Author’s Reply

To the Editor: We appreciate the recent comments submitted regarding our article previously published in your journal.1 We gave the concerns raised regarding the number of colonoscopies required to be “competent” much thought during the writing of the article and since publication. We believe this select group of physicians represents a minority of primary care practitioners. They are highly motivated procedure-focused family physicians at a rural facility. They all practice in this setting for that very reason. Before the study was begun, the objectives were well known to the participating physicians and it was clear that one of the critical goals for any colonoscopy was that the cecum be reached. In addition, as reported, our group of patients was considered “low risk,” which may have led to a higher cecal intubation rate. The difference in training experience among the 4 study physicians was apparent in their reported cecal intubation rates, time to cecum, and total procedure time.

We greatly respect the recommendations of the Gastroenterology Leadership Council2 and the Accreditation Council for Graduate Medical Education3; however, several others have already published successful reports regarding motivated rural family physicians performing colonoscopies with fewer than 100 procedures completed previously.4–6 The largest prospective colonoscopy study to date included 13,580 procedures completed by surgeons.7 This included 1368 procedures completed by surgical residents who had only completed between 11 and 49 previous cases. Wexner et al7 reported, based on their results, that “no minimum number of cases can be mandated for credentialing to perform safe colonoscopies.” Given the current shortage of physicians performing endoscopy in rural and underserved settings and the increasing demand for services, these studies support continued development of colonoscopy-trained primary care physicians.

We note that it was not the intent or purpose of our study to attempt to establish a minimum number of “in-training” colonoscopies that should be completed before privileging. It is our view that the setting of an arbitrary number of procedures to be done in training before privileging is inappropriate and unsupportable by evidence in the literature at this time. Resident and practicing physician skill in learning and performing new procedures varies widely, and we believe that the AAFP’s policy of basing privileging on “documented training and/or experience, demonstrated abilities, and current competence”8 is a far more prudent approach than assigning privileges based on completion of an arbitrary number of procedures. Thus, strategies to train family physicians in complex procedures will need to be individualized for each resident, and they should be based on the premise of training, followed by judging competence based on demonstrated abilities.