Office-Based Surgery: What You Need To Know

the-bulletinBy Morris Wortman,MD

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.

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The Benefits Are Clear

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.

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Rochester Medical Resource Guide

Dr. Morris Wortman: Surgery Without Hospitals

medical-guideBy Kevin Fryling

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.

In addition, 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.”

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Endomyometrial Resection (EMR) vs. Endometrial Ablation (EA)

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.

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First of all—What is endometrial ablation?

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.

images-Nd-YAG-laser-350x225

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.

images-Rollerball-ResectoscopeCopy-500x335Within 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!

three-devicesIt 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:

  1. To achieve a highly reliable outcome of diminished or absent menstrual bleeding compared to endometrial ablation techniques.
  2. 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.
  3. 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

Endomyometrial Resection Endometrial Ablation
Amenorrhea (no further periods) 85.5% (10) 40-50%
Pathology specimen yes no
Requiring second procedure 5% (8, 10) 25% (1 – 3, 8)

 

If endomyometrial resection (EMR) is so successful why aren’t more physicians performing it?

Pathology Slide of EMR Specimen
Pathology Slide of EMR Specimen

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!

Summary

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.

References

  1. Munro MG. ACOG Practice Bulletin: endometrial ablation. Obstet Gynecol 2007; 109:1233-47.
  2. Longinotti MK, Jacobson G, Hung Y, et al. Probability of hysterectomy after endometrial ablation. Obstet Gynecol 2008; 112:1214-20.
  3. McCausland AM, McCausland VM. Long-term complications of minimally invasive endometrial ablation devices. J Gynecol Surg. 2010; 26:133-49.
  4. Gimpelson RH, Kaigh J. Endometrial ablation repeat procedures case study. J Repro Med. 1992;37:629-34.
  5. Wortman M. Daggett A. Reoperative hysteroscopic surgery in the management of patients who fail endometrial ablation and resection. J Am Assoc Gynecol Laparosc. 2001; 8:272-7.
  6. Wortman M, Daggett A, Deckman A. Ultrasound-Guided Reoperative Hysteroscopy for Managing Global Endometrial Ablation Failures. J Minim Invasive Gynecol. 2013. IN PRINT.
  7. Wortman M, Daggett A. Hysteroscopic endomyometrial resection: a new technique for the treatment of menorrhagia. Obstet Gynecol. 1994; 83:295-8.
  8. Wortman M. Minimally Invasive Surgery for Menorrhagia and Intractable Uterine Bleeding: Time to Set Standards. Journal of the AAGL. 1999; 6: 369-373.
  9. Wortman M. Sonographically Guided Hysteroscopic Endomyometrial Resection. Surg Technol Int. 2001. Dec 1; XXI:      163-169.
  10. Wortman M, Daggett A. Hysteroscopic Endomyometrial Resection. JSLS 2000; 4(3): 197-207.
  11. Wortman M, Daggett A, Ball C. Operative hysteroscopy in an office-based surgical setting: review of patient safety and      satisfaction in 414 cases. J Minim Invasive Gynecol. 2013: 10;26-6

 

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The Advantages of Having Your Hysteroscopy at The Center

Hysteroscopy is a commonly performed procedure today often used for assisting in the diagnosis and management of abnormal menstrual bleeding including unexplained post-menopausal bleeding.

Hysteroscopic Uterine ExamIn 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 Percentage
Easily acceptable 34.5 %
Acceptable discomfort 22.2%
Tolerable discomfort 27.4%
Barely tolerable 12.4%
Intolerable 3.4%

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.

3. Cost

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.

4. Communication

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.

 

REFERENCES

  1. Bradley LD, Widrich T. State-of-the-art flexible hysteroscopy for office gynecologic evaluation. J Am Assoc Gynecol Laparosc. 1995; 2(3):263-7

Why Bother Getting a Second Opinion?

Never in the history of women’s health care have there been as many alternatives to hysterectomies.

Obviously we are not talking about life-saving hysterectomies that are performed for cancers or acute hemorrhage following the birth of a child. But many—and possibly most–hysterectomies can now be replaced with other modalities that include:

  1. Careful observation and non-surgical monitoring of the condition.
  2. Hormonal medication and Intrauterine Devices (IUDs) to control heavy vaginal bleeding
  3. Non-hormonal medication to control heavy vaginal bleeding
  4. Endometrial ablation and Endomyometrial Resection
  5. Myomectomy (removing fibroids that reside inside or outside of the uterine cavity)
  6. Uterine artery embolization or uterine fibroid embolization

In addition, if you and your physician decide that hysterectomy is an appropriate choice for you there are still many choices that include the following:

  1. Does the hysterectomy involve the removal of the entire uterus or can the cervix remain?
  2. Does the hysterectomy also include removal of the ovaries?
  3. Will the hysterectomy be done laparoscopically?
  4. Will the hysterectomy be done robotically?
  5. Will the hysterectomy be done vaginally (with no abdominal incisions)
  6. Will the hysterectomy be done with a large abdominal incision (laparotomy)
  7. If I keep my ovaries should the fallopian tubes be removed?

WHO IS BEST SUITED TO PROVIDE A SECOND OPINION?

Years ago a colleague of mine entertained the idea that he would open a “second opinion” practice in Rochester. He envisioned a practice in which he was paid for his opinion only—in other words he would not use his position of knowledge or authority to siphon patients from other physicians only to enrich himself.

This would be the “ideal second opinion.” Under the best of circumstances you can visit a physician with your medical records in hand, allow for an examination (if necessary) and a thorough history so that the physician can get to know your particular needs and expectations and together reach a decision about hysterectomy—whether it is necessary. Perhaps you might decide that no therapy is required or that a less invasive method is appropriate. If a hysterectomy should prove appropriate for your condition you would be referred to a physician (who had no financial relationship with your “second opinion doctor”) with an excellent reputation and superior skills.

A QUESTION YOU SHOULD ALWAYS ASK YOUR DOCTOR—WHETHER IT’S YOUR “FIRST OPINION” OR YOUR “SECOND OPINION”

A question you should always ask your physician who is proposing an invasive treatment is simply this—“if I was your family member, daughter, wife, sister or other loved one would you recommend this surgery?” This is a legitimate question. Most physicians are honest, well-meaning and want the best for you. But this question may have them think a little harder. It’s a worthwhile question and you should strongly consider asking it no matter who is proposing surgery.

WHY DON’T WOMEN GET A SECOND OPINION?

There are many reasons women choose to not get a second option. Here are a few to consider. There are others as well.

  1. I don’t want to offend my doctor
  2. I trust my doctor and another doctor is just going to tell me the same thing anyway.
  3. It may cost some extra money to get a second opinion.
  4. A second opinion may mean that I have to delay my surgery and I can’t live with the problem any longer
  5. My friend had the same problem and she had a hysterectomy and she’s happy.
  6. My mother had a hysterectomy and so I knew I would eventually have one anyway.
  7. “I just want it out!”
  8. I did my on-line research and a hysterectomy seems the best way to go!

This will begin a multi-part series in which we begin to explain what might be gained by a second opinion. This article may not answer all of your questions but you will likely learn that there are a vast array of options available today that were not available only 10 years ago. You may learn that some of the “latest technologies” such as “robotic hysterectomy” do not offer results that are superior to other forms of hysterectomy—and they are not “less invasive” that other treatment options.

REASONS HYSTERECTOMIES ARE PERFORMED

Hysterectomies are the second most commonly performed surgical procedure performed on women today—over 600,000 annually in the United States. In general, the reasons for which hysterectomy is recommended fall into one of 3 categories:

  1. To save livesThis is not why the vast majority of hysterectomies are performed. This group includes women with various cancers and women who have rare life-threatening hemorrhage that may follow the birth of a child.
  2. To correct serious problems that interfere with normal function. This group includes women with very large pelvic masses (including some uterine fibroids), serious and incapacitating endometriosis as well as some other uncommon issues related to urinary and bowel function.
  3. To improve the quality of life. This is the largest group of women who eventually undergo hysterectomy and includes women with heavy, irregular or painful periods. Many of these women have fibroids (though not as large as in the previous group). Other women in this group may have uterine or pelvic organ prolapse while some have moderate amounts of endometriosis or adenomyosis.

With the exception of group 1 – there is generally both time and reason for a second opinion.

PERSONAL DISCLAIMER

I have been a practicing gynecologist in Rochester since 1980. Like most gynecologists I trained to perform hysterectomies and was among the first to perform laparoscopic hysterectomies as far back as 1989. Frankly, our practice took off in a different direction and approximately 10 years ago I stopped performing them. They are still necessary and I still refer patients for hysterectomy. However, after years of looking for alternatives to hysterectomy I no longer performed enough of them to feel that I was the best person to offer them. I feel that women who should undergo hysterectomies should be referred to the best physicians I know.

Under no circumstances, should you require a hysterectomy, will I personally perform one—but I will refer to the very best talented surgeons available.