Issue 48 / 14 December 2015

IF you refer a patient for an endoscopy at Logan Hospital in Queensland or the Austin Hospital in Victoria, a nurse may perform the procedure. 
 
Nurses have been performing colonoscopies, flexible sigmoidoscopies and upper gastrointestinal endoscopies in Victoria since 2013 and in Queensland since 2014, and both states have recently announced expansions of these programs. 
 
In Queensland, 50 nurses have already started graduate certificate or masters programs in endoscopy.
 
We have concerns about the rapid rate at which the program has been rolled out. Questions remain unanswered regarding the need for nurse endoscopy in Australia — whether nurse endoscopy is cost-effective and whether the expansion of nurse endoscopy services will adversely impact training for junior doctors. 
 
Earlier this year, the Gastroenterological Society of Australia (GESA) released a position statement calling for no additional resources to be committed to nurse endoscopy unless and until a complete review of outcomes of existing programs has been conducted. 
 
GESA says that there is no shortage of medically trained endoscopists in Australia and that the factors limiting the provision of endoscopy in Australia relate more to use of endoscopy services, not a lack of endoscopists. 
 
This position statement preceded publication of a systematic review of 26 studies of nurse endoscopy by Australian researchers.
 
The review found that nurse endoscopists were less cost-effective at 1 year when compared with physicians, due largely to an increased need for subsequent endoscopies, specialist follow-up and primary care consultations. A cost-effectiveness study of nurse endoscopy in the UK in 2009 made similar findings.
 
In Australia there have been anecdotal reports of surgical and gastroenterology registrars having their access to endoscopy impeded at sites where nurse endoscopists are training or working. Given that this is a core competency for registrars training in these specialties, this situation is unacceptable. 
 
Trainees are aware that procedural competence is directly correlated with procedural experience, and access to procedural time is essential. 
 
In a recent survey of 700 medical endoscopists and 300 doctors training in gastrointestinal endoscopy, only 30% and 21%, respectively, supported a role for nurses performing endoscopy. Until further evaluation of these Australian pilot programs is completed, it is unlikely support from the profession for this model will shift.
 
It is incumbent on the medical profession to ensure patient care standards and medical training standards are not compromised. 
 
This is not a matter of opposition to an expanded scope of practice for nurses in certain situations. Nor is it an accusation that properly trained nurses cannot perform endoscopy safely in supervised metropolitan settings. This safety has been demonstrated in the literature. 
 
The pertinent question here is whether nurse endoscopy should be expanded without full review of outcomes of existing programs, when there is limited support from the profession, uncertainty about cost-effectiveness and lack of safeguards ensuring adequate training opportunities for gastroenterology and colorectal surgery registrars. 
 
Alternative options to boost endoscopy services across Australia have been proposed by the AMA Queensland
 
Rather than expand nurse endoscopy, these funds could be used to increase the number of gastroenterologists and colorectal surgeons by increasing approved training positions; increase capacity in idle or underutilised endoscopy suites; and establish a training pathway for procedural rural GPs to obtain accreditation as endoscopists through existing, internationally accepted GESA standards so they can undertake independent practice in appropriate regional facilities.
 
 
Dr Malcolm Forbes is a medical registrar, adjunct lecturer at James Cook University and chair of the AMA Queensland Council of Doctors in Training. Dr Bavahuna Manoharan is a general surgery registrar, associate lecturer at the University of Queensland and board director of the AMA.  
 
 

Poll

Do you support nurses performing procedures such as endoscopies?
  • No – it should be done by doctors (73%, 142 Votes)
  • Maybe – not for all cases (16%, 31 Votes)
  • Yes – if it’s cost-effective (11%, 21 Votes)

Total Voters: 194

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7 thoughts on “Malcolm Forbes

  1. Simon Zilko says:

    I didn’t even know this practice was occurring. It’s a great example of some administrative bureaucratic types having the brain wave that endoscopy might be provided to the community cheaper by getting people to do it whom you can pay less by way of reduced training, education and experience. 

    I am an orthopaedic surgeon, and there are many things I do which I’m sure someone with decent dexterity and intelligence with no medical training could be taught how to do  – training a technician, so to speak. But it’s manaing everything except the straightforward steps of a procedure which is the real concern with getting technicians, and not fully trained clinicians, to undertake such procedures.

    How do these technicians manage intra-operative complications and unexpected findings? How are they placed to interpret what they see or find? How are patients subsequently managed once a diagnosis is made? For endoscopy by nurses, it looks like many patients need to be referred to a gastroenterologist or physician anyway – whether it be for interpretation of results, follow-up of biopsy results, or managing of the presenting complaint. Which seems to defeat the purpose of the exercise int the first place, whilst fragmenting continuity of care at the same time.

     

  2. Emma Ericson says:

    This seems like an accepted practice in other areas of health practice.  Radiologists and radiographers work together, for example.

  3. Sue Ieraci says:

    Perhaps the skill of specialist Gastroenterologists could be better used for the cognitive aspects of the job, rather than the procedural. Many medical and surgical specialists collaborate with radiologists to obtain diagnostic information – there is no need for each medical specialist to do all their own diagnostic procedures. 

    As conditions change over time, medical systems need to adapt to meet patient needs in the most efficient ways. SOmetimes this means taking on new procedures, and sometimes it means abandoning them. We can’t argue that current workpractices should be fixed for all time. Systems have already changed dramatically from when I was a trainee, and I look forward to seeing them continue to improve.

  4. peter Brooks says:

    Surely if we need to use endoscopy for cancer screening we need to train more endoscopists. Nurses do it very well and more NEs need to be trained – they can work as a team with the GEs and we can then deliver far more episodes of service . They also don’t charge out-of-pocket expenses like many gastroenterologists. Is it not about time doctors focused on patients’ needs rather than looking after themselves -that is surely what we are here for !

  5. Chris O'Donnell says:

    The overwhelming weight of evidence in the literature supports the use of nurses to perform endoscopic procedures. The Systematic Review quoted in this article goes against this substantial body of evidence by attempting to demonstrate that nurses are not cost effective by claiming errors in the reviewed studies that are quite frankly not supported by other international peer reviews. Time and time again nurses have been shown to be safe despite the very considerable barriers put up against their practice.

    What continues to be obvious is that self-interest abounds in the unrelenting attack of of alternative models. There was a time that only Doctors could do ECG’s, because this highly technical task could not ever be performed by mere nurses. Where is practice now. Let’s put aside the typical demarcation disputes and focus on what’s good for patients. The evidence shows time and time again that nurses can perform these procedures safely, with adenoma and polyp detection rates similar to Consultant Endoscopists.

    Let’s remember why we all of got into the business of health care. Stop being shortsighted and putting up barriers to demonstrably safe practice, this only harms patients in the end. 

  6. Greg Hockings says:

    Excellent article, and excellent comment from Simon. Just who is training the nurse endoscopists? Surely not fully qualified gastroenterologists, who should be giving priority to advanced trainees in gastroenterology. As for Peter Brooks’ comment, this debate is about the quality of health care, not doctors’ incomes. These are invasive proceedures with significant risks. Who is insuring the nurse practitioners? Gastroenterologists need to be highly skilled to undertake the more difficult proceedures such as ERCP and so need considerable experience in the more straightforward proceedures first. Will we have nurses learning to coronary angiography next, and have cardiologists only doing stenting?

  7. Malcolm Forbes says:

    Sue, current clinical practices and role responsibilities should not be fixed for perpetuity. This is absurd and was not suggested. I share your enthusiasm for ongoing clinical efficiency gains. Medicine is an exciting profession to be working in with the innovations on the horizons. 

    Peter, yes the NBCSP has led to much of the increased demand. A considerable portion of unmet demand exists in rural and outer urban areas where there are limited numbers of medical endoscopists. Nurse endoscopists operate in a model where supervision is provided by a medical specialist, thus a greater number of nurse endoscopists will not reduce demand in these areas. These issues and other important questions around cost-effectiveness (specific to Australia) were not adequately adressed in the HWA APEN evaluation. Your insinuation that doctors have hitherto not prioritised patients’ needs is unfounded and would be repudiated by all of my colleagues working in clinical practice. 

    Chris, safety concerns do not exist for nurses performing endoscopic procedures in metropolitan centres. There is evidence that demonstrates this in Australian and international contexts. This was covered in the article. I am not ideologically opposed to task substitution. However, the profession must be cautious about changes that potentially jeopardise long-term capacity building and medical training (both which have direct implications for patient care) in favour of spurious expediency. 

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