To the Editor Dr Leung commented on a study in JAMA Internal Medicine on monitored anesthesia care for outpatient gastrointestinal endoscopy and advocated for further study of water exchange colonoscopy, which requires little colon distention and thus makes colonoscopy less painful compared with air insufflation. Water exchange colonoscopy can be performed without sedation and thus may be an answer to the unsustainable costs of monitored anesthesia care.