Extended Flexible Sigmoidoscopy

1
Extended Flexible SigmoidoscopyA Family Medicine
Perspective orColonoscopy-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 Familia
• Family Medicine Obstetrics
• Meharry/Vanderbilt Professor and Chair
  2000-2004
• Professor and Chair, UT-Memphis 1989-1998
• Residency Director UCLA 1979-84

2
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.

3
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
4
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 20265-269.
• 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 200215191-200.
• 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

5
AAFP Scientific Assembly 2004 Orlando, Florida
21st YearPrimary 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.

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AAFP 1994 SURVEY 2004 WHATS 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
7
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 491591-1592.
• Rodney WM. Keeping family practice whole. Fam
  Pract Mgmt 1995 211-12.
• . Rodney WM. The dilemma of emerging
  technologies as required curriculum in primary
  care. Fam Med 1997 29584-5.
• Rodney WM. Should any hospital-based training
  for family physicians persist? Fam Med 1998
  30398-399.
• 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
  59270-273.

8
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
  59270-273. 
• 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
  53209-212.

9
Generalist Physicians Became PCPs-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.

10
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.

11
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.
  95806-812

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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 436-40.
• 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 30712-719.
• 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 15191-200
• 5.Rodney WM, Hahn RG, Deutchman M. Advanced
  Procedures in Family Medicine The Cutting Edge
  or the Lunatic Fringe? J Fam Pract 2004
  53209-212.

13
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.

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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

16
If FP Colonoscopy is an Effective Tool Which
Could Improve Access and Lower Cost,Whats
Preventing Them from Providing These Services?

• Equipment costs range from 10k-70k
• Per colonoscopy reimbursements range from
  300-gt1000. Medicaid 2010 lt 300
• GI endoscopy product line-1997 90k doing an avg
  of 2.4 colons, 2.0 EGDs, 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.

17
Medicos 2000-2010Colonoscopy for the Uninsured
300
18
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.

19
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

20
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

21
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

22
Family Med Residencies 1980-89

• 1. 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 CAQs
  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.

23
If FP Colonoscopy is an Effective Tool Which
Could Improve Access and Lower Cost,Whats
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

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SVMIC Premium Classifications and Rates for
Family Medicine for 1M/3M Claims Made March 1998
and 2010
FM 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
26
If FP Colonoscopy is an Effective Tool Which
Could Improve Access and Lower Cost,Whats
Preventing FPs 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

27
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 tomorrows
  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 ASCs, some administrators may seek
  partnerships with family physicians.
• The future rests with safe, high quality, lower
  cost colonosocopy in the office.

28
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.

29
Medicos 2000-2010Colonoscopy for the Uninsured
300
30
STAGED SERIES OF BARRIERS TO FP

• American Society of Gastroenterological
  EndoscopyASGE
• 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
  aForest of Primary Care The terminology
  family doctor was replaced with Your PCP.
• Others