A Surgeon’s Scope of Practice

14 Mar 2018

For the 18th year, March has been dedicated to Colorectal Cancer Awareness. Since the mid-2000’s, we have seen a rapid decline in the incidence of colorectal cancer, mainly due to the early detection and removal of polyps during colonoscopy, and an increase in screening. However, the disease will still affect 1 in 22 males, and 1 in 24 females during their lifetime.

At a time when colorectal screening is of utmost importance, there remains competition for which providers perform the endoscopy: the surgeon or gastroenterologist? As a General Surgeon, endoscopy is an integral part of my practice. Endoscopy is a field that was developed by surgeons. I believe we possess an advantage over other endoscopists since we routinely visualize the colon anatomy during surgery. During abdominal surgery, we are allowed the opportunity to see variations in anatomy, like colon length, redundancy of the sigmoid or transverse colon, the angles of the hepatic and splenic flexure, and adhesions. This can help us guide the endoscope through the colon while keeping track of our precise location. However, surgeons have had to advocate for their right to continue to perform endoscopy procedures. Many surgeons have forgone their endoscopy privileges, some do so to preserve referrals from gastroenterologists.

From the gastroenterologists point of view, they perform many more endoscopies per year than most surgeons or primary care physicians. Their extensive fellowship training includes a higher number of procedures required for competency than a surgery resident (140 colonoscopies and 130 EGDs for gastroenterology fellows vs 50 colonoscopies and 35 EGDs for surgery residents.) They become more efficient at recognizing pathology, while completing the endoscopy in a timely and safe manner. One study suggested patients who had colonoscopies done by gastroenterologists, as opposed to primary care physicians or surgeons, had a lower risk of colorectal cancer specific death (65% lower risk for GI vs 45% lower risk for surgeons). This retrospective study does have some limitations. It did not examine any complication rates for these procedures and did not evaluate the initial indications for those colonoscopies. Many times, the patients referred to surgeons have more concerning symptoms of colon cancer, which may have affected those results.

From the surgeon’s perspective, one benefit of having a surgeon-performed colonoscopy is that our intimate knowledge of anatomy increases accuracy in locating lesions during colonoscopy. This may translate to shorter operative time and a more precisely planned surgical resection to remove the lesion. A recent comparison of localization error in colorectal cancer showed a significantly lower error rate for surgeons when compared to gastroenterologists. There was also a shorter time frame from endoscopy to surgery, which may result from eliminating the need for an additional referral. We also perform endoscopies rapidly, with low morbidity and mortality. Additional research has shown no differences in the complication rate between gastroenterologists, general surgeons and colorectal surgeons. Also, our surgical expertise is usually required to manage the potential complications such as perforation, and pathologic findings, such as complete obstruction of endoscopy.

While gastroenterologists have become the primary referral base for endoscopy, it is vital for surgeons to remain involved in the timely diagnosis and management of colorectal cancers. Plus, there is plenty of business to go around! Especially in rural and underserved areas, where surgeons and primary care physicians supplement the few gastroenterologists available. In addition, only 13% of the gastroenterologists in the US are women! A recent survey revealed that female patients have a stronger preference to the sex, primarily female, of their endoscopist than men do. Therefore, female surgeons may be able to provide endoscopy services to meet patient demand. This is why I will continue to advocate for my right to perform endoscopy. My patients deserve a choice. They deserve the best.

Dr. Lovano is a General Surgeon at Clinton Memorial Hospital in Wilmington, OH. She is fellowship trained in Minimally Invasive Surgery and is a Faculty Advisor for the Instagram Committee for the AWS. She enjoys doing the weekly ‘Surgical Instrument Saturday’ posts for the AWS IG/Facebook, and posting too many pictures of her dogs on her personal Instagram.

Our blog is a forum for our members to speak, and as such, statements made here represent the opinions of the author and are not necessarily the opinion of the Association of Women Surgeons.

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