I’d really like to thank Ethicon Endo Surgery, Ethicon Women’s Health and Urology
for sponsoring this meeting this evening. These are really two very, very interesting
and important topics. But besides that I say my new best friend over the past three
day Chris and I have been involved in meeting after meeting after meeting involving
members of my society with members, I should say our society, with members of Ethicon
Women’s Health and Ethicon Endo Surgery looking at what we can do to enhance the
practice of you the physician as well as the population we take care of and that
is the female patient. So I appreciate all the support besides this evening that
the two Ethicons, the twin Ethicons have done on behalf of the AAGL and all of us
who together comprise the AAGL. Well the first part of this symposium is discussing
really getting involved in minimally invasive gynecologic surgery from the standpoint
of the model of the hysterectomy.
And I’ve a very, very distinguished faculty, a faculty that you’ll find very, very
interesting this evening. The first, because it’s always ladies first is Lori Warren.
Lori is a private practitioner with a GYN focus. And we’re going to take advantage
of that a little bit later. She is part of Women’s First of Louisville. Fifteen
practitioners are involved. She’s involved as an Associate Clinical Professor at
the University of Louisville. To her immediate left, the younger man at the table
is Warren Volker. Warren is managing partner in private practice in Las Vegas. Twenty-two
practitioners together. He also runs a minimally invasive post graduate fellowship
and is on faculty at the University of Nevada. To Lori’s right, certainly someone
who needs no introduction to members of the AAGL, or for that matter members of
people in the gynecology community throughout the world. Steve McCarus one of my
best friends in medicine is Chief of the Division of GYB Surgery, Director, Center
for Pelvic Health, Florida Hospital Celebration, Orlando, Florida. Great group,
great group. So on that note, let’s talk about something here.
If one looks at minimally invasive surgery adoption over the last ten years, virtually
all the cases of cholecystectomy are performed by a minimally invasive technique.
Remember, we’re the ones who trained the general surgeon. Yet, nearly other cholies
are now being done a little bit more than ten years after people started doing laparoscopic
cholecystectomy for the first time. By the same token, bariatric surgery has now
reached virtually the same mark. And 70% of the appendectomies are performed by
a minimally invasive surgical technique. Yet, let’s go back to the early utilizers
of the laparoscope, the gynecologists. Look where we are in 1998 a roughly 10% and
look where we are in 2007. I submit to you ladies and gentlemen we have had problems.
There are problems with adaptation. Given that, I’d like to ask our faculty why
do you think there is such discrepancy, why is there such poor adoption of minimally
invasive surgery hysterectomy in gynecology?
Dr. Warren
I think it’s due to several reasons that we’ll be discussing throughout the program.
But I think that one of the things that I’ve been focusing on is patient awareness
and letting women know that they have surgical options. I think that’s very important
in driving this movement towards less invasive surgery for women. I think that we’re
almost at a tipping point at this point in gynecology and like Dr Miller was showing
the slides on cholecystectomies, what happened is that they were going along at
one trajectory and then all of a sudden different forces got together—patient word
of mouth, media outlets. There was also physician training and then they saw the
rise in laparoscopic cholecystectomy so now it’s the standard of care. And I think
that very soon those same type of things are happening in gynecology so I think
it’s very hopeful at this point.
Dr. Miller
Lori, I hope you’re right. Warren, let’s hear it from your perspective?
Dr. Volker
Well, I think OB/GYN is a little bit more unique in the fact that we have a long-term
relationship with our patients. I think the adoption rate, one of the issues is
in our specialty is we have a long-term relationship with our patients. In general
surgery, for example, it’s a referral base and I think our patients, because we
have a long-term relationship, they just will accept whatever kind of surgery that
they’re going to get. So there’s less pressure on us to adopt some of those procedures.
So I think that has a lot to say with what we’re doing. There are other barriers
as well. I think being an OB/GYN is tough to become educated, if you will. It takes
a lot of time, effort, time away from your practice, it costs money to be able to
go and learn on this and I think if you look at the number of cases the average
OB/GYN does three to four hysterectomies a month, it’s really tough financially
to be able to be trained and take time away from your practice to do this.
Dr. Miller
Steve, you’ve trained virtually half the world on hysterectomies. Now I’m looking
at these numbers and I’m saying the adoption hasn’t been there for it. Why do you
think that is?
Dr. McCarus
You know when I look at the number I really want to try to analyze it. I think in
early 2000 there were a lot of doubting Thomases in gynecology. A lot of us were
trying to still figure out if a laparoscopic hysterectomy was a procedure that would
fit into your practice. And the corollate , it’s really not fair to compare laparoscopic
cholecystectomy and appendectomy to a hysterectomy I think as general surgeons it’s
a lot simpler to do a laparoscopic cholecystectomy or appendectomy, it’s much more
challenging and more difficult to do a laparoscopic hysterectomy. So now you have
the problem of do I want this in my practice to offer my patients and if the answer
is yes than I’ve got a more arduous procedure to learn. So there were some barriers
as far as engaging into minimally invasive hysterectomy. There were some best practice
issues whether it’s a good operation or not and, Chuck, if you allow me to analyze
that graft a little bit more, if you look at 2002 to 2007, we actually increased
from 10% to 20%. So once collectively as a group and certainly not the folks in
this room, but the folks that aren’t at this meeting, we are engaged now. We do
realize that a laparoscopic approach to a hysterectomy is a technique that is the
best practice, it’s a technique that we can talk about how to get to that point
to be able to perform it. And I think now even though the message is the future
may not be so bright. I think that the future is going to be very bright with laparoscopic
approach to hysterectomy.
Dr. Miller
I sure do hope you’re right. I do think that there is that bond between the patient
and the gynecologist is a factor. I don’t think that gynecologists have the same
concern about losing a patient with not adapting. I also think that we do have some
payer problems that there are places in the country that reimburse better for an
open abdominal incision than laparoscopy. And let’s face it, we want to be as comfortable
as possible. So there are different issues that we want to discuss this evening
we’ll be talking about a little bit more. Well, Steve, I’m going to start with you
since you have done so much in terms of education of post graduate physicians and
now with graduate physicians as well. What do you see as current deficiencies from
a standpoint of courses that are dedicated to minimally invasive surgery, whether
it be from a standpoint of courses that a society would run or courses that industry
runs. What do you think?
Dr. McCarus
Chuck, that’s a tough question. I’m either not a good teacher or I’m trying to teach
folks something that’s very difficult to do. If it wasn’t for Prof Ed, professional
education through industry and societies like AAGL, I’m frightened to think that
the curve would still be at 10% and not at 20%. First of all I’d like to remind
us that professional education from industry and societies like this has really
been a huge home run. It’s allowed physicians access into programs where they otherwise
wouldn’t have had access, especially in post graduate, years of our careers there’s
still a struggle in residency education programs and fellowships who are trying
to answer that, giving residents access to technologies and techniques so that they
can early on in their careers look at best practice models. The gaps though that
I think we really are looking at in associating with societies and industry is finishing
a process that only gets started in meetings like this. Being exposed to technologies
and maybe going to a cadaver lab or an animal lab is only the start. Where the gap
really has been and it may be an end result of a traditional model, the apprenticeship
model that really needs significant changing. The days of see one do one, teach
one, I think are old fashioned now. That is the technologies are more challenging,
the techniques more difficult, the anatomy more challenging for us to be precise.
Chuck, to answer the question, I think the gaps we open the door but the house isn’t
built yet. We have to be able to complete construction, get from an educational
event to the operating room with hands on experience, actually doing the operation
so we can finish the journey if you will.
Dr. Miller
Okay so I’m going to take that then one step further. So now you’ve identified gaps.
Now we have to get past see one, do one, have to get past that one course and I’ve
scheduled my case on Monday. Design that ideal program to get that novice to the
point of comfort. The gynecologists are risk adverse. Bottom line, we’re risk adverse.
Yet we’re asking someone to get into a danger zone. So how do you get them comfortable
with this?
Dr. McCarus
Chuck, it’s interesting if you look at our colleagues in general surgery. I think
there are approximately 20,000 general surgeons in this country and there’s about
35,000 obstetricians/gynecologists. And that means is you do a comparison. The average
general surgeon is operating twice as much as the average gynecologist. So we have
limited exposure on a repeated event and we all know as surgeons that the repeated
event philosophy in the best practice outcome really supports that. The more operations
you do, the more surgery volume you have, the better you adapt to that particular
procedure. So my ideal professional opinion on training is once that surgeon is
in the operating room there has to be a precept or someone who can be there as an
expert on repeated events not just one day and one case but three cases a day for
five days. I think at the end of that week that surgeon has a comfort zone and is
in a surgical space that will allow him or her to really make a difference in outcomes
for their patients.
Dr. Miller
Dr. Grayson (???).
Dr. Grayson
Can’t understand question from audience.
Dr. Miller
Thank you for the comment. What Dr. Grayson was talking about is the fact that As
of January 2009, all general surgery graduated residents will be required to pass
a fundamental laparoscopic skills exam (FLS) and we just are not there. That is
something that as I mentioned in our business meeting today that our Board has taken
on as an initiative, something that we know we have to do. Can I ask a question
before I go on? How many of you started doing, let’s be honest, started doing laparoscopy,
operative laparoscopy, after a single course and just said hey, I’m going to start
doing it and I’m going to get down and dirty on it. Show some hands. So a lot of
people, a lot of people with gray hair by the way. How many of you have now gone
the other way as post graduate physicians, have gone to a course and been able to
be precepted through a series of courses, either someone at your hospital, a partner,
or someone who came in. Let me ask you that given the fact that there’s Ethicon
hierarchy all over here, how many look like, as Steve says, that that’s an advantageous
model beyond the course to constantly go back and have the opportunity to deal with
people who are getting the cases done over and over again. How many would like to
see that as part of their training? Absolutely, I think that’s very, very important.
Steve, you know there’s going to be a lot that’s happening. We’re already seeing
the Mirana IUD is beginning to change hysterectomy numbers. What do you think is
going to happen over the next few years in terms of hysterectomy as we get involved
with different types of therapies? I think it’s going to affect our future.
Dr. McCarus
I certainly don’t have the personal involvement but I do believe that we will continue
to see hormonal and nondestructive surgical techniques as we look at treatment modalities.
And I think it will change maybe the United States’ reputation to having the highest
hysterectomy rate in the world so there’s certainly room for these technologies
to be evaluated. I do believe that patient safety and data collection will increase
as these new procedures are presented to us as a group as they’re developed. And
also think the curriculum, curriculum for training will change. The model as it
stands today I think is not right. I think that curriculums will evolve as we graduate
more fellows. I think that the gynecologist may really find him or her having a
different day in the office as we know it today. I think that’s all going to change
as we do more office procedures and use non aggressive surgical treatments.
Dr. Miller
All right. Anybody want to make a comment. If there are questions, please feel free.
Yes sir? ??? Can’t hear.
Dr. Miller
Point well taken. Steve, do you want to comment on that? A little controversy in
the house
Dr. McCarus
Somebody once said you shouldn’t term vaginal hysterectomy, minimally invasive vaginal
hysterectomy. And if I understand your comment correctly, I think the only way that
vaginal hysterectomy is the best right now. And certainly that brings up more issues
around training. Right, that brings more issues around training and as one of the
docs mentioned, simulation, virtual reality training, looking at different ways
to learn that information. I would agree, I think vaginal hysterectomy is the way
to go.
Dr. Miller
I’m going take the other side. Okay, I’m going to take the other side and I’m not
going to comment on it except to throw this out to Dr. Volker and I’m going to skip
over a couple of your questions because I think this is a perfect time. Let’s face
it, people are saying gynecologists are not doing enough procedures, not the people
in this room, gynecologists in general are not doing enough procedures and it creates
problems in terms of being able to adopt. Well, one way out of this is to consider
centers of excellence. What do you think about centers of excellence? Let’s look
at it from the other side.
Dr. Volker
Well I think, Chuck, where we’re headed with this is, is a paradigm shift. And I
think economics has a lot to do with it, again. I really believe that you’re just
barely trying to survive in your practice, keep it all straight, trying to manage
your practice. As you all know, it’s becoming more and more of a challenge and with
reimbursement cutbacks and things like that. One of the things that we don’t do
is we don’t value our time. And I think if you did more minimally invasive surgery
will enhance your time. If you can do an outpatient hysterectomy and not have to
round on that patient for three days, that’s your time. We need to start thinking
about how attorneys do it. You know every time you call the clock is running. We
don’t do that and it’s just a commitment we have in medicine. I think, and in our
practice, for example, we have 22 practitioners here in Las Vegas. We have 16 OB/GYN
and we have a diversity of general OB/GYNs, we have some that like OB. There’s a
select number of us that dedicate our practice to doing nothing but GYN. We have
doctors coming through, surgeons coming through our course, this is a touch thing.
There’s a great demand for them to want to know how do I transition my practice.
How do I take my OB/GYN practice and dedicate more of my time to this? And one of
the things that we’re looking at that’s evolving is maybe that office super gynecologist
who is really, so much great technology is coming to our offices. And depending
upon lifestyle and things like that, I think there’s a divergence opportunity here
and I think a paradigm shift in the fact that if you can start doing ablations in
the office, you can start doing tubal ligations in the office, where imagine how
much less complicated your life is. Going to the OR and taking time away from the
practice costs you time, costs you money, it’s inefficient. However, if you’re going
to go do a lot of cases when you do and you’re in the hospital, it’s a much more
efficient way. So I think what we have to ask and think about is, is that a path
that might work. Is that a model? Can we have a center of excellence and the fact
that you are going to be operating in the OR then you’re doing it much more efficiently.
There is a big push and I can tell you who the push is coming from is the payers.
We have a minimally invasive, an MIP task force and we have all the payers here
in southern Nevada and they all buy into it. They all believe in this. They know
that, especially the self-fundeds and the unions, they want and in women’s health
more so than ever. They don’t get much time off after a surgery and they might get
a week of a family member coming in and taking care of them and that’s it. But I
will tell you the payers are pushing for this. And they see this a lot like what’s
happening in bariatrics. They are going to be pushing more and more and they’re
willing to pay surgeons who are dedicated to do more and more of this type, in fact
with hysterectomy. And if you look at the numbers it’s huge, 800,000 hysterectomies
done a year. They can do it. I really believe there is going to be a push for this.
I believe that there is going to be a cry for centers of excellence. And I really
think that we need to start thinking along those lines and embrace that. And this
is the group. This is the top of the top that should be thinking about that.
Dr McCarus
I certainly endorse your comments, Warren. I think if you look at laparoscopic bariatric
programs, not every hospital in your city does bariatric surgery. And the model
for center of excellence for bariatric and even colorectal is very attractive. And
it really makes you wonder if hospitals should have centers of excellence for gynecology
because not every gynecologist really enjoys laparoscopic surgery or is good at
laparoscopic surgery. But the ones that do we need to identify. The surgeons that
really have good outcomes, safe profiles, are cost effective surgeries. The doctors
in this room that stand above the rest and say I have a laparotomy rate of 10% and
an MIS rate of 90%, I really think that those surgeons need to be identified, not
only to their colleagues but also to their hospital administrators and their payers
and this concept of center of excellence to me is extremely attractive. That doesn’t
mean that I want a part of the market, be the only person in my hospital that is
in that group. I think it’s an open door center. We’ll train, we’ll help, we’ll
share, we’ll explore, we’ll collect data and we’ll see if that’s a good model. I
think in urogynecology you really have individual centers of excellence in your
urogynes. Not every hospital has a urogynecologist. But that referral pattern to
that urogyne should be set that way is really a person of excellence. So if we have
several surgeons of excellence in a center,; to me, Chuck, I think makes a lot of
sense.
Dr. Miller
You know it’s interesting. If you look at the adoption in bariatrics surgery that’s
because of one thing, it’s centers of excellence. It really does go behind centers
of excellence. So, Steve, I heard you kind of shook the site center of excellence.
You talked about recognizing proficiency. Warren what do you think about proficiency,
credentially and how that will ultimately impact potentially reimbursement, employers,
payers, whatever.
Dr. Volker
I think again along the lines of what Steve was saying and the question you’re getting
to, Chuck, is again there is a great demand for minimally invasive surgery. And
again, who’s looking at this is the payers. The payers are willing to have these
and pay for these procedures. In fact, in our neck of the woods, we’ve actually
negotiated out contracts where we get reimbursed with five of the major payers a
premium to do minimally invasive hysterectomy because we directly save them money
in doing this. What they want though, is if you have one complication increase for
every three or four hysterectomies you do it all goes out the door. And they are
looking at the bariatric model. So whether we like it or not, and I really think
Medicare and CNF is probably going to be looking at this because of the cost of
what we’re doing and the inefficiencies of the way we do it right now. So there
is some data that’s growing on that and I really believe that there are going to
be some standards. I’m not quite sure if it’s going to be standards that are going
to be promoted more by the payers and by Medicare and all that or if it’s going
to be the college or how that’s going to work. But there definitely is going to
be some standards out there that we need to achieve and it’s all going to be outcomes
based. It really is. If they’re going to be willing to pay us more to do these types
of procedures, they want to know that it can be done safely, they want to know that
the hospitals that you’re working at also buy into this cause you know one of the
biggest factors that needs to be involved with us in this, you can’t do this safely
without the hospital involvement and they’re buying in on this. The technology is
so important. This is all technology driven. And it’s going to have an impact on
the hospitals and we have them at the table and we’re talking about this as well.
Dr. Miller
Thanks. I just want a show of hands. How many of you feel that we’re now at the
time where we should document proficiency? Let me go the other way. How many of
you feel that we should go on and continue to do the present that if you know you
can do it you do it, it’s kind of the honor system? Not too many show of hands.
I do think that for the reasons that have been outlined, looking at proficiency
is becoming very, very important to us. Let me ask one question. Do you think a
society such as the AAGL should begin to start credentially so that we can begin
to identify, we can begin to say on a website that if you’re in Florida and if you
have a problem and you require a hysterectomy that patient could go to our AAGL
website and look at a name in Florida and know that that patient has been credentialed.
How many of you are looking to do something like that? Would support a program like
that? Very good. Well at this point, the question is, don’t we have the American
Council, ACGE. The ACGE has not been very active over the past several years so
the ACGE is a credentialing body, it is becoming more active and that is something
that we in the AAGL are looking at. So you’ve got to stay tuned on that one. Yes?
??? cant’ hear
Dr. Miller
Point well taken. I think we also had a question over there as well.
??? can’t hear
Dr. Miller
Lori, you are involved in the patient awareness initiative. That’s been a very great
part of your career. Tell me about that.
Dr. Warren
I had some ideas about the power of the patient. And I don’t think we can underestimate
the power of the patient just asking the question—can this be done laparoscopically.
And that’s what happened to me in my practice about four years ago. A patient came
in and requested a supracervical hysterectomy and I wasn’t trained how to do it.
So it motivated me, just that patient asking the question motivated me to increase
my laparoscopic skills and try to become a more advanced laparoscopic surgeon put
me out of my comfort zone a little bit but I always remembered how important it
was that that patient asked the question. And I think right now there’s an access
problem where patients are going to, as Warren mentioned, their gynecologist that
they trust and maybe they don’t have the surgical skills to offer the least invasive
method, may it be a vaginal hysterectomy or a laparoscopic hysterectomy, and as
we can see from the graph there are still too many abdominal hysterectomies being
done. So I think that in patients in my mind deserve to know that there are hysterectomy
options. I also think that it’s important for, like me, other surgeons that I’ve
been working with come to my program in Louisville and I say why did you come. And
about eight times out of ten they say because I had a patient ask.
Dr. Miller
So you’re now at a point where you left obstetrics and went to GYN only. How did
you prepare for that? What did you do?
Dr. Warren
Well I think that in my practice I’ve always been interested in gynecology. So about
seven or eight years ago I stopped doing obstetrics and just focused on gynecology.
I was motivated, like I mentioned, from the patient asking. And then it took some
training. I did have that absolute honor to get to watch Dr Miller and Dr McCarus
operate and have used both of their techniques in my practice and feel very lucky
to get to see how they were able to do these surgeries. But I do think that training
is a huge part. I would never want to forge ahead with a patient awareness campaign
and have patients request these surgeries of their doctors that aren't prepared
to them. So I do think that there’s some dedication. Let’s face it, there’s that
fear factor. It’s not always just second nature for some of us to jump in and start
doing laparoscopic surgery. So I think that with the commitment of doing that, I
also had to galvanize my hospital and my operating room and get them on board with
what I was doing because this is a team approach, you can’t just walk in one day
to your OR and say oh by the way I’m going to start doing laparoscopic surgery.
I want to be a laparoscopic specialist. So I really had to excite the people that
I work with in the OR and get the team approach going and that gave me efficiency
and allows me to do the surgery that I need to do. I was able to get recommendations
on instrumentation and the technology, obviously, that seeing what other people
used was really important to me. Also my practice has kind of set me up to be a
little bit more of a specialist because within my ten physician group and we have
five mid-level practitioners, we have different skills and talents and interests.
So, we can really offer almost a multi-specialty approach within an OB/GYN situation.
So I think those are some of the thing that I’ve done. I also think that if you
want to concentrate on surgery, that’s what interests you, you need to get some
help seeing just your routine patients. So I have mid-level practitioner who sees
a lot of my just routine PAP smears and routine problems that she’s perfectly capable
of handling, pill refills and I try to keep my door open to new patients and referrals.
Dr. Miller
Okay, very good, which is very similar to what you were talking about, Warren, when
you were mentioning that you’re getting this large group together you can multi-task,
you can take care of business. Okay, Karen, now we’ll come to you.
??? Can’t hear.
Dr. Miller
Good comment. Sir, over there.
??? Can’t hear.
Dr. Miller
Thanks for all your good work, good comments and good work, keep it up with the
MA. Lori, I’m going to ask you one more question. I think this is really a fundamental
question. You’ve been involved with patients. You sat down with your OR. You took
the time to put it all together. How did you market? Where do you market to make
people aware that you really are on a new course, that you’re involved in GYN only
at this point.
Dr. Warren
I think that word of mouth is always the best way to market. I think that there
are some ways that you can partner with industry and they have some marketing tools
that are available to you if you’re willing to do that and can take advantage of
some of the things that they have to offer. I think that right now the main way
that I’ve done it is open up my practice. I think that a good way to do it also
is to try to market it to your referring physicians and let them know that you’re
doing these procedures and that your open for seeing their patients.
Dr. Miller
I’d like to really thank our physicians, Dr. Volker, Dr. Warren, of course Dr. McCarus
for this very, very interesting discussion and I’m glad you are all a part of this.
