General surgeons doing EGD/Colons

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BERNZ

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I know this GI forum is not particularly active, but I thought I would post anyways. As an MSIII, interested in GI, I have rotated at a hospital here in Chicago where the general surgeons do EGD/colonoscopys as well as the GI specialists. My roommate is currently rotating in surgery at another hospital around here that also has gen. surgeons doing EGD/colons...Is this normal? Future impact on GI?

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Yes, it's normal. It's very dependent on institutions as well. Some places, the surgeons are doing ERCP.

Surgeons are procedure oriented, but some diagnostic things they are capable of doing as well. If a surgeon misses a diagnosis, however, they are subject to the same penalty (lawsuit, etc) as a GI specialist is.

There will be no great impact in the future since surgeons have been EGD's and colonoscopies since the devices were invented. Many just choose not to do them since they have other things to do...OR the institution just has the GI doc do it.
 
Training in endoscopy is currently required to be board eligible in general surgery and is included in surgical residency. As of now, the ACS does not specify a minimum number of EGDs or colons to be done just a minimum number in the category, which also includes mediastinoscopy, thorascopy, etc. Most residents fulfill the category with EGD and colons. I personally performed nearly 200 during my residency. There is push to specifically require EGD/colonoscopy training separate from other endoscopic procedures.

I know several general surgeons who spend at least a day a week doing nothing but EGDs and colons. Given the current screening guidelines for lower endoscopy and the pleothora of patients, there are more than enough to go around...I am not aware of any Gastroenterologist who is complaining that they don't have enough scope work. And as is noted above, since surgeons have been doing them for ages, I doubt very much there will be a change in the practice patterns.

It can be an essential part of the surgical armamentarium and they are very lucrative given the amount of time it generally takes to do them (ie, they pay nearly as much as an appy).
 
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Training in endoscopy is currently required to be board eligible in general surgery and is included in surgical residency. As of now, the ACS does not specify a minimum number of EGDs or colons to be done just a minimum number in the category, which also includes mediastinoscopy, thorascopy, etc. Most residents fulfill the category with EGD and colons. I personally performed nearly 200 during my residency. There is push to specifically require EGD/colonoscopy training separate from other endoscopic procedures.

I know several general surgeons who spend at least a day a week doing nothing but EGDs and colons. Given the current screening guidelines for lower endoscopy and the pleothora of patients, there are more than enough to go around...I am not aware of any Gastroenterologist who is complaining that they don't have enough scope work. And as is noted above, since surgeons have been doing them for ages, I doubt very much there will be a change in the practice patterns.

It can be an essential part of the surgical armamentarium and they are very lucrative given the amount of time it generally takes to do them (ie, they pay nearly as much as an appy).


It really depends on the practice pattern in your area. In my previous practice the GI docs would not refer to surgeons that did screening colonoscopies. None of the local surgeons outside the Trauma surgeons did EGDs. There was a particular problem with colorectal surgeons training FP doctors to do colonoscopies so they could get more surgery. In response the number of procedures needed to be credentialled at the area hospitals has risen. Previously they followed ASGE guidelines for a minimum of 140 colonoscopies independently observed and 130 EGD independently observed. Now the numbers are well over 200 for both. This allows colorectal surgeons and GI physicians to be credentialled but generally does not allow others. ERCP numbers now require 200 in some cases.

I see colonoscopies and EGD done by surgeons in rural areas much more. In some areas there are no GI providers and the surgeon may be the only one who can do endoscopy. Most hospitals in an urban environment will follow ASGE guidelines, Darling v. Charlestown Memorial Hospital saw to that.

It is partly about defending the turf to be sure. But part of working as a physician is the referral pattern. I would be very sure that your GI docs are OK with the surgeon doing routine colonoscopies before heading that way.

David Carpenter, PA-C
 
Certainly patterns of referral do vary around the country, although I find it a bit offensive that a GI physician would not refer a patient needing surgery to a surgeon who does colonoscopies. Seems a bit self-serving, but perhaps that's the way it works in the real world (disclaimer: I do not do scopes anymore and have no intention of doing them in my practice, so I care not a whit about this practice).

I can imagine that rural surgeons might be more likely to do the procedure rather than refer a patient several miles/hours away to a gastroenterologist, but it is not the case that urban surgeons do not. My experience is urban and suburban, with general surgeons doing the scopes and they work quite closely with several GI groups in town. I was never aware of any strife between them because of this practice. In reality, a couple of general surgeons doing a few scopes a week hardly makes a dent in the patient volume available to gastroenterologists, IMHO. If anything, our gastroenterologists are so busy that they simply CANNOT do all the scopes that need to be done.

I understand GI physicians feeling squeezed if surgeons are training FM physicians to do scopes, but if there is sufficient training in a general surgery residency to be competent in the procedures, then I see no reason why they should not do them. The reality is that most general surgeons do not have an interest in doing a large number of them (and ERCP even less), but as you note, one's experience may vary.
 
It can be an essential part of the surgical armamentarium and they are very lucrative given the amount of time it generally takes to do them (ie, they pay nearly as much as an appy).


Certainly patterns of referral do vary around the country, although I find it a bit offensive that a GI physician would not refer a patient needing surgery to a surgeon who does colonoscopies. Seems a bit self-serving, but perhaps that's the way it works in the real world (disclaimer: I do not do scopes anymore and have no intention of doing them in my practice, so I care not a whit about this practice).

If they are so lucrative, why not do them? You could probably do 2 to 3 colonoscopies in an office setting/ASC in the time it takes to do an appy.
 
If they are so lucrative, why not do them? You could probably do 2 to 3 colonoscopies in an office setting/ASC in the time it takes to do an appy.

Well, personally its because I don't do general surgery at all since doing a fellowship. But for those who do, they are much more lucrative if one is so inclined and enjoys doing them.
 
Certainly patterns of referral do vary around the country, although I find it a bit offensive that a GI physician would not refer a patient needing surgery to a surgeon who does colonoscopies. Seems a bit self-serving, but perhaps that's the way it works in the real world (disclaimer: I do not do scopes anymore and have no intention of doing them in my practice, so I care not a whit about this practice).

Not that they won't refer to a surgeon, but if you had a choice between someone who directly competed with you for lucrative procedures (as you stated) and someone who did not then who would you choose (everything else being equal). There are some markets that are not saturated, but have ample representation. Waiting times for endoscopy are probably the best indicator. Outside of HMOs there are places where the waiting time for colonoscopy is under 30 days. In that situation there is competition.

The other situation is that while surgeons may be able to do the technical component, they are probably not adept at treating the follow up for all the disease states they find. If the surgeon does a colonoscopy for rectal bleed and finds UC then they have to refer to GI. So the surgeons have done the most lucrative part of the encounter leaving the least lucrative part to GI. It would be similar situation if the GI docs did a subtotal colectomy and then sent the patient to the surgeon for aftercare. One of the physicians I worked with thought that it was OK for surgeons to do colonoscopies for asymptomatic patients for that reason but not for symptomatic patients. On the other hand at least surgeons can fix their complications unlike GI:D


I can imagine that rural surgeons might be more likely to do the procedure rather than refer a patient several miles/hours away to a gastroenterologist, but it is not the case that urban surgeons do not. My experience is urban and suburban, with general surgeons doing the scopes and they work quite closely with several GI groups in town. I was never aware of any strife between them because of this practice. In reality, a couple of general surgeons doing a few scopes a week hardly makes a dent in the patient volume available to gastroenterologists, IMHO. If anything, our gastroenterologists are so busy that they simply CANNOT do all the scopes that need to be done.

Nationally there is a lot of conflict. It is not only FP, but also radiology with virtual colonoscopies. With the current way that Medicare reimburses, any procedure based specialty is the one that makes money. If things get tighter then conflict will become more common. It really depends on your area.


I understand GI physicians feeling squeezed if surgeons are training FM physicians to do scopes, but if there is sufficient training in a general surgery residency to be competent in the procedures, then I see no reason why they should not do them. The reality is that most general surgeons do not have an interest in doing a large number of them (and ERCP even less), but as you note, one's experience may vary.

The problem with this is that if you don't do many of them then you have a hard time being good at it. Also while general surgery may do some procedures most hospitals use the ASGE guidelines at a minimum.
http://www.asge.org/WorkArea/showcontent.aspx?id=3004
This is a hard number to get while also doing a surgical caseload. If you look at the data on proficiency and number needed to achieve this especially for endoscopy's there are some that consider these number low.

You also want to consider the perception it gives your referral base. Most primary care referrals see colonoscopy as a relatively simple procedure. While it may be lucrative initially, it may leave some stigma (anecdotally) that the surgeon doesn't do tough cases.

Once again your mileage may vary.

David Carpenter, PA-C
 
If they are so lucrative, why not do them? You could probably do 2 to 3 colonoscopies in an office setting/ASC in the time it takes to do an appy.
Endoscopy is not lucrative. The medicare payment for a colonoscopy runs between $210 and $290 depending on where you are if I remember. The way you make money is having an AEC. That means you need all the nursing, several hundred thousand in endoscopy equipment etc. Hardly something to do a couple of cases a week. The way you make money is doing a lot of cases (more than 25) per day all week. Otherwise you are in the hospital GI lab making the physicians fee with a slow turnover (think a case an hour if you are lucky). Unless you do a fair amount of cases probably not as lucrative as surgery. If you are in a rural area it does make a nice supplement when you are not doing cases.

David Carpenter, PA-C
 
Endoscopy is not lucrative. The medicare payment for a colonoscopy runs between $210 and $290 depending on where you are if I remember. The way you make money is having an AEC.

Well, lucrative is relative. Given that you can do 4 or 5 colonscopies in the time it takes to do an uncomplicated appy, and you make two to three times as much, it does seem lucrative in comparison.
 
Well, lucrative is relative. Given that you can do 4 or 5 colonscopies in the time it takes to do an uncomplicated appy, and you make two to three times as much, it does seem lucrative in comparison.

Its all relative. The surgeons I worked with could do an uncomplicated lap appy in 25 minutes or so. If you can do one colonoscopy in an hour in a hospital GI lab you are doing pretty well. In my experience you don't do appy's as a career. You do the Appy's at 3 am so you get some good cases during the daytime. One of the best laparoscopic surgeons I knew could do two Nissen's and a chole between 8 and 12 with turnover. I would bet that pays better than 4-5 colonoscopies.

Also most surgeons go into surgery to do surgery. Where I used to work the practice patterns 10 mile apart were completey different. In one area the colorectal surgeons did lots of colonoscopies but didn't get CRC referrals because the general surgeons had better laparoscopic skills and maintained them. The referral pattern from the GIs went to the general surgeons. The colorectal guys did hemorrhoids and colonoscopies. In the other area the colorectal surgeons did very few colonscopies and lots of CRC surgery because they had good laparoscopic skills. They didn't need to do colonoscopies because they had enough cases.

The food chain works both ways. In any specialty you have two "clients" (to use the nursing venacular). The patient and the referring physician. Like most people physicians tend to remember bad things and not remember good things. If you accomodate the referral base and keep the patients happy (and have good outcomes) then you should get lots of referrals. Deviate from this at your own peril.

(the above is based on observation of two very successful GI groups in one market, YMMV). The money thing applies in other ways. I would make the practice more money chunking patients through clinic than standing in the OR holding the liver for five hours. But being in the OR is what I like to do.

David Carpenter, PA-C
 
Forget general surgeons doing colos and EGDs, lets talk about PAs and NPs doing them solo while being "supervised" by a GI doc doing another procedure in another suite or in another clinic across town.
 
Endoscopy is not lucrative. The medicare payment for a colonoscopy runs between $210 and $290 depending on where you are if I remember. The way you make money is having an AEC. That means you need all the nursing, several hundred thousand in endoscopy equipment etc. Hardly something to do a couple of cases a week. The way you make money is doing a lot of cases (more than 25) per day all week. Otherwise you are in the hospital GI lab making the physicians fee with a slow turnover (think a case an hour if you are lucky). Unless you do a fair amount of cases probably not as lucrative as surgery. If you are in a rural area it does make a nice supplement when you are not doing cases.

David Carpenter, PA-C


Unfortunately, CMS just cut the payment to ASC's/AEC's by more than 25% for the coming year. This will probably drive some out of business and, since they will continue to reimburse procedures done in hospitals at the higher rate (ie the ASC fee decreased but the hospital fee didn't) more procedures will be done in that slow-turnover setting.

BTW, nice thread in the GI section. Too bad its being run by a @#$@ surgeon.

Seriously, any gastroenterologist who is threatened by other providers learning basic colonoscopy needs to get over him or herself. There's plenty of work to go around. Also, our specialty has a fairly high complication rate for some of our procedures and its critical to have a good relationship with the person you are going to ask to clean up your mess. If you want to get sued, send a patient to a surgeon who doesn't like you for your complication.
 
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BTW, nice thread in the GI section. Too bad its being run by a @#$@ surgeon.

This is uncalled for, I guess you have a lot to learn in your "GI" career.
The minimum number of colonoscopies for graduation from GI fellowship according to AGA is 140, with at least 30 polypectomies, to be done over a course of 3 years. (http://www.gastro.org/user-assets/Documents/04_Education_Training/2007_Version_Core_Curriculum.pdf) There is a general consensus that this minimal number is grossly inadequate to meet basic proficiency. However, as a GI fellow you would do close to 150 colonoscopies in 6 months. While there is a requirement for endoscopic training in general surgery, very few people go above the minimum cases needed to meet certification requirements because you are mainly trained as a SURGEON not as an ENDOSCOPIST, which still is very different. Colonoscopy is a technically demanding procedure, not just push and advance. Yes, there are many cases where surgeons are great at it, particularly colorectal surgeons. Many of them do surveilance colonoscopies on their patients. But in general, one can see why a GI specialist is better prepared for it than a surgeon. Currently, with the development of NOTES, there is a much greater emphasis on endoscopy in general surgery training being spearheaded by SAGES. The society understands that the future of surgery is in surgical endoscopy, therefore both components need to be trained in residency. There is much overlap between the specialties, both need each other and referrals go both ways.
 
This is uncalled for, I guess you have a lot to learn in your "GI" career.
.

Again, that was a joke. Relax.

Do the quotes imply that you believe I'm not a fellow? Since you quoted the AGA website, I assume you're a member and can look in the forums there?

In total, in our fellowship, we do about 3000 procedures including a boatload of colons and uppers. The main challenge for us (as for most) is getting enough ERCP's and there is no chance of getting enough EUS without a 4th year.
 
The money train had to end sometime. There's a reason why every single patient who is ever referred to a GI doc automatically gets scome kind of scope (EGD or colo) regardless of complaint, and its got NOTHING to do iwth patient care or lawsuits and everything to do with $$$$

The madness has to end, and since doctors wont stop gaming the system, the govt will step in and cut colos down to $5 a pop if they have to.
 
i was actually told recently by a surgery resident that she needed 50 colonoscopies and 70 (or 80, i forgot) total endoscopies in order to be eligible to sit for her boards. i'm not sure if this is program-dependent or a recent change in ACS policy...

from what i'm told, the northeast region seems to have more surgeons performing endoscopy compared to other areas of the country. i, of course, take this anecdotal evidence with a grain of salt.
 
i was actually told recently by a surgery resident that she needed 50 colonoscopies and 70 (or 80, i forgot) total endoscopies in order to be eligible to sit for her boards. i'm not sure if this is program-dependent or a recent change in ACS policy...

from what i'm told, the northeast region seems to have more surgeons performing endoscopy compared to other areas of the country. i, of course, take this anecdotal evidence with a grain of salt.

I'm not aware of the ABS requiring additional endoscopic cases over and above the 29 required for board eligibility (which may also include mediastinoscopy, thoracoscopy, etc.). However, the board has recently increased the number of required advanced lap procedures (I was required to do none) and perhaps her program is increasing the required number of endoscopies that it has its residents do to prepare for any new ABS requirements coming down the pike. Then again, the ABS requirements are ridiculously low and most residents exceed them several fold.
 
Sorry...you know us knucklehead surgeons, you need to clarify things for us! ;)

(I'm just used to seeing the winky face or some other semblance of I'm j/k here. My bad).

My bad, I've never actually used an emoticon. Just can't get myself to do it...ok, here it goes...nah, just can't do it.
 
As someone who just finished GI fellowship (and residency) in Texas (and medical school in Kentucky), and is doing a 4th year, I'll add fuel to the fire.

In Kentucky, I heard from a practicing GI in the Commonwealth that 50% of digestive endoscopy there is done by surgeons. This is a combination of factors -- rural state (so not enough GIs in the boonies), and the main/largest GS program in the state (University of Louisville) imbues in their surgeons the idea that they are the complete/ultimate physician -- which isn't a bad way to train, but should be tempered by the reality that there is just too much to do for one person to be good at all of it.

Texas is obviously going to vary more depending on an urban versus rural setting. Where I did my residency and fellowship, Parkland (UTSW), we had the R4 surgeons rotate with us for a month to get their GI endoscopy #s. In general, unless it was the CRS service or a Trauma case (for an upper), surgeons just did not do any significant amount of GI endoscopy at this institution. Unless is was a surgeon planning on a laparoscopic/bariatric or CRS fellowship (or going straight into Gen Surg, but there are none of those any more :eek:), every surgeon that rotated on our service used the month as a blow off/vacation/interview for fellowship/go to an out of town conference, get by with the bare minimum experience for #s. These are good surgeons, some of the best trainees in the country, but they obviously had no interest.

Now, the ones who where planning on fellowships I mentioned above, they took the time somewhat more seriously, but they also QUICKLY realized that GI endoscopy is more than just inserting a scope into an orifice and pushing it in then pulling out. Most (not the CRS ones, of course) unequivocally stated they planned to do minimal to no flexible endoscopy in their future practice, and certainly not for screening or investigating GI complaints.

Frankly, I shudder to think about many of the screening/surveillance colons I've seen/heard of done by boarded CRSs. Don't get me wrong -- there are CRSs who are excellent colonoscopists. But, and this is a big but, there are a lot more, not to mention all the GSs out there, who don't have any idea what they are doing or what they are looking at. This last point is key -- for the most part, the dextrous parts of endoscopy (or surgery, I would venture to guess as well) can be taught to anyone with two hands, no movement impediment/disorder, and who has the desire/intention. IT IS what you do before a procedure, during a procedure (managing the findings), and with the results afterwards, that makes the real difference.

There is a big difference between dropping a flexible endoscope into someone to study your anastamosis or area of planned resection versus looking for AVMs, SUBTLE sessile carpet like polyps spanning multiple folds, inflammatory changes and the distribution of said changes, and then knowing what to do with those and a myriad of other findings. You learn these things in a GI fellowship, not in General Surgery residency or CRS fellowship. Society guidelines for polyp f/u based on size and histologic criteria are BARELY followed in the real world by boarded GIs, so when you hear of these people getting yearly colons by a CRS for hyperplastic polyps.....really, are you that surprised? And this is just colons -- don't forget EGDs and other endoscopic procedures. ERCP may be a little different, but I still believe that there is a difference in the approach that people trained as Endoscopists take compared to those who are trained as Surgeons and then learn endoscopic techniques, when it comes to the endoscopic management of patients.

For the time spent, colons (and EGDs) pay well compared to many bread and butter Gen Surg procedures (or compared to most things in Medicine and Surgery, for that matter), and better than ERCP/EUS (unless you learn to do those procedures well and can do them efficiently, for the most part). This is why GI has become one of the most competitive specialties to get a fellowship spot in. Most hospital GI labs with a busy endoscopy service have decent turnover and even without an ASC as part of your practice, GIs who only do cases in the hospital do pretty well. Not to say, that ASCs aren't a desired component for any practice (for the time being :eek:)

As for PAs/NP doing colons and EGDs, this is also a manpower distribution issue. But there is a big difference between doing screening colon for someone who has no symptoms and doing a colon as part of a diarrhea or anemia work-up. Hopefully, patient distribution will reflect that.

Bottom line -- people train to do certain things and there's a reason why there's a GI fellowship after IM or why you can fast-track Gen Surg to do Vascular Surgery. But it's all about being trained the right way, and then doing things the right way.

To speak to the original point, no Gastroenterologist I know is exactly going hungry. What does piss us off is the referral from a surgeon for a patient with diarrhea or anemia who has already had a colon done by the surgeon, and so that part of the work-up (which is the most $$$ lucrative part) is denied to the Gastroenterologist. Furthermore, you have no idea if the colon was done correctly (were random biopsies of the colon taken? Was the terminal ileum intubated and visualized?). So then you repeat the colon and hope that insurance doesn't stick your patient with the bill, denying a repeat colon so soon. This isn't right for the patient.
 
As someone who just finished GI fellowship (and residency) in Texas (and medical school in Kentucky), and is doing a 4th year, I'll add fuel to the fire.

Task,
How competitive is the advanced fellowship, specifically EUS and what is the application process?
 
I have a weird question as a first year medical student. Would the peritoneal cavity be considered a vacuum, devoid of air? on other words, in the same sense that a traumatic pneumothorax disrupts the pleural cavities vacuum, is the same true for the peritoneum? thanks
 
Yes, one can get a pneumoperitoneum. No, theres no vacuum. Im not a surgeon.
 
I was in the OR today when a general surgeon perforated a colon during a routine colonoscopy. Is a GS more likely than a GI to perf a colon? I don't know. The surgeon I'm with probably averages 5-7/week, and he seems competent (although I have no real reference point). Of course, having a GS do the colonoscopy allows the patient to be opened up in about 10 minutes in case of a perforation. I'm sure it would take closer to an hour with a GI doc doing them.

This was my first experience scrubbing with an emergent surgical case, so it was a good learning experience. At least something positive came out of it.
 
Saw this forum and had to post.

As a second yr GI fellow, I have had the opportunity to witness a couple of colonoscopies performed by surgeons. The context was a GIB and we were brought along to do the EGD. The first thing noted was that their withdrawl method was rapid (meaning they go to cecum and then pulled the scope out within about 20 seconds!). Second was that the one surgeon totally ignored a large ulceration, and only on the strong insistance of the GI attending did he take biopsies. Third, I have seen multiple patients that they scope YEARLY for hyperplastic polyps (the poor patient!).

Another thing I love is the PEGs placed by surgery, and the subsequent complications that I get consulted for. PEGs in patients with massive ascites, fevers, portal hypertensive gastropathy, severe gastritis, gastric cancer (no kidding!). It's like a reflex for these guys to put PEGs in- no thought process involved at all.

I do love when we get a patient with a complaint of chronic abdominal pain or diarrhea and the surgeon has already done the colonoscopy. We are essentially starting from scratch at that point (ie pt is probably going to have to get another colonoscopy!).

My point is not to argue that surgeons shouldn't scope people (I know there are lousy GI docs doing it!). It's that, like any procedure in medicine, you probably want someone to do it who has the most experience, and can identify the pathology (other than a polyp) you may have.
 
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