Previous research has shown that fatigue is an under­estimated cause of underperformance among physicians. The issue of production pressure and its effect on quality of care permeates every aspect of the healthcare industry, including colonoscopy. Studies suggest that fatigue or other byproducts of production pressure may negatively influence the quality of colonoscopy, which could affect the quality of colon cancer screening.

Surveying the Endoscopy Scene

In a recent issue of Gastrointestinal Endoscopy, my colleagues and I published the results of a 40-question online survey designed to assess the perceptions of practicing endoscopists regarding production pressure and its effects on their personal performance of colonoscopy. According to our results, 92% of respondents indicated that production pressure influenced one or more aspects of their endoscopic practices. Examples of production pressure included:

Proceeding with colonoscopy in patients with unfavorable risk/benefit ratios.
Reducing the length of time spent inspecting the colon.
Postponing polypectomy for a subsequent session.

Our study also found that almost half (48%) of respondents  witnessed the effects of production pressure on a colleague. Respondents working fee-for-service and those with more than 10 years since completing their fellowship were more likely to describe their weekly workloads as “excessive” when compared with those who were salaried or less than 10 years out of training.
Our survey also showed that many respondents don’t have enough time for pre-procedural assessment, and some believed that patients were discharged from their unit prematurely. About two of every five respondents (42%) identified one or more sources of inefficiency within their practice, such as an inadequate number of procedure rooms, insufficient staff, or too few beds in the recovery unit. While most endoscopists (97%) reported that the medical care that they provide now is equivalent to or better than it was 3 years ago, 79% experienced more work-related stress, and 81% indicated that they’re working harder now to preserve their practice income than they were previously.

Important Implications on Colonscopy

With the number of colonoscopies performed by endos­copists having increased significantly over the past 15 years, it’s imperative that increased output not sacrifice quality or safety. While the quality of colonoscopy does not appear to have decreased, it could be compromised as production pressures grow. Balancing quantity and quality should be addressed in order to ensure that clinicians continue to successfully implement colon cancer prevention programs and optimize the use of colonoscopy.

Hospitals and medical centers should view our study as a reminder that quality with colonoscopy could suffer if efforts aren’t made to preserve it. Continuous quality-improvement programs should be implemented that offer periodic retraining and reinforce the importance of allocating enough time per procedure. They should also evaluate and measure the pre- and post-procedural processes and procedures for colonoscopy. Such efforts may ultimately help avoid issues of fatigue and production pressure for physicians and create solutions that ensure the delivery of effective colonoscopy screenings.


Whitson MJ, Bodian CA, Aisenberg J, Cohen LB. Is production pressure jeopardizing the quality of colonoscopy? A survey of U.S. endoscopists’ practices and perceptions. Gastrointest Endosc. 2012;75:641-648.e8. Available at:

Cohen LB. Production pressure in endoscopy: balancing quantity and quality. Gastroenterology. 2008;135:1842-1844.

Chan MY, Cohen H, Spiegel BMR. Fewer polyps detected by colonoscopy as the day progresses at a veteran’s administration teaching hospital. Clin Gastroenterol Hepatol. 2009;7:1217-1223.

Sanaka M, Deepinder F, Thota PN, et al.  Adenomas are detected more often in morning than in afternoon colonoscopy. Am J Gastroenterol. 2009;104:1659-1664.

Lee A, Iskander JM, Gupta N, et al. Queue position in the endoscopic schedule impacts effectiveness of colonoscopy. Am J Gastroenterol. 2011;106:1457-1465.

Gurundu SR, Ratuapli SK, Leighton JA, et al.  Adenoma detection rate is not influenced by the timing of colonoscopy when performed in half-day blocks. Am J Gastroenterol. 2011;106:1466-1471.

Gaba D, Howard K, Jump B. Production pressure in the work environment (California anesthesiologists’ attitudes and experiences). Anesthesiology. 1994;81:488-500.

Kaminski MF, Regula J, Kraszewska E, et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med. 2010;362:1795-1803.

Freedman JS, Harari DY, Bamji ND, et al. The detection of premalignant colon polyps during colonoscopy is stable throughout the workday. Gastrointest Endosc. 2011;73:1197-1206.

Munson GW, Harewood GC, Francis DL. Time of day variation in polyp detection rate for colonoscopies performed on a 3-hour shift schedule. Gastrointest Endosc. 2011;73:467-475.