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Who should perform endoscopic procedures?
We read with great interest the report of
This work shows a limited experience with specific endoscopy trained nurses that had no significant effect on diagnostic yield, patient discomfort, or patient satisfaction compared with medical staff. Many experiences, some of them mentioned in this report, have shown that nurses can successfully perform endoscopic procedures.
Of course, nurses require a training programme, similar to the one usually offered to our residents and trainees. We are certain that specifically trained nurses could also perform liver biopsies, abdominal ultrasound examinations, diagnostic laparoscopy, and some surgical procedures, such as appendectomy or elective cholecystectomy. Any manual (surgical or endoscopic) procedure may be learnt by anyone, medical or non-medical, in common with many other forms of manual labour or craftsmanship. Frequently, and not so long ago, GPs performed some surgical procedures, such as caesarean section and appendicectomy, and barbers once performed surgery. This could be the first step towards a new perspective for medical practice in which nurses might attend our gastroenterology wards and clinics in some circumstances.
We have no doubt about the accuracy and seriousness of this report but, as the authors explain in the introduction, the main motivation for the study was economic. Public health systems, such as the British and Spanish systems, have a great deal of sanitary costs. In our day to day clinical practice, many strategies are tried with the aim of reducing costs. But some frequently overlooked ethical, scientific, and philosophical questions are implied. Nowadays, there are more restrictive conditions to teaching endoscopy to young gastroenterologists.1 Ethical and legal concerns make resident training more expensive and difficult, as our developed societies are increasingly demanding of healthcare quality and safety.2 Hence should we begin teaching endoscopy to non-medical staff? We do not believe so. We also believe that one essential function of medical practice is to provide investigation (an always limited field in terms of funds and time) in public hospitals’ busy endoscopy wards. Then, should nurses have a specific training in investigation? The excellent work of Smale et al raises many other simple questions: (1) When to stop? (2) The main goal of this work was to have cheaper endoscopists, so why not try to minimise costs by teaching nurses other physician tasks, such as physical examination or minor surgical procedures? (3) Should we begin training nurses instead of our residents in our endoscopy wards? (4) Why not begin to teach nurses other endoscopic procedures, such as endoscopic retrograde cholangiopancreatography or endoscopic ultrasound and, in this event, what is the future role for physicians?
In summary, we believe our efforts should be directed towards better clinical practice, defining indications for different medical procedures, limiting costs in the many other aspects of endoscopy and gastroenterology, and trying to perform our specific role, nurse or medical, as scientifically based and accurate as possible.