Academic OB/GYN

A reader recently send me this graphic on the costs of healthcare, which is interesting in many ways.

Created by: Medical Billing and Coding Certification

Some of this diagram I agree with, and some I do not, or at least what is implied by the information contained therein.    Overall, the diagram is correct – American’s can’t afford healthcare.  At least not the kind we try to provide.  However, I don’t feel that the diagram really addresses why Americans can’t afford healthcare in an accurate way.

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A few years ago, I was sitting in clinic with a student that seemed quite anxious.   I asked her what was up, and she said she was close to having to pick her specialty, and still hadn’t made up her mind.   She said she was caught between ob/gyn and orthopedic surgery, and couldn’t decide. 

“So which one do you like better?”  I asked.

“I like them both.”

“That’s interesting, as they are two quite different fields.”

Also on my mind was that as an OB/GYN student, I thought she was average at best.  In all honesty she seemed quite bright but not at all intersted in OB/GYN.

“So OB/GYN huh?   I didn’t peg you for that.  You don’t come across as loving it.”

“Yeah, but I do like it. And my mother thinks I should do it.”

“So what about ortho?  Do you love that?”

“I like that.  My dad thinks it would be great for me to be a surgeon, and that I would make a lot of money.”

At this point it occurred to me that of the six weeks I had worked with this woman, I had only seen her truly excited on one occassion, and that moment was when she was presenting cancer cases at our tumor board conference.  She had prepared a tremendous amount of information about the cases she was presenting, and had seemed to be particularly focused on the pathology slides.  She presented all kinds of information about the slides that other students would have just ignored.  More that that, she was just beaming as she presented it.

“So…  remember when you presented those slides at path conference?  How did you feel then?  It seemed like you were really into it.”

“I love that stuff.  I love those slides, I really like looking at them and trying to figure out what it means about the patient’s disease.”

“OK…. so you want to do OB/GYN because your mom thinks it would be good, and orthopedics because your dad thinks that would be good and you would make a lot of money.  The thing is this – you don’t really love those things, but you love looking at slides.   What if I were to tell you that there is a job out there where you can look at slides like that all day, hang out with people who also love looking at slides, have great hours, never work at night, and get paid tons of money……..   

Its called being a pathologist. 

Ever think of doing that?”

Her eyes flew open, almost startled, like she had never really considered it.

She went into pathology and loved it.  Her parents were pleased she found a job she liked, because in the end, like all parents, they just wanted her to be happy.

Drs Fogelson and Browne give updates from the recent SMFM and AAGL conferences, and discuss new articles.  Topics include PLGF and IUGR, endometrial polyps, faking resumes, and more.  Thanks for listening!

Academic OB/GYN Podcast Episode 35 – Back From The Ashes

This is a video of laparoscopic resection of deep infiltrating endometriosis with ureteral and retroperitoneal dissection and treatment of an endometrioma.  Retroperitoneal anatomy is dissected and discussed.

http://www.youtube.com/watch?v=HBnzSZU7XWs

Video embedding is temporarily problematic.  Click through to youtube to view.

I’ve gotten a fair number of inquiries as to the state of the Academic OB/GYN Podcast.  As some of you have noticed, there has not been a new episode since July 30, 2011.

The truth is that while I love doing the podcast, I have had to put it aside during my fellowship because of a lack of time.  It is quite labor intensive to prepare, record, and edit, so I decided to back burner it for now.

I really appreciate the support of all the listeners and hope to get back to it no later than this summer, if not sooner.

Regards

Nick Fogelson

Academic OB/GYN

Some Cancer Humor

I saw a patient today who presented with a large vaginal cancer.  I was discussing her care with my intern, and that it would make a big difference if the cancer were localized or if it had already spread to the lymph nodes.  Based on her exam, I thought there was a pretty good chance it had already spread.

“The toothpaste is already out of the tube”, said the intern.

I replied “I suppose… but usually we say ‘the horse is already out of the barn‘   After all, like cancer, the horse wants to leave the barn and run.  The toothpaste doesn’t want to leave the tube.  It will stay there forever until you squeeze it out.”

A look of understanding hit the intern’s face…. then puzzlement.

“But Dr. Fogelson, it seems like its a lot easier to put a horse back into the barn than it is to put toothpaste back into the tube.  If cancer was like the horse it would be much easier to cure once was spread.”

So there you have it.

Cancer acts like a horse at first, but then becomes toothpaste.

As a physician formally trained in computer science, I have the opportunity to look at today’s computerized medical record systems both from the perspective of a end user and as a software designer.  It is perhaps because of this that I have been so persistently disappointed with the current state of clinical record software.  

I am disappointed because despite all the fancy hardware and expensive software, our clinical records systems aren’t that much better than paper.  We would think that a patient could go to any doctor and present their medical records the doctor could read them, but they can’t.  We would think that it would be easy for me to get a CT scan report that was done at an outside hospital, but no.  It actually has to be printed out and faxed, requiring not only human intervention and time, but if reentered into the receiving provider’s system actually converts a digitally stored report into a picture of a piece of paper, completely breaking the idea of an electronic record system.  While information can be digital in one system, if it ever is passed on to someone working in another system, it becomes just another piece of digital paper.  The sad truth is that despite our incredible investment in EMR systems, we have only created a massive collection of information silos, and have almost no way to transfer information between them – a system little better than the paper charts we sought to eliminate.  And sadly, because these silos are hard coded and massive, innovation is stifled.

There is a very specific reason why our system operates like this, and it is that EMRs as a whole lack a common way to represent information.  Each system represents medical records in its own proprietary format, and thus lack the ability to speak to each other.  An thus no matter how wonderfully a EMR system represents information to its users, if information has to get out of the system, it can only be through pictures of pieces of paper.

So is there a solution to these problems?  I would argue yes.   But it requires a fundamental change in our paradigm – a change to a common “Model” for representing data.
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Two years ago, I penned a post entitled “Delayed Cord Clamping Should be Standard Practice in Obstetrics”, which was read by many.  Later I gave a grand rounds on the topic, which was viewed by many.  In doing so, I contributed to a growing movement towards delaying cord clamping after the birth of preterm and term neonates.  This was all well and good.  But something else happened as well.

In the eyes of many, I became an “Expert in Delayed Cord Clamping”, worth quoting to others, and even name dropped as some sort of trump card – “Well, Dr Fogelson says….”  So let me set the record straight.  I am not an expert in delayed cord clamping, if such a person even exists.   I am certainly not an activist for the idea, not am I sure that such activism could be justified in the literature.

What I am is this:

1. An educated person with access to the literature and training in interpretation of medical research.
2. A physician with intellectual expertise in maternal health, and first hand experience in its practice
3. A person with a platform where his opinion would be heard.

and

4. A person who chose to express said opinion on that platform.

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One of the interesting things about running a semi-popular blog is that from time to time the blog community decides to take up a topic and run with it, completely without any stimulation from me.  This happened recently on the Academic OB/GYN Facebook page, where a group of concerned individuals carried on a serious and passionate discussion about the merits of circumcision.   As such discussions tend to be, this one was dominated by the anti-circumcision activists, with occasional interjections by those that were less concerned about the issue, including myself.

Circumcision is an interesting issue because it crosses multiple boundaries.  It is a social tradition in many cultures, and in some cases considered a religious mandate.  It is also an ethical issue for many, with some feeling that it is an assault on an infant with long term negative impact on their psychosocial health.  For some it is just cosmetic.

As a young person, I always thought that my penis looked like penises were supposed to look. It looked like my father’s and my brother’s, and anyone else’s I had ever seen.  For the most part, I was blissfully unaware that a penis could look any other way, until one day in high school when my world completely changed.  I happened to see a friend’s penis we were showering after wrestling practice, and in that flash of a moment all kinds of things went through my mind.  Did he have some kind of growth on his penis?  Could he pee out of that thing?  A few other choice thoughts.  I can still remember the shock to this day.  All I had ever seen looked like mine, and in that moment what I saw was foreign, revolting even.  You see, from my frame of reference he looked like an alien.  It took me a few minutes and SNAP! it came to me like a ton of bricks – he has a foreskin.  He probably doesn’t have an alien death ray then.   I can relax about that one.

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Last year I wrote about a few strategies for decreasing costs in the operating room.  Since being in fellowship operating many days per week, I’ve come up with a new idea, this time a bit more radical.

In Freakonomics, Leavitt and Dubner posit that in all things, human beings respond to incentives.  If you want to understand human behavior, all you have to do is identify the incentives that drive them, be they emotional, financial, or social.  In that vein, I wonder what incentives drive us to spend so much money on healthcare, and to waste resources when they need not be wasted.

I found a potential answer in another book, Chris Anderson’s “Free: The Future of a Radical Price”  In this work Anderson investigates how an economy is affected when the marginal cost of production of a good approaches zero.  Specifically, he investigates the economy surround digital goods, that while costing resources to develop, have a marginal cost of zero to produce and distribute.  He proposes that in such a system, it is quite natural that the price of such goods will eventually approach zero, and if it doesn’t, the goods will be routinely stolen rather than paid for.

The corollary to this idea is the concept of optimal use of a resource when its cost is zero.  That is, if one gets a real benefit from the use of a resource but it costs nothing whatsoever to use it, what is the right way to use that resource?  Anderson suggests that the correct course is to use that resource to its maximal extent, and even to waste it without thinking despite diminishing returns. Read more…