Indeed, the local malpractice climate had worsened since my colleague was credentialed a few years before. At that time an American endoscopic society had published that 50 documented procedures was adequate to demonstrate proficiency. Several years later this was raised to 100 with no explanation given. At last look, the numbers have disappeared, replaced by the phrase “to the satisfaction of the instructor.” The AAFP recognized the importance of having established appropriate credentialing criteria for family physicians doing screening colonoscopies, but offered no practical solution to assist in hospital privileges, and no suggestion about how to find one.
Despite my several requests, including a letter from an attorney, I never received direct communication from the board specifying what they would require for credentialing, only that it had to be training by someone with an unspecified form of academic attachment. I found myself with no announced guidelines to follow and the prospect that any solution I may pursue could ultimately meet board rejection with no explanation.
The search ensued for a training opportunity. Month after month, I spent hours each week on the phone, calling every conceivable program, person, and location that could possibly offer assistance in what I came to realize was a unique situation. Residencies were sympathetic, but could not help. Even if they offered training, their first responsibility was to their residents. One faculty member even offered to travel to me if arrangements could be worked out. Several VA medical centers took the occasion of my inquiries to ban any endoscopic training in their facilities unless formally part of a GI fellowship program. These decisions were apologetically conveyed to me by their sympathetic gastroenterologists. Other gastroenterologists, however, abruptly hung up on me, occasionally after a few choice words.
At long last, with the help of Dr Jeffrey Borkan at the Brown Family Medicine residency in Pawtucket, Rhode Island, a workable arrangement fell into place. After another 3 months I had 50 procedures documented under acceptable preceptorship and I was granted privileges to perform screening colonoscopies this past March.
My first official “solo” colonoscopy was not one of my patients, but a local surgeon who asked to volunteer. Since March I have been doing at least 3 a week and rare is a week without the discovery of some pathology.
Has it been worth it? Yes!
My rapport with patients is invigorating and I feel a renewed sense of being productive for their benefit. Our endoscopy staff supported me throughout. I enjoy performing each procedure. I also feel very grateful to the many kind souls who offered help or encouragement during what was a very long journey.
The opportunity for primary care physicians to provide colonoscopy services remains a hot turf war in many areas of the country. Just recently, as reported in the AAFP News Now, the American College of Gastroenterology has sent mailings to hospital administrators, warning them of “potential litigation exposure” if allowing non-GI personnel to perform endoscopy.
The success of an individual physician in gaining privileges is certainly directly dependent on the opportunity to receive appropriate training; but also, unfortunately, with more universally established standards, it will continue to remain dependent on the local medico-political climate in their medical community.
CORRESPONDENCE
Dr Raiford is on the community faculty in the Department of Family Medicine, Brown Medical School, who practices in northern Connecticut. E-mail: praiford@pol.net