Extended Flexible Sigmoidoscopy—A Family

Medicine Perspective or:Colonoscopy-The Haves and

Have Nots of American Medicine CRC Screening symposium --March 20.2010; Sacramento California

Wm. MacMillan Rodney, M.D., FAAFP, FACEP Chair, Medicos para la FamiliaFamily Medicine Obstetrics

Meharry/Vanderbilt Professor and Chair 2000-2004Professor and Chair, UT-Memphis 1989-1998Residency Director UCLA 1979-84

If Community Based Colonoscopy is an Effective and Lower Cost Tool Which Improves Access,

How do we enable physicians to do it?• Colonoscopy and CRC prevention are innocent

bystanders in a larger conflict of cultures. • Lobby the medical schools and the ACGME to

incentivize training programs. Community care is being transferred to nurse practitioners. There will be a downstream cost to the entire medical profession.

• Improve infrastructure deficiencies in support and equipment? ELIMINATE THE PAIN and complexity.

• Develop and adhere to merit based, specialty neutral credentialing in hospitals and elsewhere.

• Reform medical malpractice insurance.• PAY DOUBLE FOR COMPLIANCE.

AAFP 1994 SURVEY -AVAILABILITY OF TRAINING

HOSPITAL OFFICE PLAN TO ENHANCE THE TRAINING

RIGID SIGMO 21% 27% 13%

FLEX SIGMO 70% 97% 46%

COLONOSCOPY 22% 27% 24%

EGD 18% 13% 34%

Colonoscopy Outcomes and Impact in Family Medicine

• Rodney WM, Beaber RJ, Johnson RA, Quan M. Physician compliance with colorectal cancer screening (1978-1983): The impact of flexible sigmoidoscopy. J Fam Pract 1985; 20:265-269.

• Hopper W, Kyker K, Rodney WM. Colonoscopy by a family physician: a 9-year experience of 1048 procedures. J Fam Pract 1996 43(6):561-566.

• Carr K, Worthington JM, Rodney WM, Gentry S, Sellers A, Sizemore J. Advancing from flexible sigmoidoscopy to colonoscopy in rural family practice: a case report. Tenn Med Assoc J 1998 (Jan); 91(1):21-26.

• . Rodney WM, et al. Enhancing the family medicine curriculum in deliveries and emergency medicine as a way of developing a rural teaching site. Fam Med 1998; 30(10):712-719.

• . Rodney WM, Hahn RG. The impact of the limited generalist (no procedures, no hospital) on the viability of Family Practice Training. J Am Board Fam Pract, May-June 2002;15:191-200.

• Other academic centers with published colonoscopy outcomes: Varma J-Medical College of Georgia; Harper M, Pope B, et al. LSU-Shreveport ; DervinJ. UCSF-Santa Rosa; Pierzchajjlo R, Ackerman J-Medical College Ga; Others

AAFP Scientific Assembly 2004 Orlando, Florida: 21st Year

Primary Care Association For Endoscopy

The Colonoscopy 101 sessions are review for those who have performed many exams and an introduction for those who have performed none. The balance of presentation vs. “hands-on” is difficult. Live human material cannot be presented. Clinical simulationa are used, and there is a test. Additional proctorship occurs in the community.

AAFP 1994 SURVEY –2004: WHAT’S CHANGED-OPINION

HOSPITAL OFFICE PLAN TO ENHANCE THE TRAINING

RIGID SIGMO OBSOLETE OBSOLETE OBSOLETE

FLEX SIGMO AVAILABLE BUT RARELY ACCOUNTABLE

40-60% TRY TO ATTAIN 25 PROCEDURES

DYING OUT IN 50% OF PROGRAMS

COLONOSCOPY 15% 35% 0%

EGD 15% 35% 0%

The Politics of Privileging Emerged as a Major Barrier

• Rodney WM. Health care reform: does primary care mean, “whoever gets there first”? Am Fam Phys 1994; 50(2):297-300.

• Susman J, Rodney WM. Numbers, procedural skills and science: Do the three mix? Am Fam Phys 1994; 49:1591-1592.

• Rodney WM. Keeping family practice whole. Fam Pract Mgmt 1995; 2:11-12.

• . Rodney WM. The dilemma of emerging technologies as required curriculum in primary care. Fam Med 1997; 29:584-5.

• Rodney WM. Should any hospital-based training for family physicians persist? Fam Med 1998; 30:398-399.

• Rodney WM. Will virtual reality simulators end the credentialing arms race in gastrointestinal endoscopy or the need for family physician faculty with endoscopic skills? JABFP 1998; 11(6):492-495.

• . Rodney WM. Flexible sigmoidoscopy: The unkept promise of cancer prevention. Am Fam Phys 1999; 59:270-273.

Extended “Flexible Sigmoidoscopy “was an attempt to appease the Colonoscopy Gods

• Rodney WM. Flexible sigmoidoscopy and the despecialization of endoscopy: an environmental impact report. Cancer 1992; 70S(5):1266-1271. 

• Rodney WM, Dabov G, Orientale E, Reeves WP. Sedation associated with a more complete colonoscopy. J Fam Pract 1993; 36(4):394-400.

• Carr K, Worthington JM, Rodney WM. Advancing from flexible sigmoidoscopy to colonoscopy in rural family practice. J Tenn Med Assoc 1998 (Jan):32-34.

• Rodney WM. Flexible sigmoidoscopy: The unkept promise of cancer prevention. Am Fam Phys 1999; 59:270-273. 

• Rodney WM. Will virtual reality simulators end the credentialing arms race in gastrointestinal endoscopy or the need for family physician faculty with endoscopic skills? JABFP 1998; 11(6):492-495.

• Rodney WM, Deutchman ME, Hahn RG. Advanced Procedures in Family Medicine: The Cutting Edge or the Lunatic Fringe? J Fam Pract 2004; 53:209-212.

Generalist Physicians Became PCP’s-Demographics

Over 900,000 physicians in USA.Fewer than 150,000 general internists/family

physicians.Fewer than 75,000 have access to equipment for

gastrointestinal [GI] endoscopy.Training programs are not encouraged to teach

basic endoscopy which is the gateway to early diagnosis and prevention.

Access for patients is affected, but revenues increase for the hospital. Misaligned incentives.

Does Primary care Mean Whoever Gets There First?

• Socrates said that, “…to use words wrongly corrupts the soul” and “Wisdom begins with good definitions”.

• Family Medicine was designed to provide high quality continuing care unrestricted by age, gender, organ system, and location.

• The unkept promise of cancer prevention through colonoscopy is the visible tip of a larger iceberg calling for reform.

Community Demographics

Disparities in access exist among disadvantaged groups. Screening compliance persists at less than 50% of recommended

guidelines. Patients at higher risk remain unexamined at prevalence levels

ranging from 20% to 45%. Decentralized systems are more effective than hospital-based

programs. Regulations, reimbursement, and malpractice coverage do not

encourage primary care.Taylor V, Lessier D, Mertens K, et al. JNMA 2003. 95:806-812

VALIDITY AND CONFOUNDERS

• 1. Rodney WM, Richards E, Morrison JD, Ounanian LL. Constraints on the performance of minor surgery by family physicians: Study of a "mock" skin biopsy procedure. Family Practice-An International Journal, 1987; 4:36-40.

• 2. Harper MB, Mayeaux EJ, Pope JB, Goel R. Procedural training in family practice residencies: current status and impact on resident recruitment. JABFP 1995; 8(3):189-194.

• 3. Rodney WM, Hahn RG, [Crown LA-forced to disclaim authorship], Martin J. Enhancing the family medicine curriculum in maternity care (OB) and emergency medicine to establish a rural teaching practice. Fam Med Dec 1998; 30:712-719.

• 4. Rodney WM, Hahn RG. The impact of the limited generalist (no OB, no procedures, no hospital) model on primary care training and practice in a TennCare environment. J Am Board Fam Pract 2002; May-June 15:191-200

• 5.Rodney WM, Hahn RG, Deutchman M. Advanced Procedures in Family Medicine: The Cutting Edge or the Lunatic Fringe? J Fam Pract 2004; 53:209-212.

A Fork in the Road 1972

• The Physician isolated from a medical center will not be able to provide high quality state of the art medical care.

• Technology will continue to assist the physician in the community-based office such that high quality state of the art care will be possible for over 90% of patients who walk in through the door.

Transfer of Technology Projects• Minor Surgery in the Office• ECG-CXR in the Office• Simple Lab in the Office-• Flexible Sigmoidoscopy 1979 – accepted, but died • ENT endoscopy 1984 accepted but rare• Colposcopy/LEEP 1984- accepted• OB-Gyn Ultrasound 1984- acceptance varies• Colonoscopy 1986-contested into near extinction• Computer assisted Video Tools-Free market• Others

If FP Colonoscopy is an Effective Tool Which Could Improve Access and Lower Cost,What’s Preventing

Them from Providing These Services? • Equipment costs range from $10k-$70k• Per colonoscopy reimbursements range from

$300->$1000. Medicaid 2010 < $300• GI endoscopy product line-1997; $90k doing an

avg of 2.4 colons, 2.0 EGD’s, and 1.5 Flex Sigs per week.

• Overhead 1 room, 1staff, 5 hours/week• Groups of single specialty FM or IM more likely

have volume for time share endoscopy in office.

Medicos 2000-2010:Colonoscopy for the Uninsured $ 300

If Community Based Colonoscopy is an Effective and Lower Cost Tool Which Improves Access,

How do we enable physicians to do it?• Colonoscopy and CRC prevention are innocent

bystanders in a larger conflict of cultures. • Lobby the medical schools and the ACGME to

incentivize training programs. Community care is being transferred to nurse practitioners. There will be a downstream cost to the entire medical profession.

• Improve infrastructure deficiencies in support and equipment? ELIMINATE THE PAIN and complexity.

• Develop and adhere to merit based, specialty neutral credentialing in hospitals and elsewhere.

• Reform medical malpractice insurance.• PAY DOUBLE FOR COMPLIANCE.

The Hazards of a Fragmented Health Care System

“The quickest way to starve    the dog is to assign two kids    to feed it.” 

Mary MacMillan Rodney, M.D. 1884-1968

Impact of 1997 Approval f or Medicare to Pay for Colorectal Cancer Screening

Procedures

Despite congressiona l approval or Medicare reimbursement and the subsequent creation of specific service codes, the percentage of beneficiaries

taking advantage of the benefit increased by only 1 % .” Rep. Benjamin Cardin (D.M.D.) introduces the Colon Cancer Screen for Life Act of 2003.

Am Medical News, Apri l 7, 2003, Volume 46 (#1 3 ) , p. 12

Percentage of Adults age 50-64 who had Colorectal Cancer Screening 2005 [FOBT, Flex Sig, colonoscopy];

American Medical News March 8, 2010 p.20

• Hispanics• Uninsured 12 %• Insured 33 %

• Blacks• Uninsured 22 %• Insured 40 %

• White• Uninsured 18 %• Insured 47 %

Family Med Residencies 1980-891. Program # stabilizes at 400 with wide variations in quality and content.

Lightning rod issues include ultrasound, colonoscopy, colposcopy, deliveries, ACLS, ATLS, NALS, and others

2. Family Medicine declines opportunity to merge with Emergency Medicine per the Canadian model. Geriatrics and Sports Medicine CAQ’s emerge.

3. Hospital privilege is a focus for the development of self credentialing departments of family medicine. Specialty neutral reimbursement survives.

4. There is a ten year transition from being FP residents on the internal medicine service to being on the “family medicine hospital service”.

5. FP deliveries and procedures decline under political, academic, and economic pressure. Malpractice insurance becomes an issue.

6. AAFP continues to be major force for retaining the breadth of FP.7. First generation of residency trained graduates emerge as faculty.8. National healthcare cost nears $1 Trillion per year. RBRVS is emerging

and CLIA derails the transfer of lab services to the office.9. The first computers arrive in the office. First hard drive 1984-10Mb.

If FP Colonoscopy is an Effective Tool Which Could Improve Access and Lower Cost,What’s Preventing

Them from Providing These Services? • Is the cost of medical malpractice insurance

prohibitive?-no• Are there inadequate #’s of training programs

and faculty role models?-yes• Are there economic disincentives?-yes• Do hospital bylaws exclude

nongastroenterologists from use of hospital subsidized equipment and staff? Yes

State Volunteer Mutual Insurance Company (SVMIC) Premium Classifications and Rates for the Specialty of Family Practice at the Rate of $1/$3 Million Coverage as of March 1998

and 2002

Family Practice Classification

Description Year One In Practice

1998

Year Five in Practice

1998

Year One in Practice

2002

Year Five in

Practice 2002

NO SURGERY NO OB

NO ORTHO

Includes the in-office repair of lacerations and removal of minor skin lesions, etc.

$938

$5,014

$3,316

$7,753

MINOR SURGERY

LAPAROSCOPE TUBALS

Includes procedures such as prenatal care, assisting in surgery, cast/splint simple, non-displaced fractures, minor GYN procedures such as endometrial biopsy, endoscopic procedures, etc.

$1,403

$7,992

$5,025

$12,444

OBSTETRICS NO MAJOR SURGERY

Includes the above procedures along with uncomplicated obstetrics, no C-sections, no major surgery.

$1,931

$7,992

$6,957

$16,919

MAJOR SURGERY

OBSTETRICS

Includes OB, C-sections, major surgery on own patients, breast biopsy/lumpectomies, and closed reductions of dislocations/displaced fractures

$2,806

$15,984

$10,199

$24,886

SVMIC Premium Classifications and Rates for Family Medicine for $1M/3M Claims Made March

1998 and 2010FM Category 1998 First

year in practice

1998 year 5 in practice

2009 yr 1 in practice

2009 year 5 in practice

No Surgery, no orthopedics, no OB

$ 938 $ 5 014 $ 4 189 $ 9 203

Minor Surg, Simple ortho, Gyn and GI endoscopy , Office analgesia, no OB

$1403 $ 6 007 $ 6 564 $ 15 536

Above plus normal risk vaginal deliveries

$ 1903 $ 7 992 $ 8 811 $ 21 127

Major surgery including Cesareans, appys, hernias

$ 2 806 $ 15 984 $ 12 942 $ 31 067

If FP Colonoscopy is an Effective Tool Which Could Improve Access and Lower Cost,What’s

Preventing FP’s from Providing These Services? • The cost of medical malpractice insurance? No• Are there inadequate #’s of training programs? Yes• Are there fundamental infrastructure deficiencies in

support and equipment? Yes• Is it possible that, as an unintended consequence of the

“limited generalist conundrum”, incentives are not aligned for training generalists? Yes, yes, triple yes

• Are there contested economic issues, and is there political risk? YES

Possibilities for FP Colonoscopy• The Transfer Curve for other technologies predicts an inexorable and

widening gap between the technology literate and the others.• Osteopathic medicine survived by establishing their own medical schools and

hospitals. Family Medicine will not have this opportunity, but unopposed residencies seem to have a major advantage in establishing this curriculum.

• The Luddites lost, but procedurally enriched generalists rarely participate in the academic medical centers’ shaping of DNA for tomorrow’s physicians.

• Colonoscopy training will continue for a minority of residents in 25% of programs where faculty have established specialty neutral credentialing and maintain a desire to perform colonoscopy.

• There will be a substantial role for the National Procedures Institute, the AAFP, psot.com and others as antidotes to the post residency reality of Procedural Helplessness/Apathy.

• As subspecialists abandon the hospital for their own ASC’s, some administrators may seek partnerships with family physicians.

• The future rests with safe, high quality, lower cost colonosocopy in the office.

If Community Based Colonoscopy is an Effective and Lower Cost Tool Which Improves Access,

How do we enable physicians to do it?• Colonoscopy and CRC prevention are innocent

bystanders in a larger conflict of cultures. • Lobby the medical schools and the ACGME to

incentivize training programs. Community care is being transferred to nurse practitioners. There will be a downstream cost to the entire medical profession.

• Improve infrastructure deficiencies in support and equipment? ELIMINATE THE PAIN and complexity.

• Develop and adhere to merit based, specialty neutral credentialing in hospitals and elsewhere.

• Reform medical malpractice insurance.• PAY DOUBLE FOR COMPLIANCE.

Medicos 2000-2010:Colonoscopy for the Uninsured $ 300

STAGED SERIES OF BARRIERS TO FP

• American Society of Gastroenterological Endoscopy[ASGE] – Correctly recognized the economic threat posed by loss of an economic

monopoly and training cartel– 1993 mailed a threatening legal opinion to over 6,000 JCAHO hospitals.– 1994 began to escalate the minimum numbers required for granting of

privileges. [50 to 100 to over 200].– Declared all training outside of GI fellowship and surgery residencies

invalid. FP literature also “invalid”.– Instructed members to gain control of hospital credentialing– Sedation/analgesia alliance with anesthesiology in the hospital.

• The tree of Family Medicine became invisible in a“Forest of Primary Care”; The terminology family doctor was replaced with “Your PCP”.

• Others