Evaluation of the Role as an Endoscopic Practitioner-reflective Journal - Essay Example

Only a limited number of general practioners’ are involved in endoscopic practice; nurse practioners’ trained in endoscopy may help to easethe overburdened health care system. The Joint Advisory Group on gastrointestinal endoscopy has outlined the general recommendations for endoscopy training. They have touched upon the necessary skills and attitudes necessary for trainees to make the transition from direct to indirect supervision. Effective communication skills and a knowledge of legal and ethical issues of consent are vital and help to build the doctor-patient relationship. The establishment of one-stop colorectal clinics and multidisciplinary teams (MDT) also serves to improve patient care. There are some definite indications for tissue retrieval by endoscopy along with follow-up regimes. Endoscopy in general practice Endoscopy is important in the evaluation and management of upper and lower gastrointestinal problems. Each year, around 1% of the general population has an endoscopy. However, in general practice, the opportunities for establishing upper gastrointestinal endoscopy are limited. “Only about 200 of Britains 30000 general practitioners currently work as clinical assistants or hospital practitioners in endoscopy units and only a fraction of these have access to the equipment and staff, facilities for cleaning, recovery, resuscitation and training opportunities to make upper gastrointestinal endoscopy outside hospital safe and useful. A community hospital, relatively remote from a district general hospital, may be an appropriate site for endoscopy. Flexible sigmoidoscopy is much better suited to being performed in a community setting; nurses are also able to undertake it.” (Wolfson, 1995.) In the UK, endoscopy services are under increasing strain. The inpatient lists are overbooked and there is a long waiting time for outpatient examinations. Flexible sigmoidoscopy is particularly in demand. The already overstretched service would be considerably strained with the potential introduction of flexible sigmoidoscopy screening for colorectal cancer. With this in view, the British Society of Gastroenterology supports the development of nurse endoscopy with the provision that appropriate training is available. “The available evidence suggests that the majority of medical trainees become competent after approximately 30-35 flexible sigmoidoscopies. By utilising a comprehensive training programme, nurse practitioner flexible sigmoidoscopy can be successfully carried out on an independent basis. As such, colorectal nurse practitioners may soon be able to provide a comprehensive flexible sigmoidoscopy service as part of their contribution to the "interdisciplinary" care of patients with colorectal disorders.” (Duthie GS, Drew PJ, et al 1998.) General recommendations on training in gastrointestinal endoscopy (Joint Advisory Group on gastrointestinal endoscopy ) Trainees should attend a Basic Skills (Foundation course) in endoscopy initiated by or compliant with JAG standards (JAG compliant course). Those undertaking therapeutic endoscopy should attend an advanced therapeutic upper endoscopy course initiated by or compliant with JAG standards (JAG compliant course). General endoscopic training 1. The trainees should have adequate knowledge of the structure and function of an endoscope, light source, processor and accessories, including diathermy and thermal methods for coagulation. 2. They should also have knowledge of sedative and analgesic drugs and their additive effects, patient observation and oxygen saturation. 3. The skills which are required are, being able to get patient consent in accordance with BSG guidelines. 4. The trainee should also have the attitude of being willing to obtain consent for endoscopic procedures, willing to undertake endoscopy cleaning as necessary and use the equipment appropriately, and willing to participate in a safe endoscopic practice. Training in flexible sigmoidoscopy A minimum of 200 procedures must be performed in a year by the training units. The trainees must have the correct attitude of being willing to undertake flexible sigmoidoscopy so as to minimise risk and discomfort to patients. They should be willing to take help when required. 1. The trainees in flexible sigmoidoscopy should have first acquired the basic knowledge of the principles and practice of endoscopy. 2. They should understand the correct techniques of patient preparation, the mechanics of the procedure and its indications, limitations and complications. 3. Each trainee should be able to perform at least 100 procedures within the course of a year. A satisfactory level of competence will be considered to have been achieved by them when they are able to reach the descending colon where indicated. It is expected that the descending colon intubation rate should exceed 90% in those patients without stricturing or marked faecal contamination. 4. Trainees should perform at least 50 examinations under direct supervision and at least another 50 examinations with immediate advice available. 5. Trainees should become competent in taking diagnostic biopsies. 6. Competence in flexible sigmoidoscopy does not equate with competence in colonoscopy. 7. Trainees undertaking techniques of polypectomy must undergo adequate training, including knowledge of the principles of safe diathermy technique. Independent practice is permitted only when the clinical supervisor is satisfied with the competence of the trainee and all previous practical and theoretical stages had been completed satisfactorily. Trainees should attend a basic skills (foundation course) in endoscopy and a flexible sigmoidoscopy course initiated by or compliant with JAG standards (JAG compliant courses). Communication skills Communication in medicine can be oral, written, or computer mediated. Computer- based records and telemedicine are new communication technologies. These are becoming more common now and help to increase the range of communication skills further. Appreciating the importance of effective communication, considering patients as people rather than as cases, and the contribution of different people in the health-care team can be considered as relevant attitudes of trainees. Effective communication is vital to enable patients make an informed decisions. The practioner must try to find out what the patients want to know and is supposed to know about their condition and its treatment. “Open, helpful dialogue of this kind with patients leads to clarity of objectives and understanding, and strengthens the quality of the doctor/patient relationship. It provides an agreed framework within which the doctor can respond effectively to the individual needs of the patient. Additionally, patients who have been able to make properly informed decisions are more likely to co-operate fully with the agreed management of their conditions.”( Contemporary Issues in Medicine: Communication in Medicine, 1999.) Consent in endoscopy “The process of informed consent is an ethical and legal mandate. The medical informed consent doctrine enables adult patients to make their own treatment decisions based on adequate disclosure of information by the endoscopist.”( Lofft AL) “Doctors and other health professionals should always offer information to patients about the risks, benefits and alternatives to the treatment or examination proposed. Such information should be offered in a timely fashion and in a form understandable to the patient. The professional should assess the patients ability to comprehend and to make a judgment if their consent is to be valid. Patients occasionally may refuse the offer, but this refusal does not exonerate the doctor from pointing out serious hazards. Discussions of risk must be made in a friendly manner and the patients questions invited.”( Peter Isaacs) The practioner should not withhold information necessary for decision making unless he judges that disclosure of some relevant information would cause the patient serious harm. It is the practioners’ responsibility to discuss with the patient and obtain consent. Where this is not practicable, it may be delegated to another person, provided that the person is suitably trained and qualified, has sufficient knowledge of the proposed investigation or treatment, and understands the risks involved. In an emergency, where consent cannot be obtained, the practioner can provide medical treatment, provided the treatment is limited to what is immediately necessary to save life or avoid deterioration in the patients health. Experience with a one-stop colorectal clinic Traditionally, colorectal services have been designed for the convenience of hospitals rather than patients. This is not an ideal model, especially for minor interventions and diagnostic procedures. A one-stop colorectal clinic is therefore set up to address this issue. A study was done by the Department of Surgery, Blackburn Royal Infirmary, Blackburn U.K. The methods included running weekly clinics for a period of six months from 6.00 to 9.30 p.m. on Wednesdays. A consultant or specialist registrar saw patients with rectal bleeding, altered bowel habit, anorectal symptoms and those requesting screening advice. At the end of their clinic attendance, patients were asked to fill in a questionnaire. The study concluded that the one-stop clinic significantly improved patient care. “The majority of patients were satisfied with an evening clinic. Flexible sigmoidoscopy without sedation was well tolerated and the ability to perform this at initial assessment had a marked effect on the number of patients awaiting lower gastrointestinal endoscopy.”( Jones, Nicholson) Multidisciplinary team(MDT) Many specialties are involved in the practice of gastroenterology. There is a great overlap between medical and surgical practice in gastroenterology more than in any other specialty. “For this reason, well-organized MDT working is essential. This is coordinated through MDT meetings which, following the NSF for cancer, are usually held twice a week. The MDT meeting for GI cancer involves pathologists, GI surgeons, physicians and supporting teams. Close liaison with tertiary referral centers is an integral part of the management of complex GI problems, for example, complex liver disease, pancreatic cancer, liver/small bowel transplantation and complex nutritional problems requiring home parenteral nutrition. Specialist nurses in nutrition, stoma care, GI oncology, general gastroenterology, management of viral hepatitis therapy and others play an increasingly valuable role in improving quality of service, communication and liaison between disciplines within the team.”( www.rcplondon.ac.uk) It is very important to have close links with primary care, especially because gastroenterology practice relates to the management of chronic disease. Responsibility shared between the GP, patient and specialist is essential for a good management of the patient’s problems. Indications of tissue retrieval in endoscopy (www.guideline.gov) Esophagus 1. Malignant tumors of the esophagus. 2. Barretts esophagus. 3. To detect dysplasia or adenocarcinoma. 4. Infectious esophagitis. Stomach 1. Gastric neoplasia. 2. Patients with peptic ulcer disease, gastric mucosa-associated lymphoid tissue (MALT), lymphoma, and possibly those at increased risk for developing gastric cancer (e.g., family or personal prior history of gastric cancer) should all have their Helicobacter pylori status determined. Small Intestine 1. Celiac disease. 2. Infection of the small bowel may be diagnosed by histologic examination. 3. Patients with immunodeficiency, including post-transplantation or human immunodeficiency virus (HIV) infection, may harbor agents such as Isospora belli, Cryptosporidia, Cyclospora, and Microsporidia, which may be detected on small intestinal biopsy specimens. 4. Other pathogens detected on a small bowel biopsy in an immune deficient patient include CMV, fungal organisms such as Candida species and histoplasmosis, and Mycobacterium avium-intracellulare complex. 5. Duodenal, jejunal, and gastric polyps. Colon 1. Colonic polyps. 2. Inflammatory bowel disease. 3. For the evaluation of colitis, endoscopy and biopsy may be useful in distinguishing between different causes of colitis, assisting in the management of inflammatory bowel disease and establishing the extent of bowel involved. 4. Terminal ileal biopsy may be useful in the diagnosis of Crohns disease, infectious ileitis, and lymphoid nodular hyperplasia. Follow-up regimes 1. Barret’s esophagus- If persisting low grade dysplasia is present, endoscopy is done every six months for one year. If there is no high grade dysplasia, then yearly endoscopy is indicated. 2. Adenomas or colon cancer- If the lesion is a single adenoma (less than 1cm), follow-up colonoscopy is done 3-6 years after the initial polypectomy. If the examination is normal, the patient can be screened as per average-risk guidelines. 3. In larger adenomas, (greater than 1cm) multiple adenomas and high grade dysplasia, colonoscopy should be repeated within three years after the initial polypectomy. If normal, it is repeated once again in three years. If it remains normal, then screening as per average-risk guidelines is done. 4. Inflammatory bowel disease-Colonoscopy is done every 1-2 years for those who had universal colitis for 8 years or left-sided ulcerative colitis for 12-15 years. Summary To make a smooth transition from direct to indirect supervision, a trainee must possess not just the required knowledge and skills but also the right attitude. The prescribed training regimens would ensure this transition. The increased demand by the health care system for quality endoscopic practioners can be met to a large extent by these well trained individuals. Nurse practioners can also play a large role. It is also important for the practioner to have the necessary communication skills and be able to apply the legal and ethical issues of consent in their daily practice. This will help the patient directly by improved care and a better relationship based on trust and goes a long way to prevent malpractice and related issues. The one-stop rectal clinic aims to improve patient care by providing diagnostic and therapeutic services under one roof. A multi-disciplinary team working together, dramatically improves the quality of care and coordination between different specialities. ****************************************************************************** REFERENCES Duthie GS, Drew PJ, Hughes MAP, et al, A UK training programme for nurse practitioner flexible sigmoidoscopy and a prospective evaluation of the practice of the first UK trained nurse flexible sigmoidoscopist, GUT 1998;43:711-714, November 1998. General recommendations on training in gastrointestinal endoscopy (Joint Advisory Group on gastrointestinal endoscopy.) Jones LS, Nicholson RW, Evans DA, Experience with a one-stop colorectal clinic, Department of Surgery, Blackburn Royal Infirmary, Blackburn U.K. J.R.College Surgery, Edinburgh., 46, April 2001, 96-97  Lofft AL, Gastrointestinal Endoscopy Clinic, 1995, April 5(2):457-70. Medical School Objectives Project, October 1999, Report III. Contemporary Issues in Medicine: Communication in Medicine (Association of American medical colleges) Multidisciplinary team working and working with other specialists. Retrieved October 16, 2005, http://www.rcplondon.ac.uk/pubs/books/CPWP/ConsPhys2.gastro.pdf National guideline clearing house. Retrieved October 16, 2005, http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=6492&nbr=4066#s21 Peter E.T. Isaacs, Gastroenterology Unit, Victoria Hospital, Blackpool, UK. What Information Should Be Given to Patients Undergoing Therapeutic Endoscopy? Robert BS, Gastrointestinal and liver disease, 2002, 7th edition, vol 2. Wolfson, UMDS (Guys and St Thomass Hospitals), BMJ 1995;310:816-817, April 1, 1995. Read More