When I was a pelvic surgery fellow, I was doing a bowel resection with a general surgeon who was an older, distinguished Persian gentleman with an old world sensibility to him. When it came time to do the reanastomosis, I asked the scrub nurse for a surgical stapler and was stopped by the surgeon, who asked why I wanted to use a stapler to reconnect segments of bowel. I indicated that this is how I had always done it, and it was a faster method overall. The surgeon preferred that I do a hand-sewn anastomosis. When I asked him why, he said “Why do I drive a Mercedes rather than a Ford Taurus? Both will get me to my destination, right? But the Mercedes has craftsmanship.” His point: a technician can use a mechanical device to connect bowel back together. A craftsman takes the time to do it the long way, with artistry and precision.
So that’s how I came to learn how to do old-fashioned, hand-sewn bowel anastomoses. I still preferred staplers. But there’s something to be said for craftsmanship. In surgery, how you do something is often as important, or even more important, than the end result.
I was thinking back to that surgical experience during fellowship as I took stock of all the things in ob/gyn that are not representative of craftsmanship. Unlike any other surgical field I can think of, we as a profession have been oversimplifying and undoing years of craftsmanship. Sometimes perhaps for the better. But overall, for the worse. Examples:
- Replacing the more difficult art of forceps deliveries with a much simpler (yet often more dangerous) technique of vacuum extraction
- Replacing the art of hysteroscopic endometrial ablation with office-based nonresectoscopic endometrial ablation that does not permit visualization of the endometrial cavity
- Replacing advanced operative laparoscopy with robotics
- Replacing ureteral dissection with lighted stents
- Replacing laparoscopic hysterectomy with laparoscopic supracervical hysterectomy
Why am I lamenting all this? Because rather than become fluent in advanced surgical procedures, either through fellowship training or extensive preceptorships, my specialty has tended to ”dumb down“ surgical procedures in order to make them more accessible to the ”average gynecologist.“ Years ago, when endometrial ablation came out, it was looked upon as a way to make a significant dent in the ridiculously large number of hysterectomies performed annually in the US (~600,000/year for benign disease). However, only about 20,000 ablations were done every year, because most folks either never learned the hysteroscopic skills required to perform the procedure, or else just didn’t want to do it. So in its place came an office-based procedure, erroneously termed ”global endometrial ablation (GEA)“ that is a blind procedure but often as efficacious as the hysteroscopic version.
Now, I have nothing but praise for moving appropriate surgical procedures to an office setting. It’s easier for patients and better from a cost standpoint. But it’s one thing to move a procedure to an office setting thanks to innovative medical devices in an evolutionary fashion. It’s quite another to create a new device and technique in order to make a procedure accessible to more gynecologists due to their lack of surgical skills.
I hate to sound like an old curmudgeon complaining about the lack of skills of a younger generation. But just consider what’s happened to gynecology over the years. Can’t dissect the ureter worth a damn? No problem-just ask your friendly urologist to place some lighted stents into the ureters so that you can see them during surgery. Mind you, the stents only serve to make the ureters a better target for inadvertent injury, and the additional procedure adds minor risks and costs to the overall surgery. But it makes some gynecologists feel better. If only they didn’t fear the retroperitoneum and took less than five minutes to identify the ureter, dissect it, and mobilize it out of the way without the need for stenting.
Same with robotics. Again, I’m all for medical advances. But robotics had primarily been adopted by urologists in order to do laparoscopy simply because urologists traditionally have not been laparoscopic surgeons, unlike gynecologists. But what happened? Robotics became not just an expensive marketing tool by some hospitals, but a crutch for some general gynecologists to perform laparoscopic procedures that they couldn’t have done the ”old fashioned way“ (that is, without a $1.5-$2 million robot helping to facilitate the procedure). Robotics may yet be shown to have a rational place in gynecology; I know of at least one colleague who has similar objections to robotics but feels it makes it much more possible to close the uterus in an anatomic fashion during laparoscopic myomectomy. But when I hear about gynecologists using/needing robotics for laparoscopic operations that many of us routinely performed without any robotic systems, I wonder what the future is for my specialty. Same with laparoscopic supracervical hysterectomy. In the absence of any good data supporting an advantage over total hysterectomy, many of my colleagues perform laparoscopic supracervical hysterectomy as a way to make the procedure easier. It does reduce the risk of ureteral injury, to be sure. But do we really need to dumb down gynecology?
Surgery is all about craftsmanship. And skill. While I applaud attempts to make difficult surgical procedures more accessible to a larger number of physicians, it makes me wonder why such a large number of my colleagues don’t feel comfortable with, say, operative hysteroscopy or laparoscopic hysterectomy in the first place. So many things seem to require simplification, but I am not aware of that many general surgery or cardiothoracic surgery procedures that have been simplified in order to make them more performable by the average general surgeon or CT surgeon, respectfully. And just consider the average CT surgeon; would anyone dare imply that he/she isn’t capable of doing a valve replacement or some intricate vascular procedure, and thus would require a simplified operation to be able to treat his or her patient?
We need to do a better job at producing gynecologic surgeons who are capable of performing the more complex approaches to certain operations and procedures. If such procedures can evolve and become simpler and cheaper to perform, then great. But let’s do it for evolutionary reasons. Not in order to make something accessible to surgeons who really should be able to do the original procedure in the first place. If there is a real advantage to ”GEA“ then that’s wonderful. But is there an evidence-based advantage or is it really a case of ”dumbing down“ endometrial ablations?
PassionateProvider 12:56 am on Tuesday, June 2, 2009, 12:56 am Permalink
Hey David,
Great post. Very powerful.
I’m currently in my last year of medical school. I have organized abortion training opportunities at my school since my first year. Now that I am in my internship years, I have also had the privilege of working with and learning from practicing providers. I am looking forward to a career where I can be involved in the full spectrum of women’s reproductive health. An abortion-providing baby-delivering doctor is not an oxymoron. In fact, I think it is a pretty awesome combination.
Your call for “coming out” of providers does not fall on deaf ears. I agree with you completely. I’m not quite there yet, unfortunately. The pseudo-anonymity of twitter et al. has made it easier for me to share my thoughts and passions. As I gain confidence, and, more importantly, a sense of interconnectedness to like-minded people, the need for anonymity is diminishing.
dtoub 1:06 am on Tuesday, June 2, 2009, 1:06 am Permalink
Thanks very much. I really appreciate your comments. And no, it is not at all an oxymoron. I did it as well, although I confess I was more of a laparoscopic surgeon than an obstetrician after awhile.
Don’t rush the “coming out” part. It’s an individual choice. I was very careful when I was in practice, especially after I had my daughter. It changes one’s perspective, since it isn’t just about you. But being careful isn’t synonymous with denial. I never lied about what I did and remain proud and humbled to have provided this service to many women. But it’s admittedly easier to be “out” in terms of abortion once one has left clinical practice. Many of my fellow abortion providers were genuinely scared in the 90’s and with good reason. Several providers were shot and killed, along with courageous volunteers and staff. That changed things quite a bit. So there’s nothing wrong at all with flying under the radar. But still, many established providers need to declare themselves or at least not deny what they do when asked. The more providers who speak out, the better. Good luck with your training. Guess I can’t talk you out of being a doctor.
EJ Keith 11:45 am on Tuesday, June 2, 2009, 11:45 am Permalink
I happened upon your blog in light of Dr. Tiller’s death, and I just wanted to express my utter gratitude for the work you do, and the courage and honesty with which you carry out your duties. I’m a Canadian woman, so things are a bit easier for us up here, and although I’ve never needed to consider an abortion I have friends and family members who have; and I am grateful that I live in a country that respects a woman’s life enough to allow her the courtesy of being the sole decision-maker in the choices that will most affect her.
I was born in 1980, so I grew up as a member of the first generation of Canadian women to go trough puberty post-Morgenthaler (the SC decision that abolished the last legal restrictions on abortion in Canada). Because of this, I’ve never had to go through the agony of having nowhere to turn, nor have any of my friends of similar age. I haven’t lost friends to butchers, I haven’t known anyone – of my age – to have their dreams of future children taken away from them as a result of complications from an illegal operation (although I have met older women who have had to live with this).
And for this freedom, this luxury of choice, I have you, and others like you – doctors, nurses, and other health care providers & supporters – to thank. To you and future doctors like the one who commented above me on this thread, THANK YOU, THANK YOU, THANK YOU. Although we are from different countries, with different laws, the stand you make strengthens us all.
And I can’t thank you enough for having the courage to make it.
Kindest Regards,
EJ Keith, Ottawa, Ontario
dtoub 11:53 am on Tuesday, June 2, 2009, 11:53 am Permalink
Thanks for your kind words. Your country is pretty enlightened regarding abortion, as I’ve noted before: http://dtoub.wordpress.com/2008/07/12/an-enlightened-attitude-about-abortion/.
I’m no longer in practice, incidentally, and regret not being able to provide this service and train residents. Our health care system is very different from Canada’s, and many gynecologists end up either changing states or leaving practice entirely. Hopefully Obama’s health care reform will take hold—we need a better system.