Nurses doing colonoscopies on black patients

[Splenda88]

A doctor trained nurse practitioners to do colonoscopies. Critics say his research exploited Black patients

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[Redpancreas]

Disclaimer: Interested in GI as an IM resident, but have not started any GI training outside of electives on IM.

I want some critiques on the exploitation aspect as well as the study's efficacy conclusion. @Gastrapathy @hemosuccus @IM2GI
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I'm assuming this is that physician at Hopkins?

SDN History
1. If you do GI at Hopkins, you'll be sharing scopes with NP "fellows"
2. Hopkins Has GI Residency For NPs
3. Critics say colonoscopy study exploited Black patients - STAT

Overview:
Anthony Kalloo is a Gastroenterologist at Hopkins has been training NPs to do them for a long time. This was posted on SDN a decade ago and Dr. Kalloo himself made an account to respond to SDN critics. A mod was like, Dr. Kalloo, you don't have to non-anonymous on SDN.

He's been training NPs for a while with basically the 1st year GI fellow curriculum. NPs have graduated from it in 2010-2012 . Then it seems like he then conducted a study in 2020 based off data to see if colonoscopies in particular would be done just as well by NPs as MDs/DOs. It is a small, one-center retrospective non-comparitive study. It concludes that NPs could do colonoscopies effectively could based on achieving an acceptable polyp detection rate (validated GI standard). Here is the study to review: Experience of nurse practitioners performing colonoscopy after endoscopic training in more than 1,000 patients. Allegedly, patients were asked for a preference of NP vs. MD/DO and the ones who opted for the NPs did so allegedly because of shorter waiting times. The controversy is that 75% of the patients in the study were black, but 88% of the community around Hopkins, 63% of Baltimore, but only 25% of patients typically treated at Hopkins are black. The latter stat relative to the 75% seems to be the issue in contention as per a UCLA Gastroenterologist who tweeted about it in May 2021 hence why this is blowing up now.

My take (have not done any training in GI yet and a long way to go before I get there):

Hopkins effectively exploited black patients regardless of whether that was their intent. I can't be 100% certain of whether or not these study participants were told what they should have been told ethically without reviewing the informed consent document and listening to how the researchers explained the study to the patients. This isn't in the methods or made available to us anywhere in the document so we're forced to speculate. I personally can very easily visualize situations where everything was technically written somewhere, but what was effectively done for these patients in the community wasn't thoroughly explained to them in plain English. The fact that they were talking to a scheduler with minimal medical background/experience makes it seem like there was unlikely to be any counsel to patients other than, as those responsible for the study point, patients "opted for NPs because they typically had shorter waits" which is all the schedule probably said...I highly doubt when the patient selected April 15th, the schedule was like...woah wait a second, that's an NP. As outlined in the informed consent I must share with you that...

On the flip side, the Hopkins study people are saying they drew not from their typical patient pool (people who can pay $$$ for highly specialized care) but from patients in the immediate community which is reportedly 88% black to get a 75% black population in the study. While I think that point tells us why there was such a large black population, it also virtually incriminates them as it begs the question on why community patients were the ones chosen instead of the Hopkins bread and butter population? I think the people on the study are saying it was out of convenience, but that's just a nice way of saying it was easy to experiment (I realize that's a bit of a hyperbole relative to injecting disease or using someone's cells without consent) on black people.

Inevitably, this is definitely going to be conflated with the whole NP vs. MD/DO argument. so I'll say a bit there as well. Overall, they're saying that in this limited, one institution study there was adequate polyp detection by NPs compared to standards accepted by the ASGE. They're saying this allows colonoscopies to be done cheaper since NP rates are cheaper than physicians which supposedly will free up physicians to do more complex procedures. My critiques not mentioned in the paper are

1) There is no mention on what kind of supervision was allotted to the NPs? Were they doing this like first year fellows do it with a GI doc breathing down their necks? If not, were patients notified that they were receiving something less than the standard of care? If it was done that way, is that 1:1 supervision really feasible long term? Like, for all we know, Dr. Kalloo was guiding the NPs hand while doing these procedures. That isn't that hard to fathom given there were only 3 NPs doing this.

2) I personally don't think NPs have the same ethical standards a physician is held to. That I guess is my opinion.

3) I think the study is diminishing the small sample size especially given the strongly worded conclusions and extrapolation they jump to right away.

Frankly, I am more concerned on the effect this will have on gastroenterology fellow training than GI doctors economically as compensation is going down anyways for more than one reason. You need to be able to do a high volume of normal before understanding abnormal. This encroachment or whatever you're going to call it is going to be a medical education problem for the upcoming decades where I anticipate NPs are going to try to knock fellows off these procedures in academic hospitals.

 

[Lawpy]

Wow the midlevel issue has been reported on SDN for over a decade!

 

[Ms. Incognito]

As someone with similar demographics to the majority patient pool studied and who has recently had a colonoscopy performed and from the DMV area and a M1: this is why there is a lot of distrust in anything and everything Johns Hopkins especially from minority communities in the area. It is a phenomenal medical school but when it comes to their research history in particular, it's still sprinkled with (arguably intentionally) inhumane, unethical practices.

Convenience? It's very difficult for local patients of the Black community and/or lower SES to garner trust and faith in their bioethics. Knowing these populations are the ones I plan on serving, I chose not to apply there (no offense to those who did, again, an amazing medical program). Many locals know the Henrietta Lacks story very well and her descendents who are still advocating/fighting for justice. I'll have to delve deep into the methodology of the research for more context on this...

 

[AlbinoHawk DO]

GI better stop this nonsense or their field will die income-wise. If NPs will be doing it, you bet FM will jump back to doing them with some fellowship similar to emergency

 

[Splenda88]

GI better stop this nonsense or their field will die income-wise. If NPs will be doing it, you bet FM will jump back to doing them with some fellowship similar to emergency

Where will they get hospital privilege to do it? Maybe a few rural hospitals. These big academic centers would prefer to use NP to reduce cost.

 

[GoSpursGo]

The controversy is that 75% of the patients in the study were black, but 88% of the community around Hopkins, 63% of Baltimore, but only 25% of patients typically treated at Hopkins are black. The latter stat relative to the 75% seems to be the issue in contention as per a UCLA Gastroenterologist who tweeted about it in May 2021 hence why this is blowing up now.

On the flip side, the Hopkins study people are saying they drew not from their typical patient pool (people who can pay $$$ for highly specialized care) but from patients in the immediate community which is reportedly 88% black to get a 75% black population in the study. While I think that point tells us why there was such a large black population, it also virtually incriminates them as it begs the question on why community patients were the ones chosen instead of the Hopkins bread and butter population? I think the people on the study are saying it was out of convenience, but that's just a nice way of saying it was easy to experiment (I realize that's a bit of a hyperbole relative to injecting disease or using someone's cells without consent) on black people.

I'm not going to comment on the whole NP vs. physician debate which is important, but on its face this seems like a bad use of statistics. Telling me that 25% of patients treated at Hopkins compared to 75% of patients in the study are Black=racist doesn't make any sense, because when you're dealing with a giant institution like Hopkins the overall demographics probably isn't representative of a specific clinic/service. For example, they have several studies in the literature on their sickle cell population, and naturally in that case you wouldn't say that having Black people overrepresented is surprising.

Secondly, a colonoscopy is a routine screening procedure. For a study like this, it makes perfect sense to me that they would attract disproportionately from their immediate community, as it would make no sense for someone to go out of their way to get the "Hopkins treatment" for a routine screening test. I highly suspect that, for this GI service, the general Baltimore community *is* their bread and butter population. And even as a physician, I have definitely chosen to see an NP/PA because wait times are a thing--I happen to have enough knowledge that if they tell me something fishy I can get them to talk to their attending, but bottom line there is nothing on its face that makes me think they were doing anything nefarious in this study.

Again, whether we should have APP "fellowships" or training APPs to do our procedures is a reasonable question and something worth discussing. But while Hopkins has a well-deserved reputation on this front which they need to continue to answer for, in this case I think there is a lot of controversy being made out of nothing here.

 

[Ho0v-man]

Wow the midlevel issue has been reported on SDN for over a decade!

Oh yeah. If you think people are waking up to the problems being brought up because you see it so frequently on here and Reddit, think again. IRL people get fired for talking about this stuff so it’s only going to get worse.

 

[deleted1066189]

And even as a physician, I have definitely chosen to see an NP/PA because wait times are a thing

sad but true.
just an M0, but I had to get a physical exam filled out by my PCP office for matriculation, and get titers/immunizations scheduled. Either a 6 week wait to see my PCP, or I could see the NP the very next day. Call me guilty, but I saw the NP (heck, it took 2 months just to finalize everything in the health packet, imagine if I waited).

 

[JP2740]

Great, let it happen I say. By the time I retire the field will have crashed a burned but this probably won’t be mainstream before then.

 

[Lawpy]

Oh yeah. If you think people are waking up to the problems being brought up because you see it so frequently on here and Reddit, think again. IRL people get fired for talking about this stuff so it’s only going to get worse.

I'm just surprised that this was known for over a decade and yet physicians didn't lobby effectively since then while midlevels became even more powerful

 

[Redpancreas]

I'm not going to comment on the whole NP vs. physician debate which is important, but on its face this seems like a bad use of statistics. Telling me that 25% of patients treated at Hopkins compared to 75% of patients in the study are Black=racist doesn't make any sense, because when you're dealing with a giant institution like Hopkins the overall demographics probably isn't representative of a specific clinic/service. For example, they have several studies in the literature on their sickle cell population, and naturally in that case you wouldn't say that having Black people overrepresented is surprising.

Secondly, a colonoscopy is a routine screening procedure. For a study like this, it makes perfect sense to me that they would attract disproportionately from their immediate community, as it would make no sense for someone to go out of their way to get the "Hopkins treatment" for a routine screening test. I highly suspect that, for this GI service, the general Baltimore community *is* their bread and butter population. And even as a physician, I have definitely chosen to see an NP/PA because wait times are a thing--I happen to have enough knowledge that if they tell me something fishy I can get them to talk to their attending, but bottom line there is nothing on its face that makes me think they were doing anything nefarious in this study.

Again, whether we should have APP "fellowships" or training APPs to do our procedures is a reasonable question and something worth discussing. But while Hopkins has a well-deserved reputation on this front which they need to continue to answer for, in this case I think there is a lot of controversy being made out of nothing here.

I don’t think their intent was to do anything racist. I think offering this unproven screening tool to the local community which is predominantly poor and/or black is problematic. This isn’t the only example though and hundreds of things like this going on everyday. If you have $, you don’t have to deal with this stuff.

 

[Lawpy]

I don’t think their intent was to do anything racist. I think offering this unproven screening tool to the local community which is predominantly poor and/or black is the problem.

I think it worsens systemic racism by knowingly giving minorities bad healthcare

 

[Redpancreas]

Great, let it happen I say. By the time I retire the field will have crashed a burned but this probably won’t be mainstream before then.

I'm just surprised that this was known for over a decade and yet physicians didn't lobby effectively since then while midlevels became even more powerful

I mean there’s nothing the GI lobby can say unless some people can point to something otherwise with this data or methodology. I made a few points about how exactly NPs were supervised but, I imagine in a few years if all these things show non-inferiority, it will absolutely be the standard for screening colonoscopies. The patient care argument is abstract, the $ argument is real to health care which is becoming more and more about $. I’m a bit worried about salary but I like GI so if it is that way, we’ll cross the bridge when we get there! It may be a good idea for GI physicians to adapt and have a more supervisory role in that realm which may actually be more profitable.

 

[Ho0v-man]

I'm just surprised that this was known for over a decade and yet physicians didn't lobby effectively since then while midlevels became even more powerful

Go read posts from even 5 years ago. “Midlevels could never replace us. The idea is ridiculous.” Followed by a long post of why it’s impossible. It’s still happening on here. Surgeons will tell you over and over the same thing and ignore the fact that they’re training nurses to be surgeons in the UK.

 

[YCAGA]

I think it worsens systemic racism by knowingly giving minorities bad healthcare

The larger problem with sketchy research "studies" is exploiting low income patients of any race or ethnicity. Using uninsured/underinsured patients as research subjects with undertrained nurses is...not a good look.

 

[YCAGA]

Go read posts from even 5 years ago. “Midlevels could never replace us. The idea is ridiculous.” Followed by a long post of why it’s impossible. It’s still happening on here. Surgeons will tell you over and over the same thing and ignore the fact that they’re training nurses to be surgeons in the UK.

But that is different because they practice socialist European medicine and we practice American medicine.

/s

 

[Lawpy]

The larger problem with sketchy research "studies" is exploiting low income patients of any race or ethnicity. Using uninsured/underinsured patients as research subjects with undertrained nurses is...not a good look.

I'm wondering why this crap is studied at any US school, much less JHU, if adcoms are flexing so hard on diversity essays and antiracism. Like come on med education leaders, are you guys suffering from bad cognitive dissonance here?

 

[Ho0v-man]

To the main point of the thread. I assume they got research monies in the form of some kind of grant to fund the “study” of cheaper stand-ins to do a screening exam on a marginalized community. So they found a way to save money coming and going to offset the cost of taking care of poor people.

Oh yeah, definitely nothing sketch going on here...

 

[GoSpursGo]

I don’t think their intent was to do anything racist. I think offering this unproven screening tool to the local community which is predominantly poor and/or black is the problem.

Two points:

1) I think it is a real stretch to argue that a colonoscopy is an "unproven screening tool" just because it's a midlevel is driving the scope. If anything, their premise in the abstract that demand for colonoscopies outstrips the number of providers able to perform the procedure is accurate. In this case the alternative for the majority of those patients was likely no colonoscopy, which is a different kind of disparity. I don't think the answer should be more midlevels either, but then what alternative solution do you propose?
2) The pendulum has largely swung in the other direction in research, and frequently minorities and people of color are now UNDER studied due to a lack of access to clinical trials and care at tertiary academic centers. This leads to a problem that when you read a paper and 90% of the participants are white, you can't be sure if the results are generalizable to minorities. So again, the academic community absolutely has an obligation to not exploit vulnerable populations for research and has a terrible track record on this, but you can cause a lot of unintended bad consequences by NOT actively recruiting poor minority patients to participate in studies as well.

 

[Lawpy]

To the main point of the thread. I assume they got research monies in the form of some kind of grant to fund the “study” of cheaper stand-ins to do a screening exam on a marginalized community. So they found a way to save money coming and going to offset the cost of taking care of poor people.

Oh yeah, definitely nothing sketch going on here...

There's clearly really problematic people along the process to allow exploitative and discriminatory research like this to even be approved in the first place.

I think this is the sheer hypocrisy of medicine. I was already very heavily anti-midlevel and was slamming capitalism, but this is a lot worse

 

[YCAGA]

I'm wondering why this crap is studied at any US school, much less JHU, if adcoms are flexing so hard on diversity essays and antiracism. Like come on med education leaders, are you guys suffering from bad cognitive dissonance here?

One GI doctor doing a research study is a totally different department than adcoms, especially at a giant institution like JHU. Johns Hopkins hospital has over 1,700 doctors, 30,000 employees, and JHU medical school has like 4,000+ academic faculty and staff.

Now, why did an IRB approve this? Probably because that IRB has nurses and administrator gluteus-kissers that don't want to be caught saying nurse practitioners shouldn't being playing doctor.

 

[Redpancreas]

Two points:

1) I think it is a real stretch to argue that a colonoscopy is an "unproven screening tool" just because it's a midlevel is driving the scope. If anything, their premise in the abstract that demand for colonoscopies outstrips the number of providers able to perform the procedure is accurate. In this case the alternative for the majority of those patients was likely no colonoscopy, which is a different kind of disparity. I don't think the answer should be more midlevels either, but then what alternative solution do you propose?
2) The pendulum has largely swung in the other direction in research, and frequently minorities and people of color are now UNDER studied due to a lack of access to clinical trials and care at tertiary academic centers. This leads to a problem that when you read a paper and 90% of the participants are white, you can't be sure if the results are generalizable to minorities. So again, the academic community absolutely has an obligation to not exploit vulnerable populations for research and has a terrible track record on this, but you can cause a lot of unintended bad consequences by NOT actively recruiting poor minority patients to participate in studies as well.

Your second point doesn’t refute anything mine said and is interesting.

Regarding the first, I disagree to some extent. If they did not get their screening colonoscopy, they would likely have had to wait a few months (relative to a 10 year window they have) so I don’t think the alternative was no colonoscopy. That said, who knows if they would have actually followed up/waited with all the other things going on in their life.

 

[YCAGA]

Two points:

1) I think it is a real stretch to argue that a colonoscopy is an "unproven screening tool" just because it's a midlevel is driving the scope. If anything, their premise in the abstract that demand for colonoscopies outstrips the number of providers able to perform the procedure is accurate. In this case the alternative for the majority of those patients was likely no colonoscopy, which is a different kind of disparity. I don't think the answer should be more midlevels either, but then what alternative solution do you propose?
2) The pendulum has largely swung in the other direction in research, and frequently minorities and people of color are now UNDER studied due to a lack of access to clinical trials and care at tertiary academic centers. This leads to a problem that when you read a paper and 90% of the participants are white, you can't be sure if the results are generalizable to minorities. So again, the academic community absolutely has an obligation to not exploit vulnerable populations for research and has a terrible track record on this, but you can cause a lot of unintended bad consequences by NOT actively recruiting poor minority patients to participate in studies as well.

Good points. My first question would be do the perfs and missed pathology outweigh the "saves" from this screening tool when performed by NP's?

Also...I would much rather FM do a 1-2 year GI scope fellowship if there are more scopes needed than we have GI doctors. I wonder how many scopes a GI fellow does in 3 years and how quickly an FM doc could get that. Since we are basically talking about training someone to be a routine scope machine and refer any abnormal finding to GI. I assume much of the 3 years of GI fellowship is not actually doing scopes but is medical management of GI issues, which a scope machine doesn't need to learn.

 

[Lawpy]

One GI doctor doing a research study is a totally different department than adcoms, especially at a giant institution like JHU. Johns Hopkins hospital has over 1,700 doctors, 30,000 employees, and JHU medical school has like 4,000+ academic faculty and staff.

Now, why did an IRB approve this? Probably because that IRB has nurses and administrator gluteus-kissers that don't want to be caught saying nurse practitioners shouldn't being playing doctor.

It was approved, reviewed and published. There are several bad agents in the process and i hope JHU very severely condemns the study

 

[GoSpursGo]

Your second point doesn’t refute anything mine said and is interesting.

Regarding the first, I disagree to some extent. If they did not get their screening colonoscopy, they would likely have had to wait a few months (relative to a 10 year window they have) so I don’t think the alternative was no colonoscopy. That said, who knows if they would have actually followed up/waited with all the other things going on in their life.

Yes--not a direct response. It is a major, major problem within my field. Something to keep in mind

I suspect the answer is that if you're scheduling anyone for a procedure several months out, you're going to increase your no-show rate.

 

[GoSpursGo]

Good points. My first question would be do the perfs and missed pathology outweigh the "saves" from this screening tool when performed by NP's?

Also...I would much rather FM do a 1-2 year GI scope fellowship if there are more scopes needed than we have GI doctors. I wonder how many scopes a GI fellow does in 3 years and how quickly an FM doc could get that. Since we are basically talking about training someone to be a routine scope machine and refer any abnormal finding to GI. I assume much of the 3 years of GI fellowship is not actually doing scopes but is medical management of GI issues, which a scope machine doesn't need to learn.

Would not be opposed to other specialties being able to gain training in doing scopes, but I highly suspect the GI docs would prefer to train an NP who they can collect charges from rather than "share" their procedures with another specialty. So go complain to the GI docs

 

[Lawpy]

Would not be opposed to other specialties being able to gain training in doing scopes, but I highly suspect the GI docs would prefer to train an NP who they can collect charges from rather than "share" their procedures with another specialty. So go complain to the GI docs

And thus medicine is irreversibly self destructing as selfish attendings are far more concerned in defending their turfs over helping physicians in other specialties out

 

[GoSpursGo]

Now, why did an IRB approve this? Probably because that IRB has nurses and administrator gluteus-kissers that don't want to be caught saying nurse practitioners shouldn't being playing doctor.

At the risk of causing more discontent, I feel like I should also point out that this wasn't a clinical trial, it was a retrospective study. So patients weren't "recruited" at all, they were simply given the option of a physician (and a longer wait time) or a midlevel (and a shorter wait time). Several years later, someone decided to analyze the outcomes.

So the only thing that the IRB had to approve was the retrospective collection of data from existing medical charts.

 

[YCAGA]

At the risk of causing more discontent, I feel like I should also point out that this wasn't a clinical trial, it was a retrospective study. So patients weren't "recruited" at all, they were simply given the option of a physician (and a longer wait time) or a midlevel (and a shorter wait time). Several years later, someone decided to analyze the outcomes.

So the only thing that the IRB had to approve was the retrospective collection of data from existing medical charts.

Great point, I did not catch that.

So then the question is, who let these NP's do coloscopies? This one doctor who taught them? I would imagine that the NP's had to get privileges added by the hospital through a formal process. If someone is an anesthesiologist, they can't just start drilling burr holes as part of their practice because a neurosurgeon taught them how to. In terms of their medical license they technically could, but they would get fired immediately and probably sued.

 

[Aheadbyacentury]

I'm just surprised that this was known for over a decade and yet physicians didn't lobby effectively since then while midlevels became even more powerful

The physician leaders who were supposed to push back on this kinda **** got paid off to go along with it.

 

[Splenda88]

This is what medicine has come down to:

 

[Redpancreas]

Great point, I did not catch that.

So then the question is, who let these NP's do coloscopies? This one doctor who taught them? I would imagine that the NP's had to get privileges added by the hospital through a formal process. If someone is an anesthesiologist, they can't just start drilling burr holes as part of their practice because a neurosurgeon taught them how to. In terms of their medical license they technically could, but they would get fired immediately and probably sued.

Yeah, this Kalloo guy did it single-handedly. He's basically the antithesis of the SDN anti-midlevel mentality and came on SDN at one point to defend himself. I am not sure if mods deleted that, but I saw it with my own eyes years ago...I think he stepped down from Director of GI Hopkins in 2020 and went to Maimonades.

In terms of privileges, I'm curious as to how they actually went about doing the colonoscopies. Like I guess I don't even know how GI fellows do it. From my understanding, GI fellows don't scope independently. If that's true, not sure how midlevels were allowed to to do it unsupervised?!

Also, for my learning what percentage of a GI physician's income comes from routine screening colonoscopies? I'm thinking it's something upwards of 50% especially for those using it as a cash cow.

Anyone know?

 

[Redpancreas]

This is what medicine has come down to:

View attachment 336366

It has in many ways. Physicians may lead, but NPs/PAs will serve as extensions, scraping up the previously routine-cash cow procedures that physicians use to generate a large part of their income. GI is an example here. The "9/10" EM visits is another example. Cardiac Caths are another example in Cardiology. NPs doing small surgeries and assisting on larger ones isn't unprecedented in foreign countries. Physicians will continue to be high income earners, but they're going to have to work harder to keep up and salaries across the board will inevitably fall. It's not all doom/gloom though. We will learn to adapt to the roles.

This is what happens when you spend two years of medical training learning clinically irrelevant minutiae and creating superfellowships before allowing physicians to do things. Supply will diminish and people overhead will come up with stupid ways like this to cut costs.

Another interesting note is GI and EM are in unfortunate situations for completely opposite reasons. EM is in surplus and that is driving down opportunities. GI (and other fields like Derm) on the other hand limited their supply so corporate interests have wisened up and are putting midlevels in the spot.

 

[Lawpy]

This is what medicine has come down to:

View attachment 336366

All with the help from selfish, greedy, turf defending attendings

 

[Lawpy]

It has in many ways. Physicians may lead, but NPs/PAs will serve as extensions, scraping up the previously routine-cash cow procedures that physicians use to generate a large part of their income. GI is an example here. The "9/10" EM visits is another example. Cardiac Caths are another example in Cardiology. NPs doing small surgeries and assisting on larger ones isn't unprecedented in foreign countries. Physicians will continue to be high income earners, but they're going to have to work harder to keep up and salaries across the board will inevitably fall. It's not all doom/gloom though. We will learn to adapt to the roles.

This is what happens when you spend two years of medical training learning clinically irrelevant minutiae and creating superfellowships before allowing physicians to do things. Supply will diminish and people overhead will come up with stupid ways like this to cut costs.

Another interesting note is GI and EM are in unfortunate situations for completely opposite reasons. EM is in surplus and that is driving down opportunities. GI (and other fields like Derm) on the other hand limited their supply so corporate interests have wisened up and are putting midlevels in the spot.

The thing is physicians from different specialties can serve as extenders for each other but this profession is so antagonistic and hostile that even the old timers on SDN are busy crapping on consults and how X specialty is trash

 

[Redpancreas]

The thing is physicians from different specialties can serve as extenders for each other but this profession is so antagonistic and hostile that even the old timers on SDN are busy crapping on consults and how X specialty is trash

Honestly, a see a lot of but "I would rather have GPs than NPs to do colonoscopies" talk, but in reality are they? What component of training are they better at inherently based off their training? An NP can basically do a lot because they're going to get good at doing that one thing, whereas as FM doctor unless they're really practicing out in the boonies will not get the same volume. It's not doctor v. NP/PA. It's for the patient at the end of the day. There will still be GI doctors ultimately leading these facilities, coordinating with Pathology, etc.

I'm saying this as a GI aspirant who's likely going to start practicing when this comes into play.

 

[Lawpy]

Honestly, a see a lot of but "I would rather have GPs than NPs to do colonoscopies" talk, but in reality are they? What component of training are they better at inherently based off their training? An NP can basically do a lot because they're going to get good at doing that one thing, whereas as FM doctor unless they're really practicing out in the boonies will not get the same volume. It's not doctor v. NP/PA. It's for the patient at the end of the day. There will still be GI doctors ultimately leading these facilities, coordinating with Pathology, etc.

I'm saying this as a GI aspirant who's likely going to start practicing when this comes into play.

I don't even think we need midlevels if we need specialized aides for certain routine tasks. Even training techs to do these procedures is plenty

 

[Redpancreas]

I don't even think we need midlevels if we need specialized aides for certain routine tasks. Even training techs to do these procedures is plenty

GI physician -> Midlevel -> Blood test. Another thing yet to be mentioned is that the whole screening colonoscopy thing is being replaced with blood tests already so rather than a midlevel doing all these routine colonoscopies, people are just going to get blood tests and then if they're positive, that's an indication for a diagnostic colonoscopy which is a GI physician's territory.

All in all I guess we should be happy because the goal is to screen everyone for colon cancer and I guess we're doing a good job with blood tests, midlevels, etc. I don't know the details but tons of people have hinted at lowering the age recommendation for screening to 45.

To your point about techs, I think that's a good point. Why don't we just cut out these midlevels. There's nothing proprietary about them. Let's give it to technicians and then we can supervise them LOL.

 

[GoSpursGo]

Honestly, a see a lot of but "I would rather have GPs than NPs to do colonoscopies" talk, but in reality are they? What component of training are they better at inherently based off their training? An NP can basically do a lot because they're going to get good at doing that one thing, whereas as FM doctor unless they're really practicing out in the boonies will not get the same volume. It's not doctor v. NP/PA. It's for the patient at the end of the day. There will still be GI doctors ultimately leading these facilities, coordinating with Pathology, etc.

I'm saying this as a GI aspirant who's likely going to start practicing when this comes into play.

What I will say is that while it is great for the old doc who "supervises" the fleet of midlevels and is able to charge for it, this practice is resulting in some saturated fields eating their trainees' job opportunities. There probably is nothing wrong from a patient safety standpoint, but there absolutely are some fields that are screwing the next generation.

 

[Redpancreas]

What I will say is that while it is great for the old doc who "supervises" the fleet of midlevels and is able to charge for it, this practice is resulting in some saturated fields eating their trainees' job opportunities. There probably is nothing wrong from a patient safety standpoint, but there absolutely are some fields that are screwing the next generation.

This is a tremendous, underrecognized point! Medical education is what I am worried will suffer the most with these midlevels! I think I said it somewhere else but midlevels will compete with GI fellows and fellows won't be able to learn on bread/butter.

 

[VA Hopeful Dr]

GI physician -> Midlevel -> Blood test. Another thing yet to be mentioned is that the whole screening colonoscopy thing is being replaced with blood tests already so rather than a midlevel doing all these routine colonoscopies, people are just going to get blood tests and then if they're positive, that's an indication for a diagnostic colonoscopy which is a GI physician's territory.

All in all I guess we should be happy because the goal is to screen everyone for colon cancer and I guess we're doing a good job with blood tests, midlevels, etc. I don't know the details but tons of people have hinted at lowering the age recommendation for screening to 45.

To your point about techs, I think that's a good point. Why don't we just cut out these midlevels. There's nothing proprietary about them. Let's give it to technicians and then we can supervise them LOL.

What blood test is there for colon cancer screening?

 

[Redpancreas]

What blood test is there for colon cancer screening?

I am sorry. Stool testing. Misspoke. If it's negative, it's excludes the need. If it's positive you need to go in for a diagnostic colonoscopy.

 

[Redpancreas]

What blood test is there for colon cancer screening?

Although I have heard it's on the horizon. Depending on the logistics on the blood collection, it may be something that all inpatients get tested for who haven't been screened and all PCPs do routinely like a PSA. That will exponentially broaden testing a hundred-fold more than midlevel scopes.

 

[DOVinciRobot]

Haven't seen it mentioned but every rural surgeon I know has a fairly decent sized percentage of their practice that is c-scopes.

 

[Splenda88]

Louisiana House OKs bill to let nurse practitioners work without doctors

60-41 vote sends Senate a bill that physicians say will compromise patient safety

www.nola.com

 

[VA Hopeful Dr]

Haven't seen it mentioned but every rural surgeon I know has a fairly decent sized percentage of their practice that is c-scopes.

Even in larger towns that's the case. I've pretty much stopped referring screening colonoscopies to GI because they are booked out 2+ months just for the initial appointment. The surgeons can get them fully done in less than 1 month.

 

[Redpancreas]

Even in larger towns that's the case. I've pretty much stopped referring screening colonoscopies to GI because they are booked out 2+ months just for the initial appointment. The surgeons can get them fully done in less than 1 month.

What?! You need a GI appointment prior to a screening colonoscopy?

 

[JP2740]

Two points:

1) I think it is a real stretch to argue that a colonoscopy is an "unproven screening tool" just because it's a midlevel is driving the scope. If anything, their premise in the abstract that demand for colonoscopies outstrips the number of providers able to perform the procedure is accurate. In this case the alternative for the majority of those patients was likely no colonoscopy, which is a different kind of disparity. I don't think the answer should be more midlevels either, but then what alternative solution do you propose?
2) The pendulum has largely swung in the other direction in research, and frequently minorities and people of color are now UNDER studied due to a lack of access to clinical trials and care at tertiary academic centers. This leads to a problem that when you read a paper and 90% of the participants are white, you can't be sure if the results are generalizable to minorities. So again, the academic community absolutely has an obligation to not exploit vulnerable populations for research and has a terrible track record on this, but you can cause a lot of unintended bad consequences by NOT actively recruiting poor minority patients to participate in studies as well.

I don’t care to look up anything but there’s a lot that goes into the colonoscopy screening gap. You don’t just need physicians. For every colonoscopy done there’s a need for a anesthetist (more and more, especially in the community unless you want the nurse driving conscious sedation too), a nurse (administering sedation), tech for instruments (actually becoming harder to hold onto these workers in the current climate). You also need the actual space to do this. I know my hospitals procedure unit does not have a shortage of providers performing colonoscopy - actually would not be able to accommodate more scopes being done. I know of another hospital in the state with the same problem. It’s not always a situation of if only we had more providers who could handle a scope we could just simply do more scopes.

If we are concerned about a screening gap as well then how many nurses do we need doing screening colonoscopies? Probably would need a lot. Does that create a shortage elsewhere or is there a surplus of nurses nationally? Why not have a national movement to do more stool based screening rather than train nurses who only skill will be to do a colonoscopy - essentially taking a skilled worker and making them an unskilled worker, especially if they lost that job or had to move for whatever reason. I wonder if nurses can stop being nurses for years and just go right back to do more typical nursing duties. It might not be that big of a deal

I think if it’s just screening colonoscopy, then anyone can do the procedure with training. Hopefully it’s only with anesthesia support - I don’t know if the study addressed this as I wouldn’t trust a nurse to handle complications.

 

[JP2740]

What?! You need a GI appointment prior to a screening colonoscopy?

In most locations no. There’s usually an “open access” system to refer patients directly for the procedure.