Welcome to patients at risk a discussion of the dangers that patients face when physicians are replaced with non physician practitioners. I'm your host and the co author of the book patients at risk the rise of the nurse practitioner and physician assistant in healthcare. Dr. Rebekah Bernard. Increasingly nurse practitioners and physician assistants are being asked to step into the role of
physicians. While surgeons and procedural doctors have been fairly insulated from this phenomenon the tide is starting to turn. Today we're going to explore the phenomenon of NPs and PAs performing colonoscopies, which are screening tests for colon cancer, and also used to evaluate other problems in the intestines. And there is no one better to help us understand the nuances of this procedure than colorectal surgeon. Dr. Amer Alame.
Iti's a pleasure to be here. And thanks, everybody for joining us.
Dr Alame, tell us about yourself and the training that you went through to become a colorectal surgeon.
After med school obviously, I went to residency for general surgery. After finishing general surgery I did fellowship as a colon and rectal surgeon. And that was back in 2012. For the last 10 years, I've been doing what I love best, which is treating colorectal diseases. Obviously, I do 1000s of colonoscopy. It's
me and my partners. We have the colorectal clinic of Michigan here in Michigan and we're home to four colorectal surgeons who are double boarded in general surgery and colorectal surgery
tell us who typically would be the type of person - doctor or otherwise - that would perform a colonoscopy and maybe just briefly what a colonoscopy is in case we have any patient listeners out there.
Yeah, so let's say colon cancer is one of the most easily survivable cancers, it is very avoidable because we have a very effective screening tool, which is a screening colonoscopy, which involves patients under some form of sedation, in some centers there is sort of like what patients call like a twilight. In some centers, they have an anesthesia staff member who is administering some sedation. So they're basically completely asleep, they don't remember it.
But it's a type of flexible endoscopy, where a small flexible scope, maybe like the diameter of like a pinky finger, it's introduced from the anus from the bottom, and guided all the way to the beginning of the colon, which is on the right lower side of the abdomen. And then we inspect the surface of the colon for any kind of abnormalities. So we can not only diagnose problems with it, we can also intervene when we
see these problems. And this is a very important part intervening is really what kind of give you the benefit of surviving colon cancer, because about 30%, as we'll see in articles we're going to look at later, about 30% of these colonoscopy is done for normal screening will have some kind of a polyp or something which is found that would need some kind
of an intervention. And I think that's where expertise plays a major role, let's say I mean, if somebody does 1000 colonoscopies and nothing bad happens to a patient. Is that safe? Sure, it's safe, but it depends how you define safe if let's say, somebody found 10 polyps and somehow didn't remove them. I mean, that's harm being done because that patient has to undergo another colonoscopy afterwards, to remove it by somebody who can do that.
So it so it sounds like there's different aspects that you have to be an expert in. One is of course, knowing who to do the procedure on. Two: how to actually technically perform the procedure. Three, once you get in there, what are you looking - at identifying the problem, and then four, intervening when you see something that you need to
intervene on. So typically, the doctors that perform these procedures are gastroenterologists, colorectal surgeons, maybe in some rural areas, you might have family doctors doing it, but I don't think that's super common. And I don't think it'd be very easy for a non gastro or colorectal surgeon to get credentialed to do colonoscopy is would that be true?
That is very true. Yes, the vast majority like I'd say over 99.99% of these endoscopy is are performed by endoscopists that are specialized in this field, such as like you said, a gastroenterologist who went to medical school for those four years after that they decided okay, I want to do gastroenterology. So they do internal medicine and then they specialize in gastroenterology
after that. And during your years in gastroenterology, we have performed I think a minimum of probably a few 1000 colonoscopies to basically be let loose on the world to basically perform colonoscopy as a gastroenterologist. For a colorectal surgeon like myself after completing Medical School. I'm saying completing medical like nonchalantly because obviously everybody has finished that first before you do any kind of residency as we all
know. So five years of general surgery residents Usually complete a few 100 of these endoscopic procedures. And then colorectal surgeon like myself who specialized after that, or another extra year of fellowship during colorectal surgery, I perform maybe like 600, 700 Extra colonoscopy only during one year. So basically at least over 1000, before touching a patient during colonoscopy single handedly.
Well, you know, it's so interesting because what you're saying is years and years of study, and 1000s of these procedures before you're allowed to practice them independently. But even though it's takes that long for a doctor to supposedly be certified to do colonoscopies, some people got it in their heads that maybe we should let nurse practitioners do colonoscopies. you know, why not? So we're going to examine a study that was published in
2020. And it was actually performed at Johns Hopkins, which is a place that seems to have a real special interest in working with non physician practitioners. We've talked about them with some radiology studies. But in this case, in 2020, they published a study in which they had three nurse practitioners that were specially trained, and they were trained by doing 140 supervised colonoscopies. Is that enough colonoscopies do you think and practice to be allowed to do a colonoscopy on a patient?
The easy answer is definitely no, that is
absolutely inadequate. The detailed answer to that question goes to what I alluded to earlier, if let's say, your mission is only to get a scope, from the anus, to the cecum, and back out, and no damage was done during that journey, and you want to define that as safe, then you have defined safety and medicine in your own world, and you're accepting whatever you want to accept as, like, okay, it was safe, we did 1000, or whatever the number is colonoscopy is we put the scope
from the anus all the way to the cecum. And then we pull it back out. And nothing bad happened to these patients. Um, I'll tell you the flip side to this story. Let's say somebody's grandmother is having this colonoscopy done. And then this non physician provider puts the scope and from the anus all the way to the cecum. And nothing bad has happened. And then they're coming backwards, they find something which number one, may they may not know, does this
need intervention or not. So that's a critical decision that needs to be done, which, obviously 140 scopes, you're not going to see like, everything that needs to be seen. But what's even worse, you find something that somebody who specializes in a procedure can address it right then and there. And you're done basically. So that person's grandmother, the scope exits, basically, and then they're gonna tell Grandma, 'grandma, we did the scope, we
found something. But now you're gonna need a gastroenterologist to come back and address this one' because there are specialized maneuvers like EMRs like endoscopic mucosal resection that can be done, or ESBs, endoscopic submucosal dissection and many other interventions that are in a specialist's armamentarium that you see a problem, you can just fix it right then and there. So if you ask me, 'Did we harm Grandma? Yes, we did. We sure did.' Because a bowel prep for
an elderly person. We see many patients every year, like you know, maybe 10 every year because of when you have 1000s and 1000s of people taking bowel, perhaps you're gonna have a few of these, you know, elderly patients who have taken a bowel prep that and dehydrated, you know, got little woozy because of dehydration and up in the emergency room the day
before of bowel prep. And now we're going to ask her to take the bulk prep again, let's say if if every 100 If it only happens to 10 people, that's still a very high number, because we're screening 1000s and 1000s of people. So every 1000 colonoscopy if only 100 of them or so need to be rescoped- Again, that's crazy. That's like unreal. I was kind of disappointed to see such literature coming out from a center, that we really all regard as physicians as one of the amazing places to get care.
When you have somebody from that center, really flat out saying that or just safe just go ahead and do that. And we should have nurse practitioners doing this because of increasing access and things like that. When the reference is that even higher than John Hopkins is the
American Cancer Society. The use of colorectal cancer screening is influenced by many factors, some of them individual, some of them provider, some of them the health system, some from community factors as well as public policy, but the barriers - and listen to this one - that have been identified by the American Cancer Society - not myself, not Johns Hopkins, not the best center in the in the nation - American Cancer Society identifies the barriers to screening colonoscopy is
include, number one, no usual source of care, like the individual who aren't even go to see a doctor. So this guy does not get a screening colonoscopy. Inadequate insurance coverage, like I want to get a colonoscopy, but I don't have insurance. Number three, lack of provider recommendation not lack of a provider that does it. Lack of a provider recommendation, meaning this person goes to their primary care provider, the primary care provider for one reason or not, there's not
recommended. Logistical factors like transportation, I don't have somebody to take me scheduling, I'm too busy or things like that. And language, you know, like, I can't really understand what's going on. Fear of the procedure hasn't been identified, and lack of knowledge. Notice, none of them include, there's no provider to do the procedure. This is per American Cancer Society.
So in other words, there's a lot of low hanging fruit that could be addressed before you start talking about letting people that aren't properly prepared, do the procedure. And I take your point very well, because I'm a I'm a primary care physician, I take care of a largely uninsured population, I'm very lucky that I can get the fecal immunochemical testing done for just $15. So that's always where I start and an
asymptomatic person. But if I need them to have a colonoscopy, the best price we can get in our community is about 900 to $1,000. So, I mean, it's great out there with time and I actually save up for it. But you know, it's it's a lot for a lot of patients.
Yeah, but um, but even with that, I mean, 900 some dollars is actually amazing to get a colonoscopy out of pocket. And we do have some endoscopy centers around us here in Michigan, we're located in by Metro Detroit in Southeast Michigan, we do have some industry centers that are kind enough to offer cash pay discounts for patients that don't have insurance, like you're saying, to help with
that. But with that said, the percentage of society that should be screened, has been identified as about, you know, 80% is what the American Cancer Society has identified. Michigan, we're at 74%. Currently, Florida is at exactly about 71%. So you guys are
almost there. But like you said, these low lying fruits, you know, there is not a patient that comes into my clinic, that no matter what the problem is, even if they have just belly pain, for whatever reason that I don't ask about a screening colonoscopy, because it's the easiest cancer to survive. It's the easiest cancer to not get and survive and treat really, that's part of also why I love taking care of colon cancer patients because it's a
treatable disease as well. But maybe we're I'm diverging a little bit to say..
you are but but but not in a bad way. Because when I was in my residency, actually, actually, I was an intern, one of my very first patients that are admitted to the hospital came in with abdominal pain, and she had an obstruction from colon cancer. She was in her 60s, and she had not had a colonoscopy. I don't know remember why. But unfortunately, it was so advanced, and she did end up passing away from it. And she was just the most darling,
wonderful woman. And she suffered so much with pain and different symptoms. And I'll never forget it. And actually, it's one of the reasons why I'm just like you I'm extremely passionate about talking to patients about colon cancer screening, because no one needs to go through that. That's true. So thank you for what you do.
It's so important. Well, let's we'll jump back to the study because we first of all, we said that these nurse practitioners had practiced 140 times with a supervising physician, and they were allowed to perform colonoscopies on patients. There were 1425 colonoscopies completed during the study period. But one thing that's interesting is that 400 of the colonoscopies were excluded from
the study. So the nurse practitioners did them, but they weren't included in the study data, because the patients either did not have a good enough prep, so they didn't have clean enough bowels, or it turned out that they actually had a disease process like inflammatory bowel disease. And so the physician that was supervising or I guess around, jumped in to help. So what are your thoughts about excluding those factors in this study?
That's the worst thing you can do when you want to evaluate if somebody can do something or not. I mean, are you doing it or you need somebody always on backup? Let's say the conclusion from the study is it is safe for nurse practitioners to do it. As long as a gastroenterologist is on backup standing next to them. But it's terrible.
That doesn't actually end up saving the system doesn't know anything money, because they were talking about this as a cost savings of course of the patients that had the procedure done. There were 1012 subjects. I don't know how they ended up doing 1400 colonoscopies on 1000 People I don't think they got into that. The mean age was 56 years, they were 5050 men and women. But what was interesting is that 74% of the patients were African American
I saw that - it was very weird. I've actually never read a study that had such a severe skew in demographics. But this is what happens when you have retrospective studies. Like when you have a retrospective study, you know, the patients are not randomized, you know, does this person get a nurse practitioner or physician to analyze this, that's what you get you get study where data is just so skewed. But even with that, the study does not conclude that it is safe to do this though
we'll get into the social justice question, because I will tell you that there was a lot of outrage at the disproportionate number of Black patients who received this sort of experimental evaluation. But before we get into that, let's just talk about some of the parameters that they looked at. They evaluated cecal intubation and said it was successful in 98.5% of patients. What is cecal intubation and what does that matter?
Cecal intubation is a measure of you were able to put the scope from the beginning to the end of the colon, so from the anus all the way to the beginning. And that is a quality measure that you should have cecal intubation. I mean, any fellow of gastroenterology who has not finished fellowship even can probably integrate see them like 99% of the time, almost every physician has like over 99% cecal intubation.
(So you woudn't) be impressed by this number? It's like well, yeah, they're supposed to get to the cecum.
Yeah, you're supposed exactly you're supposed to do this. These are like, the things that you're supposed to do. 101.
And then they said that the mean withdrawal time was 18.9 minutes. What does that parameter mean? withdrawal time.
Yeah. So withdrawal time, it's the time it takes an endoscopist once they reach the cecum, which is the beginning of the colon, and they start withdrawing the scope back through the colon, how much time it takes them to examine this, the minimum withdrawal time of eight minutes. It's what's recommended to say that somebody like took their time looking on their way back.
Yeah, like, obviously, you don't want to drag it out, because people are under sedation and things like that, but you need to make sure that you get a good enough look. So they use that parameter. And then they said that the mean adenoma detection rate was 35.6%. Tell our audience what is an adenoma? And what are your thoughts on this detection rate?
So an adenoma is like I mentioned earlier, when we're doing a colonoscopy, when we find aberrations or abnormalities on the surface of the colonic wall, it's usually looks like like a little wart, let's say a little polyp or little outgrowth on the wall.
That's when an endoscopist puts a little biopsy forceps or a little lasso around it and snips it off, and then we send it to the pathologist, and that is really the life saving part of a colonoscopy, because once you have eliminated the adenoma, you avoid what comes next which is carcinoma, and which is what is known as colon cancer. So we do the colonoscopy to remove adenoma. And when we remove adenoma, you don't get carcinoma or cancer and adenoma detection rate of 35.6% is regarded as a
good enough detection rate. But check this one out. So let's say if this NP is supervised by gastroenterologist, next to him or her obviously, and an adenoma is found. Did the gastroenterologist have to intervene in any way to remove that adenoma or not, or assist in any way? This is what you know, retrospective studies in this situation, I really have no power to make decisions over this right
and you know, some people question so when you look at adenoma is there's also some adenomas that are have benign characteristics and are less likely to progress to carcinoma and some that are riskier.
It's very important to know, really the whole picture to decide like what was removed? Because like I said earlier, sometimes you find an adenoma or a polyp that is more flat. And then does this endoscopist the non physician and endoscopist say,' Well, this is beyond what I can do. I'm gonna I'm gonna have the gastroenterologist do a scope again next week and remove this,' but that's a shame. Really
yes, at least 400 or 500 people had another colonoscopy done because there were 1000 people in the study and there were 1400 colonoscopy is done, but they don't give us a lot of detail that I could see on that.
I can tell I can tell you roughly I don't have the exact number of my practice, but If let's say do 1000 colonoscopy is the number of patients that have to come back and get another colonoscopy done, you can probably count on your fingers like this. And that's it. It's not 400 out of 1000. That's right. That's a pretty huge percentage, the larger number, actually,
now, they did say that there were no adverse events, including thank God, colon perforation, or delayed post polypectomy bleeding. But how frequent would those events be and is 1400 colonoscopies is enough to see those kinds of outcomes?
Let me just say, this study chooses the safest of safe patients that you're doing an endoscopy, and you're doing this in a screening colonoscopy, like somebody turned 45, or 50. And then they have zero problems, basically, and it goes to you or the other primary care physician, and the primary care physician says, Congratulations, you need a colonoscopy, you just you just graduated. Happy, happy birthday, here's your referral
for a colonoscopy. So that from 15,000 patients, they're estimating, maybe one person would have a perforation or
problem like that. This is not a patient who say has a large mass that was referred to me, because there's a large mass like, can you remove this with a colonoscopy, and who I sit in the office and tell them, we're going to try and remove it with the scope, there's a very high risk that because the wall is so thin, that something may happen, I may have to intervene surgically and fix it and
whatnot. This is we're not talking about those patients, we're talking about the patients that basically they're minding their own business going on about their day, they go to have a normal checkup, and then you need a colonoscopy as part of your normal healthy screening, they basically maybe just take a blood pressure medication, maybe they take no medication, and they still need a colonoscopy. 15,000 of those people is the number to accept like, okay, one person got a perforation.
And this is nothing for them to congratulate themselves over, you do not expect a perforation you do not expect post polypectomy bleeding, especially in this patient population.
In 1000 screening colonoscopy is if one person got perforated, you would be over 10 times the acceptable rate. So it's good that none of them are thank God for that. When you start looking at post polypectomy bleeding, now whenever we remove a polyp, we obviously shave it off the wall of the colon by one instrument or another that I mentioned earlier, it's either a little biopsy forceps like little tweezers, we grab it and pluck it off, or a little lasso that we put around it and we tighten
the lasso. So it kind of cuts it at its surface, the bigger the palette, the higher the risk of something happening afterwards, the bigger the palette, it would be basically kind of inferred from what they've done, that they've had the gastroenterologist basically do
it. So if they're dealing with the low lying fruit also, which is all you know, there's a small pilot, let me just put this off, the chances of having a post pulpectomy bleed from those polypectomy is, is extremely, extremely, extremely low and unusual. Actually, I've removed 1000s and 1000s of these polyps. The only times that I've seen posts are actively bleeding is when we've had like large like two and a half centimeters like
an inch in size, right? We're denuding parts of the wall basically to help avoid surgery.
These patients basically, the chances of the patient having postpartum ectomy bleeding is higher, I'll be at it's still low, because we do ensure that everything is nice and hemostatic the bleeding is soft, you know, at the time of the procedure, but post powerfactory So after the pulpectomy has been removed, say somebody's home in a day or two they start having bleeding is extremely low and unusual in very small polyps.
Well, we've talked about some of the major limitations of this study. But let me read to you the conclusions of the study authors. It says three fellowship trained NPs in colonoscopy.... I gotta stop right there.
I was gonna stop you before you stop yourself. But go ahead. Yeah.
They call this a fellowship. The fellowship for physicians is incredibly rigorous. It is this doing 140 colonoscopies is not a fellowship.
I don't know what to I don't want to tell you about that. I was gonna say like, the number 140. Who came up with that number?
That's the problem is a lack of standardization. We always talk about this and this is a perfect example. So their conclusion was that three fellowship trained NPs in colonoscopies satisfied the quality indicators proposed by the task forces from GI demonstrate that adequately trained NPs can perform colonoscopies safely and effectively. Is that a fair conclusion?
If you want to define safety by the patient not dying during the endoscopy, then you've really defined safety in some world that you decide to live in. Safety, in my opinion, is a situation where I would have my grandma or family member, go and get their endoscopy and I know they're gonna get care which is supposed to be delivered. If let's say, I send my family member to Johns Hopkins. Now, it seems, and a non physician provider does it and as like, four out of 10 needs to have a redo
colonoscopy. What a shame. Absolutely, is that if that's safety, then holy schnikeys Basically, what are we doing?
I always take offense to their extrapolations because they'll take these extremely narrow, limited circumstances. And they'll make a conclusion that's puts out a headline like nurse practitioners can perform colonoscopies as well as a gastroenterologist.
I think it's quite crazy to basically accept any of this study as basically solid evidence in terms of whether the structure of the study whether the conclusions from the study, and many other things, if you want to compare apples to apples, then you go ahead and see the difference between how many patients needed even a simple measure of how many patients needed a repeat colonoscopy from ones done by a gastroenterologist or a colorectal surgeon or any one who is currently the standard of
care and a non physician provider. If that number is the same, and the same interventions are done. And the same, everything is equal the same. I can argue in some way that that is a good conclusion. But for that to happen, we all know, it's, it's impossible for that to be done. And even if it is done, there's no way that it will be the same. Right? It's impossible, basically.
Well, we've really just begun to scratch the surface of this article, especially when it comes to the social justice angle. So we're going to conclude our podcast part one, and come back and join us at our next podcast where we will continue this discussion with Dr. Amer Alame. If you'd like to learn more about this topic, I encourage you to get the book patients at risk, the rise of the nurse practitioner and physician assistant in health care. It's available at Amazon and Barnes and noble.com.
And if you're a physician and you'd like to learn more about getting involved in advocating for physician led care, then please join our group. It's called physicians for patient protection. Our website is physicians for patient protection.org Thanks so much, and we'll see you on the next podcast.