Gastrointestinal endoscopy boon or beast? -
Frequently we are made aware of situa¬ tion of Gastroenterology drew up pre¬ impact on society of cise recommendations regarding the a technologic development is not as type of physicians qualifying for en¬ good as had been expected. The tre¬ doscopy training, the minimum stand¬ mendous boon of enhanced diagnostic ards of training and facilities required and therapeutic capability resulting and the type of institution in which from the development of fiberoptic endoscopy may safely be done. The endoscopy, for example, is threatened final recommendations have been forby the very factors contributing to that warded to provincial authorities for development: widespread availability of their own use. In the course of the committee's instruments and their relative ease of insertion. These, in turn, have led to deliberations the first question that arose was, Is special training necessary use of the fiberoptic endoscope by in¬ adequately trained physicians. As Pogo to perform gastrointestinal endoscopy? says: "We have met the enemy and it The answer to this was a resounding is us!" The beast within us and within Yes. In addition to the possible the profession is the tendency for in- complications due to inexperience, an discriminate, inappropriate or incom¬ erroneous diagnosis may lead to in¬ petent use of any diagnostic or thera¬ adequate or inappropriate treatment. peutic tool. Usually we, as individuals Therefore, a non-gastroenterologist, or as a profession, are able to control surgeon or pediatrician must acquire, and domesticate the beast to perform under supervision, at least a minimal level of competence in the interpreta¬ a useful task. Canadian gastroenterologists, the tion of endoscopic findings before he members of the Canadian Association can perform endoscopies providing re¬ of Gastroenterology and their col¬ liable data. Accordingly, the Canadian leagues in the United States have Association of Gastroenterology recom¬ watched with alarm the rampages of mends that endoscopies be performed the beast in that country, where uncon- by non-gastroenterologists only if they trolled use of endoscopic instruments have undergone training in endoscopy. has become a major medical problem If ear, nose and throat surgeons, who inaccurate observations are applied traditionally perform esophagoscopies, inappropriately and lead so frequently also wish to perform fiberoptic endo¬ to the wrong clinical decision as to scopy of the stomach, duodenum and offset the benefit of endoscopic ad¬ lower gastrointestinal tract, they too should undergo further training. Since vances. In Canada there should be no the instruments and techniques for room for substandard medical care. The Canadian Association of Gastro¬ gastrointestinal endoscopy are constant¬ enterology favours the general avail¬ ly changing, continued updating of ability of this useful diagnostic and training for endoscopists is essential; therapeutic tool in this country, and the Canadian Association of Gastro¬ encourages its use under acceptable cir¬ enterology suggests that endoscopists be cumstances by well trained physicians required to attend, every 2 years, at who are not gastroenterologists: but least one meeting where gastrointestinal under what circumstances, and by endoscopy is discussed. Once it was agreed that special train¬ which physicians, with how much ing is necessary, the next question to training? Addressing itself to these issues dur¬ answer was, How much training does a ing the past \Vi years the committee non-gastroenterologist require? Recogon endoscopy of the Canadian Associa¬ nizing that prior experience and indi¬ tions in which the
vidual abilities and skills vary, the Canadian Association of Gastroenterol¬ ogy recommends that, before performing endoscopy in an unsupervised prac¬ tice, a physician should perform, under supervision but as a primary endoscopist, at least 100 upper gastrointes¬ tinal endoscopies. Of these, 10 should be under emergency conditions. If the non-gastroenterologist endoscopist wishes to take up colonoscopy he should perform at least 20 colonoscopies and 10 polypectomies under similar supervision. Because an en¬ doscopist is not simply a technician, he should not learn endoscopy as an isolated technique but in the context of digestive disease. This can best be achieved by training in a gastroenterol¬ ogy unit, which would teach the trainee not only the technical procedures but also their indications and interpretation of the findings. The Canadian Associa¬ tion of Gastroenterology recommends that a short course is not adequate for training an endoscopist, whatever his background may be, but such short courses may be a useful supplement to the training obtained in a gastroenter¬ ology unit. The next question to be answered was, Where should gastrointestinal en¬ doscopy be performed? Complications are rare but occur in 1 to 2% of ex¬ aminations, mainly as reactions to drugs, vagal stimulation or occasionally perforation. Death from cardiac arrest, pulmonary embolism or cerebrovascu¬ lar accident may be coincidental but occurs in 0.3 to 0.4%. The Canadian Association of Gastroenterology recom¬ mends that endoscopy be performed only in institutions having facilities and personnel to handle such problems. A thoracic surgeon (or general surgeon capable of performing thoracic surgery) must be available together with fully equipped operating and endoscopy rooms and a specially trained nurse ex¬ perienced in resuscitation and in post-
CMA JOURNAL/APRIL 3, 1976/VOL. 114 589
endoscopy care, who is also able to look after the sensitive and expensive equipment. The pathologist should be adequately trained in the interpretation of endoscopically obtained gastrointestinal biopsies. A full-time radiologist should be available during certain endoscopic procedures and for the correlation of endoscopic and radiologic findings. In addition, the principle of peer review should apply to endoscopic procedures as it applies to other areas of medical practice. Unless these criteria are fully met by the institution, its staff should not perform gastrointestinal endoscopy. How should these recommendations
be enforced? Special licensing for gastrointestinal endoscopy would be impractical at present. It is hoped, however, that the credentials and audit committees of the institutions where gastrointestinal endoscopy is performed will take their jobs seriously to prevent inappropriate use of gastrointestinal endoscopy by inadequately trained endoscopists. For institutions that are interested in monitoring and accrediting their endoscopists, the full report of the committee on endoscopy of the Canadian Association of Gastroenterology is available from the office of the secretary of the association (Dr. Ralph Warren, St. Michael's Hospital,
30 Bond St., Toronto, ON M5B 1W8). We hope that the present warning will be taken seriously by those responsible for the quality of care in their hospitals, and that the beast will disappear from the Canadian scene, leaving us with the well deserved boon that the advances in techniques of fiberoptic endoscopy should bring to Canadian patients. We hope it is not too late. R.R. GILLIEs, MD President Canadian Association of Gastroenterology BERNARD PERRY, MD
President-elect Canadian Association of Gastroenterology IVAN T. BacK, MD Chairman, endoscopy committee Canadian Association of Gastroenterology
Hurnan rights in personal health care In Canada, where sophisticated medical care is available to all, it is generally accepted that health care is a right rather than a privilege. Paradoxically, this very acceptance means that few of us have to ask the fundamental question of what constitutes an individual's rights regarding personal health care. To which of the multiplicity of medical services should a person have an unquestionable and inalienable right? This question is more pertinent in underdeveloped and developing countries than in Canada, but it is still of value to Canadians to define human rights in personal health care: when technologic advances compel us to define essential concepts such as life and death it is equally necessary to elucidate the intangibles of health. More than half the world's population lack modern health care,1 and King2 has made the challenging statement that "nowhere do we fail more dismally to apply what we already know for the good of our fellows than in the provision of health care". Against this statement one must set the ideal that no individual should be denied the right to adequate personal health care; one then realizes how much must be done before the principle that each person has a right to personal health care can be upheld. But first one must define minimum human rights in health. King, from his viewpoint in Indonesia, has attempted to define rights to personal health care in the following manner. Each person is entitled to at least some of the many diagnostic and
therapeutic interventions that characterize medical care. These interventions can be ranked from low to high on a scale that encompasses basic and sophisticated procedures - from testing for urinary protein and suturing of a wound at one end, to radioimmunoassay procedures and heart transplantation at the other. Also, some of these interventions are associated: a hospital, however simple and poorly equipped, can offer more than a single service. Good medicine, however, is more than a catalogue of interventions; knowledge, effective application of this knowledge and kindness are also important. King puts this all together in a "health care package", which he defines as "an integrated set of components assisting the application of a particular group of interventions for the improvement of health care under specific socioeconomic conditions". Each package is directed, simplistically perhaps, towards treatment of a specific problem; each comprises not only specific information but also educational objectives for health professionals, teaching aids, evaluative methods and some measure of its epidemiologic effect. King has been concerned primarily with child care, and in Indonesia he has designed health care packages, for example, for treatment of the dehydrated child and the child with diarrhea. In terms of human rights, would his concept be useful in Canada? A key consideration is King's view that health care packages are both an approach to defining rights in health
590 CMA JOURNAL/APRIL 3, 1976/VOL. 114
care and a way of implementing them. Consider two examples: the case of a pregnant woman at term in a developing country and that of another woman in Canada. As a matter of human rights, would not access to an obstetrici.in capable of performing a cesarean section be considered basic for both women? Certainly few would disagree, but in Canada one must go further: as a matter of human rights a woman should have access also to a competent anesthetist who can, for example, perform endotracheal intubation skilfully and rapidly. Human rights in health for Canadians are in part determined by the standard of health care, in such a way that a pregnant woman should have available to her a number of health care packages, just one of which is safe anesthesia. For Canadians health care packaging is a concept that perhaps has administrative and political connotations, but it could be useful in evaluating the adequacy of health care, and its greatest use might well lie in stimulating us to analyse component problems in the entire health care delivery system, particularly primary care and the training of physicians. DAYm A.E. SHEPHARD References 1. BRYANT 3: Health and the Developing World, Ithaca, NY, Cornell University, 1969 2. KING M: Personal health care: the quest for a human right, in Human Rights in Health, Ciba Foundation Symposium 23 (new series), Amsterdam, Associated Scientific Publishers, 1974
Frequently we are made aware of situa¬ tion of Gastroenterology drew up pre¬ impact on society of cise recommendations regarding the a technologic development is not as type of physicians qualifying for en¬ good as had been expected. The tre¬ doscopy training, the minimum stand¬ mendous boon of enhanced diagnostic ards of training and facilities required and therapeutic capability resulting and the type of institution in which from the development of fiberoptic endoscopy may safely be done. The endoscopy, for example, is threatened final recommendations have been forby the very factors contributing to that warded to provincial authorities for development: widespread availability of their own use. In the course of the committee's instruments and their relative ease of insertion. These, in turn, have led to deliberations the first question that arose was, Is special training necessary use of the fiberoptic endoscope by in¬ adequately trained physicians. As Pogo to perform gastrointestinal endoscopy? says: "We have met the enemy and it The answer to this was a resounding is us!" The beast within us and within Yes. In addition to the possible the profession is the tendency for in- complications due to inexperience, an discriminate, inappropriate or incom¬ erroneous diagnosis may lead to in¬ petent use of any diagnostic or thera¬ adequate or inappropriate treatment. peutic tool. Usually we, as individuals Therefore, a non-gastroenterologist, or as a profession, are able to control surgeon or pediatrician must acquire, and domesticate the beast to perform under supervision, at least a minimal level of competence in the interpreta¬ a useful task. Canadian gastroenterologists, the tion of endoscopic findings before he members of the Canadian Association can perform endoscopies providing re¬ of Gastroenterology and their col¬ liable data. Accordingly, the Canadian leagues in the United States have Association of Gastroenterology recom¬ watched with alarm the rampages of mends that endoscopies be performed the beast in that country, where uncon- by non-gastroenterologists only if they trolled use of endoscopic instruments have undergone training in endoscopy. has become a major medical problem If ear, nose and throat surgeons, who inaccurate observations are applied traditionally perform esophagoscopies, inappropriately and lead so frequently also wish to perform fiberoptic endo¬ to the wrong clinical decision as to scopy of the stomach, duodenum and offset the benefit of endoscopic ad¬ lower gastrointestinal tract, they too should undergo further training. Since vances. In Canada there should be no the instruments and techniques for room for substandard medical care. The Canadian Association of Gastro¬ gastrointestinal endoscopy are constant¬ enterology favours the general avail¬ ly changing, continued updating of ability of this useful diagnostic and training for endoscopists is essential; therapeutic tool in this country, and the Canadian Association of Gastro¬ encourages its use under acceptable cir¬ enterology suggests that endoscopists be cumstances by well trained physicians required to attend, every 2 years, at who are not gastroenterologists: but least one meeting where gastrointestinal under what circumstances, and by endoscopy is discussed. Once it was agreed that special train¬ which physicians, with how much ing is necessary, the next question to training? Addressing itself to these issues dur¬ answer was, How much training does a ing the past \Vi years the committee non-gastroenterologist require? Recogon endoscopy of the Canadian Associa¬ nizing that prior experience and indi¬ tions in which the
vidual abilities and skills vary, the Canadian Association of Gastroenterol¬ ogy recommends that, before performing endoscopy in an unsupervised prac¬ tice, a physician should perform, under supervision but as a primary endoscopist, at least 100 upper gastrointes¬ tinal endoscopies. Of these, 10 should be under emergency conditions. If the non-gastroenterologist endoscopist wishes to take up colonoscopy he should perform at least 20 colonoscopies and 10 polypectomies under similar supervision. Because an en¬ doscopist is not simply a technician, he should not learn endoscopy as an isolated technique but in the context of digestive disease. This can best be achieved by training in a gastroenterol¬ ogy unit, which would teach the trainee not only the technical procedures but also their indications and interpretation of the findings. The Canadian Associa¬ tion of Gastroenterology recommends that a short course is not adequate for training an endoscopist, whatever his background may be, but such short courses may be a useful supplement to the training obtained in a gastroenter¬ ology unit. The next question to be answered was, Where should gastrointestinal en¬ doscopy be performed? Complications are rare but occur in 1 to 2% of ex¬ aminations, mainly as reactions to drugs, vagal stimulation or occasionally perforation. Death from cardiac arrest, pulmonary embolism or cerebrovascu¬ lar accident may be coincidental but occurs in 0.3 to 0.4%. The Canadian Association of Gastroenterology recom¬ mends that endoscopy be performed only in institutions having facilities and personnel to handle such problems. A thoracic surgeon (or general surgeon capable of performing thoracic surgery) must be available together with fully equipped operating and endoscopy rooms and a specially trained nurse ex¬ perienced in resuscitation and in post-
CMA JOURNAL/APRIL 3, 1976/VOL. 114 589
endoscopy care, who is also able to look after the sensitive and expensive equipment. The pathologist should be adequately trained in the interpretation of endoscopically obtained gastrointestinal biopsies. A full-time radiologist should be available during certain endoscopic procedures and for the correlation of endoscopic and radiologic findings. In addition, the principle of peer review should apply to endoscopic procedures as it applies to other areas of medical practice. Unless these criteria are fully met by the institution, its staff should not perform gastrointestinal endoscopy. How should these recommendations
be enforced? Special licensing for gastrointestinal endoscopy would be impractical at present. It is hoped, however, that the credentials and audit committees of the institutions where gastrointestinal endoscopy is performed will take their jobs seriously to prevent inappropriate use of gastrointestinal endoscopy by inadequately trained endoscopists. For institutions that are interested in monitoring and accrediting their endoscopists, the full report of the committee on endoscopy of the Canadian Association of Gastroenterology is available from the office of the secretary of the association (Dr. Ralph Warren, St. Michael's Hospital,
30 Bond St., Toronto, ON M5B 1W8). We hope that the present warning will be taken seriously by those responsible for the quality of care in their hospitals, and that the beast will disappear from the Canadian scene, leaving us with the well deserved boon that the advances in techniques of fiberoptic endoscopy should bring to Canadian patients. We hope it is not too late. R.R. GILLIEs, MD President Canadian Association of Gastroenterology BERNARD PERRY, MD
President-elect Canadian Association of Gastroenterology IVAN T. BacK, MD Chairman, endoscopy committee Canadian Association of Gastroenterology
Hurnan rights in personal health care In Canada, where sophisticated medical care is available to all, it is generally accepted that health care is a right rather than a privilege. Paradoxically, this very acceptance means that few of us have to ask the fundamental question of what constitutes an individual's rights regarding personal health care. To which of the multiplicity of medical services should a person have an unquestionable and inalienable right? This question is more pertinent in underdeveloped and developing countries than in Canada, but it is still of value to Canadians to define human rights in personal health care: when technologic advances compel us to define essential concepts such as life and death it is equally necessary to elucidate the intangibles of health. More than half the world's population lack modern health care,1 and King2 has made the challenging statement that "nowhere do we fail more dismally to apply what we already know for the good of our fellows than in the provision of health care". Against this statement one must set the ideal that no individual should be denied the right to adequate personal health care; one then realizes how much must be done before the principle that each person has a right to personal health care can be upheld. But first one must define minimum human rights in health. King, from his viewpoint in Indonesia, has attempted to define rights to personal health care in the following manner. Each person is entitled to at least some of the many diagnostic and
therapeutic interventions that characterize medical care. These interventions can be ranked from low to high on a scale that encompasses basic and sophisticated procedures - from testing for urinary protein and suturing of a wound at one end, to radioimmunoassay procedures and heart transplantation at the other. Also, some of these interventions are associated: a hospital, however simple and poorly equipped, can offer more than a single service. Good medicine, however, is more than a catalogue of interventions; knowledge, effective application of this knowledge and kindness are also important. King puts this all together in a "health care package", which he defines as "an integrated set of components assisting the application of a particular group of interventions for the improvement of health care under specific socioeconomic conditions". Each package is directed, simplistically perhaps, towards treatment of a specific problem; each comprises not only specific information but also educational objectives for health professionals, teaching aids, evaluative methods and some measure of its epidemiologic effect. King has been concerned primarily with child care, and in Indonesia he has designed health care packages, for example, for treatment of the dehydrated child and the child with diarrhea. In terms of human rights, would his concept be useful in Canada? A key consideration is King's view that health care packages are both an approach to defining rights in health
590 CMA JOURNAL/APRIL 3, 1976/VOL. 114
care and a way of implementing them. Consider two examples: the case of a pregnant woman at term in a developing country and that of another woman in Canada. As a matter of human rights, would not access to an obstetrici.in capable of performing a cesarean section be considered basic for both women? Certainly few would disagree, but in Canada one must go further: as a matter of human rights a woman should have access also to a competent anesthetist who can, for example, perform endotracheal intubation skilfully and rapidly. Human rights in health for Canadians are in part determined by the standard of health care, in such a way that a pregnant woman should have available to her a number of health care packages, just one of which is safe anesthesia. For Canadians health care packaging is a concept that perhaps has administrative and political connotations, but it could be useful in evaluating the adequacy of health care, and its greatest use might well lie in stimulating us to analyse component problems in the entire health care delivery system, particularly primary care and the training of physicians. DAYm A.E. SHEPHARD References 1. BRYANT 3: Health and the Developing World, Ithaca, NY, Cornell University, 1969 2. KING M: Personal health care: the quest for a human right, in Human Rights in Health, Ciba Foundation Symposium 23 (new series), Amsterdam, Associated Scientific Publishers, 1974
