On Dunning-Kruger, Surgical Self Assessment, and some Surgical Buzzwords too Watch out For
It’s been well documented that people are generally poor judges of their own skills. Dunning and Kruger studied and published on this topic, creating the term Dunning-Kruger effect, which summed up, states that “poor performers are not in a position to recognize the shortcomings in their own performance”. Ehrlinger et all followed Dunning-Kruger in their paper “Why the Unskilled are Unaware: Further Explorations of (Absent) Self-insight Among the Incompetent,” further coming to the conclusion that the relatively unskilled are unaware that they lack those skills. Other papers have shown that if you objectively split performers into quartiles, and then ask those quartiles where they believe there relative skills are, it comes out like this:
Top quartile of performers -> believes they are in the 2nd quartile
2nd quartile of performers -> believes they are 2nd or 3rd quartile
3rd quartile of performers -> believes they are in 1st or 2nd quartile
4th quartile of performers -> believes they are in the 1st or 2nd quartile
Effectively, the best performers think they are ok but could be better, while the worst performers believe they are at or near the top of performance. Effectively, they do not realize what they do not know.
Read more…Remembering Paul Underwood
Last week marked the passing of one of my early teachers and mentors, Dr Paul Underwood.
Dr Underwood was a professor emeritus at Medical University of South Carolina, where I attended a residency from 2001 to 2005.
I was fortunate to get to train in a residency that was full of extraordinary people. Little did I know that not every department was like that. MUSC was an incredibly caring environment that looked after each resident like a member of family. Paul Underwood was a big part of that.
I can also say that without Dr Underwood, I would not be an endometriosis surgeon today. There is no question that he is the one that got me started on this path.
One day in my third year of residency Dr Underwood and I were doing an abdominal hysterectomy. We unexpectedly found stage IV endometriosis. While most attending would have been concerned about the complexity of the case, Dr Underwood was utterly unfazed, being a very experienced gynecologic oncologist. At the same time, he never took the case away from me. He always encouraged me to keep operating even when the case was just outside of my normal comfort zone, giving me a few pointers here and there. He was also one of those surgeons who might let a resident go a little too far and get into trouble, knowing he could fix it.
Read more…Announcing the Endometriosis Podcast!
Hello Academic OB/GYN Fans!
I am proud to announce the launch of my new podcast project, The Endometriosis Podcast, with my collaborator and co-host Libby Hopton. The Endometriosis podcast is bimonthly discussion of the most recent literature in the endometriosis world. With Producer Andrea Muraskin as well.
Please listen, subscribe, and leave comments/reviews on iTunes.
Available at iTunes: https://podcasts.apple.com/us/podcast/the-endometriosis-podcast/id1462226534
Available at Stitcher: https://www.stitcher.com/podcast/andrea-muraskin-2/the-endometriosis-podcast
Grand Rounds at Baylor Dallas – A Few Lesson for the Residents
New Surgical Case: Excision of Endometriosis from Thoracic and Mediastinal Diaphragm with Suture Closure
This case involves a 41 year old woman with severe symptoms of diaprhagmatic endometriosis. Symptoms included severe shoulder and neck pain with menses.
Nicholas Fogelson is Movin On Up… To The Big Time – Announcing Northwest Endometriosis and Pelvic Surgery
Hello Friends and Colleagues –
As of Aug 1, 2018, I am excited to announce my new business and practice Northwest Endometriosis and Pelvic Surgery (NWEPS). NWEPS is a practice dedicated to providing world-class care to women with complex cases of endometriosis-related pain and infertility, as well as other complex benign gynecologic conditions.
The start of this new practice also marks and end to my relationship with Pearl Women’s Center, my previous practice.
So the big question is why the change?
Well a while back I wrote a popular article that talked about the finances of advanced endometriosis surgery. We talked about how some physicians were in-network and others were out-of-network. At that time, I was working in-network on my professional fees, but also had a relationship to an outpatient surgery center where I did most of my work, which allowed me to supplement what I could produce in my professional work.
Over time, I decided that this was not the model under which I wanted to practice. The biggest reason for this is that an increasing number of the cases I was performing were very complex endometriosis cases that should be done in a hospital rather than a surgical center. As I discussed before, complex endometriosis surgery pays very poorly in-network, so the reality of this was that I would generate far more income for my practice by doing a simple case in the outpatient surgery center rather than a complex case in the hospital, and in the end this didn’t really align with my desire to do complex advanced cases. In the end, the only thing we should care about is what is best for the patient, and when somebody is paying you more to do something one way or in one place than some other way or some other place, this is a unneeded distraction from making the best choice for every patient.
I also found that over the three years I have practiced in Oregon, we have had increasing difficulty getting insurance companies to pay on our claims, even at their reduced in-network rates, and irrespective of where surgeries were done. For example, I have had surgeries that took 6-8 hours of work that were properly coded with 6 or 7 individual procedure codes, where the insurance company refused to pay on more than a single code. As an in-network physician, there is little one can do about this because of contractual language with the insurance company, so even if one appeals the situation most likely the company just tells you no.
Furthermore, over time I have pushed my practice into areas that insurance companies do not recognize at all, such as neuropelveologic surgery, and as such I would have no hope of being paid for that work under insurance contracts.
As such, I decided to start a new practice that is laser-focused on endometriosis and complex pelvic surgery. Due to all the previously mentioned issues, this new practice is entirely out-of-network for insurance plans.
While there are a number of out-of-network endometriosis practices in the country, in one way we are different than the rest. As out-of-network claims are quite complicated, I have hired a law firm to do my billing – but not against my patients but rather for my patients. What I have found is that out-of-network billing appeals are extremely complex and a skilled healthcare attorney will be far more effective than a typical billing company, and also far more effective than a patient who does not have a deep knowledge of the insurance system. This service is provided at no cost to my patients. This both ensures that I am paid fairly for my work, but also that patients are able to get maximum benefit from their insurance plans and have the minimum in out of pocket expense for their care with my practice. In cases where my expertise can clearly be shown to unavailable within a patient’s insurance network (which is not uncommon), we often have success in getting out-of-network exceptions, which can dramatically reduce a patient’s out-of-pocket costs.
Academic OB/GYN as a blog will continue, though new posts will also be cross-posted to my new website http://www.nwendometriosis.com. Youtube Content will be moved to a new YouTube page as well. It doesn’t have a link yet but I will update this post when it does.
Thank you so much for your readership of the blog.
If you are interested in clinical consultation please call us at 503-715-1377. We offer free records reviews, as well as free support for out of network billing appeals as needed.
Sincerely,
Nicholas Fogelson, MD
Northwest Endometriosis and Pelvic Surgery
http://www.nwendometriosis.com
Why Double Coverage is a Scam
You have just gotten a job offer that includes health insurance. You’re lucky enough that your spouse has great family insurance already, but hey that health insurance is going to cover the cracks in the deductible and co-insurance, so you feel great about that double coverage as you sign your contract.
Well, you just got scammed. That is, double coverage is a scam, and you would have been far better off negotiating a higher salary in return for not getting insurance.
Here’s why:
Let’s say Policy A has a deductible of $1000 and 75% coinsurance up to an out of pocket max of $3000.
Policy B is identical, with a deductible of $1000 and 75% coinsurance up to an out of pocket max of $3000.
So you get $500 in healthcare. It costs you $500 because neither policy pays up to the first $500 (for simplicity let’s ignore the no-deductible services some policies offer)
Then you have a surgery that costs $5000. The first policy pays $4000 on this ($5000 minus the $500 deductible that was left, and then 75% of the remaining $2000 on your out of pocket max, plus everything over that). So that leave’s you with a $1000 bill. That bill gets submitted to your second policy, which also has a $1000 deductible. So you still have $500 to satisfy there, and so the second policy pays you $500, or if you’re unlucky in how they interpret the secondary coverage, $375. So policy 1 pays $4000, and policy 2 pays $375 to $500.
This has always seemed wrong to me. If you have two life insurance and you die, your family gets paid twice. But if you have two health insurance policies and you get sick, you only get paid once, or maybe once and a little more.
So if one policy is at more risk than the other, the employer that buys the second policy must pay less for the double coverage policy, right? No they don’t. They have to pay full freight for both policies. That’s where the scam is.
Double coverage is WAY LESS COVERAGE than the single coverage policy, but both policies are priced the same. This is a product of the fact that large employers are forced to make insurance offerings for their entire population even though that offering may be of substantially less value to some employers than others.
But there is a way to solve this. Just turn down insurance if you are offered double coverage. Then tell your prospective employer that by turning down insurance, you are saving them $8 grand a year and ask for $8000 more in salary, or more vacation, or whatever other concession you want. For them it costs the same, but for you its of dramatically greater value. When you get that value, squirrel a bit of it away for unpaid healthcare costs. If you’re lucky and don’t need it, you just have more money. If you do need the healthcare, you can get the value that would have been paid by the double coverage with a fraction of the money.
Dr. Fogelson is a gynecologic surgeon and endometriosis specialist who practices at Northwest Endometriosis and Pelvic Surgery in Portland, OR. Call 503-715-1377 for clinical consultation.
On High Volume Gynecologic Surgery, and How to Pick A Surgeon for Your Hysterectomy
If you had a serious issue with your knee and needed a surgeon to repair it, how would go about picking that surgeon? If you were like most people, you would find the most experienced and best surgeon in your area, at least within whatever in
surance network you might belong to. And that would make sense, as the experience level of your surgeon is a strong predictor of outcomes, including complications of surgery.
So you would assume that this would be similar for all types of surgery, correct? People of reasonable means will seek out the best and most experienced surgeon for whatever type of surgery they need, whether it be neurosurgery, bowel surgery, or in this case, gynecologic surgery.
The troubling thing is that in the case of gynecologic surgery, that would be wrong. In fact, the majority of gynecologic surgery in this country is performed by relatively inexperienced surgeons who research would suggest will have a higher rate of complications than more experienced surgeons.
Why Don’t Doctors Do Their Tubals in the Most Reversible Way?
Syndicated from Tubal Reversal Northwest
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.
Obamacare: The Uncanny Valley of Healthcare
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. This is
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):
Comfortably real:
Deep, DEEP in the uncanny valley:
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:
** 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:
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.
Dr. Fogelson is a gynecologic surgeon and endometriosis specialist who practices at Northwest Endometriosis and Pelvic Surgery in Portland, OR. Call 503-715-1377 for clinical consultation.
Academic OB/GYN 