Scope of Practice for Family Physicians
MS.2.15 Whatever mechanism for granting or renewal/revision of clinical privileges is used, there is evidence that the granting of clinical privileges is hospital-specific and based upon the individual's current competence.
MS.2.15.1 Privileges are related to: MS.18.104.22.168 An individual's documented experience in categories or treatment areas of procedures.
MS.2.15.3 When privilege delineation is based primarily on experience, the individual's credentials record reflects the specific experience and successful results that form the basis for granting of privileges.
Approximately 1,440 family physicians across the United States perform colonoscopy in a hospital setting, demonstrating that in many locations mechanisms exist for family physicians to be privileged in this procedure.9
In rural areas, an average of 5.7 percent of family physicians perform colonoscopy. One geographic area in Texas reported a rate as high as 42 percent among physicians who have graduated from family practice residencies since 1990.10
On the 1998 AAFP Practice Profile Survey, 1,163 family physicians reported performing colonoscopy in their offices.11
Twenty-six percent of family practice residency programs provide training in colonoscopy.12
|Chronic, stable irritable bowel syndrome|
|Chronic abdominal pain|
|Routine follow-up of inflammatory bowel disease (except dysplasia/cancer surveillance in chronic ulcerative colitis)|
|Upper gastrointestinal tract bleeding or melena with a demonstrated upper gastrointestinal tract source|
|Metastatic adenocarcinoma or unknown primary site in the absence of colonic signs or symptoms when it will not influence management|
|Known or suspected perforation|
|History of radiation therapy for abdominal or pelvic cancer|
|History of abdominal or pelvic malignancy|
|Extensive adhesions from prior abdominal surgery|
|History of complications with anesthesia or intravenous conscious sedation|
|Known history of diverticulosis/diverticulitis|
|Unstable cardiorespiratory condition|
|Early postcolectomy period|
|Bleeding||Cardiac arrhythmias or ischemia|
|Respiratory depression||Postpolypectomy syndrome|
Testing, Demonstrated Proficiency and Documentation
|Patient identification or code|
|Date of procedure|
|Name of hospital/location of procedure|
|Patient's history of prior colonoscopy, including any problems associated with previous procedures|
|Clinical indication for colonoscopy|
|Description of procedure|
|Number of procedures during training and practice|
|Outcome data, including complication rate|
|Letters from instructors, preceptors and proctors documenting training, experience, demonstrated abilities and current competence|
|Letters from previous hospitals documenting experience and outcomes|
Credentialing and Privileges
Carefully study the language of the hospital privileges policy and understand the process by which the privileges are granted.
Prepare a brief resume describing your educational background, including college, medical school, residency and board certification/recertification. Include dates of hospital affiliations, state and national medical societies, professional honors, awards, elected offices or committee chair positions. Describe any prior hands-on proctorship experiences.
Describe your years of practice and your record in providing high-quality health care in a variety of cases. This description should include the number of colonoscopies performed, your reach-the-cecum rate and your complication rate.
List all accredited continuing medical education (CME) courses you have taken that pertain to colonoscopy and include any self-study of gastrointestinal disease, such as atlases, articles, etc.
Include a summary letter from your residency or state chapter of the AAFP that supports these privileges as being within the scope of family practice.
Include a copy of the AAFP Policy on Gastrointestinal Endoscopic Training, which includes the following points21:
Gastrointestinal endoscopy should be performed by physicians with documented training and experience, and demonstrated competence in the procedures.
Training in endoscopy includes clinical indications, diagnostic problem solving, mechanical skills acquired under direct supervision, and prevention and management of complications.
Endoscopic competence is determined and verified by evaluation of performance under clinical conditions rather than by an arbitrary number of procedures.
Endoscopic competence should be demonstrated by any physician seeking privileges for the procedure.
Privileges should be granted for each specific procedure for which training has been documented and competence verified. The ability to perform any one endoscopic procedure does not guarantee competency to perform others.
Endoscopic privileges should be defined by the institution granting privileges and reviewed periodically with due consideration for performance and continuing education.22
Indicate that the AAFP strongly believes that all medical staff members should realize that there is overlap between specialties, and that no one department has exclusive rights to privileges.23
Highlight the AMA clinical privileges policy from the AMA Policy Compendium.
Highlight the JCAHO clinical privileges policy from its Comprehensive Accreditation Manual for Hospitals.
Identify to the appropriate hospital committee a physician on staff with colonoscopy privileges who is willing to proctor you.
Provide evidence of your ability to obtain malpractice insurance coverage. If your malpractice coverage includes surgical assisting, or if you are doing obstetrics, you should not have to increase your insurance class.5
Describe your plan for quality assurance. This should mean tracking your cases and providing the data to your department chair after a period of six to 12 months.
Establish a plan for continuing medical education, such as attendance at gastrointestinal conferences or board reviews, annual meetings of the American College of Gastroenterology and the American Gastroenterology Association, and Digestive Disease Week.
Express your willingness to work with the hospital to provide any information it believes is missing or incomplete.
If necessary, indicate that legal opinion and precedence have determined liability regarding the granting or failure to grant privileges for procedures based on factors other than the experience and competency of the physician in question. A legal opinion on privileges for endoscopy submitted to the AAFP in 1993 stated the following:
Hospitals and peer review participants risk liability under state law if they base credentialing decisions solely on whether or not a physician has obtained specialty certification.
The Council on Ethical and Judicial Affairs of the AMA has issued the opinion that competitive factors must be disregarded in making decisions about credentials and privileges.
There is no evidence that only board-certified gastroenterologists are qualified to perform endoscopic procedures.
Hospitals violate the Medicare Conditions for Participation if they base credentialing decisions solely on specialty board certification.
Hospitals and peer review participants risk loss of federal and state immunity from liability by basing credentialing decisions solely on whether or not a physician has obtained specialty certification.5,24
Quality assurance. Initiate ongoing case review programs/studies to monitor the endoscopic outcomes of family physicians performing colonoscopy, and compare these outcomes with those of other specialties.
Research training methods, including cognitive and procedural aspects. The learning curve issue needs to be addressed. For continuing quality improvement purposes, research is needed to determine the relationship significance, if any, between the number of procedures performed and demonstrated proficiency and maintenance of skills.