The Alzheimer’s Association reports that 5.5 million Americans suffer from Alzheimer type dementia in
the United States. This makes up approximately 70% of all dementias. It also reported that 15.9 million
Americans provided 18.2 billion hours of unpaid assistance to family and friends with Alzheimer’s and
other dementias in 2016. It comes as no surprise that almost daily I encounter a patient who shares
their story about caring for a loved one with dementia. This is my story.
In 2006, the very weekend that I graduated with my masters in nursing, my dad was diagnosed with
dementia. My mom was his primary caregiver until he passed in 2012. Losing a parent is never easy.
The person charged with your care and protection is no longer there. As I grieved the loss of my dad, it
became apparent that I was losing my mom to dementia as well. After my dad’s passing, we started to
notice a cognitive decline in my mom. Those of you that have family or friend with dementia are
familiar with this subtle progression, that at first you try to deny, but then have to admit that someone
you love is gradually being stolen away from you.
The transition for a parent to go from caretaker to being the one requiring care is often a difficult one
for both the parent and the child. For me, this adjustment coincided with my daughter’s departure out
of the house for college. It was overwhelming trying to balance the emotions of encouraging one
generation to gain independence while slowly reducing the independence of another. It was a struggle
to gain the courage to confront my mom with her disease. Then even after difficult discussions were
had, they soon evaporated as the result of the disease and had to be repeated. The weight of having a
loved one with dementia was almost unbearable.
I have sat with many patients in my office, following their annual exams, sharing our struggle with how
to best manage our loved ones’ care. Some moved loved ones into their home to care for them, others,
like me, hired home health aides in an attempt to keep them out of facilities. My experience was that
this worked for a while but as the disease progressed, my mom’s social isolation grew. Boredom is an
environment in which cognitive decline thrives. This past summer my sister and I had to face the reality
that Mom’s condition was quickly deteriorating and a change needed to be made.
The decision to move my mom out of the only home we have ever known was the most agonizing
decision that my sister and I have ever had to make. In August, we starting looking for assisted living
care facilities with memory care units. I am happy to say that our tale comes with a happy ending. On
September 23 rd we moved my mom into a facility which allowed her to bring not only own furniture but
her beloved cat, Lucy, as well. Initially she was homesick and spoke only of going home. As time has
passed, she has become content and happy in her new home. With better nutrition and socialization
she is thriving. I look forward to visits and always take fresh flowers which she loves.
All of our stories are different. Each of us will navigate through these decisions differently but we all
have love in our hearts. I still mourn for the loss of the mom that I once knew but now I am joyful as I
get acquainted with the person she is now. During my last trip to visit we took her to a restaurant/bar
near her facility. When our meal was delayed we were delighted when she joined us in a game of pool!
We are witnessing a “perfect storm” for the growth of office-based surgery (OBS) across the country. The combination of decreasing physician revenue, enhanced reimbursement for OBS and innovative technology have all stimulated the growth of minimally invasive procedures in the office setting. Many specialties offer a host of procedures in an office environment; these include upper and lower endoscopies, vasectomies, cystoscopies, many plastic surgical procedures, female sterilization, endometrial ablation and even removal of fibroids and endometrial polyps.
Office-based surgery (OBS) offers many unique advantages to patients, physicians and the office staff. Until recently there were few regulations that governed officebased surgery-in some cases with tragic consequences. In this brief article I’d like to review the advantages of OBS, the NYS regulations that govern it and offer suggestions for providing the highest standards of care.
The patient benefits are clear. Your patient is in comfortable and familiar surroundings, enjoys simplified scheduling, lower co-pays and the familiarity with members of your office O.R. Crew. Typically, patients spend only a fraction of the time in your office when compared to the same procedure performed in a hospital O.R. or ASC and are less likely to be “bumped” unforeseeable quirks of a busy O.R.
Physicians also benefit from easier and more flexible scheduling procedures and greater control over all aspects of peri-operative care. Importantly, we are present for the entire duration of a patient’s postoperative care-a luxury often not found in a hospital or ASC setting. Financial benefits arise either from increased insurance reimbursement or from the more efficient use of our time in an office-setting. Finally, an OBS setting allows physicians far greater control over the selection and training of specific members of the O.R. Crew for specific procedures.
The office O.R. Crew also enjoys significant rewards compared to their hospital counterparts as they enjoy dual roles-caregivers both in and out of the O.R. The same nurse practitioner who asks me to consult on her patient will also assist during the patient’s operative procedure. This allows members of our O.R. Crew to participate in preoperative decision making, intraoperative care and postoperative management. Not only is this comforting for the patient but it provides individual members of our team and our patients with the kind of continuity of care not seen in other settings.
Our own office O.R. Crew enjoys another potential benefit-a culture that stresses mutual cooperation and respect. Their training and error-avoidance procedures, know as Crew Resource Management ( CRM) has been used in the aviation industry for the past 3 decades. CRM encourages the input of all members of the O.R. Crew and encourages collegiality and mutual support in their devotion to patient safety. We meet regularly, as a team, exploring potential ‘weaknesses’ in our system to develop and institute solutions. Patient safety is the responsibility of every single member of our Crew. One example is our “timeouts”. Hospital “time-outs”, are often perfunctory and limited. Our “time-outs” often take 5-10 minutes to perform and include a complete presentation of the patient’s chief complaint, past medical history, allergies, pertinent social issues and particular concerns specific to this particular patient. The CRM approach allows us to tailor procedures to the individual-not the other way around.
Understanding the Regulations
Physicians considering OBS must be aware of current NYS DOH regulations. Since January 14, 2008 the DOH requires (see NYS Public Health Law Section 230-d) the reporting of any “adverse event” that occurs in an office setting within one business day of a reportable event. This includes an unplanned transfer to a hospital, an unscheduled hospital admission within 24 hours of OBS, a serious or lifethreatening event or a death.
Since July 14, 2009 offices which provide other than minimal sedation are required to be accredited by one of 3 nationally recognized agencies -The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the Accreditation Association for Ambulatory Health Care (AAAHC) or the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF). Additionally,accreditation is required for all but “minor procedures.” These are procedures “that can be performed safely with a minimum of discomfort where the likelihood of complications requiring hospitalization is minimal. .. procedures performed with local or topical anesthesia; or. .. liposuction with removal of less than 500 cc of fat under unsupplemented local anesthesia.” (http://www.health.state.ny.us/professionaIs/office-based_surgery/1aw/230-d.htm). In summary, there are 2 thresholds which require accreditation-performing other than “minor procedures” or ones that require the use of moderate or deeper levels of sedation and analgesia.
It is imperative that physicians understand that the level of sedation achieved, not the route of administration or the agent used -is what determines the need for accreditation. Whether given orally or parenterally, narcotics and sedatives pose similar risks. Minimal sedation may be achievedand does not require accreditation-with intravenous narcotics and sedatives as long as the results fall within the definitions set forth under NYS Public Health Law Section 230-d. It is also possible to induce a level of moderate conscious sedation by the injudicious use of oral agents. Some physicians, in an effort to avoid the requirements of accreditation, may perform procedures in an OBS without adequately managing pain or anxiety. As physicians we have an ethical responsibility to not compromise patient comfort in an office environment.
Before undertaking any OBS procedures one should develop a list of ‘potential’ procedures that you would like to consider in your office. After assessing the nature of the procedures and its anesthesia requirements you must determine whether or not you will require formal accreditation.
Finally, whether or not your office requires accreditation you should consider the following suggestions:
Designate a medical director with specific patient safety responsibilities.
Create a training manual and checklist for every procedure.
Simulate and practice emergencies.
Institute training and credentialing for all staff members
Develop protocols for analgesia/sedation for all procedures.
The commitment to teamwork, ongoing quality improvement and a culture of safety results in improved outcomes for your patients and enhanced professional pride.
Morris “Moe” Wortman, MD., is a “high flyer” in more ways than one. As a small plane enthusiast, he has logged air speed records in the United States and Europe; as a physician, he founded and has run one of the country’s most respected office-based surgical practices for more than twenty-five years.
At the Center for Menstrual Disorders and Reproductive Choice (CMDRC) in Brighton, ‘Wortman performs a wide range of outpatient surgical procedures to address abnormal menstrual bleeding, incapacitating cramps, and other painful reproductive disorders-all without patients ever setting foot in a hospital. “There’s so much than that can be done for women right in their doctor’s office,” says Wortman. “Traditional operating rooms are set up for sick people, but we’re mainly doing procedures on relatively healthy young women:’
In 1981, as the twenty-nine-year-old chief of OB-GYN at the Genesee Valley Group Health Association (GVGHA), Wortman saw firsthand the many problems that amict hospitals. He points out that the “one-size-fits-all” approach to health care at hospitals requires patients to repeatedly fill out the same forms, undergo multiple consultations or pre-screenings, and frequently experience over-sedation during surgery. A ten-to-fifteen minute procedure can easily drag out to six hours or more. “Hospitals don’t differentiate,” he says. “They put everyone through the same rigmarole:’
Moreover, large clinics tend to experience weaker doctor-patient communication and greater delays since a twenty-four-seven work environment and constantly shifting schedules mean doctors and nurses are mixed and matched, making it harder for them to establish routines together. (By contrast, Wortman notes the average employee at CMDRC has worked in the office for seventeen years.) Wortman decided to open the doors to his own practice over twenty-five years ago partly in response to these conditions.
Another chief inspiration was A. Jefferson Penfield, a Syracuse OB-GYN who was performing some of the country’s first non-hospital tubal ligations. “His practice had a profound influence on my professional career,” says Wortman, who received early-career mentoring from Penfield. “Even at GVGHA, I tried to bring as many surgeries out of the operating room as could safely be done:’
The OB-GYN field helped pioneer office-based surgery because so many procedures require no incisions, Wortman notes. This is because all operations may be performed “hysteroscopically,” or via natural bodily orifices. The speed and flexibility provided by office-based surgery makes it possible for a woman to schedule a procedure on Friday and need only the weekend to recover. Many patients who visit during the workweek even return to their jobs the next morning.
“In terms of your ability to plan your life, [faster recovery time] is very powerfull,” Wortman maintains. “There are numerous advantages, from the patients’ perspectives, the doctor’s perspective and-from the point of view of the insurance companies-the economic perspective. So this really is a ‘win-win-win’ for everyone.”
The list of gynecological procedures that can be performed within a private practice has grown significantly over the years, and now includes removal of uterine fibroids, and treatments for abscesses, infections, growths on the vulva, and cervical dysplasia. As a strong advocate for reproductive choice, Wortman was also one of the first office-based physicians to provide safe, pain medicine-assisted pregnancy terminations to women in Western New York.
A typical day at Wortman’s practice might include one major and four or five minor procedures, as well as consultations. The clinic’s most popular treatment, a technique of endomyometrial resection, was pioneered more than twenty years ago by Wortman and Amy Daggett, RN, ANP, an adult nurse practitioner at CMDRC. The operation, which stops abnormal menstrual bleeding without requiring a hysterectomy, remains the most successful of the endometrial ablation techniques.
Inaddition, CMDRC’s Accreditation Association for Ambulatory Health Care (AAAHC) accreditation enables Wortman to offer a wider range of procedures than many other private practices. Physicians who lack this approval are limited in the range of pain management options, which means operations either have to be stopped mid-procedure when stronger analgesics are not authorized or proceed despite severe pain or discomfort for the patient “We function like a small hospital, complete with the sort of oversight that goes along being a hospital,” says Wortman, who opened a new, larger facility in 1999. “So many more things can be done for women today quickly, safely, and using minimally invasive techniques.”
If you are considering any type of endometrial ablation (EA) you should strongly consider endomyometrial resection (EMR) and why I believe it has many advantages over any of the ablation techniques that are available today. Here’s a bit of background on each. Keep in mind that in 1988 I became the first physician in Western NY to successfully perform endometrial ablation and had extensive experience with it before I set out to on a different direction and invented the technique of EMR.
Endometrial ablation is the systematic burning of the uterine lining. The goal of endometrial ablation is to destroy –through burning—the uterine lining and replace it with scar tissue so that it no longer grows and sheds each month. If endometrial ablation is 100% successful the woman no longer experiences a monthly period. This does not cause menopause—which occurs when the ovaries stop producing eggs along with several classes of hormones. Because the uterine lining is important for pregnancy, endometrial ablation is only offered to women who have completed their families.
In order to destroy the uterine lining—and keep it from growing back–it is important to destroy the very base of the lining tissue called the endometrial basalis. A good analogy would be if you were trying to destroy a patch of grass in your front lawn using a blow torch. The only way it will work is if you apply enough heat to destroy the deep grass roots. If you simply apply heat to the blades of grass above the ground the grass regenerates and grows back. The challenge with endometrial ablation is to deliver enough heat to the lining so that the basal layer–the equivalent of roots—is destroyed without causing injury to other pelvic organs. If the basal layer isn’t destroyed the endometrium easily regenerates and grows back.
Early days of endometrial ablation (1988-1991)
When I first began performing endometrial ablation (EA) at Highland Hospital in 1988 we used a $110 thousand laser (neodymnium: YAG). The laser represented a major breakthrough in gynecology and allowed us to treat women with abnormal uterine bleeding in a simple outpatient procedure that often avoided hysterectomy. The laser was introduced through a hysteroscope so that we could actually look and work inside the uterine cavity. In the picture just below the laser fiber is introduced through a special telescope—called a hysteroscope—which then heats up or “cooks” the uterine lining.
Within a year (1989) the FDA had approved an electrified hysteroscope known as a “rollerball”resectoscope. The resectoscope was both less costly and more efficient—an example of sometimes “cheaper is better.” Although we were able to treat dozens of women with the laser it was soon replaced by “rollerball” resectoscope which was more effective in destroying the tissue inside the uterus (endometrium).
Within 2-3 years however it became apparent that even the “rollerball” resectoscope did not produce entirely predictable and acceptable results. At least 40% of women continued to have vaginal bleeding after endometrial ablation—which meant there was plenty of room for improvement.
One of the reasons, I felt, for the lack of predictability with endometrial ablation is that “burning” or “cooking” the uterine lining is not a very reliable way of destroying it!
It was the unpredictability of endometrial ablation that led us to invent endomyometrial resection (see below) in 1991.
In the meantime….
Even though endometrial ablation was performed in different parts of the world it never really caught on in the United States. But this changed in 1995 when a series of devices began making their appearance on the American and European markets. These devices were designed to improve the safety of endometrial ablation and encouraged many physicians—for the first time—to strongly consider their use.
Thanks to these devices, endometrial ablation became an important tool for gynecologists in this country and in Europe. However, while these devices improved the safety of endometrial ablation they did not improve their results! These systems—which include the ThermaChoice Balloon, Hydrothermal Ablation and NovaSure devices—account for nearly 400,000 ablation procedures performed in the U.S. each year.
The problem with endometrial ablation
It is now recognized that 25% of women undergoing endometrial ablation with these devices will subsequently undergo a hysterectomy within 3-4 years. The number of women who are dissatisfied with the results is likely to be higher but many of them simply elect to accept their results and not undergo further surgery.
Endomyometrial Resection (EMR): Definition and Goals
Endomyometrial Resection (EMR) grew out of the need to improve the results of endometrial ablation while not compromising on safety.
Definition: Endomyometrial resection is the systematic removal of the entire uterine lining (including the basal endometrium) together with the underlying muscle in order to insure that a known depth of lining tissue and muscle is removed—not burned. This is done to insure that the very base of the endometrium (lining tissue) has been removed and does not survive.
Goals: There are 3 goals of endomyometrial resection:
To achieve a highly reliable outcome of diminished or absent menstrual bleeding compared to endometrial ablation techniques.
To have a specimen that can be sent to a lab for analysis and determine whether or not there is a precancerous or cancer lesion of the uterus as well as other conditions that increase the risk for abnormal uterine bleeding.
To minimize the risk for endometrial ablation failure which frequently requires some form of subsequent surgery—especially hysterectomy.
How does Endomyometrial Resection provide more reliable outcomes than endometrial ablation? What are the specifics?
There are several ways of comparing endomyometrial resection and endometrial ablation. The first is determine how many women stop having periods altogether (amenorrhea) following both procedures. The second—and more important—is to determine what percentage of women will require a second procedure. The “second” procedure may be either a repeat procedure or a hysterectomy.
Comparison of Medical versus Surgical Abortion
Amenorrhea (no further periods)
Requiring second procedure
5% (8, 10)
25% (1 – 3, 8)
If endomyometrial resection (EMR) is so successful why aren’t more physicians performing it?
To successfully perform EMR requires 3 separate skills:
First. The physician must develop expertise in operative hysteroscopy. EMR requires the skill to operative inside the uterine cavity. Most expert hysteroscopists around the world are self-taught as these skills are generally not learned during a typical residency or fellowship program. Most “minimally invasive” gynecologic surgeons are laparoscopists who are trained to operative inside the abdominal or pelvic cavity. They utilize small, narrow instruments passed through small skin incisions. Operative hysteroscopy, however, is an entirely different skill that requires the ability to perform surgery inside the uterine cavity and without skin incisions. Most major communities have barely a handful of skilled hysteroscopists.
Second. The physician needs to be skilled in dynamic ultrasound or “ultrasound guidance”. In addition to a surgical skill the physician needs to be perform and direct imaging during surgery and learn to rely on ultrasound images to guide their surgery.
Third. The physician must be able to assemble and maintain a “team” devoted to hysteroscopic surgery. Our “team” consists of a surgeon, 2 nurse practitioners and 2 medical technicians –with over 80 years of combined experience in operative hysteroscopy.
Simply stated, this is not the kind of expertise that is easily acquired!
If you are seriously considering an endometrial ablation you should take the time to learn about endomyometrial resection. EMR is an office-based procedure (11) that is extremely safe in our hands and produces results that we believe are superior to any of the endometrial ablation techniques. EMR has been well studied – in many cases we have over 20 year follow-up. In addition to these advantages EMR also provides an abundant amount of tissue for laboratory analysis. In a significant number of patients EMR has been able to diagnose both cancerous and pre-cancerous lesions that were missed on endometrial biopsy as well as D and C.
But the bottom line for most women is simply this— the results of EMR are better. You are more likely to achieve your desired outcome with EMR compared to any ablation procedure. To learn more about endomyometrial resection contact our office and schedule an appointment for a consultation.
In nearly all communities hysteroscopy is performed either in an office, an ambulatory surgery center or a hospital.
At the Center for Menstrual Disorders we perform hysteroscopy in an office-based setting while providing excellent pain control, in a familiar environment at low cost to you and your insurer. We offer a highly experienced and skilled staff who’ve worked together for many years with proven equipment that is often unavailable even at the most well-known and respected medical centers.
1. Pain control
Hysteroscopy is a safe procedure but it is not painless. In a study by Bradley and Widrich (1) the authors studied 417 women who were referred for hysteroscopy in an office setting. The patients described the pain they experienced as follows:
Pain at Hysteroscopy
From my standpoint that means at least 15.8% (the sum of the last two groups) found office hysteroscopy to be either intolerable or barely tolerable while another 27.4% found it to be uncomfortable but “tolerable”.
Some women might find this acceptable but I personally do not. I believe that patients should not have “barely tolerable” or “intolerable” procedures. This is neither good for patients nor their physicians. Women will suffer two-fold. First, they had a bad experience and second, the information that they were supposed to get may be unreliable or not obtainable at all. Importantly, the physician does not benefit from these scenarios as she or he is rushing to get through procedure and not cause you further pain.
For this reason many physicians offer diagnostic hysteroscopy in an operating room or ambulatory surgery center (ASC). While this solves the issue of pain there are numerous other issues one must consider in a hospital or ambulatory surgery center.
Procedures there are often more expensive for the patient and the insurer
Hospital and ambulatory surgery centers do not offer the convenience of the “home-like” atmosphere found in your physician’s office.
You will be there—hospital or ASC–many additional hours dealing with the various “systems” imposed by hospitals and ASCs. Although hospitals and ASCs do a wonderful job they are not designed to tailor their routines to your individual needs. This often adds significant time and cost to their procedures.
Hospitals and ASCs do a very good job but theirs’ is a “one size fits all” approach to diagnostic hysteroscopy. At the Center for Menstrual Disorders we are able to offer a range of pain control services based on the patient’s needs. Our pain management is individualized. The one important benefit we offer is that you can begin a procedure with little or no sedation–if you wish—and then you can ask for additional medication, as you see fit, in order to get you through the procedure. If you wish you can simply decide to be asleep for the entire procedure and have no memory of it.
2. A Familiar Environment
One of the attractive features of office based procedures is that you’re already familiar with the environment. You already know how to get here and where to park your car. You’ll recognize the staff and you may have already seen our procedure room. The atmosphere is designed to be “home-like” and we feel it is a far more relaxing atmosphere than you’ll generally experience in most ASCs or hospitals today.
In general the out-of-pocket costs for most women is significantly less for an office-based procedure at the Center for Menstrual Disorders than the same procedure performed in a hospital or ASC. Please check with your insurer or ask one of our staff to check for you and compare.
Not only are hospitals and ASCs larger and more complex providers of health care but often you feel that there is no one around to answer questions for you, your family members or loved one. Because this is an accredited office based surgery center I am always here! I am available–to anyone that you’ve designated–to share medical information with anyone you wish.
5. Specialized Equipment
Hospitals spend a great deal of money purchasing and maintaining capital equipment often bring you, the consumer, advanced medical equipment and know-how. And while that’s true the same cannot be said of the limited field of hysteroscopy.
Because we specialize in menstrual disorders we have a vast array of hysteroscopes that are meant to accommodate many different situations that can unexpectedly arise. I am not making a boisterous claim in stating that we have a greater variety of specialized hysteroscopy equipment presently unavailable in any hospital or ASC in Western, New York. We do. The reason is simple. I am a specialist in a very narrow area of gynecology—hysteroscopy and hysteroscopic surgery. We invest in unique equipment that is presently unavailable in local hospitals and ASCs.
6. Knowledgeable Staff
Hysteroscopy requires a dedicated staff. Our nurses and technicians assist on hundreds of cases each year. Some of our staff have been with me for over 25 years! Two of our nurse practitioners have even published articles in scientific journals.
7. Experience, experience, experience!
We make no claim to be the best at what we do. But I have been performing office hysteroscopy for over 30 years and have completed many thousands of diagnostic and operative procedures.
Bradley LD, Widrich T. State-of-the-art flexible hysteroscopy for office gynecologic evaluation. J Am Assoc Gynecol Laparosc. 1995; 2(3):263-7