Academic OB/GYN is a blog and podcast created by Nicholas Fogelson, an academic OB/GYN physician at Pearl Women's Center in Portland, OR. His mission is to educate and amuse OB/GYN physicians and other interested parties with up to date information about our field.
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.
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.
As of Aug 1, 2018, I am excited to announce my new business and practice Northwest Endometriosis and Pelvic Surgery (NWEPS). NWEPS is a practice dedicated to providing world-class care to women with complex cases of endometriosis-related pain and infertility, as well as other complex benign gynecologic conditions.
The start of this new practice also marks and end to my relationship with Pearl Women’s Center, my previous practice.
So the big question is why the change?
Well a while back I wrote a popular article that talked about the finances of advanced endometriosis surgery. We talked about how some physicians were in-network and others were out-of-network. At that time, I was working in-network on my professional fees, but also had a relationship to an outpatient surgery center where I did most of my work, which allowed me to supplement what I could produce in my professional work.
Over time, I decided that this was not the model under which I wanted to practice. The biggest reason for this is that an increasing number of the cases I was performing were very complex endometriosis cases that should be done in a hospital rather than a surgical center. As I discussed before, complex endometriosis surgery pays very poorly in-network, so the reality of this was that I would generate far more income for my practice by doing a simple case in the outpatient surgery center rather than a complex case in the hospital, and in the end this didn’t really align with my desire to do complex advanced cases. In the end, the only thing we should care about is what is best for the patient, and when somebody is paying you more to do something one way or in one place than some other way or some other place, this is a unneeded distraction from making the best choice for every patient.
I also found that over the three years I have practiced in Oregon, we have had increasing difficulty getting insurance companies to pay on our claims, even at their reduced in-network rates, and irrespective of where surgeries were done. For example, I have had surgeries that took 6-8 hours of work that were properly coded with 6 or 7 individual procedure codes, where the insurance company refused to pay on more than a single code. As an in-network physician, there is little one can do about this because of contractual language with the insurance company, so even if one appeals the situation most likely the company just tells you no.
Furthermore, over time I have pushed my practice into areas that insurance companies do not recognize at all, such as neuropelveologic surgery, and as such I would have no hope of being paid for that work under insurance contracts.
As such, I decided to start a new practice that is laser-focused on endometriosis and complex pelvic surgery. Due to all the previously mentioned issues, this new practice is entirely out-of-network for insurance plans.
While there are a number of out-of-network endometriosis practices in the country, in one way we are different than the rest. As out-of-network claims are quite complicated, I have hired a law firm to do my billing – but not against my patients but rather for my patients. What I have found is that out-of-network billing appeals are extremely complex and a skilled healthcare attorney will be far more effective than a typical billing company, and also far more effective than a patient who does not have a deep knowledge of the insurance system. This service is provided at no cost to my patients. This both ensures that I am paid fairly for my work, but also that patients are able to get maximum benefit from their insurance plans and have the minimum in out of pocket expense for their care with my practice. In cases where my expertise can clearly be shown to unavailable within a patient’s insurance network (which is not uncommon), we often have success in getting out-of-network exceptions, which can dramatically reduce a patient’s out-of-pocket costs.
Academic OB/GYN as a blog will continue, though new posts will also be cross-posted to my new website http://www.nwendometriosis.com. Youtube Content will be moved to a new YouTube page as well. It doesn’t have a link yet but I will update this post when it does.
Thank you so much for your readership of the blog.
If you are interested in clinical consultation please call us at 503-715-1377. We offer free records reviews, as well as free support for out of network billing appeals as needed.
Nicholas Fogelson, MD
Northwest Endometriosis and Pelvic Surgery
You have just gotten a job offer that includes health insurance. You’re lucky enough that your spouse has great family insurance already, but hey that health insurance is going to cover the cracks in the deductible and co-insurance, so you feel great about that double coverage as you sign your contract.
Well, you just got scammed. That is, double coverage is a scam, and you would have been far better off negotiating a higher salary in return for not getting insurance.
Let’s say Policy A has a deductible of $1000 and 75% coinsurance up to an out of pocket max of $3000.
Policy B is identical, with a deductible of $1000 and 75% coinsurance up to an out of pocket max of $3000.
So you get $500 in healthcare. It costs you $500 because neither policy pays up to the first $500 (for simplicity let’s ignore the no-deductible services some policies offer)
Then you have a surgery that costs $5000. The first policy pays $4000 on this ($5000 minus the $500 deductible that was left, and then 75% of the remaining $2000 on your out of pocket max, plus everything over that). So that leave’s you with a $1000 bill. That bill gets submitted to your second policy, which also has a $1000 deductible. So you still have $500 to satisfy there, and so the second policy pays you $500, or if you’re unlucky in how they interpret the secondary coverage, $375. So policy 1 pays $4000, and policy 2 pays $375 to $500.
This has always seemed wrong to me. If you have two life insurance and you die, your family gets paid twice. But if you have two health insurance policies and you get sick, you only get paid once, or maybe once and a little more.
So if one policy is at more risk than the other, the employer that buys the second policy must pay less for the double coverage policy, right? No they don’t. They have to pay full freight for both policies. That’s where the scam is.
Double coverage is WAY LESS COVERAGE than the single coverage policy, but both policies are priced the same. This is a product of the fact that large employers are forced to make insurance offerings for their entire population even though that offering may be of substantially less value to some employers than others.
But there is a way to solve this. Just turn down insurance if you are offered double coverage. Then tell your prospective employer that by turning down insurance, you are saving them $8 grand a year and ask for $8000 more in salary, or more vacation, or whatever other concession you want. For them it costs the same, but for you its of dramatically greater value. When you get that value, squirrel a bit of it away for unpaid healthcare costs. If you’re lucky and don’t need it, you just have more money. If you do need the healthcare, you can get the value that would have been paid by the double coverage with a fraction of the money.