Should We Train Non-Physicians To Do Endoscopy? Yes

This is half of a two-part debate — read the opposing argument. The opinions expressed here are that of the author and do not represent the position of AGA.

Over the last 30 years there has been a dramatic rise in the demand for endoscopic procedures across the world and in the United States. This rising demand is for both colorectal cancer (CRC) screening and diagnostic procedures. At the same time, there has not been a corresponding increase in the number of providers who can perform these procedures. For example, the number of gastroenterologists being trained has remained steady in the U.S. and is expected to remain unchanged for the next several years. Consequently, there is a growing gap between the demand for and capacity to provide endoscopic procedures as well as an inability to meet the growing need for CRC screening. Therefore, the health care community is required to develop innovative solutions to help address this gap. One such innovative solution is the use of non-physicians to perform endoscopic procedures.

Several questions arise on the topic of non-physicians performing endoscopy. First, can non-physicians safely and adequately perform endoscopic procedures? Non-physicians have been performing high quality and safe endoscopic procedures since the 1970s, with the first procedure performed being flexible sigmoidoscopy. In recent years, this practice has expanded; non-physicians have begun to perform colonoscopy and upper endoscopy, although in more limited health care settings. Ample evidence exists that non-physicians can safely perform endoscopic procedures with similar quality, especially with respect to screening flexible sigmoidoscopy, colonoscopy and diagnostic upper endoscopy.1 In fact, in some cases non-physicians can outperform physicians with regards to several important quality indicators in endoscopy. Additionally, in many cases the expansion of non-physicians performing endoscopy has occurred in resource-limited settings with vulnerable patient populations; in such situations, such a practice has allowed for the expansion and increased capacity for GI that may have otherwise not been possible. For example, at our county hospital in San Francisco, California, we demonstrated that the use of non-physicians to perform simple endoscopic procedures not only adhered to national quality and safety benchmarks in endoscopy, but simultaneously allowed us to increase our endoscopic capacity by 33 percent and reduce our procedure wait times by half. An essential element to the success of our program was implementing a rigorous educational and training curriculum that was complemented by a strong supervisory role from gastroenterologists and ongoing performance evaluation of the non-physicians. Such a program requires the commitment of both the gastroenterologists and the institution for it to be successful.


Patients report high satisfaction with respect to non-physicians performing flexible sigmoidoscopy, colonoscopy and upper endoscopy, and in many cases, there is greater patient satisfaction and lower pain scores with non-physicians performing endoscopy.


A second question is whether patients and physicians accept non-physicians performing simple endoscopic procedures. Available data with regards to patient satisfaction is sparse in this area; however, limited reports illustrate that patients would be willing to undergo a repeat procedure by a non-physician and that no difference exists between non-physicians and physicians in terms of patient preference for who performs their procedure. Patients report high satisfaction with respect to non-physicians performing flexible sigmoidoscopy, colonoscopy and upper endoscopy, and in many cases, there is greater patient satisfaction and lower pain scores with non-physicians performing endoscopy. Lastly, the use of non-physicians in traditionally physician roles is not a new concept in medicine. A large number of medical fields have adopted the use of non-physicians for clinical practice. For example, the use of certified nurse anesthetists to deliver anesthesia care has been prevalent for over a century. Nurse anesthetists have consistently demonstrated efficacy and safety with high provider satisfaction and acceptance. Consequently, expanding the role of non-physicians into endoscopy would not limit the role of gastroenterologists, but rather permit them to increase services and access, and further allow gastroenterologists to focus their attention on more complex and demanding procedures/cases.

Finally, is there a need for non-physicians to perform endoscopic procedures in the U.S.? One of the largest demands for endoscopic care is based on indications for colorectal cancer screening and surveillance. In fact, over 14 million colonoscopies and nearly three million flexible sigmoidoscopies are performed annually just for CRC screening and it has been projected that gastroenterologists alone will not be able to meet this demand. Both colonoscopy and flexible sigmoidoscopy are accepted and recommended modalities for colorectal cancer screening, yet with the aging population, it is estimated that the number of endoscopic procedures that need to be performed to meet this demand far exceeds the supply of available gastroenterologists. 2 This imbalance may lead to impaired access, delayed diagnoses, higher health care costs and overall poorer patient satisfaction. Non-physicians are a suitable and safe adjunct to physicians performing simple endoscopic procedures to meet this rising demand.

The rapidly occurring changes in the U.S. health care system will have a tremendous impact on non-physicians performing endoscopy. As more Americans now have improved access to health care, we will likely see a continued increase in the number of endoscopic procedures that are requested by primary care providers as well as by patients. This will only exacerbate the supply-demand imbalance seen in providing endoscopic care to our patients. Now is the time when we need to be more thoughtful in how we will address the growing demand for endoscopic procedures and how to meet the needs for all of our patients to ensure they receive timely, high-quality care. Given that non-physicians can safely perform quality endoscopic procedures with high patient satisfaction, I believe that using non-physicians in such a role is a perfect solution to this problem.


Louis Korman, MD, provides a different view on training non-physicians to do endoscopy.


Dr. Day has no conflicts to disclose.

References
1. Day, L.W., Siao D., Inadomi, J.M., Somsouk, M. Non-physician performance of lower and upper endoscopy: a systematic review and meta-analysis. Endoscopy. 2014;46(5):401-10.
2. Ladabaum, U., Song, K. Projected national impact of colorectal cancer screening on clinical and economic outcomes and health services demand. Gastroenterology. 2005; 129(4):1151-1162.

4 comments

  • I read this debate with great interest. The usual waiting time for an appointment in our community for a procedure is 1-2 weeks and if it is needed it can be done same day. We still see holes in the schedule. I am a community Gastroenterologist where apart from board certified GI physicians General Surgeons and Primary care physicians perform at least 30 – 40 % EGD’s and Colonoscopies and it is increasing. The requirements for them to get certified to do these procedures is at best minimal. Our new GI fellows are training longer and required to do more procedures to get board certification. The leaders in teaching institutions are coming up with innovative ideas which is making it harder to practice bread and butter gastroenterology. We have competition from fecal DNA testing, CT Colonography and with time they will get better and reduce workload. I look at specialties like Orthopedics, Oral surgery to name a few who also have need for more physicians but have not increased the training slots or talk about delegating to mid level providers ( to my knowledge). Are we trying to be too progressive ?. If the goal is to eliminate the Gastroenterology as a specialty for physicians than in my view delegating to NP or PA is way to go. In future than why someone should go to medical school and train in subspecialty when you can achieve the same target with less financial burden and shorter time to train and lesser risk of litigation.

  • How many internal medicine residents did NOT match into UCSF GI fellowship or any GI fellowship that applied? Here is an idea why don’t we offer these MDs an opportunity to learn how to do endoscopy and training rather than have a lesser trained mid-level take this serious procedure. I wonder how all the GI fellows at UCSF feel about this.

  • This reminds me of the old Arabic fable. “The camel in the tent” (quick lookup). It also makes me doubt recent official numbers that there is a higher physician to patient ratio in the US.

    How about you consider hiring residents or displaced physicians. Or training and certifying Fam physician to do their own.

    Have you considered the unintended consequences? Giving this to non physicians will only embolden others and justify their claims that they are just as good as physicians. Ask some anesthesiologist how that worked for them.

  • Then allow primary care physicians to have privileges for endoscopy !!!!!

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