NPs and PAs Performing Colonoscopies: Why Not?

Tinker Ready

June 02, 2021

Highly trained nurse practitioners (NPs) and physician assistants (PAs) are just as capable of performing screening colonoscopies as gastroenterologists: this is the conclusion from a number of studies conducted across both the United States and Europe. 

So, why aren't more NPs and PAs doing them?

"We wanted it to take off, but we haven't been able to do it," said San Diego gastroenterologist Daniel "Stony" Anderson, MD. He spent decades working to expand access to colorectal cancer screening at Kaiser Permanente and other healthcare organizations, and has now been doing the same as president of the California Colorectal Cancer Coalition.

Anderson told Medscape Medical News that he isn't sure why the practice did not catch on, but added, "I don't see a groundswell for this."

One explanation has been that the centers abandoned the practice because there were enough gastroenterologists to handle the demand.

Or perhaps it was one battle too many for NPs and PAs, who are fighting at the state level and at Veterans Affairs (VA) for permission to deliver more primary care and anesthesia services.

In addition, doctors are fighting back.

The American Medical Association (AMA) runs a Stop Scope Creep campaign that opposes attempts by NPs and PAs "to inappropriately expand their scope of practice." Along with anesthesiologists, the AMA is fighting the extension of a COVID-19 waiver at the VA that allows NPs and PAs to continue delivering anesthesia without a physician's supervision. Other groups have joined in the battle against practice expansion via social media under the hashtags #stopscopecreep and #patientsafetymatters.

The battle is ongoing and ugly at times.

Proponents describe NPs and PAs as "advanced practice providers." But opponents call them "midlevel practitioners." One website called Midlevel WTF argues that the healthcare system is declining, in part, because of "the proliferation of poorly supervised or completely unsupervised midlevels across the healthcare spectrum." 

NPs Perform Colonoscopies 'Safely and Effectively

One of the studies to examine the issue of NPs performing screening colonoscopies, and how this compares with gastroenterologists performing the procedure, was published in Endoscopy International Open in October 2020.

In a retrospective analysis from Johns Hopkins Hospital in Baltimore, Maryland, the authors concluded that three fellowship-trained NPs satisfied the American College of Gastroenterology's quality indicators and "demonstrated that adequately trained NPs can perform colonoscopy safely and effectively."

There was little reaction to this conclusion when the study was published. But some months later, several gastroenterologists on social media began questioning the high percentage of African Americans in the study, and suggested that the research exploited Black patients, according to a story in STAT, a national health news website.

In a written statement, Hopkins told Medscape Medical News that, from 2010 to 2016, patients were given the option to have an NP or physician provide a screening colonoscopy. However, they are no longer offered that option. The project has been discontinued: the gastroenterologist who was overseeing the clinical program, Anthony Kalloo, MD, director of the division of gastroenterology and hepatology, left John Hopkins earlier this year, and two of the three NPs involved in the program have also left.

Kalloo declined to comment to Medscape Medical News, but was quoted at length in the STAT article. He noted that NPs regularly perform colonoscopies in the United Kingdom, and that the John Hopkins study showed, for the first time, "that we could do this in the US, and the implication of that is cost savings."

Kalloo also defended his work against claims of racial exploitation. In fact, he said, "I found those comments to be amusing...Obviously, they saw that I was the lead author from Hopkins, but they obviously didn't know what I look like." Kalloo is Black.

Kalloo is now chair of the department of medicine at Maimonides Medical Center, New York City, and he told STAT that he was interested in starting up a similar project there to train NPs to perform colonoscopies.

Other centers that explored the practice have also not continued with it.

A 2008 study at the University of California, Davis, notes: "Several barriers to colorectal cancer screening have been identified including limited access to trained endoscopists and highlight insufficient capacity to meet projected demand for colonoscopies...Training NPs to perform colonoscopy may be an effective strategy to increase access."

The study compared 100 screening colonoscopies performed by board certified gastroenterologists (GI-MD) and 50 performed by a gastroenterology-trained NP (GI-NP). There were no complications reported among the 150 cases, and "the GI-NP in our study performed screening colonoscopy as safely, accurately, and satisfactorily as the GI-MDs," the authors conclude. 

But it's not a strategy the hospital adopted. The nurse who conducted the study told Medscape Medical News she is no longer doing them and declined further comment. The University of California, Davis could not confirm whether anyone else is.

An Uncommon Practice

The American Gastroenterological Association (AGA) referred questions from Medscape Medical News to the American Society for Gastrointestinal Endoscopy (ASGE).

It is very uncommon to have NPs do coloscopies, commented Douglas K. Rex, MD, director of endoscopy at Indiana University Hospital, Indianapolis, and incoming ASGE president.

"There was more of a movement the UK, but not in the US," he said. "I can't tell you the reason. It's a combination of minimal data and also the fact that there are plenty of gastroenterologists."

The ASGE guidelines for endoscopy by nonphysicians concludes: "There are insufficient data to support nonphysician endoscopists to perform colonoscopy."

Asked about concerns that the demand for colonoscopies will increase now that the recommendation is to start colorectal cancer screening at 45 years old, Rex said he thinks the system has enough capacity.

But will it continue to be sufficient? In a 2020 white paper on colorectal cancer screening, the AGA noted that lowering the starting age to 45 years will add 21 million people to the current pool of 94 million eligible for screening, an increase of 22%.

Lukejohn Day, MD, a gastroenterologist at the University of California San Francisco, has reviewed the data collected on nonphysicians performing colorectal cancer screening. He led a meta-analysis of 24 studies conducted from 1997 to 2011, and the team concluded that "nonphysicians can safely perform endoscopic procedures with similar quality, especially with respect to screening flexible sigmoidoscopy. Far fewer data was reported for nonphysicians performing colonoscopy and upper endoscopy, but among this data nonphysicians perform both procedures within accepted national benchmarks for quality measures used in endoscopy."

Day told Medscape Medical News that he had trained two NPs to do colonoscopies and did the study to get a better sense of the practice. Even still, he said the NPs required extensive training before they could perform the procedure. 

"It's not like someone could finish school and become an endoscopist. It requires a very rigorous training program — a lot of education and mentoring," he said. "Their program is very similar to what our GI fellows go through."

Day said they faced opposition from the gastroenterologists, but they "had enough guardrails" in place to convince sceptics.

One of those guardrails was the requirement that an attending physician be in the building. But when San Francisco General Hospital moved to a new facility, they were unable to guarantee that coverage and the program ended, Day said.

Quality and Depth of Training Hard to Replicate

One place where both NPs and PAs do colonoscopies is at the VA. However, the administration doesn't keep track of how many work there, according to a VA spokesperson. Regulations on physician providers also vary from state to state, and that is reflected in its workforce.

At the St. Louis VA Medical Center, PAs have been performing diagnostic and colorectal cancer screening colonoscopies for nearly 20 years, according to a 2020 article on the quality of care delivered by PAs. The researchers looked at data from more than 700 patients treated over a year. They had colonoscopies performed by one of seven gastroenterologists, five PAs, or 32 GI fellows from two academic affiliates. The PAs performed better than the fellows and just as well as the gastroenterologists, they concluded. 

Samir Gupta, MD, chief of gastroenterology at the VA San Diego Healthcare System, California, told Medscape Medical News in an email that he thinks a range of clinically licensed healthcare providers can be trained to do high-quality colonoscopy.

"The challenge has been ensuring training structure and volume of cases sufficient to consistently enable high-quality colonoscopy practice, including achieving adequate rates of polyp detection and removal and complete exams," he wrote.

This is a challenge for gastroenterologists, but they receive ongoing medical education, and, in many settings, quality is closely monitored and managed, he wrote. He added that in a 3-year training program, most fellows do hundreds of colonoscopies.

"It is really hard to replicate this quality and depth of training outside of a GI fellowship," Gupta said.

Tinker Ready is a freelance health and science journalist based in Cambridge, Massachusetts.

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