Why Don’t Doctors Do Their Tubals in the Most Reversible Way?

November 8, 2017 1 comment

Syndicated from Tubal Reversal Northwest

 

Nicholas Fogelson, MD

As physicians that spend time helping women to restore fertility after a previous sterilization surgery, one is often left to ponder why some physicians who perform sterilizations do it in a way that makes it very difficult to reverse, when the don’t have to do that.  Specifically, there are techniques to very effectively cause permanent tubal sterilization while still preserving most of the Fallopian tube and making a reversal highly likely to succeed.  There are also ways of causing tubal sterility that will leave so little healthy tube that a reversal is much more difficult.  So wouldn’t it make sense to do the former?  It would seem so, but many surgeons don’t do this.

It really comes down to how obstetricians are trained.  We are trained that a sterilization surgery is permanent, and as such any sort of effort to make it more “reversible” would be a betrayal of the very reason we are doing the procedure.  That is, is the woman wanted a reversible method of birth control, she could get an IUD or use oral contraceptives instead of having a permanent sterilization surgery.  There is also the thought that somehow doing a more reversible tubal sterilization would decrease the effectiveness of that surgery, and further be a betrayal of the original purpose of the surgery.

The reality though, is that all of this is wrong.  First of all, it is a fact that many women who have sterilization surgery decide later in their life that they would like their fertility restored and to have another child.  This is particularly true when women have their children when they are still quite young.  In many cases a woman who has had two or three children by her early twenties feels certain she never wants another child, and has a sterilization.  At the time it makes sense and she feels sure about her decision.  Fast forward ten years, she is a different person than she was when she made the decision, perhaps married to a new partner, and feels like she would like another child.  This just happens so frequently that we have to realize that while a tubal sterilization is “permanent”, its possible that reversal will be desired one day.  As such, wouldn’t it make sense to do it in a way that is reversible as possible?

Second, some may be concerned that by doing a more reversible tubal sterilization, it would be less effective.   This is just wrong, and the data doesn’t bear this out.  In fact, many physicians use a technique that is both the least reversible AND the most likely to fail.  That makes no sense, but its true.

There are two techniques that are optimal for creating the most successful sterilization that is ALSO the most reversible.  The key thing is the amount of tube that is destroyed in the sterilization, as success rates in reversal are high related to how much tube is left to bring back together in the reversal surgery.

The most effective and reversible techniques are 1) a partial salpingectomy that removes a minimal piece of tube from each side (i.e. 1-1.5 cm of tube) or 2) the use of a Filschie clip, which destroys less than centimeter of fallopian tube. Both of these are associated with less than 1% failure rate over 10 years, and as long as minimal tube is removed has a high likelihood of being reversible if such a procedure is required.  A third option is a Falope ring, which can be used to remove a small amount of tube, though it can also remove more tube and is technique dependent.

The alternate technique of using bipolar cautery to dessicate and destroy a segment of tube is less reversible because it inevitably destroys more tube, sometimes dramatically more if the surgeon is zealous with the use of the cautery in a desire to guarantee sterility.  That said, the rate of failure with this technique is 2-3% over 10 years.  So why do surgeons ever do this, with its higher failure rates and less reversibility?  Hard to say.  Makes no sense.

In our opinion, the easiest tubal to reverse is one done with a Filschie clip, which destroys very little of the tube, as seen here (Courtesy of Dr. Modi / Youtube).  It is also the most effective, with a less than 1% failure rate at 10 years.

Another good technique that doesn’t damage very much of the tube is a Falope Ring, seen here (Courtesy of Dr Sakon / Youtube):

Other techniques are far less reversible.  The Essure technique is a permanent device that is placed via a hysteroscope and is quite difficult to reverse, with reversal success is around 30% with the best techniques available.  Sterilization via cautery to the tubes can be difficult to reverse if a significant portion of the tube is injured.  Salpingectomy (complete removal of the tubes) or fimriectomy (removal of the end of the tube) are both techniques that are either difficult or impossible to reverse.

So if you are a woman that is planning to do a permanent sterilization, be sure you don’t want further children, because reversal may not be possible.  But at the same time, realize that sometimes people change their minds, and your doctor has different options on how the sterilization can be performed.  A small partial salpingectomy, Filshie Clip, or Falope Ring will lead to the minimum tubal destruction required for infertility, while leaving the most possible tube in case a reversal is ever required.

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Drs Fogelson and Rosenfield of Tubal Reversal Northwest (dba Pearl Women’s Center) are available for clinical consultation for women seeking reversal of previous sterilization surgery.   Call 503-771-1883 of an appointment for consultation.

 

 

Categories: Gynecology

Obamacare: The Uncanny Valley of Healthcare

October 19, 2017 1 comment

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As a young person, I always believed that our country provided healthcare for the poor and indigent.  When I became a medical resident, I found out that this wasn’t really true.  There was a medicaid program, but the financial qualifications were so stringent that as far as I could tell the only people that actually qualified were the disabled, women who were pregnant (or 6 weeks postpartum), or single mothers of multiple children.  Men of working age seemed left out no matter what, and women were left out if they were not pregnant or with young children.   In many cases the uncovered had jobs, but made too much for Medicaid to cover them but far too little to afford commercial insurance.

In the same year, I had great insurance.  In fact, I had a plan so good that as long as I stayed within the system where I was a resident, my medical care was 100% covered with no out of pocket expenses.  And given that the medical school I worked for was a tertiary center, there was basically no medical care under the sun that I didn’t have access to for free.   That seemed pretty just to me, since I worked 110 hours a week, and it seemed fine that in return the medical system I worked for would provide for me if I needed it.

At the same time, it seemed quite unjust that the vast majority of the very poor people I took care of had no insurance at all, even though they were quite poor.  But that was the nature of Medicaid in the state I was in.

Basically this was true all over the country.   Working people of reasonable incomes had insurance with small out of pocket expenses, with common deductibles of 300 or 500 dollars and out of pocket maximums of 1500-2000 dollars or less.   The poor only got healthcare through emergency departments and public health clinics, or not at all.  So good for some, and very bad for others.

Obamacare tried to change this.   With Obamacare, for the first time if you were a poor person below the poverty line, you had 100% coverage of everything.  And if you had up to 300% of the poverty line in income, you would get substantially subsidized healthcare.   So that seems great on paper, as the poor were being taken care of.  And indeed, this was a great justice for the poor.

The problem was how it would be paid for.  The idea was that a tax would be levied on the most wealthy, which was an extension of the medicare tax that charged about 3% of income over 250,000 dollars.  Because the rich don’t need their money!!!  Well when you make 250,000 and you have huge medical school debt, a mortgage, and kids to put through college, let me tell you one doesn’t feel all that rich, but that’s another story.

But that’s not the issue.  Let’s just assume that this approximately 3% tax on the rich was a just and good thing, and it would pay for the poor to get their care.  Sounds great, and I could totally get behind that.

But in reality, it didn’t really work like that.  In fact, what really happened is that in order to pay for healthcare for the poor, Obamacare levied a massive tax on the middle class.  Now the Dems in congress will say “there was no tax on the middle class!!”, but in reality there was.  Because in order for all the math to work on all the new policies, the healthcare afforded to the middle class and wealthy would have to change dramatically.  Anyone that has a job today that had a job 10 years ago knows exactly what I am saying.

A decade ago most people had 500 dollar deductibles and 1500 dollar out of pocket maximums.  These days most people have 2500 or 3000 dollar deductibles and 5-7,000 dollar out of pocket maximums.  And on top of that, their employers pay more to buy these inferior policies than they had to pay to buy the better policies in the past.  Some of this is because healthcare got more expensive, but a lot of it is just the mathematics of the markets created by Obamacare rules.

So when Trump says Obamacare is crumbling on itself, in a way he is right.   Obamacare was wonderful for the poor, but it was absolutely terrible for the people who had decent healthcare before Obamacare.

And you might say “hey you have a job, you can afford to pay a higher deductible”. The reality is that in many cases that’s not true.

Recently I had a patient that needs a very important surgery.  I asked her to pay the deductible and copay that her insurance company would require for me to do her surgery and she couldn’t.  She has insurance, but really she can’t afford to use it.  It may prevent her from going bankrupt if she has a major catastrophe, and it pays for routine care, but a major surgery is out of reach.   The thing is that she will get her major surgery because I will do it and in the end I will be the one holding the bag when she can’t pay me what her insurance doesn’t pay after copays and deductibles.  And in reality thats a substantial portion of what I’m owed.  So in this type of case if its serious enough I’ll still do the work, but don’t I deserve to get paid for what I do?   Sometimes this kind of thing turns into some kind of righteous battle that a doctor should work for the love of the job, but come on.. is there one place in society where people do services for free?   Of course my staff expects to be paid even if my patient doesn’t pay me, as does the landlord for our office.  Its an aside of course, but its a problem that has been created by the deductibles and out of pocket maximums in the Obamacare system.

So if the middle and upper classes really lost in Obamacare, who won?  Well, as I said the first winner was the lower income class who went from uninsured to insured.

But the biggest winner from Obamacare is the hospitals.   Because in the past, hospitals had to eat the cost of providing unfunded care to all the poor people who didn’t have medicaid.  But now all these people are insured with very low deductibles.  So when they come to the hospital, now the hospital gets paid.  It does not go unnoticed that the publicly traded stocks of large hospital groups are up 400% or more in the last ten years.

So the poor won, the hospitals won, and really the rest of us got screwed.  We pay for something that doesn’t benefit us at all, either though a tax on high earners or because our healthcare policies don’t provide us the benefits they used to.

And that is what makes Obamacare so hard to swallow for so many.  If you are middle class or wealthy, you are paying a lot for this law.  But unlike a socialized healthcare system, where at least you would get access to government funded healthcare in return for your outsized contribution to the system, you get nothing at all.   And that doesn’t feel good.  Its makes people angry.

Obamacare is the uncanny valley* of healthcare.  It isn’t quite socialized medicine, and it isn’t quite capitalist medicine.   And in that uncanny valley is a very uncomfortable experience for most of us.

So in 2017 Trump is basically trying to tear apart Obamacare.  And the reality is that if he succeeds my health policy could get a lot better, as could the policies of a lot of middle class and wealthy people.   But at the same time, the injustice that was non-coverage of the poor would return, which seems like something the country doesn’t want to return to (and probably shouldn’t.)

I think in the end we have seen what doesn’t work about totally capitalist healthcare, and we have seen what doesn’t work about some kind of zombie hybrid healthcare.   To climb out of this, we are going to have to actually join the rest of the world and institute a real socialized healthcare system.  It’s high time for it.   The wealthy would complain at first but in the end I think the social justice that would be produced would be appreciated by all.

I think there is an opportunity to create a socialized system that is uniquely American.   The Canadian system has its problems, and I think they come from the fact that there is no way to buy healthcare outside of the system.   This promotes very long waits for healthcare, and lack of advancement in technology.   I’d rather see a hybrid system where everyone is guaranteed access to basic healthcare, with an ability for people of more means to buy higher levels of care.  Some people may call this unjust, but I think we better should think about which system is least unjust, rather than complaining that any idea is unjust and not moving forward at all.

One of the injustices of a pure socialized system is that there is very little incentive to become a true master of one’s craft.  If there is no financial rewards to become one of the best doctors in the country, then there will be less incentive to actually achieve such levels of talent.  Such systems tend to breed mediocrity and sameness across all providers.  I think we see this in systems such as Kaiser, which provides decent care but also has trouble enticing the best physicians in the area to work for them.  Most people who are part of Kaiser say they get decent care, but nobody raves about their doctor and most people feel like they are part of some kind of herd of patients.

I think an optimal system would be a hybrid system, where physicians could see patients on both the public system and the private system.  A physicians who comes out of training accept 100% of their practice from the public system.   They have no reputation and no particularly advanced skills, so there is no reason anyone would pay more to see them, which makes their 100% public practice make sense.  As such a physician gets more senior and has greater reputation, they can start devoting a percentage of their practice to the private setting, where they would charge supplementary fees for higher service.  This would allow a true market economy to continue to function.  If a physician though they could hack it in the private world, the dollars would show them if they were right.  If they increased their fees to 50% over public coverage and had business, then the market said they were worth it.  If they increased to 200% of public and nobody wanted to see them, they shot too high.  Over the years they could probably increase fees.

For someone like me, who is a national level expert in endometriosis care, I could probably charge significantly over public and have a brisk practice.   But when I was just out of residency, I would have had to accept 100% of public as full payment.

What’s important about such a system is that the public system still needs to pay their full fee schedule to a doctor whether they are working in the public sector or private sector.  So if a doc says “I’m worth 150% of public”, they still get 100% of fees from the public system and the patient has to pay the other 50%, either in cash or through private insurance policy.

I think it would even be reasonable to require all doctors to see at least 20% of their patients for 100% public fees.  This way, all people would have access to all doctors, they just may have to wait longer to see a very senior expert physician than they would to see a less experienced doc.  I think that medical schools that teach residents and students would likely accept 100% public funding for even the most advanced care, ensuring that there would be ready access to high level care for all.

Some people call the system I suggest unjust, and that it would provide a different level of care for the poor than for the rich.  Well, yes.  And that’s ok.  It is a little unjust, but also it is just.  I would call it reasonably unjust.  And this is what we need to shoot for – some kind of balance between just and unjust.  Because I think there is no system that will be just for all.  Everybody should feel like its a little unjust – then we are probably in right place.

Obamacare overshot the mark.  Pre-Obamacare was very unjust for the poor.  Now we are probably unjust for the middle class and wealthy.

We have to find a happy medium.   I hope we do it soon.

 

 

 

* the uncanny valley is a term coined by computer graphics experts, referring to computer generated copies of people that look a little too real to look like cartoons, but not real enough to be believable as people.  The uncanny valley is very uncomfortable to look at.   Obamacare is the uncanny valley of socialized healthcare.

 

One side of the valley (obviously a cartoon):

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Comfortably real:

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Deep, DEEP in the uncanny valley:

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And the classic uncanny valley, The Polar Express.  A kids movie that actually gave kids nightmares, and they had no idea why they hated it so much.  Uncanny valley is why:

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** A nerd’s second note:   Avatar is actually only able to be across the valley because the Na’vi are not real.  They look really really good, but since they are fictitious we don’t have a perfect reference for what they should look like so we accept them as real.  In reality, there has yet to be a successful traverse of the uncanny valley for a human being.  Some people think that Tarkin from Rogue One was across the valley:

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But for me, I realized that he was fake immediately and I HATED IT.  But apparently some people didn’t realize that this guy is fake.  Perhaps for the people who really benefited from Obamacare, it feels to them like this is really Tarkin, and that Obamacare is a godsend.  But in reality this is a CGI abomination and they really should have just gotten a different actor for Tarkin.  And Obamacare needs be fixed.  And don’t get me started on Leia.

Academic OB/GYN Cases – Large Abdominal Wall Endometrioma with Mesh Reconstruction

October 3, 2017 1 comment

Case:

 

41 year old woman with a history of an abdominal myomectomy followed by a pregnancy, ending in cesarean delivery.  Over time a firm mass could be felt in the abdominal wall which was swollen with her menses.  She had been seen by several physicians who were unable to clearly diagnose the mass.  She eventually was diagnosed by a new PCP, and was referred to our office for treatment.

On being seen in our office, we ordered and reviewed MRI images, which demonstrated abdominal wall endometriosis replacing a large segment of the left rectus abdominus muscle and overlying fascia.

 

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These images demonstrated the mass to be approximately 4 x 3 cm in size, with marked gadolinium enhancement in several areas.

A plan was made to do a laparotomy, with expectation that after removal there would be a significant defect in the fascia, likely requiring mesh repair.

Read more…

Why Healthcare is So Expensive Part 5 – Pharma Gone Wild

August 24, 2017 1 comment

 

A few days ago a patient of mine developed a cold sore on her lip and wanted a prescription for Zovirax, a medication she had used many times in the past.   When she got to the pharmacy, I got the dreaded call that the medication needed a prior authorization.   For Zovirax?  So strange, since its a common med and is inexpensive.

Insights-Closing-the-digital-gap-in-pharma-1536x1536-300_StandardWell I did a little research and found out that Zovirax was recently sold by its original manufacturer to Valeant, a drug company that is known for buying small drugs and jacking up the prices dramatically.  It turns out that a small tube of Zovirax now costs $2500.  For an ointment for cold sores.

What the heck is this all about?   How is it possible that it is legal for a company to corner the market on a common and old drug and makes it extremely expensive?  Unfortunately it is entirely legal.

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On Hysterectomies and Hysterectomy Alternatives

Every now and then physicians have a clarifying moment that really helps to define the way we think about how to take care of our patients.  I had such a moment when I was a third year resident.

The patient was an HIV positive woman who was somewhat ill, who had problems with severe uterine bleeding.   Her workup demonstrated that she had a 3 centimeter submucosal fibroid, meaning that she had a fibroid that was inside her uterine cavity.  This type of fibroid can cause severe bleeding, and needs to be removed to resolve the problem.  She had tried a number of medical therapies, but not surprisingly they weren’t working for her.  At the time I remember thinking that she could benefit from a hysterectomy, but was worried that she wasn’t a very well woman and I wanted to do something less invasive.
I posted the patient for a hysteroscopic myomectomy, which is a procedure to remove the offending fibroid with a scope put up through the vagina and cervix, with no incisions in the abdomen.   As we didn’t have the fancy intrauterine morcellators that we now have that make these procedures much easier, it was a fairly challenging case to complete, both because it was a relatively large fibroid to tackle this way and because as a third year resident I was not highly skilled at the procedure.uterus

Ultimately, the procedure was difficult.  In fact, we were not able to complete it in a single surgery and had to come back to the OR a second day to finish it (which was not uncommon using the technology available at that time.)  In the process of the procedure, my attending physician Dr David Soper was critical of my decision to do the hysteroscopic procedure.  He asked several critical questions.  “Did she plan on future childbearing?”  The answer to this was no, as the patient was
actually quite ill with HIV related illness.  “Did she specifically desire to keep her uterus?”  The answer to this was also no.  With these two answers, he asked “So if you can do this in three hours and maybe not succeed, and she may still have bleeding issues even if you succeed, AND you could do a vaginal hysterectomy in half the time and that would have a 100% chance of solving her problem, why again are we doing this and not the vaginal hysterectomy?” (this was before the age of the laparoscopic hysterectomy.)

The reality is that I didn’t have a good answer.  The bad answer was that I had been taught to be afraid of doing hysterectomies.   I had been taught that a hysterectomy is what you do when nothing else had worked.  And there were things I hadn’t tried yet, so I didn’t do the hysterectomy that would have worked 100% of the time.

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Categories: Gynecology, Surgery

Why American Healthcare is So Expensive Part 4 – HIPAA and Healthcare Regulation

It is said that the road to hell is paved with good intentions.   I didn’t know what that meant when I was younger, but one day in my second year of residency I found out.

We were told one that all our clinics would be cancelled on a friday the following week and we were would be required to go to a mandatory meeting to learn about new government regulations that would be impacting the waimages.jpegy e delivered care.   We all thought this would be boring and didn’t like it, but nonetheless we all gathered together in the auditorium.

In that meeting we were taught about a new law coming down the pike called HIPAA.  Basically, this law was being put into place to fix a few perceived problems in healthcare.  Some of these issues made a lot of sense, like creating national identifiers for physicians so that different insurers could identify providers across multiple policies.  It also created a national coding system for insurance claims, and that made some sense.

And then the real shit began.  They explained the HIPAA Privacy Rule.
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Why American Healthcare is So Expensive Part 3 – The Insurance System

March 10, 2017 4 comments

Today the GOP is deep in its discussions about how to take apart The Affordable Care Act and to replace it with some other kind of system to pay for healthcare.  So far, everybody in the healthcare delivery system hates it, and it may go nowhere.   But I will continue to argue this – whatever they are trying to do, it won’t work.

Why won’t it work?

Not because the system that are creating is the wrong system.  Sure maybe it is wrong.  But that’s not the real problem.

As we said before, THE PROBLEM ISN’T HOW WE PAY FOR HEALTHCARE.  THE PROBLEM IS HOW MUCH HEALTHCARE COSTS IN THIS COUNTRY.

So why is healthcare so expensive in this country?  Last time we talked about how there are incredible incentives to create and use expensive healthcare equipment, even when such equipment does nothing for patients.  Today we’re going to talk about something else: The Insurance System.1382375480209

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I think a lot of people don’t fully understand why we have health insurance.  Let’s start with why we have insurance for anything at all.

Insurance is needed when there is a potential future expense that you may not be able to pay for, but that may never happen.   Ie its very expensive to repair your car if you smash it, and there is also heavy liability involved in potential damage to another vehicle or people within it, so you insure that potential expense.  The vast majority of people who buy auto insurance do not have to make a claim, so insurance is relatively inexpensive relative to the potential size of the claims.  You do not insure buying groceries because a) it isn’t that expensive to buy groceries and 2) everybody needs to buy groceries so there is no grocery-buying risk to spread out between different insured entities.

So based on this idea, and the current costs of serious healthcare interventions, it makes sense to insure healthcare.

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