UNIVERSITY HOSPITAL
DEPARTMENT OF MEDICINE
SECTION OF GASTROENTEROLOGY
REQUEST FOR PRIVILEGES
To be eligible to request clinical privileges, the following threshold criteria must be met.
EDUCATION: MD or DO
TRAINING:
Successful completion of an approved residency training program in Internal Medicine. Successful completion
of an approved residency/fellowship in Gastroenterology. Applicant must meet the requirements for board
certification outlined in the Medical Staff Bylaws.
EXPERIENCE:
The initial applicant must be able to demonstrate training and/or experience on a level commensurate with
specialty training from an accredited internal medical residency program and residency/fellowship program in
gastroenterology or current competency in providing medical management and/or treatment to patients within the
scope of core privileges for Gastroenterology. Adequate documentation of this performance requires submission of
a case list and a reference letter. All initial applicants at completion of residency and/or fellowship must provide
an official case list and letter of recommendation assessing performance from the Residency and/or Fellowship
Program Director. All initial applicants beyond 12 months of residency/fellowship completion must provide a
case list from the hospital where the applicant has been actively practicing for the last year and a letter of
recommendation assessing performance from the hospital’s Chief of Staff or Department Chair.
Applicants must be able to demonstrate that they have successfully performed the following number of
procedures in the past 12 months:
Procedure Name / Number RequiredDiagnostic EGD / 130
Total colonoscopy / 140
Snare polypectomy / 20
Nonvariceal hemostasis
(upper and lower, including 10 active bleeders) / 20
Variceal hemostatis (including 5 active bleeders) / 15
Esophageal dilation with guide wire / 20
Flexible sigmoidoscopy / 30
PEG / 15
ERCP (including 40 sphincterotomies and 10 stent placements) / 200
EUS: submucosal abnormalities / 40
Pancreaticobiliary / 75
EUS-guided FNA
Nonpancreatic
Pancreatic / 25
25
Tumor ablation / 20
Pneumatic dilation for achalasis / 5
Laparoscopy / 25
Esophageal stent placement / 10
The reappointment applicant must demonstrate continuing competence and meet requirements for C.M.E.
according to the Medical Staff Bylaws. Reappointment is based upon unbiased, objective review of result
of care according to the hospital’s existing quality mechanisms.
SECTION OF GASTROENTEROLOGY
REQUEST FOR PRIVILEGES
PAGE 2
(This list is a sampling of privileges included in the core but is not intended to be an all-encompassing
list but rather reflective of the categories/types of privileges included in the core.)
CORE PRIVILEGES to include: REQUESTED GRANTED
Admission of patientsEvaluation, diagnosis, and provision of non-surgical treatment including consultation for
patients admitted or in need of care to treat general medical problems
Consultation, evaluation, pre/post procedure care for patients presenting with illnesses,
injuries, and disorders of the stomach, intestines, and related structures such as the
esophagus, liver, gallbladder, and pancreas
Dilation, esophagus, bourginage or pneumatic
Endoscopy including with or without biopsy, fiberoptic esophagoscopy, fiberoptic
gastroscopy, fiberoptic duodenoscopy, proctosigmoidoscopy
Endoscopy including protosigmoidoscopy with or without polypectomy, and colonscopy
with or without biopsy and polypectomy
Gastric lavage
Esophageal manometry
Needle biopsy of Liver (Liver Biopsy)
Small bowel biopsy, peroral
Tamponade, balloon, esophagus
Flexible sigmoidoscopy
PEG
Paracentesis
Nonvariceal hemostasis
Variceal hemostatis
Applicants requesting any other special privileges listed below must present documentation of training in
each privilege requested with a letter from the training director attesting to the applicant’s competence
and/or must meet any additional/other credentialing criteria which has been approved by the Medical Staff
and the Governing Board of University Hospital.
SPECIAL PRIVILEGES to include: REQUESTED GRANTED
Therapeutic ERCPEndoscopic gastrointestinal laser therapy
EUS-guided FNA: Nonpancreatic and Pancreatic
EUS: submucosal abnormalities
Esophageal stent placement
Laparoscopy
Hemorrhoidal banding
Tumor ablation
Pneumatic dilation for achalasis
Moderate Sedation
The applicant is required to submit a separate letter of
request for any privilege not included on this form.
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Applicant’s Signature Date 7/07