Archive
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 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 wa
y 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.
Read more…
A Political Letter
Nicholas Fogelson, MD
140 NW 14th Ave
Portland, OR 97206
11/9/2016
Dear President-Elect Trump,
I am writing to reach out to you, something I have never been inspired to do for a president-elect in the past. First, congratulations on your hard fought victory, and to your family. It was a surprise for many of us.
While it was probably a happy morning in your campaign and family, it was a pretty dark morning in my household. Our family was very supportive of Secretary Clinton, and felt that she was the best choice for the president. In particular, my wife was a ardent supporter, making hundreds of calls of the Secretary’s behalf. As a Canadian, she was quite looking forward to a continued progressive movement in our country.
We have lived through disappointing elections before, but this one is different. Unlike the general discontent we felt when Bush defeated Gore, today there is a lot of fear. Fear not that the country will not go in the political direction we wanted, but fear that the country will go into hell itself. The person you presented yourself as during the campaign was not a person who seemed to be able to be an effective President. Particularly your presented views on muslims, your seemingly sexist and misogynistic comments towards women, and your views towards Mexicans as well. These things just don’t seem to be what our country should be moving towards, no matter whether you are a Democrat or Republican.
It has been my feeling and hope that during the election you have created this image for the pure purpose of galvanizing a certain segment of society and achieving the victory you now have. It is my true hope that now you are President-Elect, that these incredibly difficult positions can be shed and you can focus on a productive and positive future for our country. It is my hope that these things we saw were actually a very purposeful act, a charade of sorts, and not truly who you are as a person.
My wife and I are both physicians. I am a sub specialist surgeon in the care of women with endometriosis. For the first time in our lives, we are literally considering whether or not the United States is where we want to live our lives. If you end up being a relatively effective conservative president that pushes Paul Ryan’s agenda more or less, we will go on being Democrats who probably vote against you in four years. But if instead you normalize racism, promote a military stance that invites nuclear war, and make it generally acceptable for people to be awful human beings, we would have to consider leaving. And it wouldn’t just be us. It would be a lot of people like us, people who can’t associate with the values you promoted during the campaign. And that would be a terrible thing for our country.
I truly wish you and your family the best, and for success in your presidency. You will now be the most powerful person in the world. I’m sure that already this weighs on your shoulders. Though I voted against you, you are now my President. Please be worthy of that title.
Sincerely,
Nicholas Fogelson, MD
Portland, OR
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. http://www.nwendometriosis.com
Three Problems, One Solution: A New Way to Pay for Medical Education
Case 1:
A middle aged man named called Joe decided in mid life that he would become a doctor. A former boxing instructor, Joe felt compelled to learn medicine to help his fellow man. Already in his 30s, he worked hard to develop the prerequisite education to enter medical school, which he did in the late 1990s.
I met Joe in my first year of medical school. He was a very bright guy and had a great sense of humor. He was a bit different than most of us, and not just in age. I remember him asking me once “why would we use anti-hypertensives to treat hypertension. I mean, if a person’s blood pressure is that high, maybe that’s what their body needs it to be at!”. I remember thinking it was a strange way to think, given that allopathic medicine pretty much presumes that letting the body do whatever it will may not actually be the best course for long term health.
Joe did reasonably well through the first two years of medical school. In his third year he had moderate success, and sometimes struggled with having a different outlook on what medicine should be that the attending physicians that were instructing him. Over time, this became a bigger problem, and Joe eventually made the decision that being an allopathic physician wasn’t what he wanted to do for the rest of his life.
Numerology in Obstetrics Presentations
A warning to all – this post is really for the docs out there. If you are not in the medical profession, you might find this humorous, or you might find it completely unintelligible – so read on with that warning.
When I was a medical student and resident, we routinely presented obstetrical patients in a common format:
Age – Gravity (how many times pregnant) – Parity (how many children delivered) – gestational age extra information.
For example, this patient is a 24 year old (age) G2 (gravity) P1 (Parity) at 29 6/7 weeks with a history of a preterm delivery in her first pregnancy (extra information).
To me, this format makes sense and when I am listening to a presentation it is easy to hear and process.
Unfortunately, things have changed. We seem to have adopted a new system that incorporates all the extra information into a numerical abbreviation system. Now we do this:
Age – Gravity – Parity Full Term – Parity Preterm – Miscarriages/Abortions – Live Children – gestational age – extra information ( which may not be required any more)
For example, the previous presentation would be “this is a 24 year old G2P0101 at 29 6/7 weeks”.
For some reason, this just doesn’t work for me. Inevitably what happens is that the resident quickly says all of these numbers and my brain freezes. I now have to spend the next 3 or 4 seconds of my attention processing these numbers into some actual meaning that I can interpret. During those 3 or 4 seconds the resident has continued their presentation, but I have not heard what they said because I was trying to figure out what they said before meant.
The problem here is over-abreviation. Abreviation is good when it improves efficiency, but there can be too much of a good thing, and I think we have that right here.
And so to all you med students, residents, and docs, I encourage you to set an example by extinguishing this extended numerology from your obstetrical presentations. Just say it in plain English. We will all understand you better.
You Know Nothing Jon Snow
As a physician, I occasionally encounter patients who feel like they know a great deal more about medicine than they actually do. Sometimes its a family member of a patient. Occasionally they are right, in that they have a particular cache of knowledge about a particular condition that surpasses me. In those circumstances, such patients or family members are able to augment their care. Far more often, however, their expertise is far less than they think.
For example, I once cared for someone who clearly needed a blood transfusion. A family member was in strong opposition, mostly because that family member was Jehovah Witness, even though the patient was not. That family member presented all kinds of information about alternatives to blood transfusion, and clearly right from a pamphlet they had read. At a fundamental level, said family member believed that there was always an alternative to blood transfusion and it was never actually necessary.
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On the Surgical Consent Process
Today I saw a patient for a preoperative visit and went through the ritual of “informed consent” and the signing of the surgical permit. We had decided to do a hysterectomy to treat her problematic fibroids, and she very much wanted to proceed. Having discussed the alternatives, we now had to go through the legal ritual of the surgical consent.
As usual, I discussed what we could expect to gain from the hysterectomy. There was a 100% chance that she would no longer have any bleeding, and a very strong chance that any pain that originated in her central pelvis would get entirely or mostly better. Anemia that resulted from the bleeding would improve. Other symptoms, like urinary pressure and frequency, and lateralized pelvic pain, would likely improve though it is not as strong a likelihood as the other symptoms.
We also discussed the risks. “You could have bleeding during the surgery, potentially enough to need a blood transfusion before or after surgery. You could get a communicable disease from a blood transfusion. You could develop a wound infection or abscess, which sometimes is easy to treat and other times quite complicated. Anything in the abdomen could be damaged during the surgery, such as the bowel, bladder, ureters (“which carry urine from the kidneys to the bladder” I always say), blood vessels, or other structures. Anything damaged can be fixed at the time by myself or a consultant. There is a possibility something could be damaged but we do not recognize it at the time, or that there is a delayed injury. If this occurs you might need further surgery, antibiotics, or hospitalization. Though extremely rare, you could die or be injured from an unforeseen surgical complication or complication of anesthesia.”
At this point she looked white as a sheet, as usual, and then I tempered with “but all of this is extremely unlikely, less than 1% of cases for major issues, and I have to explain it all for legal reasons. I am well trained to do this surgery and will do my absolute best for you.” I answered her questions, the consent is signed, and we had our pre-op.
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Launch Monitors and Evidence Based Medicine
I was recently at the golf course working with a clubfitter on selecting a driver that was optimal for my game. We went through lots of different clubheads and shafts, hitting each on a very advanced radar system that exactly measures launch characteristics and ballflight. I was struck at how quickly he was moving through different ideas, having me hit each variation only a few times before moving on to something else. Having fit clubs for many tour professionals, the gentleman I was working with clearly knew what he was doing – but at the same time I was struck how little he understood the mathematics of what was going on, and wondered if his advice was really as valid as he thought it was.
Boycott Makena
This month KV Pharmaceuticals gained FDA approval for their drug Makena, or 17 Hydroxyprogesterone Caproate, for use in prevention of preterm birth. This drug has been shown in randomized studies to moderately decrease the rate of preterm birth in women with previous preterm deliveries.
While this is the first FDA approved product for this indication, this very compound has been available on the market for many years, generated by compounding pharmacies nationwide for as little as $9 a dose. One major supplier, Wedgewood Pharmaceuticals, provides the product in vials every bit as professional looking as anything you would get from a major Pharma manufacturer.
The big problem, as most already know, is that KV Pharmaceuticals has decided to price their drug at approximately $1500 a week. Furthermore, they are extending legal power to prevent compounding pharmacies from creating any more of the drug.
This is outrageous. This is a well studied drug, already having gained acceptance in the community based on the landmark 17-OHP trial published in 2003. Millions of doses have been given nationwide without adverse effect. The fact that it has become FDA approved has done nothing for women or infants. The only effect has been that KV now has legal protection to price the drug at 200 times the previous price and block out competitors who previously had been providing the same drug at a tiny fraction of the cost.
An article was recently written in the New England Journal decrying this usurious pricing scheme. In their analysis, they write “For every dollar spent for compounded 17OHP, $8 to $12 in health care costs related to pematurity are saved.. by contrast, Makena will require $8 to $12 in drug spending for every dollar in such prematurity costs avoided.” Further editorials have been published in both print and digital media, such as this, this, and this. My friend @drjengunter weighs in here
KV has responded to the criticism, pointing out that they have a patient assistance program. To be fair, they are willing to give the drug for free to uninsured women making less than 60,000 a year, and at a small copay for women making less than 100,000. But to be fair to women and the world, this isn’t nearly enough. No matter what individuals are paying for the drug, the medical system will be paying billions of dollars for something that used to cost a few million a year.
Positive spin on Makena has promoted it as the first drug to decrease the rate of preterm delivery. This is an agregious mistruth. The drug has been on the market for over 50 years, and has been used for the indication for almost a decade in the United States.
At the core, KV Pharmacueticals is a leech on the blood of our society. They are providing nothing of value, but through our bureacratic process have been guaranteed that they can extract billions of dollars a year from our healthcare system – all to get a benefit we already had. They didn’t even have to do the research; it was done for them and published in 2003 (with compounded drug.) The idea that their particular FDA approved product is somehow better or safer than the compounded product is completely theoretical, cannot be justified by any data. Furthermore, the underlying efficacy of the drug KV claims has immeasurable benefit is worthy of some skepticim despite the 2003 trial, as since it went into widespread use the preterm birth rate has risen from 12.3% to 12.7%.
So what are we to do about this. I am doing this.
I will not write a single dose of Makena, and I call for you to do the same.
If I can, I will continue to use compounded 17-OHP. If I can’t, I will recommend daily vaginal prometrium, which very likely will have the same effect as 17-OHP. Its off label, but so was 17-OHP before KV got ahold of it. If a patient asks, I will politely explain that I refuse to give in to KV Pharmaceuticals and their piracy. The cost of healthcare is destroying this country, and this is an area in which we cannot afford to give in. Patients need to understand that these are the kinds of decisions that drive the cost of healthcare, and that we are all responsible for protecting our country’s healthcare future.
I encourage everyone over which I have any influence to refuse to write Makena for any reason, and to pass this message on to anyone who will listen.
The Myth of the Unnecessary Cesarean
nec·es·sar·y: being essential, indispensable, or requisite
One thing I have learned by being active in the obstetrics and birthing blogosphere is that there are a whole lot of people out there that think that most cesarean deliveries are unnecessary. While most of them will admit that some cesareans are medically required, its pretty rare that the ones that have had a cesarean looks at their cesarean that way.
A popular term bandied about is “Unnecesarean”, a catchy little phrase that implies the underlying belief that most cesareans are unnecessary. Frequently, commenters state that they had a cesarean that they didn’t want, and that at some point later in their life someone let them in on the secret that their cesarean wasn’t really necessary, and this is completely accepted as fact. In some cases, people believe that they were robbed of the vaginal birth they were destined to have, or even that they were somehow raped by the their physician.
Frankly, I am tired of it.
Academic OB/GYN 