To the Editor,

The demand for colonoscopy continues to outnumber the supply of gastroenterologists, particularly in rural, underserved, and gerocentric areas (American Association of Medical Colleges, 2012; Colorectal Cancer Awareness, 2009). By 2020, between 1,050 and 1,550 more gastroenterologists will be needed to meet current demand or at a 10% projected rate of increase (Rabin, 2009). The reasons why this deficit exists are numerous. It is difficult to attract healthcare professionals to rural and underserved areas, which are seen to be less-attractive places to live and salaries tend to be lower than those in urban or suburban areas. What then can be done to improve access to endoscopy care and improve healthcare outcomes in rural communities?

The literature has already substantiated nurse practitioner (NP) and physician assistant (PA) ability to perform colonoscopy as well as gastroenterologists in terms of safety, efficiency, quality outcomes, and patient satisfaction surveys (Hopchik, 2012; Limoges-Gonzalez et al., 2011). For years, a few gastroenterology departments in the Veterans Affairs (VA), Johns Hopkins, and the University of California Davis have demonstrated successful NP fellowships. These graduates continue to make a significant contribution to improving patient outcomes screening for colon polyps, earlier diagnosis, referral for colorectal cancer, and in reducing the fiscal burden associated with this valued procedural care.

A viable solution to getting more advanced practice registered nurses (APRNs) and PAs out in the underserved areas may lie in supporting and expanding the development and implementation of additional training programs that could bolster existing gastroenterology practices in rural settings and might also entice other gastroenterologists to follow. There would have to be a paradigm shift in thinking and culture from clinical, political, and economic authoritative bodies to make this become a reality (i.e., American College of Gastroenterology, American Society of Gastrointestinal Endoscopy, Centers for Medicare & Medicaid Services, and the Patient Protection and Affordable Care Act).

Of course, attractive compensation packages would have to be created to recruit and retain these highly skilled healthcare professionals. Carefully crafted contractual agreements would also need to be set up to ensure a continual steam of APRNs, PAs, and gastroenterologists to maintain sustainability in these underserved areas.

The Institute of Medicine Report (2010), The Future of Nursing: Leading Change, Advancing Health, promulgated that care transformation could not be achieved unless nurses functioned to the full extent of their education and training. Recently, the U.S. Department of Health and Human Services (2011) released the National Quality Strategy goals known as the "Triple Aim," which strives for better care, healthier people and communities, and affordable care. Two great exemplars recognizing and supporting the need to advance nurses' education and training to the fullest potential.

As a gastrointestinal (GI) NP at the Philadelphia Veterans Affairs Medical Center, I am the first NP trained and credentialed to perform colonoscopy in Pennsylvania. It was a long haul, but well worth the time and effort. I realize first hand that I am making a huge difference in the health and well-being of the veterans I serve. I continue to advocate and encourage other APRNs in existing GI practices or those interested in pursuing a career in this specialty, to seek opportunities to become colonoscopy credentialed.

For my clinical capstone project as a doctor of nursing practice student, I will be creating a virtual GI Community of Practice to establish a social, educational, and professional network with other credentialed APRNs and PAs, which may help expand the number of nonphysician endoscopists in the VA Healthcare system. Furthermore, a national pilot nonphysician endoscopy-training program is under consideration.

There are several million veterans who reside in the rural parts of the United States whose GI needs may not be being addressed quickly enough and whose health is potentially being jeopardized. Perhaps, by increasing the number of colonoscopy training and incentive programs to this end, we will get much closer to providing greater access and improved GI care provisions to those who have dedicated their lives to serving our country.

Respectfully submitted,

Jordan Hopchik, MSN, RN, FNP-BC, CGRN

Gastroenterology Nurse Practitioner

Philadelphia VA Medical Center

SGNA Scholar

Doctor of Nursing Practice Student

La Salle University

Philadelphia, Pennsylvania

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