Why don't family medicine docs do flexible/fiber optic naso-laryngoscopy?

[luckrules]

Hi all.

M3/4 here. I know my question may seem strange. But I just got done with a 4 week ENT rotation and something occurred to me I'd be curious to get some input on. ENT is one of those mixed surgical fields where docs could be doing anything from managing thyroid medication and cleaning out eardrums to complex free flaps. However, it seemed to me that the vast majority of what they did, at least in clinic (and I recognize this may be particular to the institution I was at), was hear about throat problems and go straight to a fiber optic naso laryngoscope. And by the end of the first day I was doing this pretty adeptly (with resident supervision (/humble brag)). And usually there was a picture/video taking technology that we could save so we could show it to the attending, who remarked on diagnosis/tx/follow up. And often times the scopes connected directly to the phone! And this was at a VA and was supposedly old technology!

I heard that a lot of the $$ in ENT comes from outpatient scopes. I guess I'm wondering why primary care docs don't do this? Besides the opportunity for reimbursement, it seems like it might be easier for patients, and its fun to do procedures. I guess I get that it might be easy to do, but take lots of experience to actually know what you're looking at. But it seems like you could rule out low risk stuff pretty easily, and or use the imaging technology to refer to a specialist without having to send your patient to a specialty clinic. Could be useful for rural areas.

Another thought I had was that maybe its just expensive to set up. These scopes were at the VA, but they still seemed pretty fancy.

Anyway thanks in advance. Curious what y'all think.

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[VA Hopeful Dr]

Not enough volume

 

[luckrules]

Not enough volume

Yeah makes sense

 

[cabinbuilder]

I never had an ENT rotation in medical school or residency. No opportunity to even learn it. Didn't realize that I should. Too busy in every day clinic to want to. Learned EGD and Colonoscopy, never did those in practice either.

 

[simpler2]

I can echo volume being the issue. Probably only feel the need to send a patient for scope visualization 2 x yearly.

 

[deleted87716]

Not enough volume

Pretty much. The equipment is expensive, and you have to do them fairly frequently to make it financially viable, as well as to keep your skills up. I don't even refer very many patients to ENT just for that. I learned to do them in residency, but never did them in private practice. Some FPs do them, but they're typically in areas that are underserved (e.g., a FQHC, where reimbursement isn't usually an issue), and are more likely to be using telemedicine.

 

[JustPlainBill]

And Captain Obvious chiming in --- so you do the scope and find something -- what are you going to do now? Unless you're out in the boonies and credentialed -- refer to ENT; Just like Ob/Gyn -- sure, I'll do PAPs, etc. but if they come back bad, even though I'm trained in culpos --- not going to do them -- why? well, if things go bad, come back bad, what am I going to do? Not trained in hysterectomies.....medical science has advanced to the point that we have so many interventional procedures that FM can't do all of it anymore....but I do still hold that some of the more detailed procedures are all that specialists are needed for -- most of the problems that people demand a specialist referral for can be handled quite nicely by FM.

 

[VA Hopeful Dr]

And Captain Obvious chiming in --- so you do the scope and find something -- what are you going to do now? Unless you're out in the boonies and credentialed -- refer to ENT; Just like Ob/Gyn -- sure, I'll do PAPs, etc. but if they come back bad, even though I'm trained in culpos --- not going to do them -- why? well, if things go bad, come back bad, what am I going to do? Not trained in hysterectomies.....medical science has advanced to the point that we have so many interventional procedures that FM can't do all of it anymore....but we can do more workups/non-procedure things --

For chronic cough, start PPI if reflux. If hoarse, can differentiate between vocal cord edema (supportive care) and lesson (needs ENT appt).

Basically you can often avoid referrals, same reason we do lots of procedures that end up needing specialists anyway down the road.

 

[Promethean]

Set aside the minimum $10k price tag for a halfway decent scope & accessories. The cost of maintaining it (proper sanitization between patients) is maybe even more prohibitive. It is definitely not as trivial as wiping them down. They need actual high level decontamination, which means even more equipment and staff education and keeping logs to document proper cleaning between cases. Just imagine the fallout if someone gets an infection that they could blame on your scope...

I'm all for FM providing as much care as is reasonable rather than referring every little thing, but this is one of those things that is worth a referral.

 

[FamilymedMD]

We did these at our family medicine residency but everywhere I've worked since then has never had enough volume to justify the equipment nor to keep up our skills. If I was setting up a big practices with 5 or 6 docs it might be worth buying one and having someone with training and experience to do them inhouse.

 

[septoplasty]

Set aside the minimum $10k price tag for a halfway decent scope & accessories. The cost of maintaining it (proper sanitization between patients) is maybe even more prohibitive. It is definitely not as trivial as wiping them down. They need actual high level decontamination, which means even more equipment and staff education and keeping logs to document proper cleaning between cases. Just imagine the fallout if someone gets an infection that they could blame on your scope...

I'm all for FM providing as much care as is reasonable rather than referring every little thing, but this is one of those things that is worth a referral.

I feel like this use to be an issue, the ENT we rotated with in residency basically made this little hanging structure on the wall (see through PVC), filled with Chlorohex solution which was in a central office area.. after each patient's visit, they would basically just put the scope in there, and use the other scope (they had 2) for the next patient, and rotate between the two, this was a hospital based clinic, so i'm sure infection control was involved in approving this, again, didn't see like it was "expensive" by any means. Not sure if Chlorohex. solution is expensive though, even if it was, they did plenty a day to justify the cost..

For the OP, I guess you could, potentially the medico-legal ramifications may be preventing people from also doing these..

 

[Promethean]

I feel like this use to be an issue, the ENT we rotated with in residency basically made this little hanging structure on the wall (see through PVC), filled with Chlorohex solution which was in a central office area.. after each patient's visit, they would basically just put the scope in there, and use the other scope (they had 2) for the next patient, and rotate between the two, this was a hospital based clinic, so i'm sure infection control was involved in approving this, again, didn't see like it was "expensive" by any means. Not sure if Chlorohex. solution is expensive though, even if it was, they did plenty a day to justify the cost..

For the OP, I guess you could, potentially the medico-legal ramifications may be preventing people from also doing these..

Just because you saw something done, doesn't mean that it represents best practices or that anyone from infection control had indeed vetted the decontamination process being used. Sometimes, it takes an outbreak or a big settlement to remind facilities that they are liable if equipment is not maintained according to standards.

What you describe is an example of Low Level Disinfection, which does not reliably kill tuberculosis or virtually any spore forming organisms. I definitely wouldn't want to have a scope "cleaned" that way used on me or anyone that I cared about. High Level Disinfection is the absolute minimum acceptable standard for reliable infection control, and none of the agents that can be used for brief contact disinfection such as you describe would be substances that you would be able to handle that casually.

This is a document about GI scopes, but the information is still very pertinent to ENT scopes. Pathogens of greatest concern vary a little, but otherwise, the principles hold.
https://www.sgna.org/Portals/0/HLD__FINAL.pdf

 

[Bacchus]

And Captain Obvious chiming in --- so you do the scope and find something -- what are you going to do now? Unless you're out in the boonies and credentialed -- refer to ENT; Just like Ob/Gyn -- sure, I'll do PAPs, etc. but if they come back bad, even though I'm trained in culpos --- not going to do them -- why? well, if things go bad, come back bad, what am I going to do? Not trained in hysterectomies.....medical science has advanced to the point that we have so many interventional procedures that FM can't do all of it anymore....but I do still hold that some of the more detailed procedures are all that specialists are needed for -- most of the problems that people demand a specialist referral for can be handled quite nicely by FM.

Maybe I read this wrong, soupy don't do Paps because of fear for need of referral?

I give my patients the option. I tell them I don't mind spin. The pap, but if things are abnormal and guidelines require intervention I need to refer them not because I can't do colpos but because we don't have the machinery because knock on wood my patients paps come back normal most of the time. Over the paps I did at the current job, only one required referral for a higher grade SIL.

 

[septoplasty]

Just because you saw something done, doesn't mean that it represents best practices or that anyone from infection control had indeed vetted the decontamination process being used. Sometimes, it takes an outbreak or a big settlement to remind facilities that they are liable if equipment is not maintained according to standards.

What you describe is an example of Low Level Disinfection, which does not reliably kill tuberculosis or virtually any spore forming organisms. I definitely wouldn't want to have a scope "cleaned" that way used on me or anyone that I cared about. High Level Disinfection is the absolute minimum acceptable standard for reliable infection control, and none of the agents that can be used for brief contact disinfection such as you describe would be substances that you would be able to handle that casually.

This is a document about GI scopes, but the information is still very pertinent to ENT scopes. Pathogens of greatest concern vary a little, but otherwise, the principles hold.
https://www.sgna.org/Portals/0/HLD__FINAL.pdf

Actually, what I said represents HLD, and it is indeed "an accepted level of disinfection" aka Submersion Disinfection, which is one of the ways Olympus (one of the manufacturers)/ as well as studies/concensus points to, does put in their "guide".

References:

1. http://medical.olympusamerica.com/sites/default/files/pdf/mic0605p74.pdf
2. Re: How to sterilize a Nasal Endoscope?
3. UK ENT Guideline on Scopes: http://www.tristel.com/sites/default/files/ent_uk_guidelines_2010.pdf (interestingly its found on one of the manufacturers of the disinfecting solution lol)

PS: Thanks for bringing this up, made me research it up! haha.

 

[NRAI2001]

How expensive is the equipement? I do know of a few PCPs that do them (atleast when I last talked to them a few years ago). If I remember correctly the scope was somewhere around $6-8K. I forgot the reimbursement rate but something like $300. Could make back you money pretty easily if those number are/are still correct within a few months.

 

[JustPlainBill]

Maybe I read this wrong, soupy don't do Paps because of fear for need of referral?

I give my patients the option. I tell them I don't mind spin. The pap, but if things are abnormal and guidelines require intervention I need to refer them not because I can't do colpos but because we don't have the machinery because knock on wood my patients paps come back normal most of the time. Over the paps I did at the current job, only one required referral for a higher grade SIL.

You read it wrong. I'm same-same as you on PAPs....just hate the need for referral if it comes back needing anything else.

 

[deleted87716]

You read it wrong. I'm same-same as you on PAPs....just hate the need for referral if it comes back needing anything else.

Meh. I probably refer one patient/year to gyn for colpo, if that. If I send anyone to ENT for laryngoscopy, it's usually EERD, which I already presumed by history.

 

[Promethean]

Actually, what I said represents HLD, and it is indeed "an accepted level of disinfection" aka Submersion Disinfection, which is one of the ways Olympus (one of the manufacturers)/ as well as studies/concensus points to, does put in their "guide".

References:

1. http://medical.olympusamerica.com/sites/default/files/pdf/mic0605p74.pdf
2. Re: How to sterilize a Nasal Endoscope?
3. UK ENT Guideline on Scopes: http://www.tristel.com/sites/default/files/ent_uk_guidelines_2010.pdf (interestingly its found on one of the manufacturers of the disinfecting solution lol)

PS: Thanks for bringing this up, made me research it up! haha.

Thank you for the correction and the references! It is great when we can use conversations here to actually learn!

 

[septoplasty]

Thank you for the correction and the references! It is great when we can use conversations here to actually learn!

Exactly, although that's how it hardly goes on online forums.. haha

 

[smq123]

Meh. I probably refer one patient/year to gyn for colpo, if that.

Really?

It must be the patient population. I send about 3-5 to GYN for colpo every month, on average.

 

[deleted87716]

Really?

It must be the patient population. I send about 3-5 to GYN for colpo every month, on average.

Definitely a population thing. You're a female physician, correct? My two female partners do WAY more gyn than I do. Most of my female patients are post-menopausal.

 

[DocSweetness]

Not enough volume

I agree with VA Hopeful Dr. I also do EGDs and Colons. I have more than enough volume to support that because I have a group practice that internally refers these patients specifically for scopes. That would not hold up with the ENT stuff because they don't always know when a scope is indicated and these would necessarily refer to a doc like me, even though and EGD and Colo are both vastly more challenging.

 

[letsdoit]

Medicare instituted RBRVS. Basically, if I do a punch biopsy and a dermatologist does a punch biopsy, the dermatologist gets paid more for the procedure than I do. So I have no incentive and therefore I refer. Same with scopes and all other procedures. Of course, it's different in a rural area where you don't always have a specialist close enough to refer.