To Editor Dr. Gary Falk

I read the debate articles by Dr. Luke John Day and Dr. Louis Korman regarding training of non-physicians to perform endoscopy with great interest. I appreciate that both sides of the argument were presented to balance the debate. Debate is important, but some positions may not deserve equal time. It is unwise and unnecessary as detailed nicely in Dr. Korman’s position. A discussion on refining medical school and the match as well as increased funding for residencies/fellowships would be a more appropriate debate. Mid-levels (nurse practitioners (NP) and physician assistants (PA)) cannot be adequately trained as they are not physicians.

Almost any person could be taught to perform a skill such as endoscopy. Other physicians such as surgeons and family medicine perform endoscopies and they help to increase access in an appropriate manner. Gastroenterology fellowship has recently increased from two years to three to four years. The training obtained in fellowship is not solely based on acquiring endoscopy skills. Mid-levels have not gone through the rigors of medical education. In addition, the education of NPs particularly is not standardized and has vastly changed from its inception. For example, there are now many 100 percent online only NP or accelerated Doctor of nursing practice (DNP) programs.1,2 There are new graduates who have never been nurses. NPs are not under the supervision of the board of medicine and are only monitored by the board of nursing. How are we to monitor the standards of practice? Any standards set by physicians can easily be circumvented through legislation. With recent aggressive lobbying, mid-levels are already practicing medicine under the guise of advanced practice nursing in many states.

NPs have independent or unsupervised practice in 23 states, the District of Columbia and counting. There is an interstate compact bill in the Nebraska legislature for reciprocity of their licenses across states.3 There is a bill to offer a Doctor of Medical Science (DMS) to some PAs in Tennessee.4 Pharmacists and psychologists are also pushing for more independence in prescribing medications.5

In some states, nurse anesthetists (CRNA) perform independent of physician anesthesiologists. A patient could see a family nurse practitioner (FNP) and have a colonoscopy or other procedure performed by a NP and anesthesia administered by a CRNA and never see a physician? Will a mid-level adequately treat ulcers, manage Crohn’s disease or screen for colon cancer syndromes? Physicians must take a better stand in protecting our patients. Primary care physicians, emergency medicine and hospitalist/intensivists have been replaced by mid-levels in some areas. Patients may be encouraged to see the mid-levels because “it’s the same as seeing the doctor” or “you will get seen faster” or “she is really nice.” Patients are unaware or misinformed of the difference in education and clinical training.

Many gastroenterologists can attest to increased unnecessary referrals and testing from mid-levels due to minimal or lack of supervision.6 This often backlogs specialists’ referrals and increases patient wait times contributing to the perceived physician shortages.

Like many gastroenterologists, I work well with mid-levels in my practice. There is a well-defined role for mid-levels in GI care within a physician-led model. The role does not include performing endoscopies.


Suwebatu T. Odunsi-Shiyanbade, MD


Latifat Alli-Akintade, MD
Shifali Arora, MD
Mary Atia, MD
Daisy Batista, MD
Asra Batool, MD
Courtney Bhat, MD
Taruna Bhatia, MD
Anita Bhushan, MD
Priti Bijpuria, MD
Sabina Braude, MD
Sarah C. Glover, DO
Lisa Cassani, MD
Nisha Chand, MD
Aline Charabaty, MD
Jennifer Choi, MD
Georgia Close, MD
Vanessa Costilla, MD
Jennifer DiNubila, DO
Anupama Duddempudi, MD
Andrea E. Reid, MD, MPH
Maysaa El Zoghbi, MD
Kim Fairley, DO
Mariam Fayek, MD
Lizabeth Fiedler, MD
Diana Franco, MD
Larissa Fujii-Lau, MD
Tian Gao, MD
Sarita Gayle, MD
Mara Goldstein-Posner, DO
Parul Gor, MD
Ruchi Gupta, MD
Nancy Han, MD
Jennifer Harley, MD
Sabine Hazan, MD
Jeanmarie Houghton, MD
Kathryn Hutchins, MD
Dalia Ibrahim, MD
Bhairvi Jani, MD
Katherine A Kosche, MD, PhD
Z. Jennifer Lee, MD
Jaspreet K Ghumman, DO
Sumyra Kachru, MD
Chethana Kanaparthi, MD
Sarina Kapoor, MD
Sukeerti Kesar, MD
Amirah Khan, MD
Suejin Kim, MD
Elisabeth Kramer, MD
Kelsey L. Able, DO
Gillian Lam, MD
Janese Laster, MD
Calley Levine, MD
Cynthia Levy, MD
Ayanna Lewis, MD
Eashen Liu, MD
Lauren V. Halvorson, MD
Sarah M. Hyder, MD
Nidhi Malhotra, MD
Carol Mallette, MD
Francene Martin, MD
Lenna Martyak, MD
Tara Menon, MD
Laleh Merikhi, MD
Nandini Nagaraj, MD
Harini Naidu, MD
Sunina Nathoo, MD
Katherine Nguyen, MD
Chinyere Nwosu, DO
Jenny O. Smith, MD
Olanma Okoji, MD
Ola Otulana, DO
Konika P. Bose, MD
Vani Paleti, MD
Nishita Patel Kara, MD
Pruthvi Patel, MD
Sheena Patel, MD
Sonaly Patel, MD
Neha Patel, MD
Amanda Pressman, MD
Carmi Punzalan, MD
Treta Purohit Goyal, MD
Thuc Quyen Nguyen, MD
Colleen R. Kelly, MD
Wendy Rabbenou, MD
Sumita Rawal Mehta, MD
Alexandra Retana, MD
Moushumi Sanghavi, MD
Reena Sanmukh Patel, MD
Bridget J. Seymour, MD
Shauna Schroeder, MD
Jennifer Seminerio, MD
Anjali Shah, MD
Rimma Shaposhnikov, MD
Punitha Shivaprasad, DO
Karen Simon, MD
Jennifer Sinclair, MD
Kristen Singer, MD
Nina Singh, MD
Pooja Singhal, MD
Caroline Soyka, DO
Julie Spivack, MD
Indu Srinivasan, MD
Shoba Theivanayagam, MD
Nundhini Thukkani, MD
Chenlu Tian, MD
Amy Tilara, MD
Jayme Tishon, MD
Radha Vankawala Menon, MD
Haleh Vaziri, MD
Roopa Vemulapalli, MD
Jamie Walters, MD
Uni Wong, MD
Samantha Woodruff, MD
Christine Yu, MD
Sunbal Zafar, MD


3. State of Nebraska Legislative Bill (L.B.) 687.
4. State of Tennessee House Bill 696 and Senate Bill 850.
6. Lohr, R. H., West, C.P., Beliveau, M. et al, Comparison of the Quality of Patient Referrals From Physicians, Physician Assistants, and Nurse Practitioners. Mayo Clinic Proceedings. 2013; 88 (11): 1266 – 1271.

Gary Falk’s response

I have the privilege of serving as editor of AGA Perspectives, an AGA magazine which prides itself on providing perspectives on a variety of current issues in gastroenterology and hepatology including controversial topics in the field. A recent debate on the topic of training non-physicians to do endoscopy has resulted in considerable interest. While the “NO” side of the debate has received a little over 800 views online, the “YES” side has received more than 7,000 views in less than one month. I would like to remind our readers that the point-counterpoint debate is just that – a debate on an ongoing controversial issue in digestive diseases. The debate should not be viewed as an endorsement of one side or another but simply a platform for debate. That said, this article in no way reflects AGA’s position on this topic and the opinions expressed are solely those of the author.

I encourage AGA members to share their thoughts on this topic here. If this is an issue that matters to you, we should continue the healthy dialogue graciously started by Drs. Lukejohn Day and Louis Korman and help AGA know where members stand on this topic.

Thank you all for your comments and opinions so far. Because AGA Perspectives is a forum for opinions, we welcome this open dialogue surrounding its content.

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