Colonoscopies

[secretwave101]

So our teaching rounds today were led by a gastroenterologist. Nice guy. Subject was abdominal pain. Fine.

When he was done, I asked him how I might go about learning colonoscopies. He gave me this crappy, loooooong answer that included how dangerous it would be to have FP's doing them, how impossible it would be for someone like me to get enough of them to get hospital privledges (150 or so), and how I could never keep my numbers up if doing only 2-3 a week in my own office.

All I wanted to do was learn how to do 'em.

He was a nice enough guy about it, so I didn't realize how much his arrogant answer was pi$$ing me off 'till later. Now I'm even more motivated to learn the procedure. I don't know if I'll try to do them in my practice. I don't know ANYTHING about how my practice will look. I wasn't asking the guy about my practice. But this is one of the most common procedures in medicine. It is a general health screening procedure. Learning it is appropriate for a FP resident. If nothing else, it can teach me to see potentially malignant polyps and the anatomical contours of the lower GI tract better.

What a punk.

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[zippy81]

He's just scared of losing business, and if you go to the right program getting good numbers isn't hard. We learn from a FM attending who does them pretty much every day, heck I got a good numbers my first month as an intern when I wasn't busy on surgery.

 

[erichaj]

Don't worry about that GI doc.

If you want to learn how to do it, find another doctor that will take the time to teach it to you the right way. If you do lots of them and feel that you practice can support it, then you may want to do it in you practice.

Good luck.

 

[JML MD]

NOTE: this reply is probably only applicable to medical students looking for residencies where they can learn endoscopy training during residency.

Colonoscopies and EGDs are procedures that you CAN perform as a family doctor. Performing endoscopies allows family physicians to provide increased continuity of care to patients and can boost your practice financially. The area of the U.S. you practice and the size of the town will be important factors, however, to whether or not you get hospital privileges. Generally, FPs in bigger cities have less opportunity to perform the procedures than FPs in more rural areas.

If after deciding that endoscopy is something you wish to offer to patients in your future practice and you are searching for a family medicine residency program that offers strong training in endoscopy, beware of some of the common answers you'll get from programs that inadequately train residents in endoscopy (if at all)...

When asking residents/faculty at programs about endoscopy, most programs will tell you that they can get you “experience”. Often, programs only tell you that – regardless of how well they actually are able to train you - because they want you at their program in these current times when programs are competing over students. If a program tells you that you can get experience, ask them these questions:

1. HOW MUCH experience will you get?
How many colonoscopies/EGDs are your residents interested in endoscopy getting by graduation?? (Many hospitals require 100 each of EGDs and colonoscopies to be credentialed to perform the procedure; if the number is less than 100 and especially if it is less than 50 – beware!).

2. HOW MANY residents do the procedure after graduation?
Ask how often residents leave the program and obtain credentials to do procedures. If they say that they can train you but very few of their grads are doing actually endoscopy after graduation, then that says something about the training you'll get there in endoscopy.
(BEWARE: programs that answer this question by telling you that few family docs do this procedure upon graduation... this is just them telling you that there is no way you'll get the proper training at their program. The reason that few family docs do the procedure (other than location of the practice as mentioned above) is that few residencies train their residents adequately because they simply cannot offer residents the numbers/experience needed. You CAN do this procedure after residency and be successful at it (easily enough so to more than compensate for the small increase in malpractice insurance) IF you get proper training in residency.)

3. WHO teaches you the procedure?
Ask who trains you in endoscopy -- there is a big difference between watching or assisting a surgeon or GI doc versus actually doing them under supervision of a family medicine faculty member. I generally recommend learning from a family medicine doc who has lots of experience, as YOU will be a family doc doing the procedure.

4. WHERE do you get your numbers?
Find out whether or not you can learn the procedure on-site (in the office or hospital) or whether or not you'll have to go somewhere else to learn the procedure. No one wants to do a rotation and hour or two away from the site just to learn the procedure and hope you get the proper numbers within that time.

The program I train at, McLeod Family Medicine in Florence SC, is one of the strongest programs in the U.S. at offering family medicine residents training in endoscopies. Interested residents easily obtain 100 EGDs and 100 colonoscopies (uninterested residents never have to touch a scope – we have great sports med, geriatrics, OB, pediatrics, and international medicine experience as well). Numerous graduates perform endoscopies in their practices, including 4 of 7 graduates in the most recent graduating class. We are trained in-house by family physicians, and residents can begin getting experience day #1. Our residents are able to train in endoscopies because we are the only residents at a 500+ major medical center, which was recently recognized on the cover of the July 2005 US News & World Report Issue titled America’s Best Hospitals.

If you are interested in truly learning this procedure, check the program out. If the southeast US is not where you are looking for your residency, then just make sure the programs you look at offer the same level of training (assuming again that learning endoscopies is important to you).

I hope this LONG reply helps. PM me with any questions!

 

[dr.smurf]

try a colorectal surgeon. they do them and are usually less territorial and arrogant about the whole FP colonoscopy thing. its a huge turf battle and the above post was right...its about the money. you may also let whoever you talk to up front that you dont want to stay in the area, then they wont feel threatened that youll setup shop next door!

 

[secretwave101]

Grrrrr. It makes me even more bummed to hear that there are programs out there that totally support this kind of thing. I love my residency, but they're still in the sigmoid world and so I'll need to make my own way to get the experience I want with EGD's and colon's.

And yeah, the advice about telling potential teachers that I won't be practicing in the area is good...it also makes me feel like some 2nd class citizen. Why can't they view me as a colleague? Why do I have to relegate myself to a zip code on the moon to get experience with a procedure that is good for patients? I MIGHT practice rurally...but I'm not willing to confine myself to that just to learn a medical procedure. Fundamentally, it offends me that I would have to make some sort of bargain with someone just to be taught something I have every right to learn.

This kind of stuff makes me pretty mad. I'm tired of FP's getting sidelined for so many things. We had a code in the hospital yesterday and I SPRINTED up to the room so I could be the one to intubate and potentially run the code. Since I was there first, the ER doc did "allow" me to try the intubation once. As soon as I missed, he "took over"...as in, "you've had your fun, little kid, now get back while the actual doctor takes over" and then he proceeded to miss twice. My R-2 just stood around and watched because although he's SUPPOSED to be running the code....some cardiologist from another hospital showed up and totally sidelined him. So, we just stood around in our stupid white coats and watched...like every other rubber-necker in the doorway, hallway and surrounding the bed.

So far, this kind of stuff has made me pretty mad, but I've played it real cool and passive in front of the "hegemonists". Soon, though, I'm gonna have to start pushing the assertiveness button because I want to get out of this program good at codes, good at EGD's and colonoscopies and dang good at deliveries. Will I use any of those? Maybe not. But that shouldn't be up to the specialists to decide. It should be up to me.

 

[bariume]

Grrrrr. It makes me even more bummed to hear that there are programs out there that totally support this kind of thing. I love my residency, but they're still in the sigmoid world and so I'll need to make my own way to get the experience I want with EGD's and colon's.

And yeah, the advice about telling potential teachers that I won't be practicing in the area is good...it also makes me feel like some 2nd class citizen. Why can't they view me as a colleague? Why do I have to relegate myself to a zip code on the moon to get experience with a procedure that is good for patients? I MIGHT practice rurally...but I'm not willing to confine myself to that just to learn a medical procedure. Fundamentally, it offends me that I would have to make some sort of bargain with someone just to be taught something I have every right to learn.

This kind of stuff makes me pretty mad. I'm tired of FP's getting sidelined for so many things. We had a code in the hospital yesterday and I SPRINTED up to the room so I could be the one to intubate and potentially run the code. Since I was there first, the ER doc did "allow" me to try the intubation once. As soon as I missed, he "took over"...as in, "you've had your fun, little kid, now get back while the actual doctor takes over" and then he proceeded to miss twice. My R-2 just stood around and watched because although he's SUPPOSED to be running the code....some cardiologist from another hospital showed up and totally sidelined him. So, we just stood around in our stupid white coats and watched...like every other rubber-necker in the doorway, hallway and surrounding the bed.

So far, this kind of stuff has made me pretty mad, but I've played it real cool and passive in front of the "hegemonists". Soon, though, I'm gonna have to start pushing the assertiveness button because I want to get out of this program good at codes, good at EGD's and colonoscopies and dang good at deliveries. Will I use any of those? Maybe not. But that shouldn't be up to the specialists to decide. It should be up to me.

I can appreciate your desire to learn the procedure. But I would have to add that EGDs and colonoscopy take an endoscopist years to learn to do effectively. You certainly need more than 50 colonoscopies, and I would argue you need to do much more than 200 colonoscopies in order to feel comfortable providing this for your patient. You can certainly learn to do a diagnostic procedure by doing at least 100 or so, but if you are going to do polypectomy or other interventional procedures, you really would want to have had much more formal training. Just like with cardiac catherizations, we live in a day and age where a diagnostic invasive procedure in place of an warranted interventional one should be questioned. Lastly, how to manage the complications of the procedure is another thing.

If you have sincere interest, why not try to go for one of these special programs, if not a full GI fellowship?

 

[Burly B]

I, too,would love to incorporate colonoscopies in my practice. I just finished a rotation with a colon/rectal surgeon. He was more than willing to teach me and get experience. He does them in his office along with an anesthesiologist. As a FM doc, I will have to have the re$ources to do it.

He says it will be hard as an FM doc to get approved, pay the insurance, and get privileges to do the procedures in the office. Would I not be recognized / "allowed" because insurance companies say it has to be done by GI specialist or colorectal surgeon???

Also, it is true. So many residency programs claim "experience and training in colonscopies" You gotta wonder which ones truly get you that experience.

 

[Mr. McDuck]

And yeah, the advice about telling potential teachers that I won't be practicing in the area is good...it also makes me feel like some 2nd class citizen. Why can't they view me as a colleague? Why do I have to relegate myself to a zip code on the moon to get experience with a procedure that is good for patients? I MIGHT practice rurally...but I'm not willing to confine myself to that just to learn a medical procedure. Fundamentally, it offends me that I would have to make some sort of bargain with someone just to be taught something I have every right to learn.

Who says you actually have to practice rurally? Just because you tell them that now so they'll show you how to do them doesn't mean you actually have to do that.

 

[deleted6669]

I know gi/colorectal pa's who do them (yes, I a mean colonoscopies, not sigs) so I don't see why anyone who wanted to learn them and had access to good training and adequate #s to become proficient shouldn't.It's just another procedure so repetition with appropriate oversight= proficiency.
these guys went through a preceptorship with a gi doc and pretty much do almost nothing else all day long.their entire scope of practice is colonoscopies and hemorrhoid related procedures. a certain % of their colonoscopies are reviewed with the # decreasing over time after training.they work in a large gi group where the backlog of scopes without them would be > 6 months. with the 2 of them doing several each/day they have a fairly short wait now.
they make good money for midlevels( >130k/yr) but they deal with a-holes all day long.....

 

[secretwave101]

Who says you actually have to practice rurally? Just because you tell them that now so they'll show you how to do them doesn't mean you actually have to do that.

True. I just don't like having to justify it. I feel like learning a screening procedure is my right and should require no justification.

And I'm tired of hearing the GI docs and the colorectal surgeons kindly and gently point out how impossible it will be for me to keep up my numbers and get insurance coverage for the procedure. They're supposed to be specialists who do pretty much nothing but rear-ends all day. They should stick to that. I can worry about the practicalities of using the knowledge professionally 3 years from now.

And the numbers thing isn't very convincing either. When the turf issue is removed, any doc who does procedures will tell you that there are doctors who do LOTS of a given procedure badly, and others who do the same procedure less frequently but very well. Procedures are operator-dependent. Some people need thousands of them because they're uncoordinated bumbling nervous wrecks. Others need far less. Yes, everyone needs SOME number to gain proficiency. But the standards the've set are arbitrary and are in part meant to keep money flowing in one direction rather than in many...to the detriment of patients.

 

[Mr. McDuck]

Nah, I agree with you. And, I think you should just say whatever it is you have to say in order to learn how to do them and get the numbers you need for privileges down the line. When it comes down to it, like you said, it will be your practice. If you want to include colonoscopies, you better start doing them now (you know this, obviously, I'm just repeating it). Do what must be done.

 

[sophiejane]

There are more programs that are making endoscopic training part of the curriculum, or at least an option.

I know of several in Texas alone.

OBGYNs say the same thing about FPs doing OB.

Just find someone who will teach you and shrug off the arrogance if you can.

 

[erichaj]

Until FP programs train their residents to do colonoscopies and give then proper numbers (like 200 +) I would say that it would be very unlikely that any hospital will credential you to do them. Unless you are in the middle of nowwhere and it is better to get one by someone rather than none at all.

I know this sucks, but the politics of this are deeply rooted in all communities.

 

[sophiejane]

Until FP programs train their residents to do colonoscopies and give then proper numbers (like 200 +) I would say that it would be very unlikely that any hospital will credential you to do them. Unless you are in the middle of nowwhere and it is better to get one by someone rather than none at all.

I know this sucks, but the politics of this are deeply rooted in all communities.

I can think of 3 FPs off the top of my head who do colonoscopies and had no problem getting hospital privileges.

One of the programs I'm applying to requires 8 weeks of endoscopy, and you can use your electives to get more experience. Say you work 5 days a week, and do 5 colonoscopies/day, that's an easy 200 in 8 weeks. I've rotated with GI and colorectal attendings who do 8-10 colonoscopies a day, approximately 3 days a week. If all you are doing is scopes as a resident, it's not at all unreasonable to expect you could get >200 of them in 8-12 weeks.

It has been argued ad nauseum about how FPs can only do procedures like colonoscopies and deliveries in the "middle of nowhere." So, what's your point? I think most people interested in or practicing FM are smart enough to realize that an FP in a city surrounded by specialists is not going to get rich on colonoscopies.

Most of the people I know who are really interested in procedures in FP are also interested in rural/underserved medicine.

It's fine with me that there is a stigma against the "middle of nowhere"...all that means is more land, patients, and pretty sunsets for me...

 

[erichaj]

Good luck with your land, patients, colonoscopies and pretty sunsets.

 

[sophiejane]

Thank you. I'm looking forward to it...

 

[Tn Family MD]

Our residency has an attending who does c-scopes in our hospital and we are in a university setting. You don't necessarily have to go unopposed to get good training. I would say that you do have to be very careful about where you end up, though.

In addition, we have a community faculty who does a ton of these in a rural community about 45 minutes to an hour from our main campus. All our residents have the option of doing a month with him 2nd year and if they desire another month with him in 3rd year.

We also get pretty darn good training in Colpo and LEEP, as we are contracted with the local health department to provide these services to all their patients who need them. Another cool procedure we get is the no scalpel vasectomy. The procedural training is out there for those who seek it.

There are good training programs out there, both university and unopposed. Just be really careful about where you choose, as there are definitely programs out there that are very subpar as I have witnessed them as well.

By the way, this is not a dig on the guy posting about McLeod a few posts above here. I interviewed there when applying for residency and thought it was top notch all the way around. I don't feel like I saw a stronger program anywhere. Full of nice folks too. It just was not the right location geographically for me.

 

[andwhat]

that is just so strange, I was just thinking about this exactly, similar thing that happened to me the other day, the GI attending that I worked with pointed out arrogantly how an FP lady messed up a colonoscopy in a University hospital, and then rudely said to me that she only did the procedure to make money, I asked what she did it for, like to do a procedure, or some type of credit, I have never heard of an FP doing a colonoscopy, mainly only Flex Sigs which arent really in use anymore, and he rudely said "What do you think? to make money" and word for word "you can convince the hospital administration to do brain surgery" man what a jerk... and now I see that it was purely insecurity that he said it... he would lose money if others could learn how to do it too.. and anybody off the street can learn a procedure, and a colonoscopy doesnt exactly take many brain cells to do... of course a GI specialist would never ever teach you how to do colonoscopies... thats just terrible man terrible...
although one of the general surgeons in our hospital is really nice, and teaches us alot of procedures, and the surgeons in general are always really nice... but comments like thos make me actually want to learn colonoscopies... man I never ever send referrals to that particular group from the hospital or clinic due to what other people have told me, and now through personal experience ditto that man 110%... hell I know of a guy, super smart, graduate of our program and he spent a whole month learning how to do colonoscopies from this particular surgeon, I will bet that that is where this animosity and heightened jealousy comes from..

What a punk.[/QUOTE]

 

[sophiejane]

that is just so strange, I was just thinking about this exactly, similar thing that happened to me the other day, the GI attending that I worked with pointed out arrogantly how an FP lady messed up a colonoscopy in a University hospital, and then rudely said to me that she only did the procedure to make money

Sorry, but why else does anyone do procedures, see patients, etc., but to make money? That's the lamest put-down ever. If that's all he can come up with, I'd just have a good laugh at him and keep on scoping...

 

[secretwave101]

Attending: Outpatient medicine is very challenging these days.

Me: How so?

Attending: These days, it's difficult to make money if you don't do some sort of measurable thing with a patient. Most family docs aren't in the game to "make" money, but they are in it to live a good life and get out of debt.

Me (to myself): What would be a good procedure that I could add to my practice that is appropriate for primary care (i.e. a screening procedure), that is generally safe, and is reimbursed well? I know...how about colonoscopies? EVERY human being is currently being told that they need one at least once in their lives. It has almost totally replaced sigmoidoscopies. And as the baby boomers age to 50, it'll take waaaay more than all the GI docs in the U.S. to get everyone screened. Perfect fit.

Me (to GI doc): I'd like to learn colonoscopies. We'll be colleagues, you and me. Shoulder-to-shoulder and all that (even though the idea of specializing in the bung-hole is a little unsettling to me).

GI doc: Bite me. You're just in it for the money.

Me (to myself): Apparently I'm embarking on a new crusade, for the principle of it. At first I was just curious. Now I want to spite all turf-heads who aren't capable of balancing their need for income with patient care. I firmly believe the two ARE compatible.

 

[sophiejane]

Sounds like the GI dudes have a bit of a chip working there.

I followed a colorectal surgeon who does a lot of teaching at the family medicine residency where I did my surgery rotation. Great guy, super nice, if a little on the odd side.

But I swear, he had the best butt jokes EVER.

I guess the colorectal folks are a little less territorial because they make a buttload ( ) doing colectomies, too.

 

[Marigold]

Sounds like the GI dudes have a bit of a chip working there.

I followed a colorectal surgeon who does a lot of teaching at the family medicine residency where I did my surgery rotation. Great guy, super nice, if a little on the odd side.

But I swear, he had the best butt jokes EVER.

I guess the colorectal folks are a little less territorial because they make a buttload ( ) doing colectomies, too.

 

[erichaj]

I remember that the colorectal surgeons in our area did EGD's and colonoscopies. One of the GI groups docs were so angry about this. It was politics.

I got to thinking, if a GI doc perforates the colon who would they call. The surgeons right. So, if anyone is going to tell one not to do a procedure wouldnt it make sense that the surgeon tells the GI guy not to do it?

Anyway, FP can learn this procedure.

 

[andwhat]

Sorry, but why else does anyone do procedures, see patients, etc., but to make money? That's the lamest put-down ever. If that's all he can come up with, I'd just have a good laugh at him and keep on scoping...

naw it was more said in a condescending manner, I mean yeah obviously I realized what the procedure was done for, my question was more open ended, as if to stimulate discussion, however he quickly got out of that type of conversation, it was hilarious...
also whined alot about how much and how often FP and IM primary care doctors ignore patient's GI symptoms, that could be something more serious. Yeah guess that your just not as important as you think, and or wish that you are.... I will certainly bypass that guy whenever I get the opportunity, that jerk makes more than enough I imagine anyways...