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.