Endoscopy Training in a Family Medicine

Residency

American Association of

Primary Care Endoscopy

San Francisco

November 2, 2012

DAVID A. MCCLELLAN, MD

TEXAS A&M FAMILY MEDICINE RESIDENCY

BRYAN/COLLEGE STATION

Endoscopy Training in Texas A&M Family Medicine

Residency

TAMFMR - Mission Statement

Our mission is to conduct comprehensive family medicine training that prepares physicians for rural practice; to provide compassionate, high quality healthcare; and to foster scholarly activity.

TAMFMR Endoscopy – History

The Early Faculty Pioneers – Brazos Family Medicine Residency• John Frederick, MD - 2000 Hospital Endoscopy Privileges• Dennis LaRavia, MD – 2001 Hospital Endoscopy Privileges

The New Faculty Trainees: Endoscopy in the FMC Endo Suite with donation of 2 Colonoscopes and 2 Gastroscopes by Fujinon 2003• Robert Pope, MD• David McClellan, MD• Stuart Quartemont, MD

Residency Transitioned to TAMHSC Sponsorship 2008• Ryan Loyd, MD• Joshua Loyd, MD

Trained in our Program: • John Simmons, MD - 2009

New Faculty:• John Rodney, MD – 2012

Faculty

Robert Pope, MD John Rodney, MD

A Visionary

Christine Pinones, RN

Searching for $ Funds $

Cancer Prevention Research Institute of Texas• Approved by taxpayers of Texas 2007• $3 billion in bonds authorized by a constitutional

amendment• Funds cancer research, prevention programs, and

services in TexasGrant application #1 - CPRIT 2010 - not funded

• Equipment now ~ 6 years oldNew Facility with New Endoscopy Procedure Suite - 2011

• Equipment now 7 years old

Texas A&M PhysiciansFamily Medicine Center

Second Try – Funded!

Grant application #2 - CPRIT 2011 – Funded• $2.7 million over 3 years. • Split between TAM FMR and School of Rural Public

Health Screening procedures, pathology Personnel Equipment: Endoscopes, Jet washer, Scope Washer

(plumbing) Simulator

CSTEP• Colorectal Screening Training & Education Program

Public Health Partners

Jane Bolin, RN, JD, PhD

Marsha Ory, PhD, MPH

Procedure Suite – New Scopes

GI Mentor Simulator

TRANSLATING RESEARCH INTO PRACTICE

CO-PRINCIPAL INVESTIGATORSDR. DAVID MCCLELLAN, MD - COLLEGE OF MEDICINE

DR. JANE N. BOLIN, RN, JD, PHD - SCHOOL OF RURAL PUBLIC HEALTH

Enhanced Colorectal Cancer Screening in a Family Medicine

Residency ProgramServing Low-Income & Underserved

GOALS

C-STEP Project

C-STEP Goal #1

Increase the number of low-income underserved Texans

>50 years of age, and those at risk, who receive colorectal

cancer screenings at the TAMHSC Family Medicine

Residency Program.American Cancer Society, 2011

C-STEP Goal #2

Improve access to cancer screenings, follow-up care and treatment in the Brazos Valley for poor, rural and/or minority

populations through community outreach and culturally-relevant

case management, from Promotoras/Community Health

Workers.

C-STEP Goal #3

Increase the number of family medicine physicians (FMPs) trained in colorectal cancer screening in Texas by 8 to 10 physicians each

year, with 43 new FMPs trained over three years of funding.

FM Resident Training

C-STEP Goal #4

Increase the pool of trained providers to conduct colorectal cancer screenings by providing

interested practicing family medicine physicians who have

prior training in flexible sigmoidoscopy with advanced

training in colonoscopy screening.

C-STEP Goal #5

Sustain colorectal cancer screening and colonoscopy

training at the Texas A&M Health Science Center (TAMHSC) Family Medicine Residency program by continued training of all family

medicine residents andby partnering with aftercare

providers.

Sources of Referrals

Community Events

Health Fiesta

Health Fairs

Community Outreach (churches, community centers, senior centers)

Tracking and evaluating through patient navigation

Tracking and evaluating through patient navigation

Promotoras and community health workers will:

Receive referrals

Work planned community outreach events to register individuals for colorectal cancer screenings

Collect relevant data

Serve as a “bridge” or patient advocate between clinical staff and patient services

Help patients navigate the complex health care system

Cancer Training Innovation

Implementation of a culturally appropriate evidence-based colonoscopy screening training.

Unique to a Family Medicine Residency Program in Texas

Enhancing colonoscopy screening training will increase colon cancer screenings in the Brazos Valley and throughout Texas, and create a model for translating colon cancer screening and prevention services into the family practice setting utilizing CHW/Promotoras.

Unique partnership between SRPH & COM.

Employment of three (3) SRPH Faculty, two (2) staff, and two (2) graduate assistants over three years.

Patient Flow

Data Flow

Average Risk: ≥ age 50 with no family Hx CRC

Moderate Risk: ≥ age 40 w/ family Hx CRC, polyps,

or positive FOBT

High Risk: Personal Hx CRC, IBD, or

genetic syndrome

CRC Screening Algorithm: Staff and CHW/Promotores review & update patient history, including family history for colon cancer. Assess for symptoms such as rectal bleeding,

anemia or inflammatory bowel disease.

•Follow USPS Task Force Screening Guidelines•Annual FOBT•Colonoscopy once every ten years

Begin colonoscopy at age 40 or 10 yrs younger than age of family member with colon ca.

Begin colonoscopy at age 40 or 10 yrs younger than age of family member with colon ca.

NORMAL? ABNORMAL

•Adenomatous Polyps Polypectomy enter surveillance at TAMFMC; •Colorectal CancerAfter Care Referral, CHW/Promotores, Navi-4Health, Surgeon Consultation, Oncology Consultation

•Routine clinical f/u

•Patient education•CHW/Promotores•Navi4Health

Link to Clinical Trials (e.g., TLSF CTNet ) forEvaluation of cancer clinical trials options.

Patient

Screenin

g

Algorithm

Partners

When should preventative screening occur?

The Need for Colorectal Cancer Screening in TAMHSC’s Service Area

Colorectal cancer is the second leading cause of cancer deaths in Texas.

Incidence of colon cancer and associated mortality is higher in rural regions than in metropolitan areas.

The Need for Colorectal Cancer Screening in TAMHSC’s Service Area

The Brazos Valley (BV) region of Texas has a significant need for improved colon cancer screening• 5 rural counties show colon cancer

rates higher than the state average.

Texas Colorectal Cancer Incidence

Colon Cancer Incidence in the Brazos Valley

CHWs in Action

The SuperColonTM

The SuperColonTM

Texas C-STEP

Results: Clinical Services

Colorectal Cancer Screenings(First year: 9/1/2011 – 8/31/2012)

401 Received CRC Screening

132 Abnormal CRC Screening Results

107 Adenomas Detected (27%)

4 Local stage cancers detected (0.998%)

Results: Clinical Services

Colorectal Cancer Screenings(9/1/2011 – 10/10/2012)

Cecum Attained – 96.54%

Average Procedure Time – 0:48

Average Withdrawal Time – 0:16

Withdrawal Rate > 0:06 minutes – 94%

Results: Professional Education

Professional Development(First year: 9/1/2011 – 8/31/2012)

30,114 Professionals Reached by Indirect Contact

(professional meetings & publications)

437 Professionals Educated by Direct Contact

(training, referral network, & provider meetings)

Results: Community Outreach

Community Outreach(First year: 9/1/2011 – 8/31/2012)

30,870 People Received by Indirect Contact

(brochures, patient education materials)

1,617 People Reached by Direct Contact

(educational programs, physician referrals/consults)

Bibliography

1) Sarfaty, Mona. How to Increase Colorectal Cancer Screening Rates in Practice: A Primary Care Clinician's Evidence-Based Toolbox and Guide 2008. Eds. Karen Peterson and Richard Wender. Atlanta: The American Cancer Society, the National Colorectal Cancer Roundtable, and Thomas Jefferson University 2006, Revised 2008.

*Take Home Points*

Be persistent Partner with anyone willing in your community Partner with nearby School of Public Health

• MPH Candidates need a “Practicum” experience• 12 weeks working in a clinical or public health setting• Assistance with Grant writing, Clinical Data

Management, Creation of an Endoscopy Patient Registry for your practice, Community Outreach, etc……….

CDC has a colon cancer screening program in some states. CDC a possible opportunity.

Contact Information

Texas A&M Physicians Family Medicine Center - Family Medicine Residency Program

David A. McClellan, MD(979) 436-0485

damcclellan@medicine.tamhsc.edu

THANKS!JANE BOLIN, RN, JD, PHDCHRISTINE PINONES, RN

SONJA WELCH, RNJANET HELDUSER, MPH

MARSHA ORY, PHD, MPHPHILIP NASH, BSCPATRICIA DUNBARCHELSEY HOLLAS

CHINEDUM OJINNAKA NICHOLAS EDWARDSON

ELISABETH ALMANZA, LVNSABRINA WASHINGTON, CHW

CPRITAND MANY OTHERS

Questions?