagulation, stent placement).
    • Endoscopic therapy of intestinal metaplasia.
    • 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).
    • Management of operative complications (e.g., dilation of anastomotic strictures, stenting of anastomotic disruption, fistula, or leak in selected circumstances).
    1. EGD is generally not indicated for evaluating:
      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:
      1. Asymptomatic or uncomplicated sliding hiatal hernia.
      2. Uncomplicated duodenal ulcer that has responded to therapy.
      3. 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.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.

    Section IV - Testing, Demonstrated Proficiency, and Documentation

    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:

    • Indications
    • Patient selection and contraindications (relative and absolute)
    • Informed consent
    • Preparation of patient
    • Limitations of procedure
    • Complications and their management
    • Electrosurgical principles
    • Indications and contraindications for simple biopsy, electrosurgical biopsy, ablation, and polypectomy
    • Complications and management of biopsy
    • Familiarity with disinfection, preparation of equipment, and Occupational Safety and Health Administration (OSHA) regulations regarding this procedure

    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.)

    • Identifies the parts of the scope and explains their use
    • Explains the equipment setup
    • Performs an oral examination on the patient
    • Inserts the scope into the patient's mouth using either the manual or the visual technique
    • Places the bite block between the patient's teeth
    • Advances the scope to the cricopharyngeus and demonstrates how it is traversed
    • Explains (or demonstrates) how he or she would handle a tracheal intubation
    • Demonstrates the passage of the scope through the esophagus
    • Discusses the decision whether or not to biopsy the distal esophagus
    • Demonstrates passage through the lower esophageal sphincter
    • Explains how the gastric pool would be aspirated upon entry into the stomach
    • Passes the scope through the stomach and demonstrates orientation and landmarks as he or she progresses
    • Demonstrates the approach to and passage through the pylorus
    • Demonstrates passage of the scope into the duodenum
    • Discusses orientation within the duodenum and the location of the papilla of Vater
    • Begins to withdraw the scope and demonstrates visualization of the duodenal bulb
    • Withdraws the scope into the stomach and identifies returning past the pylorus
    • Demonstrates the "J" or retroflexion maneuver and visualizes the cardia and the lower aspect of the gastroesophageal junction
    • At this point, or earlier when in the lower esophagus, explains how the diaphragmatic level can be identified on the esophagus or stomach
    • Straightens the scope and adequately visualizes the lining of the stomach, maintaining orientation
    • Shows/explains how a biopsy will be done
    • Correctly removes the scope from the stomach, correctly visualizing the esophagus and vocal cord

    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:

    • Appropriate aftercare of patient, including use of reversal medications (if appropriate), orders, medications, and instructions
    • Preparation of endoscopic report
    • Appropriate post-procedure follow-up

    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.

    Section V - Credentialing and Privileges

    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

    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 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 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.
    10. Be prepared, if necessary, to discuss the criteria for credentialing proposed by the ASGE in Alternative Pathways to Training in Gastrointestinal Endoscopy. 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 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.

    Section VII - References

    1. Mayeaux, EJ Jr. ed. The Essential Guide to Primary Care Procedures, 2nd edit. Philadelphia, Pa.: Wolters Kluwer; 2015.
    2. Runser LA, Short MW. Esophagogastroduodenoscopy by a family physician: a case series demonstrating health care savings, Mil Med. 2007;172(8):888-891.
    3. 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.
    4. Hedayati-Vala F. GI endoscopy in rural communities: experience of a rural family physician in British Columbia, BCMJ. 2008;50(6):300-303.
    5. Ben-Menachem T, Decker GA, Early DS, et al. American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee. Adverse events of upper GI endoscopy. Gastrointest. Endosc. 2012;76(4):707-718.
    6. Society of American Gastrointestinal Endoscopic Surgeons. Guidelines for office endoscopic services (reviewed and approved November 2008). Accessed April 25, 2017.
    7. American Society of Anesthesiologists (ASA). ASA physical classification system. Accessed April 25, 2017.
    8. Kelly BF, Sicilia JM, Forman S, Ellert W, Nothnagle M. Advanced procedural training in family medicine: a group consensus statement. Fam Med. 2009;41(6):398-404.
    9. Council of Academic Family Medicine (CAFM). Consensus statement for procedural training in family medicine residency. Accessed April 25, 2017.
    10. American Academy of Family Physicians. Privileges, documentation of training and experience (reviewed and approved September 2016). Accessed April 25, 2017.
    11. American Academy of Family Physicians. Privileges (reviewed and approved 2013). http://www.aafp.org/about/policies/all/privileges.html. Accessed April 25, 2017.
    12. American Academy of Family Physicians, Joint development of clinical practice guidelines with other organizations (reviewed and approved July 2013). Accessed April 25, 2017.
    13. American Medical Association. Patient protection and clinical privileges H-230.989 (reaffirmed 2009). Accessed April 25, 2017.
    14. The Joint Commission. Joint Commission Comprehensive Accreditation and Certification Manual for 2017. Oak Brook, Ill.: Joint Commission Resources; 2017.
    15. American Association for Primary Care Endoscopy. AAPCE Policy on Credentialing for Gastrointestinal Endoscopy. Leawood, Ks.; 2009.
    16. American Academy of Family Physicians. Procedural skills, interspecialty support in clinical procedures (reviewed and approved 2016).  Accessed April 25, 2017.

    (August Board 2002) (2017 COD)