Colonoscopy and Gastroscopy are essential procedures used to diagnose and sometimes treat conditions affecting the digestive tract. Research and audits consistently show a wide variation in the quality of these procedures carried out by doctors, with strong evidence to show that poor quality endoscopy adversely affects the patient’s diagnosis and prognosis. A poor quality procedure can miss important abnormalities, cause serious injury and cause extreme distress to the patient. Whether you need a gastroscopy or colonoscopy for investigating symptoms or for routine screening, selecting a skilled endoscopist is essential. This guide is to help you look out for factors that are likely to indicate that your endoscopist is an expert and that you’ll be in safe hands with them.
Who is an Endoscopist?
An endoscopist is a medical doctor – usually a digestive surgeon or a gastroenterologist – who specialises in performing endoscopic procedures. Depending on the doctor’s area of subspecialty these might include:
- Gastroscopy – Examining the oesophagus, stomach and duodenum (upper small intestine)
- Colonoscopy – Examining the rectum, colon and terminal ileum (last few centimetres of small intestine)
- Flexible Sigmoidoscopy – Examining the rectum and left half of the colon only
- ERCP (Endoscopic Retrograde Cholangiopancreatography) – Examining the bile system and pancreas
Key Factors to Consider When Choosing an Endoscopist
1. Qualifications and Training
Do some detective work online e.g. the doctor’s website and explore their training programme, their qualifications, which institution they trained in, if they were themselves a trainer of other doctors in endoscopy (usually only the best endoscopists may train others) and how long they have been a specialist. In some countries there might be specific certifications of the doctor by an Endoscopy training program or a professional regulatory body. If this information isn’t apparent online, ask your prospective endoscopist about their pedigree – good ones have nothing to hide and really don’t mind a polite enquiry.
2. Experience and Specialisation
The more experience an endoscopist has, the better the quality of their work and the better their outcomes tend to be. Ask:
- How many endoscopic procedures they perform yearly and how many years they have been doing endoscopy (low volume practices and novice endoscopists have worse outcomes compared to their higher volume and more experienced peers)
- How many they perform on a list and how many minutes they assign to each procedure (avoid over-busy lists which sacrifice quality for volume of work)
- Their expertise in specific endoscopic procedures and their boundaries for leaving it to others (an acknowledgement that they might not be the best person in NZ for a particularly tricky job shows insight and integrity)
- If they specialise in conditions related to your symptoms (i.e. can they manage all eventualities that they might come across when doing the procedure)
- What complications they have seen in their own practice (never trust someone who says that they never have complications)
3. Facility Accreditation and Technology
The ability to find abnormalities in your digestive tract depends on many variables. The technology being used is one such factor. Enquire about which models of cameras they use (most manufacturers upgrade their models approximately every 5 years) and whether their systems provide Scope Guide (a system that helps identify if the camera is in a tangle) or HD/4K monitors or AI-assisted identification of polyps. These technologies are all cutting-edge and show clinical benefit. The facility should have a reputation in the sector for high quality endoscopy, so ask around. Most high quality facilities are independently audit by patient advocacy groups like DAA. The facility should be clean, tidy, organised, efficient and respectful of your dignity. Look at the doctor’s or facility’s website to get a feel of the place.
4. Polyp Detection and Caecal Intubation Rates (For Colonoscopies)
For colonoscopies, key performance metrics are:
- Adenoma Detection Rate (ADR) – The percentage of patients in whom the doctor finds polyps. A good endoscopist has an ADR of at least 25% for men and 15% for women. Does your doctor know what their statistics are for their practice, or do they blow you off with generalisations? Is their data verifiable by neutral third parties?
- Caecal Intubation Rate (CIR) – The ability of the doctor to successfully reach the beginning of the colon (caecum) during a colonoscopy, which ensures a thorough examination. A good rate is above 95%. Can they quote their CIR? Can it be independently verified?
- Patient Comfort Scores – Colonoscopy can sometimes be unpleasant and a good endoscopist or facility measures every patient’s comfort score. It is a scale of 1-4 and nearly all patients should score 1 or 2, with very exceptional cases of 4. This should be audited regularly and where there is more than one endoscopist using a facility, Patient Comfort Scores can be compared amongst each other or against Best Practice targets. Does your endoscopist do this? What is their median Patient Comfort Score? How many patients opt not to have sedation at all (a good endoscopist can sometimes comfortably complete the procedure in a fully awake patient)?
- Withdrawal Time – The time spent examining the colon while withdrawing the scope from your bowel correlates with higher rates of adenoma detection. The recommended withdrawal time is at least 6 minutes, as this ensures thorough inspection. Ask your endoscopist if they measure withdrawal times in their practice and what is their median time for patients who had adenomas. They should be both able and willing to furnish you with this information.
For Upper Endoscopy (Gastroscopy) key performance metrics are:
- Esophagogastric Junction Inspection Rate: Ensures a careful examination of the junction between the esophagus and stomach, which is crucial for detecting early cancer or Barrett’s esophagus.
- Photo Documentation Rate: High-quality endoscopists take images of key anatomical landmarks to ensure a complete and accurate examination.
5. Patient Reviews and Recommendations
I am not a great believer in these methods for endorsing an endoscopist. Patient testimonials and online reviews can offer insights into a doctor’s communication skills, bedside manner, and the overall experience at their facility, but be a little wary of these patient testimonials: the process is vulnerable to bias and selective publication. It is often better to ask an independent endoscopy nurse who they would recommend, since they work in the sector. A single person’s experience of a procedure can also be misleading, as they might have been lucky to have had a pleasant experience, or unlucky to have an unpleasant one at the hands of the endoscopist, yet 100 patients might have had a very contrary experience to theirs. GP testimonials or recommendations are sometimes useful, especially where the GP has been on the receiving end of an endoscopy themselves or when they have no link to the endoscopist but a professional one. For others there is inevitable (if inadvertent) bias because we are a small country and often there is a link between two doctors through their schooling, undergraduate training, specialist training, spouses or children.
6. Sedation and Comfort Options
Find out what sedation options are available to you. Choice and flexibility are admirable qualities when choosing a facility or specialist. Some refuse to do procedures without sedation, if this is your preference, so look to someone who will offer you this option. Some patients prefer light conscious sedation and if your endoscopist has a reputation for giving heavy doses of sedation, you might wish to avoid them. Typical doses of Midazolam are 2-4mg (depending on your age and your general health) which can be topped up if necessary during the procedure, but avoid endoscopists who give you heavy doses upfront – it is both dangerous and often used to mask poor technique or expedite the procedure. Some patients need a general anaesthetic because of safety concerns or bad previous experiences of conscious sedation: ask your endoscopist if they can facilitate this for you or not if you are someone who needs a general anaesthetic, or if you are frail and would welcome the added security of having an anaesthetist oversee your procedure whilst the endoscopist focuses on the endoscopy alone.
7. Complication Rates and Safety Record
Ask about their complication rates, especially regarding:
- Perforation (tears in the digestive tract)
- Post-procedure infections
- Bleeding complications
A good endoscopist should have low complication rates and follow strict safety protocols. Be wary of those who say they have no complications.
8. Insurance Coverage and Costs
Check whether the doctor and the facility accept your insurance plan. In New Zealand there should be no out-of-pocket costs to you if you are insured. Ask about these costs, if in doubt. If you are self-funding your procedure, ensure that your endoscopist can give you a detailed list of potential expenses (including itemised billing) for any equipment or steps taken beyond the baseline diagnostic steps of your procedure. For example, ask about the escalation of costs after baseline for the likes of basic polyp removal, tattooing of polyp sites, use of clips to secure bleeding, biopsies, advanced polyp removal techniques like EMR etc. You can be sure that the facility knows these costs, as they raise invoices for them, so be sure to get a solid answer to your questions.
9. Pre- and Post-Procedure Care
A good endoscopist provides clear instructions on:
- Preparation – Comprehensive dietary and medication adjustments before the procedure, where they are located, when to arrive, what to bring with you, who is qualified to take you home, emergency contact details etc.
- Post-procedure Care – What to expect afterwards, both at their facility and beyond, how you will be informed of results, when you might need a follow up appointment, what symptoms to expect, how to recognise and deal with complications that arise when you are home again etc.
10. Personal Comfort and Communication
Lastly, choose an endoscopist who listens to your concerns, understands that you are a unique person with a unique set of circumstances, who explains personally or by proxy the procedure to you thoroughly, who considers alternative strategies to get answers, and makes you feel comfortable and confident in their ability to keep you safe. A friendly and well-qualified doctor with a patient-centered approach can reduce your anxiety and improve your overall experience of endoscopy.
Final Thoughts
Choosing the right endoscopist is crucial for accurate diagnosis, effective treatment and a safe experience. By considering factors like qualifications, experience, accreditation and high performance standards you can make an informed decision and ensure that you undergo a safe, high-quality endoscopy. The information is out there – just ask!