Gastroenterologist Fernando Bermudez, MD, medical director and a member of the board at Eastside Endoscopy Center and a physician with G.I. Medicine Associates, both located in St. Clair Shores, Mich., shares his comments on a recent study published in the journal Medicare Care claiming to show primary care physicians performing colonoscopies in licensed ASCs have comparable performance quality indicators and lesion detection rates to those for experienced gastroenterologists.
Dr. Fernando Bermudez: I believe the premise that the low compliance with recommendations for CRC screening (about 50 percent) is mainly due to an inadequate specialist workforce is incorrect. I believe the two main factors are low referral by PCPs for CRC screening and resistance to patients to proceed with colonoscopy for screening purposes. The PCP can be very helpful affecting positively these two factors.
In general terms, a PCP or any physician can perform colonoscopies as efficiently as a gastroenterologist but some requirements are necessary to reach that goal:
- Same level of training in colonoscopies. Obviously the more significant part of training of a G.I. fellow in colonoscopy is the gradual supervision of a minimal number of colonoscopies. The number of procedures is not an absolute number; some trainees need more supervised procedures than others trainees to reach proficiency but at the end is the preceptor who decides if the trainee has reached proficiency. The training in endoscopy is part of a global training in gastroenterology; during this global training the trainee also acquires the knowledge necessary to make decisions about indications for endoscopies, risk of the procedure, how to minimize the risks, when the risk outweighs the benefits, etc.
- Minimal number of procedures performed regularly to maintain proficiency. Using rough mathematics in the study, a PCP performed about five colonoscopies a month during the five years of the study. This is far below what is considered standard for a gastroenterologist to maintain proficiency.
- Endoscopy is an evolving technical skill. In order to stay up to date, the endoscopist needs to keep up with advances usually published in specialized journals and/or covered at specialized meetings. My guess is that the family practice/internal medicine journals and meetings do not cover the colonoscopy topics adequately. A PCP performing colonoscopies will have to dedicate significant extra time and effort to maintain his/her knowledge and keep skills up to date
- The physician performing colonoscopy should participate in a quality assessment program that measures quality colonoscopy indicators on a regular basis.
I am not certain how much of the "good" results in the study is the result of a backup specialist.
If the main purpose of the study is to address the issue of " inadequate specialist workforce" (that in my opinion, as I mentioned before, is not the main issue), I think that the model used in the study of a university setting with PCP’s performing colonoscopies in an ASC with a backup specialist can not be easily reproduced in most communities.
In summary, we want to improve the compliance with CRC screening. More can be accomplished by PCPs educating and motivating his/her patients about the importance of CRC screening than by PCPs performing colonoscopies. I wonder what the results would be of a survey of physicians, asked who they would prefer perform his/her screening colonoscopy. I think that we need to subject our patients to the same standards that we would expect for ourselves.