By Herbert A. Goldfarb, MD
During the last thirty years hysterectomy has been performed in this country between 600 and 700 thousand times each year. At least two thousand women die from the procedure each year. Can you believe that Hysterectomy has become the cure all procedure for women’s health problems? Hysterectomy is a major operation with a myriad of potential complications. Women die from this procedure and the loss of female hormones results in serious sexual dysfunction. Psychological trauma is common and often results in the loss of a sense of wellbeing and inner strength.
Let’s first look at normal function, and then some of the conditions that serve as excuses for hysterectomy. When women menstruate each month it is the endometrium or “lining of the uterus” that is shed after being hormonally stimulated by a combination of Estrogen and then Progesterone produced in the ovaries. This hormone milieu creates a succulent bed which given fertile sperm and a normal egg will create and foster a new life.
About 30% of women grow abnormal benign tumors called fibroids, which are cancerous only about 1?2 of 1 % of the time. Almost 50% of women develop episodes of abnormal menstrual bleeding usually caused by malfunction of the hormone sequences that result in significant abnormal bleeding called dysfunctional bleeding. Of course, there are other causes or abnormal bleeding, including malignancy. If you happen to have completed your family or be over” 35” years of age, then your gynecologist may have the ultimate solution for your problem, “Hysterectomy”. If you are over “40” then “we should remove your ovaries too in order to prevent” ovarian cancer” a terrible disease. This scenario has been played out over 650,000 times each year.
Why is this happening? How did we get to this state? What can we do to stem the tide?
The history of Hysterectomy parallels the progress in surgery and anesthesia. In 1860 Lister began to advocate antisepsis for surgery. While Thomas Keith was the first surgeon to significantly reduce mortality by improving surgical technique. Early surgeons would tie sutures and leave them long extending out of the wound in order to promote drainage and allow exit of “evil humors”. Keith was the first surgeon to cut the sutures short and close the wounds. So called drainage sutures allowed for drainage but also allowed an open portal for infective agents.
Remember that penicillin was not developed until the late 1930’s. In that era, open
Drop Ether was used for anesthesia. This anesthesia was actually administered by dripping the liquid agent onto a mask covering the patients face, without providing concomitant oxygen. It was perhaps acceptable for the healthy patients but the mortality was significant for the medically challenged.
In 1930, the country was in the grip of the great depression and physicians were not among the monied class. There was little or no health insurance. Fees were relatively meager, and few had money to pay for their health care. Medicine was an honorable profession. Physicians were respected and were dedicated to healing. Fees were low and patient’s ability to pay determined whether any compensation was received, and they were never turned away for inability to pay. Patients respected their physicians and physicians cared for and respected their patients. Emergency rooms treated true emergencies, not a cornucopia of patients who did not have access to a physician or money to pay for one.
Remember, today 38 million Americans do not have health care insurance. The only places obligated by law to care for these people are emergency rooms. Don’t forget that caring for uninsured people, many in deep poverty costs money. Hospitals have been ordered to absorb these costs by becoming more efficient. Of course we all know what that means to a service industry. Less service, less money for capital improvements, less money for new technology, and God forbid you end up in a hospital with a few dollars in the bank and a job but without health insurance. You’ll be paying for the rest of your life. What changed everything?
With the advent of Obama Care a whole new set of problems will be present. Who will care for 20 odd Million new patients. Who will pay for this care? The answers sound easy but they never are.
History of Current Medical Care
After the conclusion of WWII skilled labor was at a premium and industry began offering health insurance to attract workers. With insurance came oversight by the companies and eventually a demand to control the deliverance of health care. Malpractice insurance began to spiral out of control as lawyers discovered the golden goose. Physicians of course took advantage of insurance coverage by providing what they thought was the ultimate care for their patients. What about care for poor people? Doctors used to provide care gratis for those in need. Now, Medicaid, an insurance plan to provide aid to dependent children in poverty which reimburses very poorly took over the responsibility. The problem with treating Medicaid patients is that with meager reimbursements came a myriad of rules and regulations. Entrepreneurial Docs (I can’t consider them in the class with real physicians) set up clinics to move these people in and out like so much cattle, shuffling them back and forth between multiple physicians and wracking up the fees . The all knowing Government got wise and made a wise rule, “Only one service per visit.” So now the Docs are not stupid either and they adapted to these regulations. Each day the poor people were sent to another specialist. Of course the poor patient who was employed was caught in a never ending cycle of needing healthcare and having to travel day after day to multiple specialists. So if you go to a dermatologist and have five moles, he would only remove the first three in that visit, because that’s all he is paid for by managed care.
On and on the circle went. Of course with assembly line care came poorer results, which increased the complications and brought out the lawyers like so many ants going to fallen ice cream. Not that you can blame them, they have to make a living too. This feeding frenzy spilled over to the private practitioner who is held to a zero tolerance mistake level which no human being can achieve.
As the Rabbi has written, “Sometimes bad things happen to good people.”
As a sometimes medico-legal consultant I can relate to how personally offend some lawyers get when they are told that the bad result was not the doctor’s fault.
The second and equally important factor has to do with feeling good. With the advent of the sexual revolution Women began to feel important. With it came the right to matter and the right to feel healthy. Women as do men want the right to good satisfying sexual orgasm.” The Joy of Sex” catapulted the story to the front page. The advent of oral contraceptives freed women from the fear of unwanted pregnancy, while “Roe vs. Wade” and the right to choose solidified this new found freedom. However with the sexual revolution came an increase of sexual transmitted diseases.
Pelvic inflammation disease is the end result of sexually transmitted disease “S.T.D.” This was classically caused by gonorrhea which is rather catastrophic in symptoms and results in reproductive destruction. Other STD’s include mycoplasma and chlamydia infections which are rather silent but may be equally as destructive. In addition many women are delaying pregnancy to pursue careers. As a result another scourge to be dealt with is endometriosis” the career women’s disease.”
Endometriosis has been labeled the career women’s disease because it is often seen in women who have delayed pregnancy to concentrate on fulfilling their intellectual and business pursuits. This disease is defined by the displacement of endometrial tissue from the lining of the uterus to adjacent pelvic structures .Why does this occur? An oversimplified explanation is that spasm of the cervix during menstruation forces endometrial tissue and blood out of the fallopian tubes and into the adjacent pelvic structures. Subsequent devastation of reproductive capacity and chronic pelvic pain may ensue. With the new found safety in performing surgery, improved blood banking, newer broad spectrum antibiotics and anesthesia improvements including electronic monitoring of oxygen saturation and other vital functions physicians were quick to offer a simple solution to the problems of fibroid tumors, irregular bleeding, and endometriosis. That solution was believed to be hysterectomy.
At each Tuesday morning preoperative conference the chief resident at our hospital presents all surgery scheduled for the week. When I ask, “Why is this woman having a hysterectomy?” The reply is often “fibroid Uterus, and abnormal uterine bleeding”. I then ask,” have any alternatives been considered?” Then I ask” why are her ovaries being removed? ” Often the answer is “It’s the physician’s choice and the patient’s request.” In thirty years of private practice very, very few women have made a personal request of me to have a hysterectomy, no less to have their ovaries removed. Ophthalmologists do cataract surgery, podiatrists do toes, surgeons do gallbladders, and gynecologists do hysterectomies.
Actually overall Obstetrician Gynecologists are a sorry and depressed lot. They are the women’s primary physicians, and held to a higher standard than many medical specialists. Every woman expects and demands a healthy normal baby. If the baby is born deformed then why didn’t the doctor know this in advance? The lawyers call it wrongful birth. If the baby ends up in special education then the obstetrician is liable for any abnormalities attributed to his care until it reaches age 21 or for seven years after the discovery that a so called deviation from the expected level of practice took place. Believe me there is always some ‘expert’ who will testify that a deviation took place. Obstetrics is the only field of specialization where many of the MDs look forward to giving it up as soon as they finish their training. Of course that is an over-simplification, there are many dedicated physicians who specialize in the field of fetal maternal medicine and they’re in it for the duration. On the other hand many fetal maternal physicians espouse academic medicine.
During Residency training a young gynecologist assigned to the Operating room felt like he was in the cockpit of a jet plane, while the labor and delivery suite was likened to being in the trenches, or worse to hand to hand combat. I must admit that early in my career I loved to deliver babies. Even in the middle of the night bringing a new life into the world gave me a high. I could stay up in the delivery suite all night, catch a few hours of sleep, go to the office the next day and never miss a beat. After a while, however, father time starts to catch up with you. In the early 80s I trained in microsurgery and when laser surgical techniques were developed I eagerly adopted the new technology. In 1979, Dr Milton Goldrath described a technique of putting an NdYag laser fiber into the uterine cavity using an endoscope called a hysteroscope, for the purpose of destroying the uterine lining to control bleeding. That was the beginning of a new era. Dr. Robert Neuwirth performed intra Uterine Hysteroscopic surgery in the 70s but without much fanfare. I was fortunate indeed to have both of these innovator physicians as my mentors. With the advent of NdYag laser endometrial ablation to treat persistent abnormal uterine bleeding, the whole field of minimally invasive surgery came alive. Of course there was a significant learning curve, but skilled physicians were soon able to perform many procedures via the laparoscope that previously required open abdominal surgery. In 1988 the first hysterectomy via the laparoscope was performed. Now the minimally invasive gynecologists were off to the races. Courses and training centers sprang up throughout the country often sponsored by the surgical supply companies that made disposable equipment for the laparoscopic surgeons. This was big business with sales of these companies in the hundreds of millions of dollars. The companies had a tremendous interest in physicians being trained to offer ” kinder and gentler hysterectomies”. In 1990 I performed the first Myolysis procedure (a technique whereby a laser fiber or later electrosurgical bipolar needles are used to destroy blood supply to uterine fibroids) in the United States to destroy uterine fibroids and preserve the uterus, but few were willing to listen. They were having too much fun doing hysterectomies, and making too much money doing them. It wasn’t the academic Universities teaching the techniques but rather private centers and surgical supply companies that had the capital to set up these centers to try to make laparoscopists out of weekend warriors. Of course there was a steep learning curve necessary for physicians to accomplish this procedure laparoscopically and this made for a great number of complications. Physicians were using patients as guinea pigs to learn this procedure. The hospitals loved it because they got paid. The doctors had a new cause celebre “the kinder and gentler hysterectomy”. These procedures have inherent risk because they require much more skill than open abdominal surgery. When the abdomen is open the surgeon sees in three dimensions and can use his sense of touch. The laparoscopic surgeons view the abdomen via a two dimensional TV monitor often with less than state of the art optics. Actually I was fortunate to have microsurgical training which was invaluable in making the transition. There were and still are too many complications caused by incompletely trained physicians who want to keep up with their fellow MD’s. These physicians are well meaning but they don’t have the case load to become competent. Most hospitals don’t have training facilities to teach these techniques in the laboratory where it belongs.
How does all this relate to the burgeoning hysterectomy rate? The goal of the gynecologist is maintain women’s reproductive health. Hysterectomy was and is believed {misguidedly so} to create a healthy pelvis in women who had simple problems. The young Docs became proficient in that operation. It is relatively easy to do, pays the best of all the procedures that they and makes them feel like real surgeons. As my mother in law’s Gynecologist told her more than forty years ago, “You’ve had your children you certainly don’t need your uterus. You’ll feel so much better without it. Then we’ll give you estrogen replacement. Feel good don’t worry, its routine surgery.” If that’s not salesmanship then I don’t know what is. This trend continued unabated right through the eighties.
Subsequently gynecologic surgeons learned how to perform myomectomies thru the laparoscope. At this point we can also reconstruct very large myomatous uteri thru mini incisions. Just as few auto mechanics want to bother nor do they have the ability to take apart your engine and put it back together again, so do most Obstetrician-Gynecologists prefer to concentrate on delivering babies and not concentrate on the advanced nuances of uterine reconstruction.
Now enter the era of managed care. Some would have you believe that managed care means more efficient care and better access to health care. Efficient care means more patients seen per hour so physicians can maintain their incomes and in many instances can keep up with their payrolls. Have you ever been to an efficient hotel? It’s a code word for diminished service. Hospitals cannot be too efficient and still keep up with the latest technology, have money for capital improvements and provide service to sick people. Managed care is not about quality, it’s not about service. Managed care is about MONEY. Sure hospitals were inefficient and there was a lot of waste. The government and managed care companies not only cut out the fat but they have stripped the muscle. Good care is now a rarity. Just read the papers to hear about the errors that go on in some our most famous hospitals. Many of these errors occur because the redundant layers of checks and balances have been removed. Why managed care? Medicine was getting too expensive for industry. Actually 30% of the health care dollar is spent for the last 30 days of life. Right now in my hospital a young women with advanced ovarian cancer lies dying. She has been hospitalized for over thirty days as of this writing. She has had numerous surgical procedures to debulk the cancer each one has resulted in additional complications. The bill for her care may reach over half a million dollars. Who will pay for this? The hospital already is running at a big deficit. Who will pay for that? I can’t help but fume at billions of dollars voted by Congress to rebuild Iraq while stripping our hospitals of millions of dollars needed to remain solvent. Our system is being broken by misguided efforts to make it super efficient while the rest of government languishes in excess. Can you imagine the hue and cry if we tried to make the military economically efficient. What better way could we provide humane care for this women? It’s hard to be efficient and provide tender loving mistake free care, while encompassing all the new worthwhile technology.
Some new technology was developed by industry to meet specific needs. While other technological advances were developed without a specific need. The effort was expended to find a need and sell it to the medical profession.
The global ablation technique is a great example. As we learned earlier NdYag laser endometrial ablation was developed in 1979 by Dr Milton Goldrath to treat uncontrolled uterine bleeding. Many hospitals had at least one physician who was trained to do this procedure. An NdYag laser costs more than fifty thousand dollars. Soon those lasers became obsolete replaced by other less expensive techniques. The rollerball technique is one of the original operative hysteroscopic procedures with each procedure costing less than one hundred dollars in disposable equipment. Soon however industry had developed hot water balloons to scald the endometrium. Microwave probes, cryo probes, bipolar electro grids and finally, free circulating hot water units, all to do essentially the same thing. The upside to this technology is that it is safe, quick, and effective. Most importantly, it’s rather easy for the non expert to perform. It will help reduce the numbers of hysterectomies. The downside is that it is expensive with units costing upwards of $35,000 and $600- to $750 per case. Why don’t we just continue to do the inexpensive rollerball technique? The reason is simple most physicians are not trained to do these procedures, and the managed care companies don’t reimburse enough to make it worthwhile. Many of these global endometrial ablation techniques were developed for office use. BUT unless you have a fully approved operating suite at your disposal you will not get reimbursed a facility fee. Industry is pretty smart, however. They have vast resources and have lobbied extensively to get these procedures approved and reimbursed. Busy Obstetricians don’t have time to learn and master new techniques. The managed care companies don’t want them let loose doing procedures in their offices with few if any controls. Managed care knows it’s cheaper to practice old time medicine. The real point of this paper is that hysterectomy turns out to be cheaper for them because there are obviously no failures requiring a second procedure. The old fashion abdominal hysterectomy is significantly cheaper for them in the long run, even factoring in a 25% complication rate. One patient after another has related to me how their MD has scared them with the bromide of how dangerous uterine reconstruction is (extensive myomectomy) and how much blood you can lose. Actually we rarely need to administer blood. When we do, we use the patients own blood its called autologous transfusion.
The patient is still the fall guy. Doctors sell hysterectomies. Few have the skill, confidence or experience to reconstruct and repair female organs. There is little or no incentive to learn these difficult procedures and they don’t want to lose the income by referring these patients out. In addition most highly skilled surgeons won’t accept the meager reimbursements of HMO’s. So if you don’t have ‘out of network benefits’ you’re out of luck in getting the cream of the crop doctors to take care of you.
As a modern retailer has said, “our best customer is an informed consumer”. The internet is replete with groups offering alternative therapies to replace hysterectomy; some good, others, not so good. The most difficult job a patient has is to become informed. Finding a good physician who will present an unbiased view is sometimes extremely difficult. As with the stock market, it’s hard to find unbiased research.
Paternalizing by physicians, while trivializing procedures, is no longer acceptable. Informed consent means understanding the positives as well as negatives of a procedure. As physicians we have a legal, moral and ethical mandate to educate our patients as well as ourselves to what’s happening in our specialty.
It shouldn’t be about the money, but as long as the lawyers insist we be perfect, as long as the insurance premiums keep rising while the reimbursements keep falling it will be just about the money. As long as an obstetrician gynecologist has to earn $200,000 just to pay expenses before he can keep a dollar for himself, it will always be all about the money.
Herbert A Goldfarb MD is the author of the “No Hysterectomy Option” Your Body – Your Choice, published by John Wiley and Sons. Dr Goldfarb is Assistant professor of Clinical Obstetrics and Gynecology at New York University, Director of Endoscopic Surgery, Director of Gynecology and Associate Chief, Department of Obstetrics and Gynecology at the NY Downtown Hospital.
Dr. Goldfarb will be speaking on this topic at MISWeek this year in Boston.