An NP's Journey to Credentialing for Colonoscopy

[Taurus]

An NP's Journey to Credentialing for Colonoscopy
Blazing a trail for a training fellowship

By Jordan Hopchik, MSN, FNP-BC, CGRN
Posted on: September 3, 2012

Timing is often a key ingredient and of critical importance in determining whether or not a personal or professional endeavor is a success or failure. When an opportunity presents itself, you must take the necessary steps to translate creative thoughts into reality. This was certainly the case when I wanted to become the first nurse practitioner in my workplace to create a nurse practitioner colonoscopy training fellowship.

Beyond the requirements for educational preparation, certification and licensure, NPs ultimately hold the key to maximizing their potential and defining their career trajectory, which sometimes means stretching beyond one's comfort level and seeking unique opportunities. Soon after starting my position in gastroenterology (GI) at a Veteran Affairs Medical Center in 2003, I observed an emerging trend I knew was worth pursuing. In the Veterans Affairs Healthcare System (VAHCS), demand for colonoscopy has far exceeded the supply of gastroenterologists, resulting in veterans often being wait-listed for months before getting their procedures scheduled. While alternative colorectal cancer screening tests exist, none replace colonoscopy for polyp and colorectal cancer surveillance.1

In our facility, in order to meet this demand, we established a temporary contract with a private endoscopy center. More than 60 patients per week were referred out, costing taxpayers more than a quarter of a million dollars each month. After conducting telephone interviews with credentialed nurse practitioners and physician assistants performing colonoscopy in the VAHCS, I found only a handful of qualified NPs and PAs performing colonoscopy. The driving force that created their training programs was similar to what I was observing in my workplace: high procedure demand, low physician supply and high outsourcing costs.

Armed with these staggering facts and an exhaustive literature review of NPs and PAs credentialed to do colonoscopy,2 I submitted a training proposal to my facility's executive nursing and medical leadership. After months of protracted negotiations, I was finally granted permission to start the first ever NP colonoscopy training fellowship. But first, I myself had to be trained.

Hurdles to Overcome

As the first NP in Pennsylvania to seek this credentialing, I encountered and overcame many hurdles while trailblazing my way into the world of gastroenterology medicine. Throughout my training, many challenged how and why I could be permitted to do colonoscopy when I had not graduated from medical school or completed a residency or gastroenterology fellowship.

I explained to those who asked that my training had been approved at the medical and nurse executive level, there were other credentialed NPs and PAs in the VAHCS, and this training was a growing trend in the private sector, as evidenced by Johns Hopkins Gastroenterology department's successful NP colonoscopy fellowship program.3

Colonoscopy Training

My training fellowship was modeled after the American Society for Gastrointestinal Endoscopy's colonoscopy core curriculum.4 In order to be eligible for colonoscopy credentialing, the endoscopist in training must have completed at least 140 supervised colonoscopies and demonstrate technical competence removing a minimum number of various polyps. I was held to the same training expectations as a GI fellow and followed a similar Mayo Clinic colonoscopy skills assessment tool as I progressed through the credentialing process.5

It was a long haul, from start to finish. My training began in 2005 but was interrupted for a year and half when the gastroenterologist with whom I initially started training left after she completed her fellowship. It was not until November 2006 that I officially resumed training and continued to train in piecemeal fashion. In April 2009, having done more than 325 colonoscopies and over 150 polypectomies, I was granted clinical privileges to perform colonoscopy independently as long as I had a backup attending available if I deemed it necessary.

Looking Back

Reflecting back on this intense training, I have no regrets, only a true sense of personal and professional accomplishment. Of course, there were tense moments when I was ready to throw in the towel, but somehow I kept my head up high and drew on inner strength, knowing one day my vision would be realized. I also gave thanks to family, friends and colleagues who supported me when I felt discouraged.

Currently, I perform about 10 procedures a week and may increase my procedure profile when staffing patterns improve. From an outsourcing standpoint, my current contribution translates to a facility savings of about $750,000 per year. Since becoming credentialed, there has been a positive shift in collegial attitudes and behavior. As time goes on, I am gaining more respect and admiration as my proficiency improves. On a few occasions, the department head has asked me to oversee GI fellows with colonoscopy training so he could perform administrative duties. There is still more work to be done, as our colonoscopy backlog remains high and outsourcing continues.

Down the Road and Words of Advice

After completing my capstone thesis project and graduating with my doctor of nursing practice degree in 2014, I hope to implement a nationally recognized colonoscopy fellowship program for NPs and PAs in the VAHCS. Using NPs and PAs as endoscopists in the VAHCS should prove to be rewarding to the individual, enhance healthcare delivery for our veterans and help save millions of healthcare dollars.

NPs and PAs today are highly sought after as healthcare providers and have demonstrated skill level and competency, often on par with physicians in terms of clinical outcomes and often surpassing them in patient satisfaction of care.6 With an ever-increasing demand for more primary care and specialty healthcare providers, this is a perfect time for these providers to forge ahead with new healthcare delivery models. Leading by example and creating innovative ways to improve access to preventive and maintenance healthcare, NPs and PAs will continue to play a major part in shaping America's future healthcare landscape. These innovations will produce safer, more effective, patient driven, fiscally responsible healthcare.

My final word of advice is the following: if you find a golden opportunity to make a great change in clinical practice, do not hesitate to use all your nursing and healthcare acumen to test it out and make it a reality!

As former U.S. president Franklin D. Roosevelt said in addresses to the public, "The only thing we have to fear is fear itself," and "The only limit to our realization of tomorrow will be our doubts of today." These are fitting messages for NPs and PAs in healthcare today.

Jordan Hopchik is a family nurse practitioner and endoscopist at the Philadelphia VA Medical Center.

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[Taurus]

Jordan Hopchik, MSN, FNP-BC, CGRN, Colonoscopist

Jordan Hopchik is pursuing his Doctor of Nursing Practice at La Salle University in Philadelphia, Pennsylvania. Mr. Hopchik was the first nurse practitioner credentialed to carry out colonoscopy in the state of Pennsylvania and is nationally certified by the Society of Gastroenterology Nurses and Associates. He works as a colonoscopist performing colorectal cancer screening at the Philadelphia Veterans Affairs Medical Center and as a gastroenterology nurse practitioner. Mr. Hopchik’s capstone project is to design and implement a formalized colonoscopy fellowship program for NPs at three VA Medical Centers in Northeastern Pennsylvania. His plan is to take the program nationwide in the future.

 

[ijn]

Good. The cheaper we make colonoscopies, the better.

 

[Socrates25]

Unbelievable.....

 

[Socrates25]

this isnt the first nurse GI fellowship. Hopkins started one awhile back and they let nurses do their scopes as well.

So we have nurses doing scopes in Philadelphia and Baltimore. Hardly the kind of rural areas where people cant get scoped because there are too few GI docs.

 

[Winged Scapula]

In April 2009, having done more than 325 colonoscopies and over 150 polypectomies, I was granted clinical privileges to perform colonoscopy independently as long as I had a backup attending available if I deemed it necessary.

So pretty much completely independent practice.

 

[PikminOC]

DNP=calls himself doctor in front of patients..

 

[Buzz Me]

This looks like the beginning of a dangerous trend...

 

[Apollyon]

this isnt the first nurse GI fellowship. Hopkins started one awhile back and they let nurses do their scopes as well.

So we have nurses doing scopes in Philadelphia and Baltimore. Hardly the kind of rural areas where people cant get scoped because there are too few GI docs.

I find it funny in an ironic way that these are two cities well-known (well, to some - I might guess some-to-many folks on SDN might not be so well-versed) by the nicknames of "Killadelphia" and "Bodymore, Murderland". Those apply to crime, usually gang-related, but, still...just coincidental.

 

[LoudBark]

I wonder if the patients are given full informed consent in knowing that the colonoscopy is being done by a NURSE and NOT a doctor. I wonder if patients are even given the option of having the procedure done by a doctor. I wonder if patients even are aware that the person doing their procedure is not a doctor.

Even the stupidest of the stupid patients would not choose to have a non-emergent, elective procedure done by a nurse if given the choice between a nurse and a doctor (a physician that is, not a Doctor of Nursing).

And here is the ultimate insult: "On a few occasions, the department head has asked me to oversee GI fellows with colonoscopy training so he could perform administrative duties." So this nurse is actually training GI fellows sometimes????????? For full disclosure, when the GI fellows are interviewing, does the program director inform candidates that "At my esteemed program, when me or some of the other faculty are performing administrative duties, you may be supervised when doing your colonoscopies by a nurse........but rest assured, he is a very good nurse."

 

[fishsnack]

We have to ask ourselves if the current system of paying GI docs absurd salaries for performing routine screening colonoscopies is sustainable. I feel like this is exactly the type of procedure thats well suited for an extender. I doesn't involve much decision making or complex understanding of pathology, and carries limited risk. Most importantly, screening tests with irrefutably positive results should be very cheap, and obviously GI docs won't let that happen. I applaude them for at least having a structured plan for training.

 

[anonperson]

We have to ask ourselves if the current system of paying GI docs absurd salaries for performing routine screening colonoscopies is sustainable. I feel like this is exactly the type of procedure thats well suited for an extender. I doesn't involve much decision making or complex understanding of pathology, and carries limited risk. Most importantly, screening tests with irrefutably positive results should be very cheap, and obviously GI docs won't let that happen. I applaude them for at least having a structured plan for training.

Way to sell out a fellow specialty.

I think you're under estimating the "ease" of a colonoscopy, even a screening colonoscopy. It is a procedure that takes a fair amount of skill to perform efficiently and safely.

Regardless, why are you advocating for a mid level provider to gain the skills to perform this procedure? Where does it end? A lap appy or c section are generally straightforward surgeries except when $hit hits the fan. Even more 'complex' procedures/surgeries can probably be performed by a mid level if exposed enough.

Here's a novel idea, if you want the skills of a physician, go to medical school and pursue the goal through a legitimate method instead of making up an entirely new route.

As far as the 'cost' of a screening colonoscopy. That's based on medicare reimbursement. A physician will essentially earn what is allowed, no more. In regards of the comment on the safety of the procedure, it's safe because people who are well trained perform the procedure so they've minimized risk.

 

[Dwindlin]

As far as the 'cost' of a screening colonoscopy. That's based on medicare reimbursement. A physician will essentially earn what is allowed, no more.

Exactly, the cost savings argument put forward by mid-levels (all kinds) is bull****. The only person who sees the savings is who ever has hired them, the patient is getting billed the same no matter who is doing the damn thing...

 

[midwestGI]

Here's a novel idea, if you want the skills of a physician, go to medical school and pursue the goal through a legitimate method instead of making up an entirely new route.
.

this. if you want to spend your career doing colonoscopies and EGD's, then apply to medical school, then residency, then fellowship. if you can't get into medical school or "don't want to", then you shouldn't be doing these procedures.

 

[bala1]

I doesn't involve much decision making or complex understanding of pathology, and carries limited risk..

Would you call a bowel perforation "limited risk"? Serious question!! How about missing a cancer? a flat polyp? Now is not the time to be training nurses to do this thats for sure

 

[bala1]

Way to sell out a fellow specialty.

I think you're under estimating the "ease" of a colonoscopy, even a screening colonoscopy. It is a procedure that takes a fair amount of skill to perform efficiently and safely.

Regardless, why are you advocating for a mid level provider to gain the skills to perform this procedure? Where does it end? A lap appy or c section are generally straightforward surgeries except when $hit hits the fan. Even more 'complex' procedures/surgeries can probably be performed by a mid level if exposed enough.

Here's a novel idea, if you want the skills of a physician, go to medical school and pursue the goal through a legitimate method instead of making up an entirely new route.

As far as the 'cost' of a screening colonoscopy. That's based on medicare reimbursement. A physician will essentially earn what is allowed, no more. In regards of the comment on the safety of the procedure, it's safe because people who are well trained perform the procedure so they've minimized risk.

Very well said.

Same thing with anesthesia. They say anesthesia is sooooo safe nowadays. Yeah its safe because we (physicians) have made it so.

 

[nope80]

Doctors need to start writing articles about this and giving the public more information about the dangers of midlevels. The public has no idea but I'm sure if they did, they would have a big problem with it. We need to get the word out so that people start asking questions...

 

[PikminOC]

Doctors need to start writing articles about this and giving the public more information about the dangers of midlevels. The public has no idea but I'm sure if they did, they would have a big problem with it. We need to get the word out so that people start asking questions...

the problem is there is no united voice..nurses unions are strong..
we nitpick..thats opthos problem, thats Gi's problem..

we are weak and work too much to fight for anything TOGETHER..

 

[CanIMakeIt]

the problem is there is no united voice..nurses unions are strong..
we nitpick..thats opthos problem, thats Gi's problem..

we are weak and work too much to fight for anything TOGETHER..

Exactly my point.
http://forums.studentdoctor.net/showthread.php?t=972755

 

[duckie99]

Mr. Hopchik's capstone project is to design and implement a formalized colonoscopy fellowship program for NPs at three VA Medical Centers in Northeastern Pennsylvania. His plan is to take the program nationwide in the future.

Doctors who work at the VA have brought this upon themselves. They don't work at the same pace as private practice or academic doctors often leading to 6+ months wait for a screening colonoscopy. I have worked at the VA on some outpatient rotations (away from the main ones connected to resident training facilities) and the doctors there are all extremely slow, mostly IMGs with english as a second language, and refuse to see more than 7-8 patients a day (they end at 3 pm with an hour for lunch). It takes months and months to get an appointment with the PCP. I can't imagine it is much different depending on the specialty. This is also compounded by the VA's funding problems and inability to hire more doctors (though each doctor has their own nurse and each NURSE will have an assistant to help them check patients in... so that's three health care providers per patient who is scheduled for 30 min each --- 7-8 patients a day, 4 or maybe 5 days a week).

There is a reason it blows to be a patient at the VA (and it's not that the care is bad, just soooo slow and inefficient)... In the end it's pretty ridiculous what it has come to but someone has got to do the colonoscopies. The question that needs to be addressed: Is it better the colonoscopies simply do not get done or get done much later OR is it better that a NP trained specifically with the only capability to perform screen colonoscopies does them and calls the doctor when necessary? Are patients at increased danger in this situation?

This is also in the VA system. I'd be surprised if something like this ever spread beyond. There needs to be more equivalency studies addressing the utilization of NPs without physician supervision. I just haven't seen them.

 

[duckie99]

I wonder if the patients are given full informed consent in knowing that the colonoscopy is being done by a NURSE and NOT a doctor. I wonder if patients are even given the option of having the procedure done by a doctor. I wonder if patients even are aware that the person doing their procedure is not a doctor.

The problem is patients don't have a choice because it's the VA system. If they show up after waiting 7 months and are told the NP will be doing the colonoscopy... sure they can say "no" but then they have to come back in another 8 months.

Part of the fault is on the doctors. As I said the doctors who work at the VA are just so slow it's hard to describe. They aren't compensated for working harder and seeing more patients so why do so? They are mostly IMGs who come to the USA to make money. That is their goal so why work harder? The doctors there are government workers.

The other fault lies within the VA's government funding system. These procedures are done at taxpayer expense. There are no payments (a government agency cannot pay another government agency). The VA does not provide the funding to hire more doctors. The VA is all about saving money so if an NP can do the procedure as safely there they will. Though this presents the interesting question of then creating further costs by finding more cancers, resulting in more surgeries, more hospital stays, more screenings, etc etc etc.

 

[PikminOC]

Patients at other hospitals wont care either bc a) they wont know as the consent forms are 15 pages long and b) they wont have a choice..

Youll see..

 

[lowbudget]

Wow. That's messed up.

All those years where general internists and family physicians couldn't get access to training for screening colonoscopies, and this is where we end up.

 

[PikminOC]

yeppers..

 

[sanj238]

Thats a really harsh assessment. I just rotated at the GI clinic and more patients are definitely seen than 7-8 a day. I think on average something like 9 to 10.

Jokes aside- the VA is notoriously inefficient. But thats not because they're all FMGs- a lot of good English skills but are 1. not burdened by overhead so not really motivated to work harder and 2. ALL Cost is borne by the VA. That is, x number of patients seen per day are NOT generally billable but totally cared for by the VA. Thus, if the VA says we'll pay x dollars regardless of the patients seen and if the patients aren't paying (or are paying exceedingly low amounts)- the VA saves money on fewer procedures done.

 

[Weinberg Angle]

...

 

[Silent Cool]

I'm not surprised this is happening, and frankly Milton Friedman called it. To paraphrase: If organized medicine artificially keeps down the number of training spots (400 GI spots anyone? 600K starting income?), then other health care providers will eventually find a way to provide the same services. This is exactly what is happening through all of health care right now, and Dr. Friedman foretold of this happening decades ago. In medicine it started first with Osteopaths. I certainly don't support the marginalization of medical training, but is anyone really surprised? Scopes are fairly easy, right? Even you, Taurus, suggested awhile back that Radiologists could learn to do basic scopes. Anyway, I don't think there really is anything to be scared of here. Are there suddenly going to be 1000's of nurse endoscopists out there? No way. The highest SOC will still be having a GI doc.
A number of years ago, I remember my Mother predicting that lower cost insurance will be made available to people through the use of these mid-levels. In other words, if you are dirt poor and can't reasonably afford better insurance, then you can buy cheap health insurance that will cover the cost of midlevel care--if you want to see a physician, you have to pay more. I for one would happily pay more for physician-level care, and I'm sure many others would, too.

 

[sanj238]

I'm not surprised this is happening, and frankly Milton Friedman called it. To paraphrase: If organized medicine artificially keeps down the number of training spots (400 GI spots anyone? 600K starting income?), then other health care providers will eventually find a way to provide the same services. This is exactly what is happening through all of health care right now, and Dr. Friedman foretold of this happening decades ago. In medicine it started first with Osteopaths. I certainly don't support the marginalization of medical training, but is anyone really surprised? Scopes are fairly easy, right? Even you, Taurus, suggested awhile back that Radiologists could learn to do basic scopes. Anyway, I don't think there really is anything to be scared of here. Are there suddenly going to be 1000's of nurse endoscopists out there? No way. The highest SOC will still be having a GI doc.
A number of years ago, I remember my Mother predicting that lower cost insurance will be made available to people through the use of these mid-levels. In other words, if you are dirt poor and can't reasonably afford better insurance, then you can buy cheap health insurance that will cover the cost of midlevel care--if you want to see a physician, you have to pay more. I for one would happily pay more for physician-level care, and I'm sure many others would, too.

Thats a fairly insulting position on Osteopaths- considering they've been around the medical establishment for the past 40 years as full blown physicians. When exactly did they begin to crowd out the other doctors for income? They're a fraction of the physicians in this country. The reality is that a lot of medicine these days does not need to be done only by a GI specialist.

There was a study in BMJ England that found absolutely zero difference in outcomes including ability to diagnose and find pathology with scopes between nurses and physicians. The patients were followed for up to one year out.

I used to be on the side of physicians only- but I'm thinking, what exactly separates a doctor from the rest when after years of specialization all that medical knowledge atrophies...most medical students cant even remember the anatomy they studied first year by the years end. And all my friends I've talked to who have specialized- etc- proudly claim how they've forgotten most of what they learned- autonomics etc.
If a physician won't remember most of his medical training and is specialized- how is he any different from someone who receives said training at the mid level. I'm not saying this applies to everyone. I think most surgical specialties, cardiology, etc require physician training and those years studying physiology, IM, pathology are essential- but to do scopes? Or cataracts? I'm not familiar with anesthesiology at all- but from what I see its fairly complex and I cannot understand how CRNAs can take over. Regardless- I'm uncomfortable with the assertion that only dermatologists should do skin or that dermatopathologists and MOHs training can claim the salaries they make due to volume- when so much of it is what the PAs are doing at rural hospitals. No doubt the training and so forth is essential- but to monopolize it on unsubstantiated claims is silly.

For what its worth- when most of the medical students who go into specialties promptly forget what they learn in medical school- how is it fair to claim those years of studying as an important skill set? From what I can see- its more than anything a means to an end. Once you get past each stage - step 1 step 2 its time to move on (with no heed for whats learned- unless its needed). The cold hard irony of course is that we need that continuation of knowledge in the IM field and yet this is the field that gets paid a lot lower than others (derm, ophtho).

I don't have anything against any of these fields on a personal level. I'm considering ophth as well but I just think its interesting that I see this on the forums on such a consistent level - on the one hand 4 years of med training makes us special and on the other hand- students using it merely as a means to an end with no real interest in retaining that knowledge.