Endoscopy: Have we gastroenterologists lessened our value through the perception of us as professional proceduralists?

Abstract

This is a commentary on the recently published meta-analysis by Wilkins et al which concluded that primary care physicians are able to provide comparable quality in performing colonoscopic colon cancer screening as gastroenterologists.

Key Words: Gastroenterologist, Endoscopy, Proceduralist, Professional

INTRODUCTION

On January 12, 2009, the press in the United States picked up a disturbing and “flawed” meta-analysis from the Department of Family Practice at the Medical College of Georgia, my home institution. The article by Wilkins et al[1] entitled “Screening Colonoscopies by Primary Care Physicians: A Meta-Analysis” concluded that: “colonoscopies performed by primary care physicians have the quality, safety, and efficacy indicators that are comparable to those recommended by the American Society of Gastrointestinal Endoscopists, American College of Gastroenterology, and the Society of American Gastrointestinal Endoscopic Surgeon”.

DISCUSSION

Unfortunately, Dr. Wilkins’ meta-analysis was “flawed” analyzing 12 studies with 13363 of the 18292 patients (73%) coming from a single unpublished non-peer reviewed report[1]. This single analysis came from a South Carolina, USA endoscopy center that additionally employed a gastroenterologist and general surgeon, to assist primary care endoscopists to complete the colonoscopy or therapeutics necessary if the primary care endoscopists were unable to do so themselves. The background from this endoscopy center was not mentioned in Dr. Wilkins’ meta-analysis. When the data from this study is excluded the actual cecal intubation rate was an unacceptably low 83.5% for the remaining 4992 colonoscopies. This “potentially misleading” study was recognized by the American College of Gastroenterology, resulting in a scathing rebuttal by Drs. Eamonn Quigley and Douglas Rex[2].

Still this begs to question whether in the near future (given further endoscopic technical advancements): “Will our primary care colleagues be able to catch up with the endoscopic skills of a gastroenterologist?” Sadly, I believe the answer may be yes (at least for basic endoscopic procedures). This article must serve as a wake up call to all of us practicing gastroenterologists and our trainees that our gastroenterological professional niche goes beyond just completing procedures; rather it involves the correct interpretation of the normal and disease processes that we may visualize in our patients when endoscopic procedures are performed, followed by the application of appropriate requisite therapeutics. More importantly, I believe that gastroenterology practice involves the initiation of the correct systems-based courses of action that we take in treating disease processes encountered in our patients. The unique skill of a gastroenterologist comes from the lengthy 3 year fellowship training process (in the United States), where we are immersed in gastroenterological disease biology, genetics, research, and therapeutics. The clinical skills acquired in fellowship, ultimately allow us to apply the necessary therapeutic and emotional support for our patients in dealing with the gastroenterological diseases with which they are afflicted.

We need to change the current public perception that the role of a gastroenterologist is just to perform procedures, rather than being a physician who is uniquely qualified to diagnose, treat, and palliate gastrointestinal diseases. Without this necessary change in public perception, and an imminent gastroenterological physician specialty shortage on the horizon, we will give our patient base (our livelihood) no good reason to seek our care.