Who should be an expert in endoscopy?

Introduction

With the emergence of nurse endoscopists and proposals that physician assistants might be allowed to practise in this area, the question which now frequently faces courts in cases of alleged negligence is whether an expert must come from the same professional background. It is a fundamental issue, which crops up in other areas of clinical practice. For example, should decisions made by inflammatory bowel disease specialist nurses on the clinical care and treatment of patients with Crohn's disease and ulcerative colitis only be reviewed by nurses, despite the fact that they are working as part of a team under the direct supervision of a consultant gastroenterologist? If physician associates actually come to practise endoscopy will defence teams claim that the only expert able to comment on their practice will be another physician associate?

This paper specifically addresses the issue as to whether the standard of care in respect of an endoscopy carried out by a nurse must and/or can only be assessed by an expert who is a nurse. It considers the fact that there is a unified training program and formal assessment for all endoscopists, together with ongoing monitoring, and these are organised and supervised by the Joint Accreditation Group (JAG). It considers the fact that patients are more concerned with the technical skill of the endoscopist than his or her background. Consequently, it is important for patients and for practice that a distinction is not drawn between the standards of a nurse endoscopist and a medical endoscopist.

Background

In 2015, Jones et al reviewed the background to the development of a common training program by the Joint Accreditation Group (JAG). ¹ Their paper specifically compared the training of gastroenterology registrars and surgical registrars. However, it usefully summarises the background to the national training program for all endoscopists:

“In 1994 the UK Joint Advisory Group on GI Endoscopy (JAG) was set up and tasked with ensuring standards of endoscopy provision in the UK. Over more recent years, it has set clear standards that clinicians need to meet in order to achieve accreditation in both upper and lower GI endoscopy.”

It noted the change in the nature of training over the years:

“The previous volume based assessment has been replaced by a combined volume and competency assessment, with trainees required to achieve a minimum number of procedures, a proportion of which are formally assessed as a direct observation of procedural skills (DOPS) … The certification process has also been streamlined with the development of an online training portfolio (the JAG Endoscopy Training System [JETS]) as well as the introduction of the endoscopy global rating scale to allow direct assessment of quality of training delivered by endoscopy units.”

In a review, Siau et al examined the impact of the Joint Advisory Group on Gastrointestinal Endoscopy in the UK. ² They noted:

“The Joint Advisory Group on Gastrointestinal Endoscopy (JAG) was initially established in 1994 to standardise endoscopy training across specialties. Over the last two decades, the position of JAG has evolved to meet its current role of quality assuring all aspects of endoscopy in the UK to provide the highest quality, patient-centred care. Drivers such as changes to healthcare agenda, national audits, advances in research and technology and the advent of population-based cancer screening have underpinned this shift in priority. Over this period, JAG has spearheaded various quality assurance initiatives with support from national stakeholders. These have led to the achievement of notable milestones in endoscopy quality assurance, particularly in the three major areas of: (1) endoscopy training, (2) accreditation of endoscopy services (including the Global Rating Scale), and (3) accreditation of screening endoscopists.”

This paper goes on to note that in 2004:

“The concept of certification was proposed, which relied on trainee adoption of a ‘JAG logbook of experience’, engagement in summative assessment and supervisor sign-off. Direct observation of procedural skills (DOPS) and direct observation of procedural polypectomy skills (DOPyS) were introduced to standardise assessment, and highly focused courses were developed for trainees and trainers. JAG-approved basic upper and lower GI endoscopy courses became compulsory for certification, while specific training-the-trainer courses evolved to improve training standards at base hospitals.”

The important concept which emerged with the creation of JAG was that all endoscopists were and are trained in the same way and their performances in endoscopy are subsequently also monitored in the same way. Indeed, it is commonplace for nurses to train doctors and doctors to train nurses when they are going through the training program for endoscopy.

The direct comparability between different groups of endoscopists was shown in a study by Maslekar et al. of lower gastrointestinal endoscopy (LGE). ³ They found:

“503 patients were surveyed after LGE. Examinations were performed by nurse (n = 105), doctor (n = 191), or NMEs (n = 155). There were no differences between three groups in terms of completion rates/complications. No differences were detected between endoscopists in patient rating for overall satisfaction (P = 0.6), technical skills (P = 0.58), communication skills (P = 0.61) or interpersonal skills (0.59).”

The patient perspective

Tierney et al. examined the view of patients as to what they considered important when undergoing endoscopy and found: ⁴

“Studies of patient-reported value repeatedly identify the importance of the practitioner–patient interaction and specifically, the endoscopists’ technical skill (including the ability to control discomfort) and communication skills. These are ranked as of greater importance to patients than environmental factors such as single-sex environments, noise and even privacy.”

For patients, the technical skill of the endoscopist was the most important issue in their interaction. The purpose of a common training program for gastroenterologists, surgeons, nurses and other nonmedical endoscopists is to ensure that they all share a common skill set. Anything less would mean that patients could not have confidence in the practitioner. Patients need to feel that the endoscopist has comparable skills, regardless of their professional background.

The legal perspective

Endoscopists undergo a common training program, their competence is assessed by the same mechanism and their ongoing performance monitored in the same way. Consequently, any endoscopy practice should be assessed by another endoscopist. It is completely inappropriate to suggest that a nurse endoscopist can only be assessed by a nurse. This would be completely contrary to the practice of endoscopy in the United Kingdom that has existed throughout the 21st century. Such an approach would suggest that there are different standards for endoscopists from different professional backgrounds. Such a view would undermine the confidence placed by patients in the endoscopist when they are about to undergo an endoscopy. Requests to the court by defence teams that where there is alleged negligence by a nurse endoscopist, the only appropriate expert must be a nurse and any expert report by a medical practitioner must be disregarded, because he or she is not a nurse, must be rigorously opposed. The implications of such a decision must be made very clear to the judge.

The standard of care expected of a nurse endoscopist is exactly the same as that expected of a consultant gastroenterologist. Interesting parallels can be drawn to the decision, more than 50 years ago, by the Court of Appeal in Nettleship v Weston [1971] 2 QB 691, which held that a learner driver should be assessed to the same standard as a qualified competent driver. In rejecting the concept of a variable standard Lord Justice Megaw wrote:

“Why should the doctrine, if it be part of the law, be limited to cases involving the driving of motor cars? Suppose that to the knowledge of the patient a young surgeon, whom the patient has chosen to operate on him, has only just qualified. If the operation goes wrong because of the surgeon's inexperience, is there a defence on the basis that the standard of skill and care was lower than the standard of a competent and experienced surgeon? Does the young, newly qualified, solicitor owe a lower standard of skill and care, when the client chooses to instruct him with knowledge of his inexperience?”

Conclusion

Consequently, it is entirely appropriate that a consultant gastroenterologist, acting as an expert in endoscopy, should assess a nurse endoscopist’s practice. There is no justification for appointing a separate nurse endoscopist as this would imply that there was a different and lower standard for nurse practitioners. Indeed, the accreditation of all endoscopists requires that they are trained to a common standard and practice to that standard.