The authors of the article on flexible sigmoidoscopy in this issue of American Family Physician¹ have crafted an excellent review of what many had hoped would become a diagnostic tool frequently used by generalist physicians. Gastrointestinal symptoms and colorectal cancer screening are well known in family practice, and the benefits of endoscopic examination are proved. However, too few family physicians are screening their patients.

When introduced in the early 1980's, flexible sigmoidoscopy was going to be the catalyst leading to widespread compliance with screening recommendations for the prevention of colorectal cancer.^2–4 One published study⁵ revealed a large initial change in physician behavior. However, more recently, another round of data described widespread under-use of flexible sigmoidoscopy among family physicians.^6–9 I estimate that only one half of the 65,000 family physicians in this country maintain their diagnostic and therapeutic procedural skills in flexible sigmoidoscopy.

One reason for this low rate is that a substantial percentage of residents do not receive adequate training in this procedure. Claims of compliance with high rates of technical procedures at residency programs continue to suffer from selection bias, reporting bias and a lack of competency-based testing.^10,11

Among physicians who maintain their skills, doing so is a labor of love.^12,13 Increasingly, financial disincentives have discouraged physicians from regularly performing sigmoidoscopies in their offices. Several of my graduates have announced that they will be seeking jobs where procedures are automatically referred to subspecialists. Reimbursement for office-based flexible sigmoidoscopy is frequently in the range of $100 to $200. The family physician also has to purchase his or her own equipment, maintain staff, and understand disinfection/cleaning procedures. These additional costs and responsibilities cause some family physicians to give up flexible sigmoidoscopy and refer.

What about colonoscopy? Reimbursement for this procedure is much higher. The average Medicare reimbursement in Tennessee for colonoscopy is $300, compared with only $85 for flexible sigmoidoscopy. In addition, the hospital receives another $350 to $500 as a facility fee in supporting colonoscopy. If the patient has private insurance, the total reimbursement is over $700 for the physician and over $700 for the hospital.

Unfortunately, family physicians are even less likely to perform colonoscopy than flexible sigmoidoscopy. The higher reimbursement rates have provided an incentive for gastroenterologists to maintain an aggressive campaign for control of colonoscopy and endoscopy procedures. Besides, patients who undergo colonoscopy require sedation/analgesia.^14,15 Some physicians are uncomfortable with parenteral administration of these drugs, and, in fact, some states restrictively regulate intravenous dosing by primary care physicians.

It is a shame that flexible sigmoidoscopy and colonoscopy are not performed more frequently by family physicians. The importance of office-based screening by flexible sigmoidoscopy and fecal occult blood testing is well established. Colonoscopy is an even better screening tool: it offers greater sensitivity and therapeutic options and appears to be preferred by patients in many cases. Yet, patients are not getting the screening they need: one study¹⁶ showed that less than 9 percent of patients over the age of 50 years had flexible sigmoidoscopy in the past few years, and that less than 20 percent have received fecal occult blood testing, a much less invasive test.

In my opinion, the best hope for improved screening is to reinforce the physician-patient relationship.¹⁷ Restrictive regulations create rationing through inconvenience. Lack of training further demoralizes physicians. Both impede effectiveness of any cancer prevention program. The bond between physician and patient is the key to patient cooperation with any cancer screening procedures that are unpleasant or inconvenient. Meanwhile, we must increase family physician interest in doing flexible sigmoidoscopy. Legislators need to realize that regulations have gutted incentives for primary care physicians. Also, we must make every effort to support family physicians who wish to perform colorectal cancer screening procedures. And, just as important, our training programs must provide opportunities to improve proficiency in flexible sigmoidoscopy and colonoscopy.