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 and health care, Dr. Rebekah Bernard. Today we're going to explore the phenomenon of NPs and PAs performing colonoscopies, and there is no one better to help us understand the nuances of this procedure than colorectal surgeon. Dr. Amer Alame
A pleasure to be here,
Where we left off, we were talking about the study at Johns Hopkins of nurse practitioners performing colonoscopies. And one of the issues with this study that a lot of people got upset about is that there were concerns that maybe there was some social injustice going on here, because about 75% of the patients that were enrolled in the study were African American. Now, the argument was that the Baltimore area does have a large African
American population. However, when they looked at the patients that are treated in the Hopkins hospital system, only 25 to 31% of patients were African American. So this was disproportionate from their usual practice. So Dr. Alame, do you have any thoughts on when you see those kind of numbers? Does that cause you any concerns?
Yes. So in any study, when you have such a huge discrepancy in demographics, you're really questioning like, number one, how are these patients selected? And number two, when you see this, you immediately question like patient groups that are sub selected for whatever reason, like why why these patients? Why is it skewed so severely like that? Do non Blacks have access to a gastroenterologist than a Black patient? They, they would not give them access to a
gastroenterologist. These are things that randomization in studies takes care of automatically when you randomize. And obviously, we know that this study was retrospective in nature, it's true that the Baltimore area does have a higher demographic of African American in fact, demographics in Baltimore has 62.3%, Black or African American 29.7%, White, Indian 0.3 and Asian 2.5. But even with that, their study has more, right? By a significant number. It's not like by you know, like, a
smaller number. Significantly more African Americans are selected in the study. So it behooves us to ask this author why.
And it's especially important because African American patients are disproportionately affected by colon cancer. In fact, they're 20% more likely to get colon cancer than white people, they're 40% more likely to die from colon cancer. So would you say that that's a another particular issue?
Correct. And unfortunately, the statistics you see you mentioned are accurate. And it goes to many reasons access to care, and many other factors that unfortunately, cause a higher mortality with African Americans as it relates to other demographics.
So as I mentioned, the this disproportionate number of black patients did create a bit of a stir on social media. But what also happened was that a group of colorectal surgeons actually published a letter to and it was in Endoscopy International Open. And they pointed out that perhaps this study is contributing to a two tiered
system. And they question whether or not there was targeting of marginalized patients, and really called out the study they said, you know, we know you try, you mean well, but this has a lot of unintended consequences. And it's really not the way we're supposed to do things.
That's exactly what I mentioned earlier, that a White patient got a gastroenterologist and you've basically, whether intentionally or not, still makes it bad, that you've basically selected all these African American patients to be treated by a non physician basically, not basically truly like by not so they were treated by not a doctor, and you're accepting that as, oh, you know, nothing bad happened to them.
Well, a 400 of them need to have anesthesia again, or sedation again, I would beg to beg to differ like No, something bad did happen, because now they need to have sedation again, they take their bowel prep again. And that is not I'd like something to be taken mildly. We're having a hard time just having patients take their bowel prep and get the screening colonoscopy once, right? Do it twice? Good luck with that one- that's not happening.
In response to the criticism, Dr. Kaloo, he was one of the main investigators. He said, Well, this can't have been a racism issue, because look at me, and pointing out that he's actually black. He's from, I think Trinidad. But that doesn't matter because implicit bias can occur in any of us no matter what.
So that's what I was saying. It may not have been intentional, at least we hope it's not intentional. But even if it's not intentional, doesn't make it right. Doesn't make the study, right. If he's saying, Oh, I'm from Trinidad, he should tell us who did his colonoscopy if he's over 45.
That's only I always say like all the politicians that vote for full practice authority. I'd like them to initiate and continue their care with nurse practitioners and PAs, if that's good enough for everyone, it should be good enough for them too
I would guess that, even if he says, sure, I wouldn't mind to have a non physician do my endoscopy if they're capable. But we're going to tell them, there is no gastroenterologist on standby during that procedure. And let's see then what the attitude would be and I'm sure it will be different. I have a feeling it would be. Yeah, because if you're going to tell me that it's okay for non physicians to
do endoscopy. As long as there's a gastroenterologist within an earshot basically, that can be dragged into the room, we did not solve any problem with this one, you still have somebody else who, whose time is being consumed, you did not save anything. Basically, you've just subjected patients to more endoscopies, more sedation, less specialized care, and so on and so forth. So I may sound very passionate about the subject because I really am, I deal with colon cancer day in and day out,
that's my life. Basically, I deal with it day in day out, I see how easily the problem can be fixed. And when it's not dealt with properly, what kind of ramifications it can have. The American Cancer Society says if you want to help these patients, for a social worker, help them get insurance for a primary care physician, tell them to get a colonoscopy, promote them, encourage them to
do it, educate them. If there's a language barrier, translate, have somebody translate for them break that barrier, get them to get a colonoscopy by a gastroenterologist or surgeon like myself, or anybody who already does it as a standard of care. Why are we trying to create another tear of care? And then we're trying to prove that that tear is in some way, even acceptable to have and, you know, that's just, it's just disturbing for me to even have to deal with reading a study
like this. And then I'm like, why are we even doing this? You know, like, this is not something you do if you just direct your energy. If you have these non physician providers, advise patients to get their colonoscopies done, you've probably achieved more good than any of this.
Absolutely. Well, you know, you do wonder if it's not about promoting an agenda, rather than actually improving care. And I know that you hate to read these studies, but I'm gonna give you another one. And it's a 2020 study by the Journal of the Academy, American Academy of Physician Assistants. And the summary was pas performed colonoscopies as well as gastroenterologist is, again, that blanket statement.
And they looked at screening colonoscopies for 597 out of 743 consecutive patients over about a year period, they excluded patients that had an advanced risk of colorectal cancer, those who exhibited symptoms or had a family history of intestinal cancer, and those who did not have an adequate bowel prep, is that important that those factors were excluded.
So again, goes to the what we mentioned before, if you have a problem, I can't take care of you. If you don't have a problem, I'll try to take care of you. But then many times I will not be able to take care of you. I don't understand what kind of logic comes out of this. But again, if you want to say per what they've said, a trained pa provider can perform it by the same efficacy as a gastroenterologist, you have automatically negated that result by saying we cannot do it
for this person. We cannot do it for this person. We cannot do it for this person. So you're automatically Creating, like, Okay, if we have a feeling that things may be okay, we will try and give you a non physician provider. But if we have any hint of something could be arise, something weird could be going on. Better give it to somebody who knows what they're doing. A patient would say, let's say I'm the patient, I'll be like, You know what, don't just give me that person no matter what
Give me the person that deal with whatever they find. I don't want to do this twice. It makes no sense.
Give me the person who knows what they're doing.
Yeah, I think that's a fair thing to ask for. What my favorite part of this study is that remember, I told you that their summary was that PAs could perform as well as gastroenterologist. But they excluded from the study instances in which the PA required assistance. So they can do as well except when they can't
Yeah. So So basically, it's all good until it's not
But how do you get a headline saying one thing and basically, the study says the exact opposite? Because they don't even tell us how many they just say that they exclude it? Well, it must be. Let's see, they analyze 597 out of 743. So I'm guessing maybe you know that 150 or so patients make required assistance? I don't know. They don't really tell us.
If, let's say the hostesses on a plane, the sword says we're able to land the plane 100 times safely. But 1000 other times where the pilot had to intervene, so they don't crash into the ground. But they landed it 100 times. And they didn't need assistance in those 100 times, so they can perform it just the same as another as the pilot themselves. So I got news for whoever wrote that study, if they were able to perform something adequately until they were unable to do it
adequately. And you're only saying, well, they were able to do it adequately this many times. That in my not just my opinion, really medically, is severely unacceptable. You cannot say or so and so did it safely, except when they needed somebody to help out because the situation was about to be unsafe.
it's so interesting, and I definitely feel like these studies are being done to promote an agenda of advancing nonphysician practice, especially considering that a study was published in 2015, called nonphysician endoscoposts, a systematic review. So in 2015, comprehensive evaluation of studies showed that every study that's ever been done evaluating nonphysician endoscopists were
not done well. There were major methodological limitations, including a lack of randomization, a lack of control, but ultimately what they found even despite all that, that the nurse and das Kapus were less cost effective, because patients needed to have another procedure or see a specialist again, or see another doctor again. And that's exactly what you're saying.
I'm gonna tell you something about NPs in in the field of gastroenterology. Currently, I'm Chief of Staff at one of the hospitals here in Metro Detroit. I have been in an academic setting for over 10 years and I have seen section of gastroenterology have nurse practitioners for the past 10 years. Many of them have been with the gastroenterology team for over 10 years. They have seen what our gastroenterologist do day in day out during endoscopy out of endoscopy and
things like that. The other day before our talk here. I actually asked one of them. I said, you know I said her name and I'm like, what if Dr. So and So, tells you he wants you to stand by him and observe him doing the endoscopy which you've done over 100 or 1000 times now, during your during your last 10-15 years because she's watched him do the endoscopy while she's talking to him about patients or
whatnot. And then he wants you to do 140 endoscopy is by yourself, he will stand next to you if you need him, he will intervene he will do whatever and then we want you to start screening patients. She laughed
and she's like, No thanks. There is not enough money or anything that would make me do this endoscopy is because these patients she knows these patients deserve Dr. so and so or Dr. So doing these endoscopy is because she sees what an endoscopy fully entails not only reaching the cecum and pulling
the scope back. You have to identify something When you see it, do you have to biopsy that or do you not have to biopsy that if it does not need a biopsy, and you biopsied it, and the biopsy comes back benign? Guess what I like or some let's say somebody sees a lipoma, which is seen during an endoscopy, me and my exams routinely, it looks like a little hump. It's nice and smooth, many gastroenterologists will look at it because they're like, Well, I don't touch it. And I would see it that way,
lipoma, don't touch it. But if let's say an nonphysician, says, I'm not so sure. Let me biopsy it; you biopsied it, number one, you did an unnecessary intervention. Number two, the patient's going to pay for that pathologist to look at that normal pathology. And number three, since they're talking about post polypectomy, bleeding and whatnot, you're doing procedures, maybe one of them's going to have some kind of issue situation, that you really don't have to subject somebody for
that. So not only you need to know, if you have to do something, you also have to know when you don't have to do something. And when you have to do something, you have to be capable of doing something about it, not just like, oh, this is like the basic elementary thing?
Sure, then I'll do it. If it's not basic elementary, just just like what you saw in this last study, which actually I've read with the with the PAs are doing the endoscopy is a lot of them needed to have repeat endoscopy is and that actually skyrocketed the cost of care for them. Guess who's paying for that? Us?
That's right, the patient or the taxpayer
in addition to the patient, I'm paying for it, you're paying for it, the patient is ultimately paying the biggest price for it because they're being subjected to another procedure. And who knows, really, when is there an anesthesia complication or something like that, although it's very safe, but you just crank up higher and higher numbers for no reason. You're really asking for it. That's, that's plain and simple.
There's really not a Choosing Wisely, you know, we're always being told, choose wisely. And certainly this is would not be. And my guess is that the nurse, you talk to me, I've seen in all these years, a few bad things happen. You know, it happens, it's, again, it's very safe. But especially with patients that have other medical conditions or on medicines or have, you know, different reasons, they can have a perforation, they can have bleeding, this does happen.
Correct. But it doesn't even have to be some crazy complication happening. It could just be some finding that needs expertise, intervention, so that you don't need to have something bad happen for the patient. In, for medically, something too bad have happened.
If you put a scope in and out of grandma, and find a polyp that you could not remove, but somebody else could have removed, you have actually harmed Grandma, you know, like, now she has to take the prep again, she has to see a gastroenterologist or a surgeon to remove it. And this and this and that. If people are saying, well, nothing bad happened, this must be safe. It's the same as me telling you last night, I got home and I didn't get in a car accident. I must be a safe
driver. But then I tell you, it was three in the morning. I was drunk and I was driving 100 miles an hour. But I made it home but I wasn't in a car accident. I must be a safe driver. No, you are not. I we put the scope in to the cecum. And we pulled it back. No perforations, our metrics were okay. We must be safe endoscopists; No, you're not.
Yeah, that's a logical flaw. So I guess what you're saying then is that there was a really good reason for you to spend all that time in school and all that training, it does make a difference.
It not only makes a difference, it saves lives and it reduces complications. It is really how care should be delivered. Point blank. There is no other way of saying it. If somebody says, Well, I'm African American, I would never discriminate against my demographic, then you know what, if you want to live by it, then you should go have a non physician provider, do endoscopy for you not have an endoscopy list or not have a physician on standby during that endoscopy because you're saying it's the
same. That's what you want to live by them live by what you preach, basically.
Well, you know, it's so funny because Governor Schwarzenegger in California and President Clinton both advocated for nurse anesthetist to practice independently, but when they had surgery, they had a physician anesthesiologist, and I think your point is excellent. If someone is promoting non physician practitioner practice, then Get there, get your care from it. I mean, it only makes sense. But I have a feeling we're not going to see that happen.
I'll bet you anything, you're not going to see somebody who is a physician advocating for the studies that you've read, getting their care whether it's endoscopy, or otherwise, by someone who's not a physician. It's as simple as that if basically put your money where your mouth is, if you're saying to say the least, I mean, they have easily access to 1000s and 1000s of these residents that what a shame that they are not even allowed to practice,
even in the same capacity. You see, I'm getting dragged down the rabbit hole here. I don't know what to tell you about this. But like if somebody finishes, at least more than twice the training, and I'm saying this, like very flat out, just say that I'm not even close, in an estimation, at least twice as much training as an NP that closes NP or anything, why can't you at least have them practice? At least in that capacity? What a shame.
If that's not considered safe, then how can this be? And I agree, you know, we have all these unmatched graduates that are ready to learn how to be doctors, they're so close, they just need to do that final stage. And there are not enough programs. We also have tons of international graduates coming from abroad, who many of them are already skilled physicians
in their country. And we could certainly make it easier for them to practice there are lots of different solutions that we could take, if we were invested in it.
Many of them actually are very close from the these these subsets that you're mentioning, whether unmatched or graduated from another country, one of my best friends as a hospitalist. He was a cardiologist in France. He came in here to be an he's just an internist. Basically, not just an internist. He's not a cardiologist is what I should say. When my family members are in the hospital. I asked him to take care of them. He graduated out of the country, but I trust
him. So basically, with your family, so that says, it's it's just unreal. What even exacerbates that problem is you have these so called non physician residencies, and non physician and fellowships that what you've seen mentioned here, why not open more physician residences and physician fellowships, and fix your problem, like properly? Basically,
I agree, why reinvent the wheel? And why dumb it down? And I mean, the only answer to me is politics doesn't make sense. And I think in the long run, it really does not save money, it's going to cost money. And seems like there are very simple solutions if anyone out there is listening. So thank you so much, Dr. Alame. Do you have any other things you would like to share with our audience before we close out,
Get your screening colonoscopies, everybody, Dr Alame for you
I love it, and we will definitely get that message out.
Pleasure. Thank you.
Thank you so so much. 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 healthcare. It's available at Amazon and at 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.