Endoscopist as a key determinant of patient pain: a sigmoidoscopy screening model for unbiased assessment

BACKGROUND: Despite increasing standardization of training and growing attention to quality in lower gastrointestinal endoscopy, patient-reported pain during sigmoidoscopy varies considerably. This study explored whether this variability arises from differences in endoscopist performance or patient characteristics. METHODS: This cross-sectional study included unsedated sigmoidoscopies performed between 2014 and 2019 within a population-based screening trial. Neither patients nor endoscopists selected each other. Pain was self-reported on a Likert scale: no pain, mild, moderate, severe. Patients were considered to have experienced pain if moderate or severe pain was reported. We used multivariable logistic regression to identify pain predictors, reporting odds ratios (ORs) and 95% confidence intervals (CI). RESULTS: A total of 23,483 sigmoidoscopies were performed (49.0% in men) by 47 endoscopists. Pain was reported by 607 (5.3%) men and 1612 (13.5%) women and varied substantially across endoscopists, ranging from 4.3 to 21.3%. Independent predictors of pain included young age, female sex, specific endoscopist, and presence of diverticula and inflammatory bowel disease. Greater endoscopist experience correlated with lower pain rate (OR 0.82 per additional year of experience, 95% CI 0.79-0.85). Pain was associated with lower examination completion rate (OR 0.33, 95% CI 0.29-0.37) and a trend towards a lower adenoma detection rate (ADR; OR 0.91, 95% CI 0.79-1.04). CONCLUSION: In this large study of unsedated sigmoidoscopies, the specific endoscopist strongly predicted patient-reported pain. Pain was linked to lower completion rates and ADR. Findings support ongoing quality monitoring and targeted training to minimize pain and improve outcomes. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT01538550.