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Currently, she performs the colonoscopies alone, but with a physician available within the hospital. On the average case, to assist her, she has a nurse who administers conscious sedation and an assistant or tech in the room during the procedure.
As for adverse events, "I have had some," she admits, "but not above the average for that procedure. I have had one bleed, two perforations … no anesthesia problems, no other adverse events at all."
Is this the wave of the future or only an Alaska aberration?
 

drfunktacular

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From another thread:

From a recent edition of the BMJ...

Cost effectiveness of nurse delivered endoscopy: findings from randomised multi-institution nurse endoscopy trial (MINuET)
Gerry Richardson, Karen Bloor, John Williams, Ian Russell, Dharmaraj Durai, Wai Yee Cheung, Amanda Farrin, Simon Coulton
BMJ 2009;338:b270, doi: 10.1136/bmj.b270 (Published 10 February 2009)
http://www.bmj.com/cgi/content/abstract/338/feb10_1/b270

Effectiveness of nurse delivered endoscopy: findings from randomised multi-institution nurse endoscopy trial (MINuET)
John Williams, Ian Russell, Dharmaraj Durai, Wai Yee Cheung, Amanda Farrin, Karen Bloor, Simon Coulton, Gerry Richardson
BMJ 2009;338:b231, doi: 10.1136/bmj.b231 (Published 10 February 2009)
http://www.bmj.com/cgi/content/abstract/338/feb10_1/b231
[From the on-line .pdf article]
Performs independent endoscopies:
Docs: OGD 67/67 (100%); Flexible sigmoidoscopy 64/67 (96%); Colonoscopy 59/67 (88%)
Nurses: OGD 16/30 (53%); Flexible sigmoidoscopy 27/30 (90%); Colonoscopy 2/30 (7%)

"Patients were significantly more satisfied with nurses one day after the procedure. Nurses were more thorough in the examination of stomach and oesophagus, carried out more biopsies than doctors, and omitted fewer items
from reports."
It's ON!!!
 
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Currently, she performs the colonoscopies alone, but with a physician available within the hospital. On the average case, to assist her, she has a nurse who administers conscious sedation and an assistant or tech in the room during the procedure.
As for adverse events, “I have had some,” she admits, “but not above the average for that procedure. I have had one bleed, two perforations … no anesthesia problems, no other adverse events at all.”
Is this the wave of the future or only an Alaska aberration?
Then , who is liable for the adverse events and who repaired the perforations?? I hope not the MDs!!!Basically, they/the nurses work as technicians eg. GI, anesthesiology..etc.
 

gej

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Who cares? There are way more demands out there than supplies in terms of endoscopy expertise. Plus, these NPs/PAs will always need supervision (kind of like CRNAs) by a gastroenterologist. Think about it: only a small percentage of the population are currently getting appropriately screened for colon cancer, and there is already a pretty long wait time to get scheduled for colonoscopy in most places. As more and more people get screened, the demand will just get even higher. As long as universal screening is in-place, there will always be way more patients out there that need to be scoped than what the GI's/surgeons can handle on their own. So, if the NPs/PAs want to help out in screening, I say go ahead.

Also, they are (and should be) only doing screening procedures. Diagnostic and therapeutic procedures are (and should) still only being done by GI's.
 

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Who cares? There are way more demands out there than supplies in terms of endoscopy expertise. Plus, these NPs/PAs will always need supervision (kind of like CRNAs) by a gastroenterologist. Think about it: only a small percentage of the population are currently getting appropriately screened for colon cancer, and there is already a pretty long wait time to get scheduled for colonoscopy in most places. As more and more people get screened, the demand will just get even higher. As long as universal screening is in-place, there will always be way more patients out there that need to be scoped than what the GI's/surgeons can handle on their own. So, if the NPs/PAs want to help out in screening, I say go ahead.

Also, they are (and should be) only doing screening procedures. Diagnostic and therapeutic procedures are (and should) still only being done by GI's.
Would you send your mom to see a nurse for her colonoscopy? Would you yourself (a licensed MD) like to have your screening colonoscopy done by a nurse?
 

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this isn't new. the hmo near me in a major west coast metro area has a colorectal clinic run by midlevels and has for more than 15 yrs....they do screening colonoscopies and deal with hemorrhoids all day long...not a job I want but they are very well compensated for it...
 
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Taurus

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Who cares? There are way more demands out there than supplies in terms of endoscopy expertise. Plus, these NPs/PAs will always need supervision (kind of like CRNAs) by a gastroenterologist. Think about it: only a small percentage of the population are currently getting appropriately screened for colon cancer, and there is already a pretty long wait time to get scheduled for colonoscopy in most places. As more and more people get screened, the demand will just get even higher. As long as universal screening is in-place, there will always be way more patients out there that need to be scoped than what the GI's/surgeons can handle on their own. So, if the NPs/PAs want to help out in screening, I say go ahead.

Also, they are (and should be) only doing screening procedures. Diagnostic and therapeutic procedures are (and should) still only being done by GI's.
Don't be so naive. That's the same attitude that anesthesiologists had when they first trained CRNA's. Now look at what has happened to the anesthesiology field. Why does anyone need to go to med school, IM residency, GI fellowship to master sticking tubes through your mouth or up your anus? You can teach high school dropouts to do that.
 

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A couple of points here. If you read the British study they are comparing EGDs and Flex sigs. Essentially they are comparing a poor mode of screening. The other issue is that they are using the wrong criteria. If they are comparing completeness they should be doing serial screening (ie with another provider doing a flex sig the same or the next day) and comparing the results. Or you could use another modality such as CT. This is how the validation studies were done and this is how the miss rates for colonoscopies done by GI were established.

As someone who has done both flex sigs and EGDs and done a few coloscopies under close supervision, there is a huge difference in doing the different studies. From a difficulty level I would say Flex sig < EGD < Colonoscopy. Doing polypectomies well is even more difficult and has the most risk of any procedure (outside of ERCP). If I am reading the British study the nurses or physicians doing the flex sigs are not doing polypectomies. They are referring those patients for colonoscopy. In my opinion the miss rate for flex sig is unacceptably high and outside of some very rural practices opens the provider to a lot of liability (not as much a problem in the UK).

If you read the article about the NP in Alaska, she is working in a Health Service hospital in AK. Her supervisors are surgeons. I am guessing that there are no GI on staff. The surgeons have no real interest in doing screening colonoscopies so they trained someone to do them. Once again the metrics are missing here. I am guessing that the 50 unsupervised colonoscopies means supervised but its still less than you would need to be credentialled if they were GI. Also again are they doing metrics to compare here rates with the published GI rates?

There are around 50 PAs doing colonoscopies in the US. The vast majority are in HMOs or the VA. There are a few that are in very rural areas of the NE or west. All of these work with a supervision. On the other hand I found the comment by the Dr. Poisson very naive. There is nothing in any state practice act that would forbid a PA or NP from doing this. The restriction will continue to be at the hospital level in the same way that GI has kept FP out of the endoscopy suite. The one model that is very interesting is one used on in a west coast city. There they have an 8 suite endoscopy center. Each Gastroenterologist watches up to 4 NPs or PAs doing colonoscopy. They have mics and can direct them to re look at certain areas. If they see a polyp then the GI goes in and does the polypectomy. In their mind this puts the riskiest part of the procedure in the hands of the most qualified provider.

Eventually CT or MRI colonography preferably with digital substraction will become the norm for screening (my opinion for what its worth). This will move GI toward therapeutic endoscopy.

David Carpenter, PA-C
 

gej

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Don't be so naive. That's the same attitude that anesthesiologists had when they first trained CRNA's. Now look at what has happened to the anesthesiology field. Why does anyone need to go to med school, IM residency, GI fellowship to master sticking tubes through your mouth or up your anus? You can teach high school dropouts to do that.
What's wrong with the anesthesiology field? I don't see anesthesiologists out of work and scrambling for jobs. CRNA's still only practice under the supervision of an anesthesiologist. In fact, a lot of anesthesiologists that I talked to love this because they can essentially supervise and bill for multiple rooms at the same time with the CRNA's. If I were a private practice GI and own my endoscopy unit, I would love having NP's working for me doing colonoscopies while I "supervise" them. By doing this, I can have multiple rooms going and billing at the same time while I only have to pay them an NP's salary. Since these NP's can only do these procedures supervised by an attending, the addition of these NP's will just add to the revenue generated for the GI physician.
 

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Just wondering, who gets the blunt of it if complications happen? I'm assuming it's gonna be the doctor?
 

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What's wrong with the anesthesiology field? I don't see anesthesiologists out of work and scrambling for jobs. CRNA's still only practice under the supervision of an anesthesiologist.
Maybe you should do your homework before you post such naive statements. Spend some time on the anesthesiology forum and see how active the discussion is concerning CRNA's. 14 states have opted out, meaning that CRNA's can work independently of anesthesiologists. Independent CRNA groups actively compete with anesthesiology groups for hospital contracts. CRNA's even tried to argue that they should be allowed to do pain medicine -- after just two weekend courses. Pain med is a fellowship typically anesthesiology residency. So, again, you're in over your head with your posts.
 
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Here is how I look at, we go throught an undergrad degree to prepare for med school. Then we take the MCAT. Then med school. After that it's residency. In the process we compile a huge debt. We also compile a wealth of knowledge.

On the flip side, how long does an NP go to school for. What about a CRNA. I am not taking away from them, but their education does not compare to ours. They have a tough schooling.

On the surface, they want to do the MD job, but without going through med school. At the end, they take up the same jobs as MDs. I don't that's fair.

I think it is hazardous to patient care to have somebody with an MD degree take charge of patient's lives.

Our state has a semi-organized medical society that tries to lobby for our interest. I think that is our only resort to protect our profession.
 

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The issue of NPs doing colons doesn't just stop at the procedure itself. There is also the tail end of a procedure. Okay, you've done it. You found pathology. Do you know what you are looking at? Do you know what to do next? Do you know how to manage the condition?

GI is a three year fellowship. They learn the tail end of the procedure.
 

gej

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Maybe you should do your homework before you post such naive statements. Spend some time on the anesthesiology forum and see how active the discussion is concerning CRNA's. 14 states have opted out, meaning that CRNA's can work independently of anesthesiologists. Independent CRNA groups actively compete with anesthesiology groups for hospital contracts. CRNA's even tried to argue that they should be allowed to do pain medicine -- after just two weekend courses. Pain med is a fellowship typically anesthesiology residency. So, again, you're in over your head with your posts.
Taurus, I am not sure if the condescending tone in your post is adding to your argument or making you sound arrogant. I do not spend time on the anesthesiology forum because, well, I'm not an anesthesiologist. What I merely tried to state in my posts is that despite the increase in scopes of the work of CRNA's, we are not seeing anesthesiologists being forced out of work or replaced by them. Compensation and availability of jobs in medical specialties are driven by supply/demands as well as liabilities. While CRNA's can push for all the increase in independence they want, whether this actually translate into decreased number of jobs and compensation for anesthesiologists would depend more on the actual demands and medical liabilities required of hospitals/surgical groups to hire unsupervised CRNA's. From my interaction with anesthesiologists, including some from the aforementioned 14 states, it doesn't seem like they are currently losing jobs or compensation to these CRNA's. This is most likely due to the fact that the demands >>> supplies in many of these states that opted out and many hospitals/surgical groups would not want to shoulder the additional cost of medical liabilities at this point. Of course whether or not this will change in the future remains to be seen. My previous post was simply in response to your statement of "now look at what happened to the anesthesiology field" as if the lives of practicing anesthesiologists are doomed and they are now scrambling for low-paying jobs.

Now back to colonoscopies, an area that I certainly have more experience with. You are right in that "you can teach high school dropouts" to "master sticking tubes through your mouth or up your anus", as simple endoscopy skills are not hard to learn. The technical aspect of navigating the scope through the GI tract takes dexterity and experience (which even gastroenterologists only begin to learn during fellowship), but not really specific knowledge/experience from med school or residency that NPs would not have learned. However, the diagnostic and therapeutic aspects of the procedures are different. These do require medical knowledge and decision making, and that's why I don't think these parts should be done by NPs. That's also why I have no problem with NPs performing (with supervision) the technical aspect of navigating the scope for a screening colonoscopy (much like an ultrasound tech obtaining images for the radiologists). However, any abnormalities seen (e.g. polyps, masses etc.) should than be handled by the supervising MD. Non-screening EGDs or colonoscopies (e.g. bleeders, varices surveillance, etc.) should not be done by NPs, period.

On reading these kinds of threads in the GI forum, one thing that I find a little annoying as a prospective gastroenterologist is the kind of dooming talks about the field whenever alternative methods appear for screening colonoscopies (e.g. CT colonography). It almost makes it sound like the GI field is dead without screening colonoscopies. Believe it or not, there are many more aspects to GI, both intellectually and technically, and I actually find it a little insulting to the field to imply that gastroenterologists are just procedure monkeys. It is not true and even if GIs are never allowed to do screening colonoscopies again, there will still be all the liver/pancreas/biliary/IBD/GIB/etc patients that need to be managed.
 

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I do not spend time on the anesthesiology forum because, well, I'm not an anesthesiologist.
Maybe you should so you understand the slippery slope you're putting GI on if you allow NP's to do even screening colonoscopies. If you've been following the DNP debate, you would know that they would love nothing better than to get a foothold onto the specialties. It's not about competency or knowledge about disease and management with them. It's about increasing their paychecks. They use lies and propaganda to lobby for their nursing agenda. Putting out bogus studies is one of the first steps. Not many people are convinced that they just want to do primary care. It seems you would give them GI on a silver platter.
 
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gej

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Maybe you should so you understand the slippery slope you're putting GI on if you allow NP's to do even screening colonoscopies. If you've been following the DNP debate, you would know that they would love nothing better than to get a foothold onto the specialties. It's not about competency or knowledge about disease and management with them. It's about increasing their paychecks. They use lies and propaganda to lobby for their nursing agenda. Putting out bogus studies is one of the first steps. Not many people are convinced that they just want to do primary care. It seems you would give them GI on a silver platter.
I think the situation with GI and screening colonoscopies is somewhat different from anesthesia though. Other than the fact that this is only a portion of what a gastroenterologist does, there is also the issue of population need to consider. Even with the current guideline for universal screening, the percentage of the population who is actually getting appropriately screened now is still fairly low. At this time, even with only a small percentage of population undergoing screening colonoscopy, the system is already fairly overloaded. In many places, it is not uncommon for patients to wait for months before they can be scheduled for their procedure. Situations in rural areas and smaller states are even worse, where there frequently is only one person or no one trained to do these procedures at all. With increased education and (hopefully) an improved health care system, the demands for these procedures will only go up, further overloading the current supply system. Advances such as CT colonography will only serve to further increase the need for patients to undergo colonoscopy, as more patients will likely get screened leading to more polyps discovered that require colonoscopy for removal. In addition, all these patients with polyps discovered will need their surveillance colonoscopy in 3-5 years, further adding to the burden on the system and feeding into the cycle.

The only way to actually satisfy the need for these patients is to increase the supply (i.e. more people performing the procedure). There are many ways to go about it, none of which would be ideal to gastroenterologists. The most obvious one would be to increase the number of GI's being trained by increasing number of fellowship spots. Another way would be for more surgeons or even FPs to perform screening colonoscopies (which is already happening in some places). The last one would be to have people like NPs doing these procedures while being supervised by GI's. From a GI's point of view, would you rather have more MD's (either more within your field or from other fields) taking these procedures from you, or would you rather have NP's doing them under you? This, I think, is a major difference between GI and anesthesia as well, since GI is also competing with MD's from other fields trying to do these procedures. It is like trying to pick the lesser of the two evils. As a gastroenterologist, I would rather hire some NPs to my practice to do the simple screening under my supervision to increase the number of patients being scheduled (thus increasing revenue for me) then to lose out these procedures to surgeons or FPs.
 

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Maybe you should so you understand the slippery slope you're putting GI on if you allow NP's to do even screening colonoscopies. If you've been following the DNP debate, you would know that they would love nothing better than to get a foothold onto the specialties. It's not about competency or knowledge about disease and management with them. It's about increasing their paychecks. They use lies and propaganda to lobby for their nursing agenda. Putting out bogus studies is one of the first steps. Not many people are convinced that they just want to do primary care. It seems you would give them GI on a silver platter.
I have been following this debate for years, and wholeheartedly agree with Taurus. I looked closely at Anesthesia as a field, and the whole CRNA debacle was one of the key reasons I decided to steer clear. At the hospital where I am currently completing my internship the nurses ( most with two-year associates degrees from the local community college ) are quite vocal about how "dumb" the interns are and about how they are going to become NPs and treat patients "just like doctors". They equate the ability to write a script for aspirin or a beta blocker with being a cardiologist. It is both frightening and appalling to see these nurses push their agenda. MDs need to aggresively defend their turf on every single level, every single procedure. If you don't believe that then take a trip over to allnurses.com and prepare to be rudely awakened to the reality.

As a soon to be radiology resident I am delighted with the recent decision to shoot down Ultrasound Techs. plight to interpret Ultrasound studies. All fields need to be equally as cognizant as Radiology and nip these Midlevels in the bud. Everyone wants to be a doctor and wear the white coat, and be called "doctor" in the clinical setting. How many are willing to invest 11+ years of their lives, $200,000+, and accept the responsibility and liability that goes along with being a PHYSICIAN? It is myopic for GI docs to think that these NPs will be happy with their lot of screening colonoscopies. As has been discussed with respect to anesthesia, we, the physicians, need to educate the public about who will be performing these procedures. Would you like a Doctor or a Nurse Maam? No contest, nor should there be. If you want to practice Medicine, you go to Med. school. No excuses.
 

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I think the situation with GI and screening colonoscopies is somewhat different from anesthesia though.
Keep thinking that...

gej said:
it is not uncommon for patients to wait for months before they can be scheduled for their procedure.
And what exactly do you think will happen when/if we get/got universal healthcare? That the demand would go down?:laugh:

People are waiting months for procedures/clinic visits in countries with universal healthcare that we wait hoursfor.

gej said:
Situations in rural areas and smaller states are even worse, where there frequently is only one person or no one trained to do these procedures at all.

gej said:
The only way to actually satisfy the need for these patients is to increase the supply (i.e. more people performing the procedure).
Pumping out more NPs with ever increasing autonomy is not the best approach. This is the TRICKLE DOWN theory...if we graduate a surplus of NPs (or DNPs or MDs), then the excess will trickle down to the rural areas. It's just not happening. This has been demonstrated in surveys of graduating NPs.

What is happening, is that people are willing to make less money to stay in urban areas with ever increasing competition. Don't believe me, then look at physician reimbursement in California.


gej said:
From a GI's point of view, would you rather have more MD's (either more within your field or from other fields) taking these procedures from you, or would you rather have NP's doing them under you?
gej said:
As a gastroenterologist, I would rather hire some NPs to my practice to do the simple screening under my supervision to increase the number of patients being scheduled (thus increasing revenue for me) then to lose out these procedures to surgeons or FPs.

This is why people like you pi$$ me off...you would prefer to destroy the profession to make a few extra bucks a year. Wake up man, NPs don't have to work UNDER us in many states. When DNPs start getting pumped out, they will work BESIDE us. I would rather compete with physicians for jobs (with comparable education and comparable education debt) than Dr. Nurses (with inferior education and nonexistent debt).

I raise the issue of debt because carrying a $200,000 liability makes it impossible to compete with DNPs directly for jobs. They will always be able to do the job for less.

gej said:
GI is also competing with MD's from other fields trying to do these procedures.
Sure, FPs and surgeons are doing Colonoscopies, but no where near on the level that GIs perform them.
You do not understand the concept of referral. In an urban area, a particular surgeon may get away with a few colonoscopies, but when/if the large GI practices catch wind you can bet your @$$ that surgeon's referrals will dry up.

When the DNPs graduate, and say "Hey, we've been doing colonoscopies for years as NPs....now that we're DOCTORS we can perform them independently."

The nurses you train in your clinic will be the same ones training the DNPs.

Your patients are already calling nurses "Dr."
 
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BlackNDecker

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Those of you who are a member of the ACP hopefully read the position statement on nurse practitioners. Yeah, the situation is dire enough that the ACP is issuing a position statement. <Nevermind the AMA, they're worthless>

In it, they discuss the issue of NPs trying to take USMLE step 3 for accreditation. OUR STEP 3!!!!!!!!:eek:


http://www.acponline.org/advocacy/where_we_stand/policy/np_pc.pdf
 
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gej

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And what exactly do you think will happen when/if we get/got universal healthcare? That the demand would go down?:laugh:

People are waiting months for procedures/clinic visits in countries with universal healthcare that we wait hoursfor.

Wait, isn't that exactly what I said in my post? That the demands for these procedures will only go up with increased access to healthcare? Or am I hallucinating?


Pumping out more NPs with ever increasing autonomy is not the best approach. This is the TRICKLE DOWN theory...if we graduate a surplus of NPs (or DNPs or MDs), then the excess will trickle down to the rural areas. It's just not happening. This has been demonstrated in surveys of graduating NPs.

What is happening, is that people are willing to make less money to stay in urban areas with ever increasing competition. Don't believe me, then look at physician reimbursement in California.

The fact that the "trickle down theory" that you refer to is not happening is another proof of how much demand >>> supply at this point in terms of colonoscopy. Look, it is a simple law of supply and demand. Yes, people are willing to make less money to stay in urban areas, but only to a certain point. The fact that the demand still far outpaces supply even in urban areas such as California keeps the market price for GI's in these areas from dropping to the point where people are driven to rural areas. I do suggest that you look at GI physicians' reimbursement in different states by asking the GI fellows at your program. Ask them for the postcards and emails that they receive from recruiting firms. I can tell you that the current offers for GI's fresh grads to private practices range from the mid 200K all the way up to 750K (from the ones that I have seen). States like California and Massachusetts typically have the lowest range (~mid 200K to mid 300K). Places like Texas or Florida are usually in the middle (~mid 300K to mid 400K). More rural areas and states are the ones with crazy offers up to 600-700K. As you can see, even if you take a paycut to live in urban places like California, you are still making a decent salary. Many people are still willing to take that paycut. If the market price in these places are driven down more with increased supply (e.g. to below 200K or less), more people will decide that the cut is not worth it and move to rural areas with huge pay.


This is why people like you pi$$ me off...you would prefer to destroy the profession to make a few extra bucks a year. Wake up man, NPs don't have to work UNDER us in many states. When DNPs start getting pumped out, they will work BESIDE us. I would rather compete with physicians for jobs (with comparable education and comparable education debt) than Dr. Nurses (with inferior education and nonexistent debt).

No, I do not "prefer to destroy the profession" nor do I care about making "a few extra bucks". What I do care about is satisfying current patient and healthcare needs more so than my feeling of superiority as a physician over nurses with their "inferior education". Note that I am specifically talking about screening colonoscopy. How difficult do you think it is to thread a colonoscope up the anus and advance to the cecum? What special knowledge do you possess right now, with med school under your belt and half way through residency, that would allow you to be so much more technically ready in advancing an endoscope? The answer is none. In fact, most non-GI physicians still have many misconceptions about endoscopy itself (e.g. many still think that an urgent colonoscopy can stop lower GI bleed like urgent EGD does with upper bleed [not true] and that an NG tube can be placed through an endoscope [again,not true]). My point is that the skill of advancing an endoscope does not require much actual medical knowledge. It is merely a way to take images for evaluation (much like ultrasound techs obtaining images for radiologists). If we can increase service by having multiple NPs performing the technical aspects of the procedure under the supervision of a GI, I think that would help with the issue of satisfying the needs of patients and the society.

I do still believe the diagnostic and therapeutic aspect of the procedure should remain with GI (as opposed to NP/surg/FP), because GI's are trained specialists to diagnose and manage these problems, which, obviously, require actual knowledge of the area at the specialist level.


I raise the issue of debt because carrying a $200,000 liability makes it impossible to compete with DNPs directly for jobs. They will always be able to do the job for less.

This is an overly simplistic view of the hiring situation. I think it goes back to the issue of people always equating the entire field of GI to screening colonoscopies. There are many, many more aspects to the field of GI than screening colonoscopies. It makes absolutely no economical sense to hire someone who can only do screening colons over a qualified specialist who can take care of the whole spectrum of diseases within the field, even with a pay differential. If I have to pay the malpractice insurance and salary to hire someone, I would rather have a person who can also take calls, deal with GI bleeds, manage IBDs including the use of anti-TNFs, treat hepatitis with antivirals, take care of complex cirrhotics, manage necrotizing pancreatitis, interpret manometry/impedence/pH studies, etc, etc, even if it takes a higher salary. Again, this is why the situation with GI is different from anesthesia. Screening colonoscopy is only one procedure within a wide, wide range of diseases/services managed by GI's, and it is also probably the one that requires the least amount of actual knowledge. Therefore, debt or no debt, until NPs/DNPs can perform all the aforementioned services independently, they will not be in a position to actually compete with GI's for their jobs. And if they do start doing all those independently, then I think it will be more then just the field of GI that we need to worry about....


Sure, FPs and surgeons are doing Colonoscopies, but no where near on the level that GIs perform them.
You do not understand the concept of referral. In an urban area, a particular surgeon may get away with a few colonoscopies, but when/if the large GI practices catch wind you can bet your @$$ that surgeon's referrals will dry up.

Actually, I do understand the concept of referral very well, but you don't seem to understand the current practice trend. General surgeons, specifically those without subspecialization, are doing more and more screening colonoscopies in their practice. This is because there are simply not enough cases for general surgeons without subspecialization to do if they don't also pick up screening colonoscopies. Due to the long wait time with GI's, more and more patients are being referred to the general surgeons by their PMDs. Once a surgeon has done some procedures for the PMDs in the area, there is no reason why the PMDs would stop referring to him/her even if there are other large GI practices around. There is simply no reason for the PMDs to preferentially refer these procedures to GI's over surgeons, especially if the patients can get the procedures sooner. Take the Boston area, for example, an urban area full of high-power tertiary centers and large GI groups (both academic and private), there are still many general surgeons doing screening colonoscopies. In fact, for some general surgeons, screening colonoscopies make up a large portion of their practice. If you don't believe me, ask any senior general surgery resident who is looking for practice without subspecialization.
 
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gej

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I have been following this debate for years, and wholeheartedly agree with Taurus. I looked closely at Anesthesia as a field, and the whole CRNA debacle was one of the key reasons I decided to steer clear. At the hospital where I am currently completing my internship the nurses ( most with two-year associates degrees from the local community college ) are quite vocal about how "dumb" the interns are and about how they are going to become NPs and treat patients "just like doctors". They equate the ability to write a script for aspirin or a beta blocker with being a cardiologist. It is both frightening and appalling to see these nurses push their agenda. MDs need to aggresively defend their turf on every single level, every single procedure. If you don't believe that then take a trip over to allnurses.com and prepare to be rudely awakened to the reality.

As a soon to be radiology resident I am delighted with the recent decision to shoot down Ultrasound Techs. plight to interpret Ultrasound studies. All fields need to be equally as cognizant as Radiology and nip these Midlevels in the bud. Everyone wants to be a doctor and wear the white coat, and be called "doctor" in the clinical setting. How many are willing to invest 11+ years of their lives, $200,000+, and accept the responsibility and liability that goes along with being a PHYSICIAN? It is myopic for GI docs to think that these NPs will be happy with their lot of screening colonoscopies. As has been discussed with respect to anesthesia, we, the physicians, need to educate the public about who will be performing these procedures. Would you like a Doctor or a Nurse Maam? No contest, nor should there be. If you want to practice Medicine, you go to Med. school. No excuses.

Look, I absolutely agree with you in that physicians should work together to fight the agenda of the nurses when they try to cross the line of practicing medicine. However, I don't agree that we should inflexibly say that we "defend" every single procedure within every single specialty in a blanket statement. Each specialty has its own unique circumstance, difficulties, and needs. I think that we physicians should be more forceful in drawing the line within our own specialty. This boundary should be different for each specialty based on their unique needs. For example, radiology decides to draw the line at ultrasound tech being allowed to perform the ultrasound but not allowed to interpret the images. As a prospective gastroenterologist, I happen to think that given the high demands for screening colonoscopies, it is to the benefits of the patients and the society that alternative ways be found to satisfy this need in a safe manner. We want more people to get screened (and return for their surveillance colonoscopy) to decrease the incidence of colon cancer. If we can increase output and get more people screened by having multiple NPs work under a supervising GI MD, it would be beneficial to the patients and society as a whole. But, you are right, if GI's choose to draw the line at supervised screening colonoscopy only, then we need to work hard to maintain that line and fight any nursing agenda attempting to cross it.
 
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bulletproof

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Look, I absolutely agree with you in that physicians should work together to fight the agenda of the nurses when they try to cross the line of practicing medicine. However, I don't agree that we should inflexibly say that we "defend" every single procedure within every single specialty in a blanket statement. Each specialty has its own unique circumstance, difficulties, and needs. I think that we physicians should be more forceful in drawing the line within our own specialty. This boundary should be different for each specialty based on their unique needs. For example, radiology decides to draw the line at ultrasound tech being allowed to perform the ultrasound but not allowed to interpret the images. As a prospective gastroenterologist, I happen to think that given the high demands for screening colonoscopies, it is to the benefits of the patients and the society that alternative ways be found to satisfy this need in a safe manner. We want more people to get screened (and return for their surveillance colonoscopy) to decrease the incidence of colon cancer. If we can increase output and get more people screened by having multiple NPs work under a supervising GI MD, it would be beneficial to the patients and society as a whole. But, you are right, if GI's choose to draw the line at supervised screening colonoscopy only, then we need to work hard to maintain that line and fight any nursing agenda attempting to cross it.
I appreciate your concern for the well-being of society at large. I agree that getting as many people screened is in the best interests of the patients. But using NPs is not our only option here. We could arguably train PAs to do the same thing, and they can never ever practice independent of a Physician. Doesn't this make a lot more sense? This line of thinking has been argued again with respect to anesthesia and the consensus amongst the prudent is that groups should hire AAs over CRNAs given that they are dependent upon physicians for survival. The problem is with NPs attempting to establishing a precedent, and then publishing bogus Nursing research showing that they are "equivalent or better" to physicians, and then attempting to redefine what falls under Nursing practice. Let there be no doubt about it. This is their goal, and they are militant about achieving it. I wish you the best of luck in your future career as a GI doc.
 

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As a soon to be radiology resident
I can envision a day when radiologists will open up colonoscopy centers where pts are initially screened with CT colonoscopy and if they find something then the radiologists does the colonoscopy themselves. This would be similar to the idea of mammography centers where the radiologists run the show. Hey if gen surg, GI, FP, and even NP's can do colonoscopies, why not radiologists? :D
 

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I appreciate your concern for the well-being of society at large. I agree that getting as many people screened is in the best interests of the patients. But using NPs is not our only option here. We could arguably train PAs to do the same thing, and they can never ever practice independent of a Physician. Doesn't this make a lot more sense? This line of thinking has been argued again with respect to anesthesia and the consensus amongst the prudent is that groups should hire AAs over CRNAs given that they are dependent upon physicians for survival. The problem is with NPs attempting to establishing a precedent, and then publishing bogus Nursing research showing that they are "equivalent or better" to physicians, and then attempting to redefine what falls under Nursing practice. Let there be no doubt about it. This is their goal, and they are militant about achieving it. I wish you the best of luck in your future career as a GI doc.
Actually, I agree that PAs would be the better option. In fact, at a lot of VA hospitals, PAs are already trained in this manner to help the GI docs.
 

Taurus

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Look, I absolutely agree with you in that physicians should work together to fight the agenda of the nurses when they try to cross the line of practicing medicine. However, I don't agree that we should inflexibly say that we "defend" every single procedure within every single specialty in a blanket statement. Each specialty has its own unique circumstance, difficulties, and needs. I think that we physicians should be more forceful in drawing the line within our own specialty. This boundary should be different for each specialty based on their unique needs. For example, radiology decides to draw the line at ultrasound tech being allowed to perform the ultrasound but not allowed to interpret the images. As a prospective gastroenterologist, I happen to think that given the high demands for screening colonoscopies, it is to the benefits of the patients and the society that alternative ways be found to satisfy this need in a safe manner. We want more people to get screened (and return for their surveillance colonoscopy) to decrease the incidence of colon cancer. If we can increase output and get more people screened by having multiple NPs work under a supervising GI MD, it would be beneficial to the patients and society as a whole. But, you are right, if GI's choose to draw the line at supervised screening colonoscopy only, then we need to work hard to maintain that line and fight any nursing agenda attempting to cross it.
It is physicians like you who lacked the foresight to see that you would be screwing over future physicians by creating the NP's in the first place and hiring them. If you need more physicians, then create more. The practice of medicine should have always been restricted to physicians only, not non-physicians. What is even more offensive to me is that nursing calls it "advanced practice" nursing when in fact they are practicing medicine. Then they put out the bogus studies and the lies and propaganda. And here you are trying to defend them and their behavior? That's unconscionable. If I ever hire midlevels, it will be PA's.
 

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I can envision a day when radiologists will open up colonoscopy centers where pts are initially screened with CT colonoscopy and if they find something then the radiologists does the colonoscopy themselves. This would be similar to the idea of mammography centers where the radiologists run the show. Hey if gen surg, GI, FP, and even NP's can do colonoscopies, why not radiologists? :D
Indeed my friend. Indeed.:D
 

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Indeed my friend. Indeed.:D
Never happen. No economic incentive for any radiologist to spend a year learning endoscopy. Seriously, people choose rads to keep from talking to patients. Nursing, recovery rooms, stool...does this really sound like a radiologists wet dream? This is almost too silly to comment on. Besides, CT colonography will be toast within 5 years. Too much HGD in the small polyps that CT ignores. Colonoscopy may lose its primary screening role too but it will always be necessary for polyp removal.
 

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Never happen. No economic incentive for any radiologist to spend a year learning endoscopy. Seriously, people choose rads to keep from talking to patients. Nursing, recovery rooms, stool...does this really sound like a radiologists wet dream? This is almost too silly to comment on. Besides, CT colonography will be toast within 5 years. Too much HGD in the small polyps that CT ignores. Colonoscopy may lose its primary screening role too but it will always be necessary for polyp removal.
We wont need to -- we will have our Nurse/PA do the colonoscopy. :laugh:
 

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i'm an anesthesiologist...and we don't love CRNAs. in fact, CRNAs have already gained the right to practice anesthesia without oversight of an anesthesiologist in 16 states. don't foul yourselves. it's a very slippery slope.


What's wrong with the anesthesiology field? I don't see anesthesiologists out of work and scrambling for jobs. CRNA's still only practice under the supervision of an anesthesiologist. In fact, a lot of anesthesiologists that I talked to love this because they can essentially supervise and bill for multiple rooms at the same time with the CRNA's. If I were a private practice GI and own my endoscopy unit, I would love having NP's working for me doing colonoscopies while I "supervise" them. By doing this, I can have multiple rooms going and billing at the same time while I only have to pay them an NP's salary. Since these NP's can only do these procedures supervised by an attending, the addition of these NP's will just add to the revenue generated for the GI physician.
 

Gastrapathy

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i'm an anesthesiologist...and we don't love CRNAs. in fact, CRNAs have already gained the right to practice anesthesia without oversight of an anesthesiologist in 16 states. don't foul yourselves. it's a very slippery slope.
Its kinda an interesting conflict, since endoscopy centers often use CRNAs for propofol sedation. Ironic.
 

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Wow, I really don't agree with any of your logic...and I'm really trying to understand your viewpoint here.

gej said:
The fact that the "trickle down theory" that you refer to is not happening is another proof of how much demand >>> supply at this point in terms of colonoscopy.
The "trickle down theory" is not happening for many reasons, the most important is that the logic is flawed. People don't inherently want to live out in the "boonies." Quite the opposite, the 50+ year trend of people migrating to urban/suburban areas shows no sign of slowing. Why should highly trained/educated individuals be any different? I don't see many Harvard law grads going to work in rural courts.

The point I'm making is that simply increasing the number of "advanced practice" nurses with DR degrees (esp. when the majority train at urban academic hospitals) is not going to satisfy the need for rural primary care.






gej said:
No, I do not "prefer to destroy the profession" nor do I care about making "a few extra bucks".
Then why not hire an MD? If you don't want to drive a scope then do a hepatology fellowship.

gej said:
What special knowledge do you possess right now, with med school under your belt and half way through residency, that would allow you to be so much more technically ready in advancing an endoscope? The answer is none.
What's next, you gonna let the NPs perform ERCPs????:eek: Why not? The line is gray my friend...and once you cross it's very hard to go back.

FACT: Critical care NPs do the majority of bronchoscopies at the Med school I trained at...in fact, they run the SICU allowing the surgeons to spend more time in the OR. The majority of my SICU rotation I was supervised by a NP...they observed >80% of my line placements.



gej said:
I do still believe the diagnostic and therapeutic aspect of the procedure should remain with GI (as opposed to NP/surg/FP), because GI's are trained specialists to diagnose and manage these problems, which, obviously, require actual knowledge of the area at the specialist level.
<shaking my head> What you believe doesn't matter if you've opened the door for NPs to perform the procedures. Wake up man, there is no regulatory board to say this is or isn't acceptable for an NP to do. It's all based on PRECEDENT...have you done this before in situation X? OK, now let's perform this procedure in situation Y and situation Z. Each with an increasing level of diagnostic/therapeutic challenges.

SCENARIO: A medium sized Pulm/Crit private practice group of 3-8 aging doctors, er MDs (gotta be clear nowadays) decides that they wanna expand so they don't have to take call at night anymore. Well, to hire a freshly minted Pulm/Crit fellow would cost $250,000+. "Wait," says one of the partners, "we could just hire a Critical care NP to cover the ICU at night...I mean, they are trained to perform diagnostic/therapeutic bronchs."

One less job for an MD. Many dollars saved for the practice. Did this decrease "demand?" No.

Face it, the only real regulation is whether or not the individual performing the procedure will be reimbursed. You can take a weekend seminar on any "procedure" and start performing them in your clinic on Monday.


gej said:
It makes absolutely no economical sense to hire someone who can only do screening colons over a qualified specialist who can take care of the whole spectrum of diseases within the field, even with a pay differential.
And what pray tell makes you think NPs/DNPs will stop at SCREENING? :laugh: It's doesn't take a great leap of intellect to resect a polyp rather than simply identify one is present. Plus, having an NP screen then having a GI doc perform the therapeutic aspect makes absolutely no "economical sense." This defeats the whole idea of colonoscopy (diagnostic AND therapeutic) and doubles the cost.



gej said:
Again, this is why the situation with GI is different from anesthesia.
<shakes head while NPs continue to plot the mutiny of GI>


gej said:
And if [NPs] do start doing all those independently, then I think it will be more then just the field of GI that we need to worry about....
I believe you are in the minority. Many of us are worried now...
 

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tibor75

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It is physicians like you who lacked the foresight to see that you would be screwing over future physicians by creating the NP's in the first place and hiring them. If you need more physicians, then create more. The practice of medicine should have always been restricted to physicians only, not non-physicians. What is even more offensive to me is that nursing calls it "advanced practice" nursing when in fact they are practicing medicine. Then they put out the bogus studies and the lies and propaganda. And here you are trying to defend them and their behavior? That's unconscionable. If I ever hire midlevels, it will be PA's.
I just gotta laugh at comments like this. Health care costs are out of control, large areas of the country are underserved, and scared doctors are whining about NPs taking over for doctors? :smuggrin:

There probably isn't a profession that cries about everything more than doctors. Waah waaah, I won't get $450,000 a year. Oh noes!
 

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tibor75 said:
There probably isn't a profession that cries about everything more than doctors. Waah waaah, I won't get $450,000 a year. Oh noes!
Actually, the only person (besides yourself) who brought up salary was gej, the individual arguing in favor of NPs doing screening colonoscopies. Usually your posts are erudite, but I think this comment was misdirected.

Again, having an NP perform a screening colonoscopy then repeating the prep and colonoscopy just so a GI doc can perform the therapeutic portion makes absolutely no "economical sense." This defeats the whole idea of a colonoscopy (diagnostic AND therapeutic) and doubles the cost. This is akin to performing a "screening" cardiac catheterization without the ways and means to place a stent...sure it happens, but not for much longer.
 

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Actually, the only person (besides yourself) who brought up salary was gej, the individual arguing in favor of NPs doing screening colonoscopies. Usually your posts are erudite, but I think this comment was misdirected.

Again, having an NP perform a screening colonoscopy then repeating the prep and colonoscopy just so a GI doc can perform the therapeutic portion makes absolutely no "economical sense." This defeats the whole idea of a colonoscopy (diagnostic AND therapeutic) and doubles the cost. This is akin to performing a "screening" cardiac catheterization without the ways and means to place a stent...sure it happens, but not for much longer.

Unfortunately, you seem to have misunderstood what I said before. What I described about having an NP (or PA) perform a screening colonoscopy with the GI MD performing the therapeutic portion does not mean that the patient needs two procedures. What I was suggesting is to have multiple NP/PA/etc. doing screening colonoscopies in different rooms while the GI watches on monitors in a back room. Whenever a polyp is discovered, the GI can then go to that particular room, gown up, take over the scope, and snare it out. The NP/PA can then resume the rest of the screening. The snaring would take just a few minutes. It would not require the patient getting separate procedures.

In fact, one of the most tedious parts of doing a colonoscopy is the cleaning of the colonic wall to allow adequate visualization of the colonic mucosa. Even in many people that are described as having excellent preps, there are frequently liquid stools/bile that are stuck on various parts of the colonic wall preventing complete visualization. GIs frequently have to waste a lot of time spraying and cleaning the colonic wall just so that they can have a look. I think that it would be much more efficient and time better spent if the NPs/PAs take care of these mindless parts while the GIs focus on polypectomies or other therapeutic portions of the procedure.

BTW, the issue of salary was brought up by multiple people in different contexts. I never whined about making less. In fact, if more people can get appropriately screened by having more GIs (therefore, lower compensation due to increased competition), I'd be all for that as well. Unfortunately, it doesn't seem like the number of fellowship spots is going to increase any time soon (even though I would have loved that because it means that it would be easier to get in).
 
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