Endoscopy Training in a Family Medicine Residency

1. Endoscopy Training in a Family Medicine Residency American Association of Primary Care Endoscopy San Francisco November 2, 2012

2. Endoscopy Training in Texas A&M Family Medicine Residency David A. McClellan, md Texas a&M Family medicine residency bryan/college station

3. 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.

4. 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 Fujinon2003 • 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

5. Faculty • Robert Pope, MD • John Rodney, MD

6. A Visionary • Christine Pinones, RN

7. 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 Texas • Grant application #1 - CPRIT 2010 - not funded • Equipment now ~ 6 years old • New Facility with New Endoscopy Procedure Suite - 2011 • Equipment now 7 years old

8. Texas A&M PhysiciansFamily Medicine Center

9. 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

10. Public Health Partners • Jane Bolin, RN, JD, PhD • Marsha Ory, PhD, MPH

11. Procedure Suite – New Scopes

12. GI Mentor Simulator

13. Enhanced Colorectal Cancer Screening in a Family Medicine Residency ProgramServing Low-Income & Underserved Translating Research into Practice Co-Principal Investigators Dr. David McClellan, MD - College of Medicine Dr. Jane N. Bolin, RN, JD, PhD - School of Rural Public Health

14. C-STEP Project Goals

15. 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

16. 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.

17. 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.

18. FM Resident Training

19. 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.

20. 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 and by partnering with aftercare providers.

21. Sources of Referrals

22. Community Events • Health Fiesta • Health Fairs • Community Outreach (churches, community centers, senior centers)

23. Tracking and evaluating through patient navigation

24. 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

25. 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.

26. Patient Flow

27. Data Flow

28. 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. Patient Screening Algorithm 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 • 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 • Routine clinical f/u • Patient education • CHW/Promotores • Navi4Health • Adenomatous Polyps Polypectomy enter surveillance at TAMFMC; • Colorectal CancerAfter Care Referral, CHW/Promotores, Navi-4Health, Surgeon Consultation, Oncology Consultation Link to Clinical Trials (e.g., TLSF CTNet ) for Evaluation of cancer clinical trials options.

29. Partners

30. When should preventative screening occur?

31. 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.

32. 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.

33. Texas Colorectal Cancer Incidence

34. Colon Cancer Incidence in the Brazos Valley

35. CHWs in Action

36. The SuperColonTM

37. The SuperColonTM

38. Texas C-STEP

39. 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%)

40. 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%

41. 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)

42. 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)

43. Bibliography • 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.

44. *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.

45. Contact Information Texas A&M Physicians Family Medicine Center - Family Medicine Residency Program David A. McClellan, MD (979) 436-0485 damcclellan@medicine.tamhsc.edu

46. Questions? Thanks! Jane Bolin, RN, JD, PHD Christine Pinones, RN Sonja Welch, RN Janet Helduser, MPH Marsha Ory, PHD, MPH Philip Nash, Bsc Patricia Dunbar ChelseyHollas ChinedumOjinnaka Nicholas Edwardson Elisabeth Almanza, LVN Sabrina Washington, CHW CPRIT And many others