Health Care Article of the month
May 1999

Preamble

This is one of a series of statements discussing the utilization of gastrointestinal endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this update, a Medline literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When little or no data exist from well-designed prospective trials, emphasis was given to results from large series and reports from recognized experts.

Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data appear. Clinical considerations may justify a course of action at variance to these recommendations.

Purpose

Gastrointestinal endoscopy is defined as the visualization of the digestive tract with flexible or rigid diagnostic tools. Endoscopic technology has advanced rapidly over the past thirty years, becoming an integral part of clinical gastroenterology. The ASGE has continually promoted safe and responsible endoscopic practice. Guidelines have been developed and disseminated regarding appropriate use of and training in endoscopy. Given the increasing demands for endoscopy, as well as the growing range of its diagnostic and therapeutic options, non-physician endoscopists have been trained to provide screening sigmoidoscopy, and in some cases, upper endoscopy and colonoscopy (1). The purpose of this guideline is to address the issues surrounding endoscopic practice by non-physicians.

Definitions

Competent endoscopic practice requires thorough training in both the cognitive and technical aspects of endoscopy.

Cognitive skills: include knowledge of procedural indications/contradictions, risks, benefits and alternatives as well as accurate identification and interpretation of gross pathology (2). It also includes the ability to assess the implications of information regarding the patient's condition and the capability to integrate endoscopic findings into clinical practice.

Technical Skills: refer to the ability to perform the physical aspects of endoscopy, such as insertion, advancement, maneuvering through the gastrointestinal tract, biopsy, therapeutic interventions and withdrawal of the instrument. Trained physician endoscopists include, but are not limited to, physicians with fellowship training in gastrointestinal disease and formal training in endoscopy as defined in prior ASGE publications (3). Non-physician endoscopists are defined as any non-physician medical personnel performing endoscopy, including but not limited to, nurses, nurse practitioners, physician assistants, and medical assistants.

Discussion

The decision to utilize non-physician endoscopists should be made based upon competence in endoscopy. Additionally, factors to consider include availability of physician resources and volume of procedural demand as dictated by local conditions. Physician endoscopists undergo extensive formal training in gastrointestinal disease as well as endoscopic procedures. It is unreasonable to expect non-physicians to be trained to this extent. Because of this, non-physicians will not attain the cognitive expertise necessary for optimum patient care as is expected of a physician. In this light, non-physicians who have performed endoscopy have been trained and subsequently supervised by physician endoscopists.

At this time, the majority of non-physician endoscopists perform flexible sigmoidoscopy only. Flexible sigmoidoscopy requires fewer supervised examinations to attain objective measures of technical competency (4) than other endoscopic procedures, does not require sedation, and has a low rate of endoscopically related complications. Non-physician endoscopists have been performing sigmoidoscopies since 1972 (5), and there have been several studies supporting the safety and efficacy of flexible sigmoidoscopy by non-physicians (6-8). A recent randomized controlled trial demonstrated no significant differenced in depth of insertion or polyp detection between gastroenterologists and nurse endoscopists (9).

Screening flexible sigmoidoscopy is becoming a population-based screening tool for colorectal cancer, which is the third most commonly diagnosed cancer and the second leading cause of cancer-related mortality in the United States. An estimated 131,000 new cases of colorectal cancer will be diagnosed and over56,000 will die from it each year (10). Retrospective (case-control) studies have demonstrated a 55-70% reduction in colorectal cancer related mortality with screening sigmoidoscopy (11-13). Currently, less than 10% of the at risk U.S. population undergoes screening sigmoidoscopy, which is in part due to the lack of available skilled endoscopists (14). By the year 2000, over 50 million individuals in the U.S. will be eligible for screening sigmoidoscopy (14). The British Society of Gastroenterology and the Society of Gastroenterology Nurses and Assistants in the U.S. have written policy statements endorsing the practice of flexible sigmoidoscopy by registered nurses (15,16). Currently, 34% of state boards of nursing do not approve this practice, but allow flexible sigmoidoscopy by nurse practitioners (17).

Some non-physician endoscopists also perform upper endoscopy and colonoscopy (17). The prevalence of this practice is unknown at this time. However, studies assessing the non-physician's ability to administer sedation, perform endoscopic therapy, and evaluate for and treat complications are no available. The performance of these procedures demands intensive training as well as supervision during procedures by a physician endoscopist. The thresholds for determination of endoscopic competence should be equal that expected of a physician trainee. It is unclear at this time whether patient needs and demand for endoscopy merit performance of endoscopy by non-physicians (other than screening flexible sigmoidoscopy). Performance3 of endoscopy whether by both physicians and non-physicians should be subjected to a quality monitoring program as discussed in the ASGE guideline (18).

Recommendations

The delivery of health care in gastroenterology has been expanding at a rapid pace. This phenomenon has begun to modify the traditional roles of non-physician medical personnel. These individuals have increasingly performed the role of non-physician endoscopists.

At this time, the medical literature supports the utilization of non-physician endoscopists for flexible sigmoidoscopy only. The less demanding requirements for training compared to other endoscopic procedures, the absence of sedative use and the need for large scale screening further support this practice. It is recommended that any non-physician endoscopist work directly under the immediate supervision of a physician specifically trained in digestive diseases.

Certification of non-physician endoscopists should remain within the purview of state licensure as well as institutional policy. This guideline is not meant to substitute for local determination of practice and policy.

References

1. Lieberman DA, Ghormley JM. Physician assistants in gastroenterology: should they perform endoscopy? Am J Gastroenerol 1991; 87:940-3.
2. Health and Public Policy Committtee, American College of Physicians. Ann Int Med 1987; 107:589-91.
3. ASGE guideline Appropriate use of endoscopy, 1998.
4. Cass OW, Freeman ML, Peine CJ, Zera RT, Onstad GR. OBjective evaluation of endoscopy skills during training. Ann Int Med 1993; 118:40-4.
5. Spencer RJ, Ready RL. Utilization of nurse endoscopists for sigmoidoscopic examinations. Dis Col Rectum 1977;20-:94-6
6. Maule WF. Screening for colorectal cancer by nurse endoscopists. N Eng J Med 1994;330:183-7.
7. Schroy Pc, Wiggins T, Winawer SJ et al. Video endoscopy by nurse practitioners: a model for colorectal cancer screening. Gastointest Endosc 1988;34:390-4.
8. Schoenfeld P, Lipscomb S, Dominguez J et al. Accuracy of polyp detection during screening flexible sigmoidoscopy by gastroenterologists and nurse endoscopists: a randomized controlled trial. (in press).
9. Landis SH, Murray T, Bolden S, Wingo PA. Cancer Statistics 1998. CA Cancer J clin 1998;48-:6-29.
10. Newcomb Pa, Norfleet RG, Storer BE, et al. Screening sigmoidoscopy and colorectal cancer mortality. J Natl Cancer Inst 1992;84:1572-5.
11. Selby JV, Friedman GD, Quesenberry CP Jr, Weiss NS. A case control study of screening sigmoidoscopy and mortality from colorectal cancer. N Eng J Med 1992;326:653-7.
12. Muller Ad, Sonnenberg A. Protection by endoscopy against death from colorectal cancer. Arch Intern Med 1995;155:1741-6.
13. Ransohoff DF, Lang CA. Sigmoidoscopic screening in the 1990's. JAMA 1993;269:1278-81.
14. British Society of Gastoenterology Endoscopy Section Working Party. The Nurse Endoscopist. Gut 1995;36(4):795.
15. Society of Gastroenterology Nurses and Associates Practice Committee. Performance of flexible sigmoidoscopy by registered nurses for the purpose of colorectal cancer screening. Gastroenterology Nurs 1997;20:S1-4.
16. Cash BD, Schoenfeld PS, Ransohoff DF. Licensure, utilization and training of paramedical personnel to perform screening flexible sigmoidoscopy. (submitted for publication).
17. ASGE guideline 1998. Quality Improvement of Gastrointestinal Endoscopy.

Return to the Perry Hookman, M.D., P.A. Home Page