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Guidelines for training non-specialists in screening flexible sigmoidoscopy
American Society For Gastrointestinal Endoscopy
Guidelines for Training Non-Specialists in Screening Flexible Sigmoidoscopy INTRODUCTION The American Society for Gastrointestinal Endoscopy (ASGE) endorses performance of screening flexible sigmoidoscopy by non-specialists who have received adequate training and demonstrated competence in the procedure. Performance of screening flexible sigmoidoscopy by non-specialists is especially important in order to screen the large numbers of average risk asymptomatic individuals who deserve screening for colorectal cancer and polyps, as recommended by the American Cancer Society and American College of Physicians. “Non-specialist” refers to practitioners who have not received formal training in gastrointestinal endoscopy during a fellowship in gastroenterology or during a surgical residency (e.g., internists, family physicians, etc.). The ASGE acknowledges that other medical personnel have demonstrated competence in screening flexible sigmoidoscopy1. State laws and other regulations vary as to which non-physician personnel may perform screening flexible sigmoidoscopy (e.g., physician assistants, clinical nurse specialists, nurse practitioners, registered nurses, licensed practical nurses, etc.) and should be consulted by non-physician personnel seeking training in screening flexible sigmoidoscopy2. Colorectal cancer is the third most common cancer, and screening flexible sigmoidoscopy has been shown to decrease mortality from distal colorectal cancers by 40% - 50%3,4. By the year 2000, over 50 million people in the U.S. will be eligible for screening flexible sigmoidoscopy5. Given the large numbers of individuals in the general population who qualify for colorectal cancer screening under current recommendations, there is an acute need to implement colorectal cancer prevention programs. ASGE Publication No. 1038 Published 2000 *Request for reprints of these itmes and this statement should be addressed to: American Society for Gastrointestinal Endoscopy 13 Elm Street Manchester, MA 01944-1314 www.asge.org [email protected] VOLUME 51, NO. 6, 2000
The ASGE has consistently promoted safe and responsible endoscopic practice, and in that context this guideline describes categories of information that physician (specialist) instructors should provide to trainees learning screening flexible sigmoidoscopy. For trainees, the guideline describes categories of didactic information that should be mastered as well as the minimal hands-on supervised training that should be undertaken before screening flexible sigmoidoscopy is performed independently. COMPONENTS OF TRAINING Mentor / Training Director Hands-on supervised experience is required to attain competence in flexible sigmoidoscopy. For practitioners already in practice, establishment of a student-mentor relationship with a specialist in gastrointestinal endoscopy, to whom patients are referred, is recommended. The physician responsible for training the non-specialist in screening flexible sigmoidoscopy should be a specialist trained in gastrointestinal endoscopy. Short Courses A training program in screening flexible sigmoidoscopy for the non-specialist may be supplemented by information acquired in a “short course” setting, but short courses alone cannot assure competence in the procedure. The ASGE recognizes the potential benefit of short courses and has published a policy regarding their appropriate place as part of an endoscopic training program6. Experience in short courses or acquisition of basic information on flexible sigmoidoscopy by other such means cannot substitute for supervised hands-on experience with patients, which should remain the core of a training program in screening flexible sigmoidoscopy. Evaluation of Competence Flexible sigmoidoscopy requires fewer supervised examinations than other endoscopic procedures to attain competence7. Thus, it lends itself to performance by non-specialists. Available data suggest that the usual trainee should perform at least 25 GASTROINTESTINAL ENDOSCOPY
783
Author
flexible sigmoidoscopies under supervision before competence is assessed8,9. Some trainees may require additional procedures before attaining competence. Competence refers not only to technical achievement of performance standards of the examination (e.g., reaching the extent of the endoscope unaided in 80% - 90% of exams), but also to understanding the cognitive aspects of the procedure, including risks, benefits, and alternatives to the procedure. Such performance standards have been published previously by the ASGE and should be adhered to by specialists as well as non-specialists performing endoscopic procedures10. A recent randomized controlled trial demonstrated no significant difference in the depth of insertion or polyp detection rate among gastroenterology fellows, general surgeons, and a registered nurse trained in flexible sigmoidoscopy, supporting the extension of screening flexible sigmoidoscopy training to nonspecialists, including selected non-physician health care professionals11. CURRICULUM Colorectal Cancer Screening Trainees should acquire an understanding of the principles underlying colorectal cancer screening. This includes knowledge of the epidemiology of colorectal polyps and cancer, including the incidence of colorectal cancer in average-risk and high-risk persons and the prevalence of colon polyps by age and gender. Trainees should understand the mortality reduction demonstrated by randomized controlled trials of fecal occult blood testing and case-control studies of sigmoidoscopy and the rationale for combining fecal occult blood testing with flexible sigmoidoscopy. Trainees should understand the indications for screening flexible sigmoidoscopy in average-risk patients and for screening/surveillance examinations in high-risk patients as outlined in guidelines from the Agency for Health Care Policy and Research and the American Cancer Society12. They should also possess at least a rudimentary understanding of applicable national and local rules governing reimbursement for screening flexible sigmoidoscopy. Indications and Contraindications Trainees should understand accepted indications for screening flexible sigmoidoscopy by the non-specialist. This should include explicit recognition that a training program in screening flexible sigmoidoscopy prepares non-specialist trainees to perform examinations in an asymptomatic population at average risk for colon cancer but does not prepare them to perform diagnostic examinations to evaluate 784
GASTROINTESTINAL ENDOSCOPY
Title
symptoms such as diarrhea, abdominal pain, or rectal bleeding. Trainees should know contraindications to flexible sigmoidoscopy and indications for which screening flexible sigmoidoscopy is not appropriate and for which diagnostic flexible sigmoidoscopy or more extensive colon evaluation (e.g., colonoscopy) by a specialist/endoscopist is preferred. Recognizing Pathology Trainees should be familiarized with the normal anatomy and endoscopic appearance of the anorectum, sigmoid colon, and descending colon. They should be trained to recognize the various endoscopic appearances of colonic pathology, including colon polyps, cancer, diverticula, and hemorrhoids. These abnormalities should be recognized promptly and reported to the supervising physician or specialist. Endoscopy Issues Trainees should understand the fundamentals of endoscope design and function. Training must cover the risks of flexible sigmoidoscopy, risks of not having the procedure, alternatives to the procedure and how to obtain informed consent. Trainees should understand available methods of preparing the colon for sigmoidoscopic examination. They should receive information on office and equipment needs for performing screening flexible sigmoidoscopy, understand the components of an adequate sigmoidoscopy report, and know how to properly code for reimbursement for screening flexible sigmoidoscopy. Trainees must understand the risk of transmission of infection posed by flexible sigmoidoscopy. They should be taught the principles and methods of high-level disinfection of flexible sigmoidoscopes. Standards regarding disinfection of endoscopic equipment have been published previously by the ASGE13. If performing screening flexible sigmoidoscopy in a practice setting employing the sheathed endoscope system, trainees should be thoroughly familiar with the correct usage of that system. Trainees should understand the techniques of proper insertion and withdrawal of a sigmoidoscope with special attention to avoidance of complications and performance of a careful, thorough examination. Although the clinical significance of small adenomas (less than 5-10 mm in size) remains a source of controversy, in most settings small polyps identified at screening flexible sigmoidoscopy should be biopsied during the screening exam to determine histology and guide subsequent management. Individuals who have received adequate training to achieve competence in performance of plain-forceps biopsy and have been adequately trained to recogVOLUME 51, NO. 6, 2000
Title
nize which polyps warrant biopsy may perform these procedures at the discretion of the supervising physician. In some areas, however, insurance restrictions or local regulations may place limitations on the performance of endoscopic biopsy during screening flexible sigmoidoscopy performed by non-specialist endoscopists. If biopsies are obtained, the physician directing care is responsible for determining appropriate clinical management based on biopsy results. In some care settings local preference may dictate that colonoscopy be performed by a specialist/endoscopist when any polyps are identified at screening flexible sigmoidoscopy performed by a non-specialist. Resources The following resources may be of use to non-specialists seeking training in flexible sigmoidoscopy. This list is not necessarily comprehensive and will be updated periodically. Textbooks • Katon RM, Keefe EB, Melnyk CS. Flexible Sigmoidoscopy. Orlando: Grune & Stratton, 1985. • Rex DK, Lewis BS. Flexible Sigmoidoscopy. Binghamton, NY: Blackwell Science, 1996. • Schapiro M, Lehman GA. Flexible Sigmoidoscopy: Techniques and Utilization. Baltimore: William & Wilkins, 1990. CD-ROM A CD-ROM on flexible sigmoidoscopy from Georgetown University including many video segments of normal and abnormal findings is available through Interactive Drama, Inc., Bethesda, Maryland. (Phone # 301-654-0676). Flexible Sigmoidoscopes Fiberoptic and video flexible sigmoidoscopes are available through the major endoscope manufacturers (Fujinon, Olympus, Pentax) and Welch-Allyn. Vision Sciences manufactures a unique system with a disposable external sheath, which eliminates the need for disinfection. Fujinon 1-800-872-0196 Olympus 1-800-433-1909 Pentax 1-800-431-5880 Vision Sciences 1-800-874-9975 Welch-Allyn 1-800-535-6663
VOLUME 51, NO. 6, 2000
Author
REFERENCES 1. American Society for Gastrointestinal Endoscopy. Endoscopy by non-physicians: Guidelines for clinical application. Gastrointest Endosc 1999;49:826-28. 2. Cash BD, Schoenfeld PS, Ransohoff DF. Licensure, use, and training of paramedical personnel to perform screening flexible sigmoidoscopy. Gastrointest Endosc 1999;49:163-9. 3. Selby JV, Friedman GD, Quesenberry CP Jr, Weiss NS. A case control study of screening sigmoidoscopy and mortality from colorectal cancer. N Engl J Med 1992;326:653-7. 4. Muller AD, Sonnenberg A. Protection by endoscopy against death from colorectal cancer. Arch Intern Med 1995;155:1741-6. 5. Ransohoff DF, Lang CA. Sigmoidoscopic screening in the 1990’s. JAMA 1993;269:1278-81. 6. The American Society for Gastrointestinal Endoscopy. Statement on Role of Short Courses in Endoscopic Training. Gastrointest Endosc 1999; 50:913-4. 7. Cass OW, Freeman ML, Peine CJ, Zera RT, Onstad GR. Objective evaluation of endoscopy skills during training. Ann Intern Med 1993;118:40-4. 8. Hawes R, Lehman GA, et al. Training resident physicians in fiberoptic flexible sigmoidoscopy: How many supervised examinations are required to achieve competence? Am J Med 1986;80:465-70. 9. Schertz RD, Baskin WN, Frakes JT. Flexible fiberoptic sigmoidoscopy training for primary care physicians: results of a 5-year experience. Gastrointest Endosc 1989;35:316-320. 10. American Society for Gastrointestinal Endoscopy. Principles of training in gastrointestinal endoscopy. Gastrointest Endosc 1999;49:845-53. 11. Schoenfeld PS, Cash B, Kita J, Piorkowski M, Cruess D, Ransohoff D. Effectiveness and patient satisfaction with screening flexible sigmoidoscopy performed by registered nurses. Gastrointest Endosc 1999;49:158-62. 12. Winawer AJ, Fletcher RH et al. Colorectal cancer screening: Clinical guidelines and rationale. Gastroenterology 1997;112: 594-642. 13. American Society for Gastrointestinal Endoscopy. Infection control during gastrointestinal endoscopy: Guidelines for clinical application. Gastrointest Endosc 1999;49:836-41.
COMMITTEE ON TRAINING Glenn W. W. Gross, MD Eugene M. Bozymski, MD Russell D. Brown, MD Oliver W. Cass, MD Grace H. Elta, MD Brian C. Jacobson, MD Gary R. Lichtenstein, MD Mark H. Mellow, MD James J. Nackley, MD Rig S. Patel, MD Frank G. Gress, MD Kris V. Kowdley, MD
GASTROINTESTINAL ENDOSCOPY
785
Guidelines for Training Non-Specialists in Screening Flexible Sigmoidoscopy INTRODUCTION The American Society for Gastrointestinal Endoscopy (ASGE) endorses performance of screening flexible sigmoidoscopy by non-specialists who have received adequate training and demonstrated competence in the procedure. Performance of screening flexible sigmoidoscopy by non-specialists is especially important in order to screen the large numbers of average risk asymptomatic individuals who deserve screening for colorectal cancer and polyps, as recommended by the American Cancer Society and American College of Physicians. “Non-specialist” refers to practitioners who have not received formal training in gastrointestinal endoscopy during a fellowship in gastroenterology or during a surgical residency (e.g., internists, family physicians, etc.). The ASGE acknowledges that other medical personnel have demonstrated competence in screening flexible sigmoidoscopy1. State laws and other regulations vary as to which non-physician personnel may perform screening flexible sigmoidoscopy (e.g., physician assistants, clinical nurse specialists, nurse practitioners, registered nurses, licensed practical nurses, etc.) and should be consulted by non-physician personnel seeking training in screening flexible sigmoidoscopy2. Colorectal cancer is the third most common cancer, and screening flexible sigmoidoscopy has been shown to decrease mortality from distal colorectal cancers by 40% - 50%3,4. By the year 2000, over 50 million people in the U.S. will be eligible for screening flexible sigmoidoscopy5. Given the large numbers of individuals in the general population who qualify for colorectal cancer screening under current recommendations, there is an acute need to implement colorectal cancer prevention programs. ASGE Publication No. 1038 Published 2000 *Request for reprints of these itmes and this statement should be addressed to: American Society for Gastrointestinal Endoscopy 13 Elm Street Manchester, MA 01944-1314 www.asge.org [email protected] VOLUME 51, NO. 6, 2000
The ASGE has consistently promoted safe and responsible endoscopic practice, and in that context this guideline describes categories of information that physician (specialist) instructors should provide to trainees learning screening flexible sigmoidoscopy. For trainees, the guideline describes categories of didactic information that should be mastered as well as the minimal hands-on supervised training that should be undertaken before screening flexible sigmoidoscopy is performed independently. COMPONENTS OF TRAINING Mentor / Training Director Hands-on supervised experience is required to attain competence in flexible sigmoidoscopy. For practitioners already in practice, establishment of a student-mentor relationship with a specialist in gastrointestinal endoscopy, to whom patients are referred, is recommended. The physician responsible for training the non-specialist in screening flexible sigmoidoscopy should be a specialist trained in gastrointestinal endoscopy. Short Courses A training program in screening flexible sigmoidoscopy for the non-specialist may be supplemented by information acquired in a “short course” setting, but short courses alone cannot assure competence in the procedure. The ASGE recognizes the potential benefit of short courses and has published a policy regarding their appropriate place as part of an endoscopic training program6. Experience in short courses or acquisition of basic information on flexible sigmoidoscopy by other such means cannot substitute for supervised hands-on experience with patients, which should remain the core of a training program in screening flexible sigmoidoscopy. Evaluation of Competence Flexible sigmoidoscopy requires fewer supervised examinations than other endoscopic procedures to attain competence7. Thus, it lends itself to performance by non-specialists. Available data suggest that the usual trainee should perform at least 25 GASTROINTESTINAL ENDOSCOPY
783
Author
flexible sigmoidoscopies under supervision before competence is assessed8,9. Some trainees may require additional procedures before attaining competence. Competence refers not only to technical achievement of performance standards of the examination (e.g., reaching the extent of the endoscope unaided in 80% - 90% of exams), but also to understanding the cognitive aspects of the procedure, including risks, benefits, and alternatives to the procedure. Such performance standards have been published previously by the ASGE and should be adhered to by specialists as well as non-specialists performing endoscopic procedures10. A recent randomized controlled trial demonstrated no significant difference in the depth of insertion or polyp detection rate among gastroenterology fellows, general surgeons, and a registered nurse trained in flexible sigmoidoscopy, supporting the extension of screening flexible sigmoidoscopy training to nonspecialists, including selected non-physician health care professionals11. CURRICULUM Colorectal Cancer Screening Trainees should acquire an understanding of the principles underlying colorectal cancer screening. This includes knowledge of the epidemiology of colorectal polyps and cancer, including the incidence of colorectal cancer in average-risk and high-risk persons and the prevalence of colon polyps by age and gender. Trainees should understand the mortality reduction demonstrated by randomized controlled trials of fecal occult blood testing and case-control studies of sigmoidoscopy and the rationale for combining fecal occult blood testing with flexible sigmoidoscopy. Trainees should understand the indications for screening flexible sigmoidoscopy in average-risk patients and for screening/surveillance examinations in high-risk patients as outlined in guidelines from the Agency for Health Care Policy and Research and the American Cancer Society12. They should also possess at least a rudimentary understanding of applicable national and local rules governing reimbursement for screening flexible sigmoidoscopy. Indications and Contraindications Trainees should understand accepted indications for screening flexible sigmoidoscopy by the non-specialist. This should include explicit recognition that a training program in screening flexible sigmoidoscopy prepares non-specialist trainees to perform examinations in an asymptomatic population at average risk for colon cancer but does not prepare them to perform diagnostic examinations to evaluate 784
GASTROINTESTINAL ENDOSCOPY
Title
symptoms such as diarrhea, abdominal pain, or rectal bleeding. Trainees should know contraindications to flexible sigmoidoscopy and indications for which screening flexible sigmoidoscopy is not appropriate and for which diagnostic flexible sigmoidoscopy or more extensive colon evaluation (e.g., colonoscopy) by a specialist/endoscopist is preferred. Recognizing Pathology Trainees should be familiarized with the normal anatomy and endoscopic appearance of the anorectum, sigmoid colon, and descending colon. They should be trained to recognize the various endoscopic appearances of colonic pathology, including colon polyps, cancer, diverticula, and hemorrhoids. These abnormalities should be recognized promptly and reported to the supervising physician or specialist. Endoscopy Issues Trainees should understand the fundamentals of endoscope design and function. Training must cover the risks of flexible sigmoidoscopy, risks of not having the procedure, alternatives to the procedure and how to obtain informed consent. Trainees should understand available methods of preparing the colon for sigmoidoscopic examination. They should receive information on office and equipment needs for performing screening flexible sigmoidoscopy, understand the components of an adequate sigmoidoscopy report, and know how to properly code for reimbursement for screening flexible sigmoidoscopy. Trainees must understand the risk of transmission of infection posed by flexible sigmoidoscopy. They should be taught the principles and methods of high-level disinfection of flexible sigmoidoscopes. Standards regarding disinfection of endoscopic equipment have been published previously by the ASGE13. If performing screening flexible sigmoidoscopy in a practice setting employing the sheathed endoscope system, trainees should be thoroughly familiar with the correct usage of that system. Trainees should understand the techniques of proper insertion and withdrawal of a sigmoidoscope with special attention to avoidance of complications and performance of a careful, thorough examination. Although the clinical significance of small adenomas (less than 5-10 mm in size) remains a source of controversy, in most settings small polyps identified at screening flexible sigmoidoscopy should be biopsied during the screening exam to determine histology and guide subsequent management. Individuals who have received adequate training to achieve competence in performance of plain-forceps biopsy and have been adequately trained to recogVOLUME 51, NO. 6, 2000
Title
nize which polyps warrant biopsy may perform these procedures at the discretion of the supervising physician. In some areas, however, insurance restrictions or local regulations may place limitations on the performance of endoscopic biopsy during screening flexible sigmoidoscopy performed by non-specialist endoscopists. If biopsies are obtained, the physician directing care is responsible for determining appropriate clinical management based on biopsy results. In some care settings local preference may dictate that colonoscopy be performed by a specialist/endoscopist when any polyps are identified at screening flexible sigmoidoscopy performed by a non-specialist. Resources The following resources may be of use to non-specialists seeking training in flexible sigmoidoscopy. This list is not necessarily comprehensive and will be updated periodically. Textbooks • Katon RM, Keefe EB, Melnyk CS. Flexible Sigmoidoscopy. Orlando: Grune & Stratton, 1985. • Rex DK, Lewis BS. Flexible Sigmoidoscopy. Binghamton, NY: Blackwell Science, 1996. • Schapiro M, Lehman GA. Flexible Sigmoidoscopy: Techniques and Utilization. Baltimore: William & Wilkins, 1990. CD-ROM A CD-ROM on flexible sigmoidoscopy from Georgetown University including many video segments of normal and abnormal findings is available through Interactive Drama, Inc., Bethesda, Maryland. (Phone # 301-654-0676). Flexible Sigmoidoscopes Fiberoptic and video flexible sigmoidoscopes are available through the major endoscope manufacturers (Fujinon, Olympus, Pentax) and Welch-Allyn. Vision Sciences manufactures a unique system with a disposable external sheath, which eliminates the need for disinfection. Fujinon 1-800-872-0196 Olympus 1-800-433-1909 Pentax 1-800-431-5880 Vision Sciences 1-800-874-9975 Welch-Allyn 1-800-535-6663
VOLUME 51, NO. 6, 2000
Author
REFERENCES 1. American Society for Gastrointestinal Endoscopy. Endoscopy by non-physicians: Guidelines for clinical application. Gastrointest Endosc 1999;49:826-28. 2. Cash BD, Schoenfeld PS, Ransohoff DF. Licensure, use, and training of paramedical personnel to perform screening flexible sigmoidoscopy. Gastrointest Endosc 1999;49:163-9. 3. Selby JV, Friedman GD, Quesenberry CP Jr, Weiss NS. A case control study of screening sigmoidoscopy and mortality from colorectal cancer. N Engl J Med 1992;326:653-7. 4. Muller AD, Sonnenberg A. Protection by endoscopy against death from colorectal cancer. Arch Intern Med 1995;155:1741-6. 5. Ransohoff DF, Lang CA. Sigmoidoscopic screening in the 1990’s. JAMA 1993;269:1278-81. 6. The American Society for Gastrointestinal Endoscopy. Statement on Role of Short Courses in Endoscopic Training. Gastrointest Endosc 1999; 50:913-4. 7. Cass OW, Freeman ML, Peine CJ, Zera RT, Onstad GR. Objective evaluation of endoscopy skills during training. Ann Intern Med 1993;118:40-4. 8. Hawes R, Lehman GA, et al. Training resident physicians in fiberoptic flexible sigmoidoscopy: How many supervised examinations are required to achieve competence? Am J Med 1986;80:465-70. 9. Schertz RD, Baskin WN, Frakes JT. Flexible fiberoptic sigmoidoscopy training for primary care physicians: results of a 5-year experience. Gastrointest Endosc 1989;35:316-320. 10. American Society for Gastrointestinal Endoscopy. Principles of training in gastrointestinal endoscopy. Gastrointest Endosc 1999;49:845-53. 11. Schoenfeld PS, Cash B, Kita J, Piorkowski M, Cruess D, Ransohoff D. Effectiveness and patient satisfaction with screening flexible sigmoidoscopy performed by registered nurses. Gastrointest Endosc 1999;49:158-62. 12. Winawer AJ, Fletcher RH et al. Colorectal cancer screening: Clinical guidelines and rationale. Gastroenterology 1997;112: 594-642. 13. American Society for Gastrointestinal Endoscopy. Infection control during gastrointestinal endoscopy: Guidelines for clinical application. Gastrointest Endosc 1999;49:836-41.
COMMITTEE ON TRAINING Glenn W. W. Gross, MD Eugene M. Bozymski, MD Russell D. Brown, MD Oliver W. Cass, MD Grace H. Elta, MD Brian C. Jacobson, MD Gary R. Lichtenstein, MD Mark H. Mellow, MD James J. Nackley, MD Rig S. Patel, MD Frank G. Gress, MD Kris V. Kowdley, MD
GASTROINTESTINAL ENDOSCOPY
785