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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

October 21, 2018 2 comments

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Reposted from the new blog home at Northwest Endometriosis and Pelvic Surgery:
This week I had the honor of being invited to give Grand Rounds at Baylor Dallas, under invitation from the chair Dr Anthony Gregg. I spoke to the residents about endometriosis surgery, discussing what we understand about the origins of endometriosis, as well as the rationale for excision surgery. I also showed videos from a number of different excision sugeries, with cases varying from stage I endometriosis, stage IV pelvic endometriosis with bowel resection, abdominal wall endometriosis, and thoracic endometriosis. These sorts of talks are important we are exposing young doctors to something that they otherwise might never be aware of.
I also had the pleasure of working with the residents as we dissected a fresh cadaver, demonstrating the entire retroperitoneal anatomy. I took down the entire side of the pelvic sidewall and identified and demonstrated every named artery, vein, and urinary tract structure. We also demonstrated and dissected the path of the ureter from pelvic brim all the way to the bladder, and replicated technique for a radical laparoscopic hysterectomy.
Finally, I dissected all the pelvic neuroanatomy, including obturator, sciatic, pudendal nerves, as well as nerve roots S1-S4 on each side. We also demonstrated how one performs a pudendal nerve release, cutting the sacrospinous ligaments and coccygeus muscle to open up the pudendal canal to free pressure on the nerve.
I had a great question from one of the residents. She asked how a young doctor can become an endometriosis surgeon. My rather long answer was this:
1. Even at this early stage in your career, resist the urge to think about surgery as a series of steps. Many will do this. That is, when learning to do a laparoscopic hysterectomy many young surgeons will memorize and learn a series of steps that leads from the beginning to the end of the surgery. The problem with this is that while it may work in ordinary situations, one will inevitably encounter variations in anatomy or scarring and adhesions that will make your steps useless. And then you will be paralyzed, and either you will abort your surgery or you may continue and if unlucky, you will injure the patient.
2. Instead of learning a series of steps, focus on learning surgery as three legs to a stool. The three legs of the stool are knowledge of anatomy, knowledge of technique, and knowledge of intention.
Knowledge of anatomy means that the expert surgeon is the master of every anatomical structure in the vicinity of their operative field. Most gynecologists, probably 98% of them, would fail this criteria. The level of mastery required to truly excel means you understand the anatomy of nerves, arteries, veins, bones, and muscle structures, and the relationships between them. When a surgeon has mastered this leg of the stool, no anatomical variation is going to be scary, because they understand where everything is and where they can safely go to complete their task. Knowledge of anatomy does not come from operating under supervision and identifying anatomy as one learns. It instead comes from a specific intention to learn anatomy from all the resources available outside of the operating room, such as books, videos, and cadaver dissections.
The second leg of the stool is knowledge of technique. This means the ability to manipulate tissue and complete one’s tasks without creating undue bleeding or accidentally injuring something, and the ability to successfully stop bleeding when it occurs. It also means a mastery of one’s equipment, such as an deep understanding of the electrosurgical and other energy-based equipment that we use on a daily basis. Just using the settings your attending used is inadequate. One must truly understand why one sets a piece of equipment a certain way, and why one uses that equipment in a certain way, in order to deal with the situations where one might like to change those settings for better effect.
The third leg of the stool is the easiest one. It is the understanding of surgical intention. For example, the surgical intention of a hysterectomy is to remove the uterus from the body while leaving every arterial and venous connection between the uterus and the body secured and sealed, while preserving the support structure of the body. In many ways this is obvious. But in some cases it is more difficult to understand, such as whether or not one should remove a piece of bowel that appears involved in endometriosis. We call this surgical judgement.
Taking these three steps together and intentionally seeking mastery of each, one is bound to be an excellent surgeon. Once one is on this path, becoming an endometriosis surgeon is easy. There are a zillion patients with endometriosis around. Follow these principles and operate to remove the endometriosis. If you try to do endometriosis surgery as a series of steps you will fail miserably, because every surgery is different. But if you apply these principles, understanding anatomy, using good technique, and understanding that the goal is to remove all of the endometriotic tissue, you will succeed and your patients will benefit.
3. The third thing I said is that to be a strong surgeon, one should always cultivate a feeling of responsibility for your patient’s outcome. I see too many surgeons experience complications in their surgeries and then strive to prove to themselves that they weren’t at fault in what happened. This is fundamentally wrong. The surgeon is almost always at fault when something goes wrong. Ureters are cut in hysterectomies 1% of the time not because “it just happens sometimes”, but because in 1% of cases the surgeon failed to apply proper surgical principles and to understand the anatomy of the surgery they were performing. Even the apparent faultless complication of a postoperative infection often originates in a failure of antisepsis or sterile technique, which are controllable factors. If one has a misadventure and chooses to externalize the responsibility for this event, one has lost the opportunity to grow from the error. And unfortunately, that means that if one operates enough, one will repeat that error one day again.
It was a pleasure to speak to the residents and faculty at Baylor Dallas and to teach anatomy to the residents, and I hope that a few of them go on to serve women with endometriosis. It all starts with the young.

New Surgical Case: Excision of Endometriosis from Thoracic and Mediastinal Diaphragm with Suture Closure

October 15, 2018 1 comment

This case involves a 41 year old woman with severe symptoms of diaprhagmatic endometriosis.  Symptoms included severe shoulder and neck pain with menses.

 

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.  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):

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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.

 

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.

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.

Read more…

Why Healthcare in America is So Expensive Part 2 – Surgical Equipment

February 27, 2017 8 comments

With this essay we embark on a journey through the world of medical cost.   In my last essay, I argued that while our government struggles to create a system that pays for the healthcare system we have, the true problem is the outrageou
s cost of that system, not how we pay for it.

Today, we will examine the surgical equipment industry, and how expensive i
nnovation and technology is valued over actual contribution to patient outcomes, and how every incentive exists to make medical equipment as expensive as possible.

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A few years ago, I was involved in a project with a number of students from Georgia Tech’s biomedical engineering department.   I had an idea to solve a basic problem in laparoscopic surgery, and these students were charged with cSurgical-Instruments-11.jpg
reating a prototype solution to the idea.  We came up with an elegant solution to an issue that occurred in every laparoscopic surgery in this country, and eventually the students presented this idea as their senior project for their degrees.

Subsequently, I approached my University’s Technology Transfer department (the group that helps faculty to commercialize their ideas.)  We went through a process of idea disclosure with the hope that the University would help me to bring this idea to market.  In the end, though, it fizzled.    They said they weren’t interested in developing the idea.  So I approached several industry groups.   Again, no interest.  Over time I talked with three different groups that develops ideas, and no one was interested.

The kicker of all of this is that the lack if industry interest had nothing to do with the utility of my invention.  In fact, all parties agreed that the idea was great and the solution was elegant.  They also agreed that they could imagine the device in practice.   The problem wasn’t that the device wasn’t a good one, it was that the device was too simple, and too inexpensive to manufacture.  I had imagined a device that would probably cost about 5 dollars in every surgical pack.  In the end, the development market had little interest in such a device, given what it costs to develop bring a device to market and the likely payout at the end.  This thing actually saved money in time and in replacement of more expensive equipment already in use in the OR.   But what I found out was that there wasn’t much interest in devices that causes industry to make less money.

Read more…

Healthcare Reform Has It Wrong: Why American Health Care is So Expensive Part 1

February 19, 2017 5 comments

Having been a physician now for 16 years, I have had a first hand view at the variety of healthcare reforms and regulation put into place over that time.   Most recently, the Affordable Care Act has been at the center of our attention, but it is by no means the only thing the government has done over that time.

One-Dollar-Bills.jpgToday, President Trump and the Republicans are working to repeal the Affordable Care Act, and possibly replace it with something else (Something Great if you listen to Trump.)  I have mixed feelings about this.  I think that the ACA did some good things, but also got some things wrong.  At its fundamental core, by forcing all people to buy healthcare through a private insurer (albeit through a government funded network), it was trying to create universal coverage.  Unfortunately, the ACA struggled to get healthy people who would pay more than they consumed to enter the system, thus creating a system where there were often more claims than premiums.

Read more…

Thoughts on Hemodynamic Instability, Laparoscopy, and Ectopic Pregnancies

February 3, 2017 1 comment

As a young physician, I was taught that when a patient presents with a ruptured ectopic pregnancy and was hemodynamically unstable, the corimagesrect course was to perform a laparotomy for immediate control of the bleeding.  At that time (around the year 2000), complex laparoscopy was not really in wide practice, a
nd a physician who suggested that they could control bleeding laparoscopically as quickly as they could via laparotomy would have been met with skepticism.  In some cases, a physician suggesting a laparoscopic approach to the problem might be blocked by the atten

ding anesthesiologist, who often holds veto power over certain surgical decisions.  The idea was that the bleeding needs to be stopped quickly, and the way to do that is a laparotomy.

But over time, our ability to do things quickly and effectively via laparoscopy has changed, and I think our understanding of hemodynamic instability in young women has changed as well.

Read more…

Academic OB/GYN Podcast Episode 38 – The Endometriosis Podcast Launch

January 12, 2017 1 comment

Cross Post of Episode 1 of our new project The Endometriosis Podcast!   Dr Fogelson and new co-host Libby Hopton discuss new literature on endometriosis and answer question from the endometriosis patient community.  Topics include endometriosis research production, BPA and endometriosis incidence, outcomes after resection of bladder endometriosis, and more!

Sponsored by TrueLearn.  For a 10% discount on your order use the code “academicobgyn”

 

Academic OB/GYN Podcast Episode 38 – The Endometriosis Podcast Launch

 

A Holiday Message from Nicholas Fogelson and Academic OB/GYN

Merry Christmas and Happy Holidays from Nicholas Fogelson and Academic OB/GYN!   Dr. Fogelson is available for clinical consultation at the Pearl Women’s Center in Portland, OR at 503-771-1883.  He is a better gynecologic surgeon than he is a rapper.  And he’s not completely terrible at rap so there’s that.

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