Reply to Dr. Tursi

We appreciate the comments raised by Dr. Tursi. Medicolegal issues are indeed important in any field of medicine, including endoscopy. Growing health care demands and costs in all Western countries require unprecedented solutions, including selective use of resources and rescheduling of tasks. The latter includes rescheduling of tasks from registered nurses to other personnel, as well as rescheduling tasks from physicians to specialized nurses. We fully agree that this can only be done under strict legal authorization. To accomplish this, one first needs evidence that nurses can perform a task competently, adequately, and safely; hence our research as presented in Endoscopy [1]. The next step is to search for legal possibilities. In the Netherlands, for example, rules for health care professionals are set by the Individual Health Care Professionals Act (Wet BIG). This act authorizes nurses to be trained in and perform specific delegated tasks, provided the tasks are performed in accordance with the quality standards and under a prespecified level of supervision. Nurses trained and assessed to be competent to perform a specific procedure will be judged accordingly, and are personally responsible for the procedure, including its complications. Medical liability insurance for hospitals and professionals covers medical malpractice costs. However, it is the responsibility of local institutions to define these rules and responsibilities to clarify the medicolegal implications.

We fully agree that there are several other potential solutions to increase endoscopic capacity, such as reducing the demand for endoscopy by effective and appropriate utilization of existing endoscopy services. Studies have shown that substantial endoscopic resources are being used for inappropriate indications or at inappropriate surveillance intervals compared with the guidelines [2]. In addition, the endoscopic demand resulting from colorectal cancer screening depends on the chosen modality of primary screening, the target population, population adherence, and, finally, the surveillance protocol. All established screening methods have considerable impact on endoscopy services [3 – 7]. Endoscopic capacity serves as a barrier to colorectal cancer screening [8, 9]. The new screening strategies proposed by Tursi are promising for the identification of persons at high risk of early-stage disease and will potentially reduce endoscopic demand. However, before being considered for use in primary screening, these strategies need to be validated in population-based studies [10 – 12].

• References

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• 12 Kuipers EJ, Rösch T, Bretthauer M. Colorectal cancer screening – optimizing current strategies and new directions. Nat Rev Clin Oncol 2013; [Epub ahead of print]