Family Physicians Perform High-Quality Colonoscopies, but Access Is an Issue

Kenny Lin, MD, MPH
Posted on January 13, 2025

Most patients who choose colonoscopy as a screening test for colorectal cancer are referred from primary care to a gastroenterologist or other specialist who performs endoscopy. But that wasn’t the case for the estimated 1 in 15 US patients whose screening colonoscopies were performed by family physicians in 2021. A study of an insurance claims database found that family physicians are more likely to perform colonoscopies in older, male patients residing in more rural areas of the Midwest, South, and Western United States.

The American Academy of Family Physicians (AAFP) maintains that clinical privileges should be based on documented training and experience rather than the physician’s specialty. In 2000, AFP published an AAFP position paper (an updated version currently resides on the AAFP website) emphasizing that “colonoscopy can be a natural extension of the total care provided by a well-trained family physician.” In 2008, a Society of Teachers of Family Medicine consensus statement classified colonoscopy as a core procedure that family medicine residents should not only be exposed to but also “have the opportunity to train to independent performance.”

A 2009 meta-analysis of 12 studies (n = 18,292) of screening colonoscopies performed by primary care physicians and a later study of faculty and residents at a single, university-affiliated family medicine center concluded that their performance on quality, safety, and efficacy indicators (reach-the-cecum rate, major complication rate, and adenoma detection rate) was comparable to those recommended by the major gastrointestinal endoscopy societies. In addition, a recent analysis of colonoscopy quality at two high-volume rural programs (University of Texas Southwestern and University of North Dakota) for family physicians, general surgeons, and gastroenterologists found no statistical differences in performance by provider type.

Data indicate that screening colonoscopies are overused and that a colonoscopy-first strategy may only be marginally better than sequential fecal immunochemical testing in reducing colorectal cancer mortality. Nonetheless, millions of US adults older than 50 years have never been screened for colorectal cancer and could potentially benefit from having access to family physician–performed colonoscopy services. Thus, the decline in endoscopic care (including flexible sigmoidoscopy) by family physicians in both urban and rural areas is cause for concern. From 2016 to 2021, the percentage of screening colonoscopies performed by family physicians decreased from 11.3% to 6.7%, and less than 2% of board-certified family physicians report performing colonoscopy in their practices.