By Peter Broderick, MD, MEd

I HAVE ALWAYS BELIEVED that family physicians had the ideal foundation from which a specialty competency could be acquired. Yet, the disparaging "Jack of all trades, master of none" indictment of family medicine often dissuades medical students from our specialty.

I prefer to think of family physicians as "pluri-potential," capable of focused mastery within a narrow domain of medicine, while maintaining our specialty's roots
in primary care. A comprehensive perspective complements well the integration of a particular area of focus, providing efficiency and continuity to a patient's medical home.

The question of competency is always raised when a family physician challenges the established order. This is an argument we should not try to fight. Our patients need us to be competent to deliver whatever care we provide. However, competency is demonstrable and should be standardized. When competency determinations rely on measurements independent of skill and experience, it is often for anti-competitive, not competency, reasons.

Facing the Challenge
I have encountered this challenge in my local environment with colonoscopy. After 10 years of trying to acquire local support to expand my endoscopy practice, I have learned a great deal about the hurdles and tactics for success.

Unarguably, one prerequisite of competency and skill is procedural volume. I am fortunate to work within a large primary care organization that can concentrate referrals for GI procedures to a single clinic. Over my 20 years of endoscopy, I have performed more than 3,000 sigmoidoscopies and teach this within our residency program. Yet even with this level of experience, I was willing to submit to a long period of proctoring any collaborative specialist would require. I was never interested in usurping patients rightfully kept within the specialists' domain. There is ample unmet need for screening colonoscopy across many sectors of our nation, and this was certainly true for us locally.

My first disappointment occurred when the gastroenterologist who had instructed me in sigmoidoscopy 10 years earlier categorically refused to support my training in colonoscopy, even though he admitted my skill was unmatched in our institution and that his upcoming departure would leave our institution in great need of this procedural support. He was opposed to family physicians doing colonoscopy on principle alone, irrespective of skill.

The Struggle Wasn't in the Learning
After several years working beside the new gastroenterologist retained by our organization, I broached the subject of expanded practice once again. This time I was given lukewarm support. In preparation for proctoring, I attended training sessions organized by the National Procedural Institute (NPI) on colonoscopy and moderate sedation.

Upon my return from this training, I organized sessions in which my patients' colonoscopies would be done by me while the gastroenterologist stood in. I was careful to structure these cases so that there was no economic impact on the gastroenterologist, even to the point of offering him the professional fee for the case. But, he was agitated during our first session, not letting me do any of my own referred cases. In a subsequent meeting, he recanted his support, saying if I were to be trained, I would have to find outside proctoring. This time, it wasn't open opposition; it just wasn't his job to train me.

Resourcefulness, creativity and patience are virtues all family physicians need, particularly when "pushing the envelope." In our institution, we also had a surgeon who did occasional colonoscopies without any resistance from our gastroenterologist. I approached him and was met with easy acquiescence and interest.
I cheerfully organized my sessions, again with my own patients, but was stunned when he approached me before our first clinic to say that he was unable to proctor me. On further inquiry, he clearly admitted not wanting to get involved in something that was politically awkward. It wasn't a question of capability, but a question of appropriateness at this time.

Somewhere around this same time, the division of gastroenterology at the hospital where our residency admits (different from the institution where I am employed) passed a requirement that colonoscopy privileges could only be granted for physicians who documented at least 150 procedures. This is 50 more than even the most restrictive national organization requires for competency demonstration.(1) The consequence of this move was to eliminate surgeons, who typically receive some colonoscopy training in residency, from doing this procedure at our hospital.

Undaunted, I approached a gastroenterologist who had constructed his own surgical center a couple of years later, hoping that the prospect of referrals would alleviate his anxiety about my skill and competency. I again structured this so that all economic advantage would fall to the proctor, and it worked for a short time. I impressed him as a technically skilled endoscopist, and all seemed set.

Lack of collegiality among specialists is commonplace in my environment, but it became nasty when someone threatened to report to a state agency that he was teaching endoscopy in his surgical center. This shouldn't have been a concern, as long as proper safety and monitoring procedures are followed, since residencies and fellowships do this all the time. However, for a businessman with a sizeable debt at risk, he could not take the chance. He pulled his support, not because I wasn't skilled, but because it "might" not be legal.

A Competency Catch-22
As family physicians, we can attend as many NPI courses as we want, but our assertion of competency can only be validated with procedure numbers. Yet, how can one show numbers without a way to perform the procedure? If we forego patient safety and set up our own shop without proctoring, who are we serving?

I needed to find an unimpeachable organization in which family physicians perform GI endoscopy without threatening the economic base of the current endoscopists and with a culture of education. In short, I needed to find a residency program.
I work within a large family medicine residency network affiliated with UC Davis. At one of our affiliates, I was able to establish a novel position as a member of their salaried medical staff with privileges in colonoscopy and EGD, but with extended proctoring requirements. Under this arrangement, I am employed by the host organization and covered by their malpractice. A family physician colleague graciously donates her GI procedures until I meet my proctoring requirements. After that time, I should be able to continue acquiring the volume needed to successfully challenge my restrictive local environment. Such an arrangement is possible only because I am a known commodity and my sponsors have courage to support my professional development.

Going Forward
This journey has been long and is far from over. But any further arguments for excluding my expanded endoscopy practice once I surpass the required number of procedures will expose the true anticompetitive intention. Family medicine should demand that competency be measured and standardized in a technically meaningful way that is fair and reasonable. We need to create venues where physicians can safely and expertly train with sufficient volume so that we can meet these standards.

As family physicians expand their roles into areas of specialty care and procedures, I want us to be technically excellent in our selected specialty procedures - not to confiscate the role of the specialist, but to acknowledge the responsibility for which we are asking from our specialty colleagues. We should disprove the "...master of none" moniker by sustaining a practice volume and concurrent education sufficient to warrant competency and mastery. We should hold our standards to the highest, but they must be based on experience, skill and technical excellence. Our patients will be well served when the pluri-potential family physician can be a "master as well as a jack of many trades".

Peter Broderick, MD, MEd the program director for the Stanislaus Family Medicine Residency Program in Modesto.

1. American Society of Gastrointestinal Endoscopy states 100 cases and 20 snare polypectomies are necessary for minimum competency.