health
More family physicians doing colonoscopies
■ A recent study says they can be done safely. Hospitals, however, are slow to credential generalists, and specialists say they do the screening test better.
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Jeffrey Edwards, MD, a family physician at St. Mary's Hospital and Clinics in Cottonwood, Idaho, has performed hundreds of colonoscopies. These patients usually come to see him because they don't want to travel great distances to see the nearest specialist, wait months for an appointment or deal with a physician they don't know. He refers those who are at high risk for complications. But he cares for those at low risk on-site.
"Some of our folks come as far as two and three hours away, and they'd have to go another hour farther to a major medical facility," he said. "Being able to provide these services here has been really valuable."
He's one of a growing number of family physicians, particularly in rural areas, who are adding colonoscopy to the services they provide. A paper, authored by Dr. Edwards and published in the September-October issue of the Journal of the American Board of Family Physicians, suggests they may be doing the right thing. The study found family physicians trained in the procedure can provide safe and effective colonoscopy and achieve results similar to that of other specialties.
Those family physicians who do the procedure say it is a natural addition to the cancer screening they already carry out and is not much more complicated than the flexible sigmoidoscopy that many perform routinely. Advocates also say making this procedure a regular part of primary care could dramatically increase access to it, and not just for rural residents. For example, anecdotal evidence suggests that demand for colonoscopy has outstripped supply in some urban areas, resulting in long waits.
"I certainly hope that family physicians ... start taking the training and performing this service for their patients," said David Kresnicka, MD, a family physician in Marion, Iowa. "We owe it to the public."
Difficulties involved
The barriers to including colonoscopy as a regular part of family medicine, however, are significant. Those supporting it acknowledge that not every family physician wants to do colonoscopy. According to the American Academy of Family Physicians annual Practice Profile Survey, nearly three-quarters were not interested and only about 3% offered it.
"This is not for every family physician," said Thomas Norris, MD, the paper's co-author and a professor in family medicine at the University of Washington in Seattle. "For a subset practicing in a rural or urban underserved setting who have the interest, training and experience, I think it's quite appropriate."
But even if family doctors want to and complete the training, hospitals may not be willing to credential them. The same survey also found that colonoscopy was the second most contested privilege for family physicians.
"Some physicians may perceive that family doctors shouldn't be doing this and blocking access to privileges," said Rick Pierzchajlo, MD, a family physician in Tifton, Ga. "But it's inevitable that family physicians will have to do this on a very widespread basis if we're to implement recommendations for screening."
In response, colonoscopy experts said it was appropriate for family physicians to offer the procedure with training, particularly in underserved areas. They expressed concern, however, that a busy primary care physician may not be able to complete the number of procedures required to become proficient. For example, a study published in the June 1997 issue of Gastrointestinal Endoscopy found that a cancer was five times more likely to be missed if the colonoscopy was performed by a nongastroenterologist.
"It may be better to have colonoscopy by somebody who has a little bit less training if that's the only colonoscopy that you can get," said Douglas K. Rex, MD, one of the authors on that paper and president of the American College of Gastroenterology. "But our feeling would be that patients deserve to undergo colonoscopy by people who are trained to do it."