An Internist Is Able to Successfully Perform Diagnostic Colonoscopy after Training by Gastroenterologists: A Single VA Medical Center Pilot Program to Address the Increasing Demand for Diagnostic and Surveillance Colonoscopy

Abstract

Purpose: Colorectal cancer (CRC) is the third most common cancer and the second leading cause of cancer-related mortality in the United States. Currently the resources required to screen every eligible person using colonoscopy do not exist. In the future, the nation will face a shortage of all physicians, including gastroenterologists. We hypothesized that training a primary care physician with a prior experience in performing flexible sigmoidoscopy through a comprehensive training program supervised by a group of gastroenterologists, could result in the safe performance of quality colonoscopy. Methods: An internist who was interested in performing colonoscopy and had a vast experience in performing flexible sigmoidoscopy was selected. A program was developed for her to learn how to perform colonoscopy which included: watching videos of different colonoscopies and polypectomy techniques, performing colonoscopy on a pig model of colon, training with four gastroenterologists over a period of 14 months followed finally by evaluation by them after performing 100, 200 and 400 colonoscopies. After each benchmark, her cecal intubation rate, and polypectomy techniques were evaluated. Results: She performed a total of 320 independent colonoscopies over a period of 7 months at the Loma Linda VA Hospital. Of the 320 patients, 287 (90%) were males. The mean age and BMI were 63.8 ± 10.6 years and 30.2 ± 6.1, respectively. The majority of patients were Caucasians (n=196 patients, 62%). The main indication was surveillance (n=245, 30%). Her cecal intubation rate was 95% compared to 94% and 93% for gastroenterology fellows and attendings, respectively (p=0.31). The number of colonoscopies during which she found a polyp was 218 (68%) compared to 32 (39%) and 181 (44%) for gastroenterology fellows and attendings, respectively (p < 0.0001). Her adenoma detection rate (ADR) was 56% versus 33% for fellows and 34% for attendings (p < 0.0001). She had no complications.Table: [536] Findings ( n =818)Conclusion: Unfortunately, the capacity for a national colonoscopy screening program is limited secondary to the short supply of gastroenterologists and the unmet demand for colonoscopy for colorectal cancer screening as well as surveillance. We feel that in underserved areas that are unable to keep pace with the demand of colonoscopy, whether the indications are for screening or diagnostic purposes, primary care physicians trained by gastroenterologists may be a valuable asset in providing the standard of medical care for all.