The Utility of Colonoscopy Simulators

QUESTION: FROM JSB CONTRA COSTA

Hi Folks: These babies cost a bundle: ~$200,000 which far exceeds my credit-card limit. (attached is file from Company selling simulation equipment for EGD, IV Access (central as well), Colo, Laparascopy, Cardiac Cathing, etc. We are looking into the Colo machine at $200,000 (looking for a Grant).

We are looking into finding Grant money for the Endoscopy simulator, the others are quite interesting as well. I am particularly surprised to see a PTCA + Stent simulator which opens up all kinds of possibilities. Does this mean an IR person could get trained with this simulator and start doing Caths somewhere if they could get priveleges? Hmmmm. Caths are getting to be about as common as PAP smears and are far more common than Chest Tubes, Venous cutdowns, surgical trachs and some other stuff we talk about training FP's to do.

Would it be a useful framwork to focus our energies on training Family Physicians to do the most common procedures done by physicians? The most neglected that can save lives (Colos)?

So, what do people think about these simulators? Effective? Worth it? A techno-play-thing without much benefit? A great way to determine competence?

Thoughts?

In reply to Dr. Fish's unanswered question about the utility of colonoscopy simulators I am reminded of the simulators I see accumulating dust in various residencies with previously unspent grant funds. During the twenty years I taught coloncosopy for the AAFP, we used the simulators as an "add on" teaching station during the years 1999-2002, but they did not add value. Because their manufacture was contingent upon the ability to sell them for a profit, the industry collapsed for lack of market demand. The potential for improved simulation remains, but , similar to the Welch Allyn "primary care" endoscopy experiment, these business failures are slow to rebound.

The technology is available to produce an improved product, but, aside from a handful of mildly interested family medicine educators, there is no market. Also there would be the need for field testing and publication. This would exceed the attention span of current grant agencies where imbedded gastroenterologists seek out and destroy any semblance of organized resistance to their current monopoly on training. Also, the loss of such a monopoly would threaten the academic house of cards which requires an intricate and costly system of internal medicine fellowships for medical school accreditation from the LCCME.

The power of family medicine remains among those with control over their community office environments. We know the clinical need is there among the patients we see every day. Flexible sigmoidoscopy was a political device and skills compromise which served as "training wheels" for colonoscopy. All of our early literature referred to the 60 cm scope as a short colonoscope. Therefore the training material is within reach of every motivated young family physician.

In California and Florida there is the need to deal with the newly minted regulations on sedation/analgesia, but these are paper tigers. Almost always family physicians have successfully won battles against discrimination on the issue of reimbursement. Lack of training progress is due to the fact that most family physicians have voted with their feet to accept 40 hour per week jobs as limited generalists. They do not wish and do not seek further training. The AAFP and NPI courses continue to reach about 100 family physicians a year. Maybe a little more. Jack, you can help me here.

Wm MacMillan Rodney MD

Adjunct Professor of Family Medicine

Adjunct Professor Surgery/Emergency Medicine

Meharry/Vanderbilt School of Medicine

Medicos para la Familia

Memphis and Nashville, Tn.

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