one way to enhance patient safety and provide rational care: how about if physicians hold a conference prior to operating on patients?
Each week, all the gynecologists at the local hospital here get together to meet and discuss each of their forthcoming surgical cases. They are asked why they are doing them, what alternatives might be considered, whether the patient is appropriate for the procedure, whether such treatment is consistent with standard evidence-based guidelines, etc. I commended my colleague and said this was a great idea. Then he indicated surprise that I’d be at all surprised by this; apparently it is not only standard of care here in The Netherlands, but also is done in the UK and elsewhere. But not generally in the US. Other than occasional multidisciplinary groups, like the treatment planning groups at MD Anderson Cancer Center in Houston in which a radiation oncologist, gynecologic oncologist and medical oncologist all meet and examine the patient and then discuss what the appropriate initial treatment should be, I don’t know of many instances where physicians in the US get together to prospectively plan treatment. But what they do in the EU goes beyond this-it is not limited to complex gyn oncology patients (where a multidisciplinary approach really is critical, and something that I wish were performed more widely rather than just in large cancer centers), but is essentially a peer-review process in which one’s colleagues get to discuss whether or not what you’re planning to do makes sense.
Why is this such a nice idea? Because in the US, any of us can pretty much do whatever the hell we want to with our patients, evidence-based or not. If we decide Betty Yifnif should have a hysterectomy for fibroids, then that’s what is offered. If we decide she should have more conservative treatment, then great. If we decide to do an abdominal hysterectomy rather than a less morbid vaginal hysterectomy, that’s ok too.
In other words, there is little or no proactive oversight of what any of us surgical types do, outside of some preauthorization by third-party payors. In the UK, the National Health Services (NHS) has strict guidelines that one should perform vaginal hysterectomy rather than laparoscopic hysterectomy due to the known increased complication rate from the latter. Unlike the US, the NHS has reduced its benign hysterectomy rate by mandating that less invasive, more conservative therapies are offered first. Therapies such as the levonorgestrel intrauterine system (LNG-IUS; Mirena) or nonresectoscopic endometrial ablation (NREA).
What happens in the US? We also have NREA. We perform 450,000 of these procedures each year. Yet we’re still performing the same 600,000-650,000 hysterectomies each year for benign uterine conditions. Which begs the questions that I know the payors are also asking: why are we doing so many NREA procedures if they’re not coming out of the women who are otherwise appropriate for hysterectomy? Perhaps it might be because NREA is a pretty easy, blind procedure that is fairly quick and also very well reimbursed?
I know that there is a lot of bitching and moaning by many of my colleagues in the US about evidence-based guidelines and how health care reform will require too much “cookbook medicine” by physicians. Just mention “pay for performance” and observe the look of frank hatred on most physicians’ faces. Look, I hate being told how to practice medicine as much as the next person. But at the same time, there should be some agreement that certain things really need to be done in the majority of patients with a certain condition or disease. Can’t we agree that if we have a diabetic, he/she should have a hemoglobin A1C determination several times per year? Is that unreasonable?
And if someone has fibroids, why not require that the physician consider other options rather than simply whack out the uterus? There certainly are women who desire hysterectomy regardless of other options being available. I’ve had patients who listened to me present several options that were less invasive, and they chose hysterectomy. Those cases I can’t argue with-it’s the woman’s choice, whether I agree with her decision or not. But in many cases, it isn’t the woman’s choice. It’s the physician’s choice. And therein lies the problem.
If someone were to ask me if hysterectomy is required for some women with fibroids, I’d probably answer no, that myomectomy (removal of the fibroids with preservation of the uterus) is almost always technically feasible. I used to remove 40-50 fibroids in some women, and never had to then do a hysterectomy or transfuse blood. I’m not saying that it isn’t possible that after removing that many fibroids, there may be too little normal uterus to surgically restore to normal anatomy. But it never happened in my experience. So at least in the vast majority of cases, myomectomy is absolutely possible. Not every gynecologist may be particularly comfortable doing multiple myomectomy, and while I find that strange, given that this is a standard operation that is taught in residency, that certainly seems to be the reality. So why not refer the patient, then, to someone who is comfortable doing uterine-preserving therapy?
Back in the late 60’s, one of the main ob/gyn journals had a paper that argued the following (and no, I’m not making this up):
“The uterus has but one function-reproduction. After the last planned pregnancy, the uterus becomes a useless, bleeding, symptom-producing, potentially cancer-bearing organ and therefore should be removed.”
Wright, Obstet Gynecol 33:560, 1969.
So what if we had surgeons and gynecologists meet with their colleagues and critically review each case they are planning to do, in order to see if it really passes muster with the general consensus and expert opinion? I suspect it couldn’t happen in my country, since we all love our autonomy and hate the increasing encroachment upon our clinical judgment. I empathize, but only to a degree. All I have to do is then think about the fact that hysterectomy rates vary widely from one part of the country to another, and the fact that at Brigham and Women’s Hospital, I was encouraged to do many operative deliveries with forceps but no one was allowed to do vaginal breech deliveries while across the street at Beth Israel, their residents could do neither, and in Philadelphia, I could do both. That says, right there, that this all has little to do with evidence and much to do with individual judgment or lack thereof.