Should NPs Perform Colonoscopies? New Study Leads to Controversy

A new study from John Hopkins is causing quite a stir on social media. It centers on three nurse practitioners who were trained to perform colonoscopies. The study looked at more than 1,000 patients who received this procedure from the NPs between 2010 and 2016, 75% of whom were black.

The study is raising eyebrows for its questionable ethics; some have been criticizing it for its lack of consent and transparency.

The Need for Colonoscopies

The medical community is bracing for a surge in demand for colonoscopies as the population continues to age and baby boomers head into retirement. It’s considered a life-saving cancer screening tool, but many men are reluctant to sign up for the procedure. 

The death of actor Chadwick Boseman last year intensified the issue. The beloved Black Panther star passed away from colorectal cancer at the age of 43. His death was a wake-up call to both patients and providers. Colorectal cancer is becoming more common among younger men, particularly African Americans, which is why testing is so crucial among all age groups.

Researchers at John Hopkins were looking to see whether nurse practitioners could perform colonoscopies, which is typically done by a gastroenterologist. The NPs completed a year-long GI training fellowship before practicing independently. They were then asked to perform colonoscopies on patients in the Baltimore area to see if they could deliver the same standard of care as medical doctors.

For comparison’s sake, it’s important to note that gastroenterologists typically complete three years of internal medicine training and a three-year gastroenterology fellowship before working on their own in the field.

Courting Controversy

It’s true that African Americans make up 63% of Baltimore’s population, but they make up just 25% to 31% of those typically treated at John Hopkins. The hospital said it provided the procedure to those living in the community, but the racial dynamics of the study generated quite a reaction on social media.

Some have called the study exploitative. Fola May, a gastroenterologist at the University of California, Los Angeles, was one of the first to speak out. “That is a huge red flag because that could not have happened randomly. Did they preferentially pick black patients to be in the study and to get the NP colonoscopies?”

She also tweeted that the paper documenting the study was “fueling the woes and fears of experimentation and exploitation in the black community yet again!”

Jazmyn Shaw, an emergency room nurse and medical student, added on Twitter, “Feels a lot like medical experimentation (*cough* racism) to me.”

“Trying to wrap my head around how they managed to get ~750 black people to sign up for this. I can’t even convince my family to get vaccinated,” wrote Kerry Mitchell, a plastic surgeon at Ohio State University Wexner Medical Center.

Others argue the patients involved in the study didn’t have consent over their care. Rachel Issaka, a gastroenterologist at the Fred Hutchinson Cancer Research Center in Seattle, commented, “When I saw the paper, my immediate concerns were around informed patient consent. I really wanted to know, were those patients told up front that their colonoscopy was being done by a nurse practitioner, because that’s not the standard of care in the United States.”

It’s not clear whether John Hopkins told the patients that the procedure was going to be performed by a nurse practitioner instead of an MD.

Some say that since African Americans face a higher risk of colorectal cancer, they should receive the gold standard of care.

Ruqaiijah Yearby, a bioethicist at Saint Louis University, added, “They don’t just need somebody who was able to do it, they actually need somebody who can catch all of the problems that they may suffer because they’re at increased risk of a higher rate of disease, cancer, and death.”

The study was authored by Anthony Kalloo, a gastroenterologist, who’s been a fierce advocate of the research. He says increasing the number of providers who can perform colonoscopies makes perfect sense. “My God, it’s such a no-brainer to me almost. Why wouldn’t you want to save costs, especially when you have demands for a procedure that’s increasing and increasing,” he said. “So, the logical thing, in terms of supply and demand, would be to train nurse practitioners to do this.”

He also shrugs off the idea that the hospital went out of its way to include black people in the study. “There was not a selective intent to seek out patients of minority [groups],” he added. “And as I said, I am a minority.”

Each of the NPs performed at least 140 colonoscopies under the supervision of a gastroenterologist during the fellowship program before completing them on their own. Sophie Balzora, a gastroenterologist at NYU Langone Health, says most people need more time and training to perfect the procedure.

“By the end of first year, you would have several hundred under your belt, and you still wouldn’t be comfortable performing procedure after procedure on your own without any supervision,” she said.

The need for more colonoscopies is clear, but the push to have NPs perform this procedure remains controversial.