Academic OB/GYN Cases – Large Abdominal Wall Endometrioma with Mesh Reconstruction
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.
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.
Why Healthcare is So Expensive Part 5 – Pharma Gone Wild
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.
Well 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.
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.
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.
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…
Why American Healthcare is So Expensive Part 3 – The Insurance System
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.
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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.
Why Healthcare in America is So Expensive Part 2 – Surgical Equipment
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 c
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.
Healthcare Reform Has It Wrong: Why American Health Care is So Expensive Part 1
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.
Today, 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.
Thoughts on Hemodynamic Instability, Laparoscopy, and Ectopic Pregnancies
As a young physician, I was taught that when a patient presents with a ruptured ectopic pregnancy and was hemodynamically unstable, the cor
rect 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.
Academic OB/GYN Podcast Episode 38 – The Endometriosis Podcast Launch
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.
Academic OB/GYN 