Episode 6.6 Overconsulting and Surgical Training

In this episode we welcome back Stuart Winkler to discuss over-consulting in OB/GYN and how to improve surgical eduction in our training programs and how to balance generalists vs subspecialists. Plus, colace!

00:00:02 Misuse of Docusate Sodium

Links Discussed

Efficacy and safety of traditional medical therapies for chronic constipation: systematic review

Influence of gum chewing on postoperative bowel activity after complete staging surgery for gynecological malignancies: a randomized controlled trial

Effects of coffee consumption on gut recovery after surgery of gynecological cancer patients: a randomized controlled trial

Multicentre randomized clinical trial of the effect of chewing gum after abdominal surgery

Ceruminolytic effects of docusate sodium: a randomized, controlled trial

Involvement of gynecologic oncologists in the treatment of patients with a suspicious ovarian mass

Sentinel lymph node mapping in patients with endometrial hyperplasia: A practice to preserve or abandon?

Transcript

Howard 00:18

Antonia.

Antonia 00:19

Howard.

Howard 00:20

What are we thinking about on today’s episode?

Antonia 00:22

Well, finally, one of our former guests has returned today. So Dr Stuart Winkler is here with us, but he’s our gynecologic oncologist friend in San Antonio, Texas. He’s probably roasting right now with the little heat waves.

Stuart 00:37

Absolutely yeah.

Antonia 00:39

Well, I don’t envy you, but so he’s here to talk about why generalists shouldn’t consult him so much.

Howard 00:46

Okay, yeah, I guess so Well. Note to Dr Winkler’s colleagues. Please don’t consult him.

Stuart 00:52

No, I’m glad to be here, it’s great to see you guys again, and now I do love being consulted, but yeah, you’re right, we’re here today to talk about appropriate consults and specifically not, or just in general, the culture of over-consulting that’s taken on a whole of our field.

Howard 01:07

Yeah, is this the guy, Antonia, you said you were going to replace me with as co-host? I see what’s happening here. I’ll just shirk off to the side.

Stuart 01:16

No, no, Howard, how are you irreplaceable?

Howard 01:19

We know he has to do the thing we do for no reason, then, since you’re going to give him my reins, Okay, well, I mean, what is the thing we do?

Antonia 01:27

for no reason.

Stuart 01:28

Sure, well, I thought we could talk about an oldie but goodie. This is one that’s been addressed before with the Choosing Wisely campaign, and it’s been highlighted on some other podcasts that our listeners may be familiar with, such as curbsiders, but it’s still a big problem, as we’ll talk about. So, of course, we’re talking about the use or misuse of Docusate Sodium in treating and preventing constipation.

Howard 01:52

Our friend Colace. I will say all of us have loved the Choosing Wisely website in that program. But if you don’t know, they’ve shut it down. I guess they ran out of funding, and so they’ve actually removed all the recommendations off of there. You can’t even see what used to be on there. The website’s still there, so some of this stuff has come to an end, unfortunately.

Stuart 02:12

Maybe we’ve just fixed our practices such where it’s necessary.

Howard 02:16

Yeah, there’s not a problem anymore. Yeah, I think that’s probably it so that’s the end.

Stuart 02:19

Well, tell us about Colace, well, sure. Well, it’s an old drug. It’s been around since the 50s. Actually, my grandfather, who was a pharmaceutical rep way back in the 60s and the good old days when reps used to be able to take docs out with their families for long Caribbean vacations and those sort of things, he remembers this being sold at that time under the name Doxinate. Since that time, colace has become one of the most prescribed drugs on the market, and I’ll be quoting a lot from a great review on the misuse of Docusate from Robert Fickery and Frank Chelly in a 2019 issue of the Journal of Hospital Medicine.

Antonia 02:52

Yeah, that is a great article and we’ll link to it in the show notes.

Stuart 02:56

So they cited a population based study that estimated that a full half of medical and surgical patients are discharged with Colace just as part of their discharge meds. And if you include all Dacusate products that are purchased over the counter and prescribed, total healthcare spending in North America exceeds $100 million annually just on this drug, which would be a lot even if it worked, but unfortunately it doesn’t.

Antonia 03:20

Yeah, that’s right. There’s at least seven high quality randomized controlled trials dating back to over 50 years ago, in both the ambulatory and hospital settings, and they all show no benefit of Colace over placebo or control in the treatment of prevention of constipation. These are not necessarily very large studies, but they are all consistent with each other.

Howard 03:43

I think this speaks to how we teach residents and how residents learn from us and how much just tradition, particularly for little things. The episode we did about vaginal delivery was a good example of everybody just learned how to do vaginal delivery in the first month you felt comfortable but maybe never really thought about the evidence. And people learn by osmosis. And then also people say, well, what’s the harm if it helps somebody that kind of thing? And you’ve addressed the cost, which is huge, especially considering it’s a cheap drug. I mean, that’s just an astounding number of doses to get to that dollar. But I think there’s also a bigger harm when we tell patients that we’re giving them something that will help them, when we know that it doesn’t or at least we should know that it won’t and that becomes a trust issue too.

04:22

I think of melatonin for sleep, for example. But there are actually effective, evidence-based treatments for constipation if that’s what the patient needs. There was a 2005 systematic review which summarized the evidence for several different treatments for constipation and at least from that review, the best evidence is to use osmotic laxatives like polyethylene glycol, which is miralax, and then perhaps lactulose or bulking agents like psyllium or metamucil.

Stuart 04:46

Yeah. So when it comes to looking at full return of bowel function and prevention of ileus, there’s some other things as well, such as gum chewing and coffee consumption that have both been shown to shorten the time to return a bowel function and decrease the length of stay, at least in post-op gyn-onc patients. There was a recent randomized control trial in a general surgery population that’s more current, using current ERAS protocols that showed it was less effective. But again the evidence is a little bit mixed on that. And also just the use of ERAS principles to minimize the opioid use and in some cases the use of mu blockers such as themapan or enteregg in certain settings might help to prevent opioid-induced constipation. These can be beneficial at times.

Antonia 05:27

Yeah, and we also deal with a lot of pregnant and postpartum women. We know it’s on their order sets quite a bit, because postpartum women frequently struggle with constipation. Well, so do pregnant women too, but I think it’s very freely prescribed to them because there are no known safety concerns that I’ve heard of for pregnancy or breastfeeding. So they think this is one of the few things that we can, just we can prescribe without any concerns. But it’s also probably commonly prescribed because maybe it’s a little bit more palatable to have the patient swallow a tiny little gel cap than to have them drink a whole glass of mixed laxative powder or liquid magnesium. Both of those can have an unpleasant taste.

06:11

But if you look for evidence of the effect of docusate in postpartum patients, it pretty much doesn’t exist. I looked at the latest Cochrane review and they barely mentioned it at all. They mentioned it just in reference to what’s its mechanism of action, but I didn’t even find it a trial that this Cochrane review included. The most recent trial I could find on postpartum women was what I I would probably call it more like a case series from 1957 because there was no controlled group, but these authors, or a single author, actually concluded that it was beneficial because 82% of his patients who took it reported having a bowel movement by three days postpartum.

Howard 06:53

That sounds like early tocolytic study.

Antonia 06:56

Yeah, and actually I don’t think this wasn’t even docusate. It was something closely related, maybe one of the closer things they had at the time. It was called diactyl sodium succinate, which has the same mechanism of action, but we don’t have that medicine around, so talk about an absence of anything close to real evidence of benefit in postpartum women. But none, nonetheless, docusate has definitely murmured its way into those hospital order sets almost universally.

Howard 07:21

And even into heiress protocols for gynecologic surgery, which generally are evidence-based. We’ve talked before, though, about the problem of bundling bundles for prevention of infection or bundling for heiress, for example, and so Colace and a lot of ineffective things can work their way into a bundled approach. There’s a sample protocol and up-to-date for aero-ice protocols in gynecologic surgery that lists Colace and Senna as part of the standard post-op bowel regimen, even though we know from trials back in the 1960s that docusate and Senna are no better than placebo for first time during bowel movement. But then it gets integrated into somebody’s protocol and the protocol overall works, and people forget which parts of the protocol are effective and which aren’t.

Stuart 08:00

Yeah, and sometimes I think we use the word bowel regimen just as a catch-all. You’re taught in training that if somebody’s on an opioid in the post-op period, then you need to be on a bowel regimen as well. We don’t necessarily think about the granularity of that. I think we tend to think in bundles as well, but interestingly I thought I’d bring this up. While I was reading about this I did learn something and I learned that Colace maybe it’s only beneficial medical use might be as a serotonolytic. So essentially it’s a detergent and it’s actually can be used to help clear earwax and there were some trials looking at this and it actually can allow better visualization of the entire tympanic membrane. So that’s interesting.

Antonia 08:37

Okay, so it’s good to put in ears, but maybe not the digestive system. Yeah, got it. Well, Stuart, we wanted to talk to you today about consulting subspecialists and particularly the pattern of over-consulting, and it’s probably important that we address this in several different contexts, because the consulting patterns likely are different between an academic program versus an urban private practice versus a rural practice.

Stuart 09:05

Yeah, absolutely, that’s definitely true. So for me there are some no-brainers. Regardless of the context for which patients need an oncology referral, there’s ample evidence that patients with ovarian cancer have better outcomes when their first surgery is done by a gynecologic oncologist, and I have some references for this that we can put in the show notes. But you think that if you have a 57-year-old, say, with bloating and a complex ovarian mass with a CITES, that this patient should go to a G1 oncologist?

Howard 09:33

Yes, definitely. There’s nothing that we’re as general as going to do that’s going to benefit that patient.

Stuart 09:38

Yeah. So what’s actually interesting is this exact vignette was sent to almost 600 OBGYNs and out of those 600 OBGYNs, only two-thirds of them said that they would refer this patient to gyn-onc.

Antonia 09:50

Yikes, that sounds like it’s gross under-consulting. Aren’t we talking about over-consulting, though?

Stuart 09:55

Yeah, you’re right, I just had to get that in there. But yes, you’re right, so I’ll stay on track. But I guess we’re really talking about appropriate consulting. So these are the patients that a gynecologist needs to keep the schedule open for or you’re a gyne or whatever the subspecialty is. So for gyn-onc, unfortunately, about 50% of the cases that we do are for benign reasons, and I was actually at an SGO meeting this past spring. One of the speakers was addressing this issue of consulting and she did a poll everywhere for the audience and well over half of the gyn-oncs in the room, so that the referrals for benign conditions detracted from their care for their cancer patients. So some of it is for patients with comorbidities, extreme obesity or prior surgeries, but some referrals are just softer calls, if you will. I’ve definitely been consulted to do a hysterectomy for pelvic pain with suspected endometriosis and somebody who hadn’t even had a prior surgery. So that does happen as well.

Antonia 10:52

Well, that’s a bit okay. Yeah, that’s more over-consulting. It sounds a bit shameless of an example there, but I’ll admit I have also referred patients to Gyn oncology that had endometriosis and wanted surgical management. But only if I’ve seen inside their abdomens myself and decided there’s no way I’m going to do this without causing an injury. Or maybe if I’ve seen a prior op-note that another surgeon did and they documented severe adhesions, can’t even visualize the uterus or those kinds of things and recommend advanced surgeon or oncologist. Sometimes they even specifically will say that in their notes.

11:31

I will say too that I had a patient with suspected endometriosis once that was referred to me and she had already had an MRI that suggested implants throughout her pelvis and involving the bowel and that thought occurred to me like well, I wonder if this is someone, should I refer her?

11:50

But I did her laparoscopy and there were no adhesions, there were no implants, totally clean. So I think that was the lesson that clinical suspicion of maybe endometriosis, at least without any kind of exam or surgical evidence of significant adhesions, is not enough to warrant going straight to a subspecialist. I can see how some generalists might worry that if I do a surgery that then I’m just going to have to refer them, then that’s two surgeries and they could have just had one. Or maybe if I do the surgery and then I refer them by me doing the surgery, somehow I’ll make their condition even worse in terms of adhesions that then the oncologist has to work through. So that might be some of the things people are thinking about when they just want to just push the patient out of their clinic and straight to the subspecialist.

Howard 12:37

I think a lot of oncologists just don’t do a lot of surgery. I mean, there’s a study out there that 70, 80% of OBGYNs do fewer than I think it’s six hysterectomies, a year.

12:46

So they’re certainly not going to do anything complicated. That being said, why is that that way? And one of the things that we’ve got to talk about is how not taking on a slightly more challenging than the easiest case of all helps to keep your talent and your skill set and helps you grow into mastery. And I’ll admit, I feel embarrassed when I send a case to my oncologist that turns out to have been benign, like that’s the litmus test. I’m also embarrassed if I operate on somebody who turns out to have cancer that I didn’t catch.

13:14

So, but I think it’s a fairly easy line to draw. I don’t see where it happens and I guess we’ll talk about that. But you know, for those more advanced endometriosis cases, just for our own edification, that’s an opportunity to work with a more experienced partner. That’s an opportunity to call in your general surgery colleagues and say I need help with the bowel on the back of the uterus here. That’s an opportunity to do a lot of different things. Or which specialist should get that in a world where the gynecologic oncologists need to be taking care of those patients? Maybe that’s where MIGS Docs come in too. If you don’t feel like you have the skill set to do that, maybe the MIGS person is the one who you should send it to

Stuart 13:50

, yeah, yeah, that’s a great point, so, yeah, so, for instance, when I get consulted to do a hysterectomy for a patient with recurrent CIN, for instance, who’s been appropriately evaluated with a diagnostic excisional procedure with negative margins all the things that she would do when that patient comes to a gynecologist, she’s more likely to get more surgery than she needs. Just to be frank, I think we’d all agree, especially on this podcast, that vaginal hysterectomy is the most appropriate route for this patient. But not a lot of oncologists do these as part of their practice. Now, last year my residents did give me the oncologist most likely to perform a vaginal hysterectomy award because I did one that year, but for better or worse, I just don’t do that many of them anymore, and I’m fortunate that there are several generalists in my department who are actually really good vaginal surgeons, do a really great vaginal hysterectomy. They’ll post two or three in a day with the residents to get them good reps back to back, and so I prefer to send those patients to them if I need to.

Howard 14:47

Yeah, and that’s not everybody’s good at the same things, and a lot of centers do have people who are really good at vaginal hysterectomy. And then it’s nice if the gynecologic oncologist can be honest that the 400-pound patient is better suited by having a vaginal hysterectomy for that case, rather than desperately trying to take lymph nodes out on every single patient and taking somebody who’s not a good endoscopic candidate for endoscopic surgery. The same gynecologist sometimes will put two moraine IUDs in that patient rather than let the vaginal hysterectomist, who might be a generalist, do a definitive surgery just for what’s my thing to handle, but I don’t know how to do it. So I mean in the lines of we’re drawing about consulting. What we should all do is respect our limitations and then find the people who have the talents that we don’t have, and that goes both ways.

15:29

Unfortunately, I think it’s a subspecialist in residency training who often define what a generalist should and should not do, and residents often learn the wrong messages from this. If all of the transobturator tapes or transvaginal tapes are done by the gynecologist which is maybe great because you’re learning from the expert, well, that doesn’t mean you shouldn’t do them when you’re in, when you’re out in practice, or if the gynecologic oncologist does all the cold knife cones or something like that or has a clinic for a colposcopy, okay, that’s fantastic. So you’re learning from the expert, but that was so that you could go out and do those surgeries and unfortunately, I think that those boundaries aren’t made clear. Like, I’m teaching you this because I’m an expert in it and I have a research expertise, but this is something you should be doing in training.

Stuart 16:10

Yeah, I absolutely agree with you there. I think one thing I try to do with my chief residents before they graduate is I sit down with them and I say, okay, what is your scope or practice going to look like? Because you really do tend to set the tone for your practice really early on. I think once you start letting things drop off you’re unlikely to pick those things back up again, and that can be difficult in lower volume settings which I was technically in a lower volume setting straight out of residency that it really can be a volume issue.

16:39

So right out of training I did my own slings as a generalist for a couple of years. But the further I got out I realized I was really only doing maybe two or three slings a year. And then concurrently I had a specialty or a fellowship trained Urogynecologist come to the hospital and she started operating twice a month at our hospital and I just felt like these patients were going to be better served by somebody who does literally dozens of these a year. But same way I recognize that not all gynecologists have easy access to Urogyn and I think that if I hadn’t had that Urogyn come to my hospital I probably would have hung on to slings a little bit longer, but I don’t know, to be honest.

Antonia 17:17

Yeah, speaking of slings specifically, I’ve had the exact same experience working at larger hospitals that had Urogyns and that started with my training, and these were settings where really none of the generalists were comfortable doing the slings and it seemed like it developed into this pattern where referrals for incontinence, like for initial evaluation, just got sent straight to the Urogyn. They didn’t even come through the general GYN clinic so the generalists and the residents that were working under them rarely if ever saw patients who they might consider offering a sling to, unless they went to their Urogyn rotation. So it set up this attitude that all incontinence automatically requires a subspecialist to even assess it, let alone treat it.

Howard 18:04

Yeah, these unspoken rules. There’s a quote, and I don’t remember the author. I used to use it in the slide deck, but essentially that most education is unspoken, and what you all are talking about is this sort of unspoken education. Nobody said that all incontinence should go to the Urogyn, but it just seems like it should. I will say, though, there was a wonderful editorial about a decade ago in the Green Journal by a Urogynecologist who talked about exactly what we’re discussing, which is there aren’t enough subspecialists in America to take these things, and women will just not have care.

18:32

There aren’t that many Urogynecologists, and so you guys in referral centers or in larger centers may and this is where people train, right.

18:40

You train in a center like that, where you have the luxury of a Urogynecologist, but in the real world, where I practice in a rural location, I do two or three slings a week, because that’s what patients actually need, and that means that that’s hundreds of patients a year who are getting care that they otherwise would not get, because there aren’t Urogynecologists available for every hospital in every city, just as there aren’t gynecologic oncologists available, or reproductive endocrinologists or maternal field of medicine doctors although there’s more of them, you know. Maybe now, especially in the age of self-reading and testing, they have some capacity all of a sudden. But yeah, a well-rounded generalist should be able to take care of these needs. But you’re right, both of you are right. You’ve got to do it to maintain it. I’ve done more slings in a lot of practicing Urogynecologists so I wouldn’t do something. As Stuart said, if you’re only going to do it three times a year and you shouldn’t be doing it- yeah, yeah, and I like what you said, Howard, about.

Stuart 19:28

I think it addressed the issue of the setting and I think that’s definitely important the volume that you’re getting in the setting that you’re in, whether that be rural or urban or academic or whatnot. So one other issue I wanted to bring up for discussion. This has been a hot topic of late, particularly in the gyn-onc literature, but it’s the question of what to do with EIN. So endometrial intraepithelial neoplasia, formerly known as complex atypical hyperplasia, and all sorts of other terminology that we’ve moved past. So this is a pathology that is common, but it’s the question should this always be managed by an oncologist or is it appropriate for a generalist to do these cases? So we know that up to 40% of EIN on biopsy will end up being cancer on the final path. But 90% of this cancer is going to be low grade, early stage stuff that we wouldn’t. Typically it’s a cancer that’s cured with hysterectomy, essentially, and based on the Mayo criteria, we know that low grade cancers with less than 50% of gross invasion and a tumor size less than two centimeters have a less than 1% chance of no involvement. In historical data sets, about 10% of the cancers that come that are diagnosed with the preop diagnosis of EIN will be higher grade and or sometimes advanced stage, and for these adjuvant radiation is usually recommended.

20:51

So it may depend on your setup, on what’s appropriate as far as generalists versus an oncologist.

20:56

If you’re a generalist doing EIN and you have an oncologist available, it might be reasonable to send a frozen section and call in the oncologist on the rare case that there’s a risk for nodes to be involved Although once you cut the uterus out you would have to do a full lymphadenectomy and you wouldn’t. We’d avoid the benefit of a sentinel node potentially, and you might also take more care to note your preop imaging. We don’t always do preop imaging, but you might want to do a little bit more if you’re a generalist who’s taking care of EIN and there is some evidence that if you have a preop diagnosis of EIN and your endometrial mass or your endometrial thickness is greater than two centimeters, that your risk of cancer is particularly high, even higher than the 40%, and so in that case that may be the one that you want to send to Oc. But I think a lot of it depends on your local practice patterns, what people are doing in your community and just what your availability as specialists might be.

Antonia 21:52

Yeah, I’ve had the chance to work with lots of different oncologists through my training and then my subsequent duty stations.

22:00

Pretty much all of the ones I’ve worked with previously did not want to be called in unexpectedly because a generalist did a frozen section and got cancer on that, because usually they’re not just sitting there waiting for that call, they’re seeing clinic or doing other things.

22:16

I also think in that case that the patient would need to have been counseled and consented on what might have happened during that surgery. If a frozen section was planned and then it found cancer and then the oncologist was called in, this would mean for the generalist just counseling them on some extra surgery is going to be done by someone that’s not me, possibly and they don’t necessarily know all of the different complications to discuss with that. So I think a lot of generalists probably wouldn’t be comfortable with that counseling and consent process beforehand. But my previous oncology consultants then, whenever I asked them just beforehand or even just in general, what do you want us to do with EIN? They either wanted us us to just do the hysterectomy, don’t send a frozen section, let the final pathology dictate subsequent follow-up or they wanted to be involved from the very beginning and basically for them to be the ones to take the patient for their initial surgery and usually to do sentinel lymph nodes. But nothing really in between that.

Howard 23:22

Yeah, I think you have to know your local oncologists and settings and things like that. And this is a patient I’m talking about too like for my setting, this is probably in many cases I mean one recently 500 plus pounds. Well, I don’t know that, the oncologist would have taken her uterus out, but it’s out and pathology has it. I mean, are you going to do lymph nodes with a 1% chance or less on a patient that size? So I do think there’s some room for individualization, but for the most part we don’t have compelling data that says that one pathway correct me if I’m wrong that says that for EIN that planning to do lymph nodes or doing sentinel lymph nodes has a mortality benefit.

24:00

So it’s this theoretic thing that it might save you a second surgery in the 1% of patients who might need it and then again access things like that and for patients that I can do, a same day vaginal strike to me on that. A lot of people wouldn’t even operate on because of their size. I keep these.

Stuart 24:16

Yeah, and I mean you’re right about the. You’re right, there is no study that I know of that has shown any sort of mortality benefit. There’s always the fear of under treatment but even the vast majority of patients will end up with either vaginal cuff radiation or even local radiation and I hope there are no radiation oncologists listening but that’s never been shown to improve mortality either. So yeah, that’s a good comment, but there was a recent study that was done at Sloan Kettering that just looked at their EIN experience and again, this is obviously one of the highest volume cancer centers in the country. But of the 221 patients in their review, 98% had cancer on final path. Again, this is retrospective. Maybe these patients were being sent to Sloan Kettering for other concerns other than just EIN, but regardless, and out of those 98 who had cancer, only one patient had lymph node involvement and their practice they would do sentinel lymph nodes on all these patients.

25:12

And it’s interesting that the authors focused on the safety of sentinel lymphadenectomy. That’s always interesting how these studies get reported. Complications were equivalent and operative time was only six minutes longer in the lymphadenectomy group. So the authors actually argue that sentinel lymph node is a good thing to do and we can link to that in the show notes. But in order to do sentinel nodes most of us have to utilize the robot. We have protocols based on the FIIRS trial where we utilize ICG and the Firefly technology on the robot and it is possible. There’s some technology that we can do that with straight stick, but it’s a little clunky and honestly, not quite as well studied. So the vast majority of us use the robot as a tool for managing EIN, which has its own pluses and minuses that I’m sure Howard can talk to us about.

Howard 25:59

Oh Lord, that’s a whole other episode. I will say, though just you may not know the answer to this, Stuart, but is there a difference between EIN diagnosed from a blind pipelle biopsy and EIN diagnosed from a hysteroscopy DNC in terms of those future need for lymphadenectomy?

Stuart 26:17

rates. Yeah, the risk is a little bit and I’m sorry I don’t have the numbers off the top of my head but it’s. I believe the risk of cancer is about 10% lower if it was based off a hysteroscopy D&C, but it’s still much higher than you think it would be. So, it’s still in the above 25% range.

Howard 26:33

So maybe a strategy of imaging and things like that Overall operability, candidacy and life expectancy and things like that might dictate those patients, but we’re still talking about an intervention that has a very low, if any, mortality benefit in terms of the intervention being sending all these patients to oncology and flooding their oncology practices. But certainly, as you mentioned, a greater than two centimeter endometrium or focal mass on imaging things like that should probably go on.

Stuart 27:01

Yeah, so what I’ve just talking again about, referrals to subspecialists. What I’ve seen in some big private practices that I rotated through as a fellow is that a lot of the cases that were done by the subspecialists really I hate to say it, but really weren’t indicated hysterectomies for AUB, where the patients had never tried hormones or that sort of thing. And you get that because if you’re a gyn-onc, you’re a surgeon. You’re not going to manage AUB with hormones and then see the patient back in three months. You’re just not going to do that. So they’re sent to you to operate and so that’s what you do.

27:34

So I can’t really fault the attendings I was working with, but you just have to know when you send somebody to gyn-onc they’re going to get a surgery and so not all those surgeries are going to be indicated. I love this, to lend a quote that I still keep on my desk, and it says what does a profit a woman if the operation is technically perfect and the procedure unnecessary or even harmful? And I worked with a lot of gyn-oncs who were technically perfect. I mean, they were incredible surgeons. But even the most perfect surgery has a complication rate and if the surgery is not indicated to begin with, you can really get your patient in trouble.

Howard 28:08

Yeah, I don’t think that oncologists, in a certain sense, are held to the same scrutiny. That sounds like they might have had an inappropriate hysterectomy if they hadn’t had an appropriate trial of conservative therapy. But when it’s a gene oncologist submitting to insurance that the patient needs a hyst, it just gets approved. And on the other side of that too, if the gene oncologist has a complication, a ureter injury, a bowel injury, a bladder injury, I think it’s just assumed that there it was inevitable. I mean, this was the oncologist is just dealing with cancer, even though half the cases are benign. So in that sense, both for meeting requirements for hysterectomy, for billing and also for peer review, they should be held to the same standards, if not higher standards, than generalist OBGYNs.

Antonia 28:47

I think there’s some variation in this, at least from what I’ve seen. I know in my training program I had oncologists that were absolutely against doing surgery that wasn’t indicated. So I remember a BRCA one patient who was ready to get her risk salpingo-oophorectomy. She was in the right age range and was done childbearing and she wanted a prophylactic hysterectomy. Didn’t have any bleeding complaints or anything else and the oncologist was going to do it.

29:17

I know that they don’t have to be the ones to do this risk reducing surgery, but there was a little bit of overlap at that time. But they said no. They said that there maybe is a risk of the uterine papillary serous carcinoma from the BRCA one mutation, but it’s so tiny that a hysterectomy just isn’t indicated for that reason. So I took that as a lesson moving forward. But then at another facility I worked at, I saw the very opposite thing happen, at least in one case. Oncology took a patient with that same mutation who was going in for that same risk reducing saloingoophorectomy, and then they just added on a hysterectomy, again with no GYN or bleeding complaints, and of course they used a robot to do it. I think that was just their default method of doing surgeries, because I don’t recall there being any historical factors that would have made the case surgically challenging. But now that’s coming from the team that presented it, so there could be some nuances that maybe that team missed.

Howard 30:17

But there probably weren’t.

Stuart 30:21

Yeah, I mean again to paraphrase that Talyn quote it doesn’t matter how perfect your technique is if the surgery wasn’t indicated to begin with. In this case, the NCCN doesn’t explicitly recommend that a hysterectomy be performed for BRCA1 patients, even though there is that two or so percent risk of uterine papillary serous. It can be a discussion, but I mean the oncologist was technically right and in some settings where there may not be a financial benefit to do that surgery, maybe the oncologist was a little more constrained by evidence.

Antonia 30:53

Yeah, and I think that at least that oncologist was studying for their oncology board exams and all of them, at least in my training, were either studying or had fairly recently passed, whereas in the other setting they had been board certified for many years. So I don’t know if that plays into.

Stuart 31:10

It does, as somebody who’s currently case collecting it definitely does you want to make sure you’re. It’s good to do things that are indicated.

Antonia 31:17

It’s absolutely.

Stuart 31:18

But yeah, you want to be even more, even more sure that what you’re doing is right.

Howard 31:22

It’s a discussion. I left a uterus just in the last couple of weeks with no ovaries and a similar setup. There should be an indication for why you do things, although honestly, a lot of people do have. By the time I operate on them they have concomitant prolapse or incontinence or something else that I’ll fix while I’m there, even though that might not have been the primary reason for the surgery.

Antonia 31:40

But I do think, to veer off on a tangent, I do think sometimes if we’re talking about presenting a case to the rest of the department in an academic setting, the resident teams may miss parts of the discussion or even key details from a surgical plan. If that plan was made by somebody else, that then isn’t there to clarify during that presentation. That happens quite a bit. I’ve seen that quite a bit so I could.

Stuart 32:06

Yeah, no, I agree, I’ve seen this too. I’m currently at an academic program, I’ve had a fellowship at an academic program and sometimes you’ll see this in those pre-op conferences where there’s this self-sabotage. That can sometimes happen if there’s maybe not the level of preparation that needs to be there, or if the teams have recently switched or if somebody was just notified very recently that they’re presenting a pre-op conference. All those things can certainly happen and sometimes I feel like I don’t know. The details can definitely get lost and it can be a problem when you’re trying to have a productive educational discussion and maybe you’ve had some discussion that’s been documented with the patient where there’s not a clear answer, but there’s some shared decision making there, but it doesn’t necessarily get translated to pre-op conference.

Antonia 32:50

Yeah, I’ve been on both sides of this. But back to what we were talking about, I certainly agree that an unindicated surgery, it doesn’t matter how good it is, it’s still the wrong thing. But certainly if someone’s doing an unindicated surgery, they better be the best at it, because they don’t want to be the one that just has a bunch of complications from a bunch of surgeries that weren’t were wrong to begin with. But, as you said, eventually even the best surgeon is going to have some complications sooner or later.

Howard 33:20

Yeah, and when you do, hopefully the surgery was indicated and depending on how you define it I mean one could argue that as many as 80% of hysterectomies aren’t strictly indicated that there was some alternative to hysterectomy, or medical management or an IUD or something that would have better served the patient. And so we definitely live and this isn’t just gynecology, by the way, this is ortho. This is a lot of different specialties doing a lot of unindicated surgeries because there’s financial incentives to do surgery.

Antonia 33:46

Yeah, that 80% is quite a lot and I know that over the decades, with new management modalities, hysterectomies specifically have become less frequent. For example, now we have endometrial ablation. That didn’t use to be around and at least earlier in my career I’ve had the tendency to always try to bring up the least invasive thing first, and then the next, and then the next, and I’d bring up endometrial ablation to almost anyone who wanted a hysterectomy for bleeding, because- Do you want me to give my opinion on endometrial ablation?

Stuart 34:17

Do?

Howard 34:17

you want me to give my opinion on endometrial ablation.

Antonia 34:19

Well, I’ve heard oncologist’s opinions on it, so I’m sure that I can imagine what you’re going to say. But I understand there’s always tradeoffs to everything and over time I have made it a point. If I bring up ablation, I also bring up the point that this could possibly delay diagnosis of endometrial cancer in the future. If you develop it, you might not bleed as early as you would have if you hadn’t had the solution.

Howard 34:43

And lead to an increased stage at time of diagnosis.

Antonia 34:46

Right, or if we had just done a hysterectomy, you wouldn’t get this to begin with, but I know that that’s a little controversial and probably poorly defined. I know it’s been looked at least in kind of case series, but I don’t know of a consistent rate of what is the risk of endometrial ablation patients later getting more advanced cancer in the future much less like what’s their survival compared to Right.

Stuart 35:12

And I was joking a little bit, but I think this actually goes back to the over-consulting thing. So in my practice, what do I see? I see patients who had a BMI of 50, who had two failed endometrial ablations, who come to me with a 1b endometrial cancer that wasn’t detected because their os was scarred off because of the prior ablation. So I joke. I understand there are roles for endometrial ablation. Unfortunately, as a specialist, I see the horror stories, and this is the nature of subspecialty too, is you tend to see the things that went wrong or the things that should have been managed different, and because of that I have a negative view of endometrial ablation, although I’m sure there are times when it’s appropriate.

Howard 35:55

I share that. I think the literature is clear at this point that the increasing risk of endometrial cancer and more advanced endometrial cancers is related to and coincides with a few factors, but one of the largest ones is the uptick and ablations about 10 or 15 years ago that were done on obese, anovulatory oligomenorrheic patients and 15 years later they have cancer. Yeah, on poor surgical candidates, essentially People are like oh, this is a poor surgical candidate, but they were a better candidate 15 years ago.

Stuart 36:25

Yeah, no, you’re absolutely right.

Antonia 36:26

Yeah, yeah.

36:27

And in the moment when, at least when the generalist is looking at this patient who is a poor surgical candidate and has all the risk factors for endometrial cancer, then sometimes it’s hard to know which way to go, because you can make an argument against either one, and this is assuming they don’t want medical management instead.

36:46

So I think sometimes which way the surgeon goes may be partly driven by that surgeon’s own level of experience and comfort with those complex gynecologic surgeries. So if they’re really worried that if I take her back she’s going to have a major bowel injury or bladder injury or I won’t even be able to get through it and completely remove the uterus, then they may tend towards the ablation. Or that might be a case, at least nowadays, where maybe the generalist would say, okay, I’ll just refer to Ankh then for this benign hysterectomy because I don’t want to end up with the injury that I can’t repair. But then it sets up this vicious cycle and a self-fulfilling prophecy whether that surgeon is doing an ablation or referring the patient away, they never get that experience or comfort with those adhesions and those harder surgeries, and then the oncologist and sub-specialist gets ever more overloaded with those types of patients.

Howard 37:42

Different communities and practices need a partner or two who are comfortable. They don’t have to be a sub-specialist, MIGS, Urogyn, Onc, whatever, but somebody who’s comfortable doing cases like that. Or I’ve just been thinking about vaginal hysterectomy the whole time for these exact patients you’re talking about, because we do this all the time on three, four hundred-pound patients with these risk factors.

Stuart 38:02

Yeah, absolutely yeah. I mean I know we’ve talked about this a little bit before as far as tracking and that sort of thing, but I think what you said, Howard, there makes sense as far as having somebody in your community and your working group that can be the person to help out with these more difficult cases.

Howard 38:19

Yeah, we need more generalists in general to meet the demands of the patients in America, not more sub-specialists, who tend to not live in rural areas. They tend to aggregate in the metros or in larger hospitals and things like that, and also, by the way, that’s a deterrent to people entering the specialty. If you think I’m going to do seven years of training, I’ve got to do four years and you see places like that.

38:40

Now I’ve got to do four years of residency plus three years, and the truth is we used to get this extra training from our senior partners. We used to go and with four years of residency yeah, we didn’t all leave residency skillful and masterful, but you had a senior partner that screwed with you for two or three years and you learned more things and you had people out there who were competent at some of these harder cases and the practice model and the training model isn’t promoting that now.

Stuart 39:04

Yeah, no, I agree with you. I do think we need more generalists. I just the problem is, or the danger there is, that what we don’t need is more under trained, low volume generalists.

Howard 39:14

Yeah, that’s definitely true, and, you see, in my Vag hyst book I quote that a program director survey that talks about how unskilled folks were entering into residencies, but the thing is, we’ve always had a problem with this and again, like what we’re not getting, are these folks coming out and practicing with their mentors? We need more mentorship. I will say this, though when people talk about these outcomes, just appreciate this we are better as a profession now than ever before in terms of outcomes. I talk a lot, obviously, about things that we don’t do well and things that we can do better, but ask yourself this question would you rather have a gynecologic cancer or a need for a gynecologic surgery today, in 2023, or in 2000, or 1980, or 1960,? I think we romanticize because of the survivor bias and seeing older, experienced attendings who are really good at what they do and don’t realize that when they were 30, they suck too.

40:06

But, they had the benefit of mentorship and so we are better as a profession and we’re really just talking about how to make things even better than they are. But again, I don’t think that in the training programs, the way it is now, where residents are losing slings to the Urogyn Fellows and basically all hysterectomies to the MIG Fellows are a cold knife cone to the Ankh.

40:26

Fellows, that’s just absurd and they need to be trained to do that. And there we go, and talent exists on a continuum. Not everybody is going to be good at things, and that’s fine. Don’t do things you’re not good at. But everyone should be able to do basic surgery C-section, a cesarean hysterectomy, a minimally invasive hysterectomy, a LEEP, a cone, I think a sling. If you’re practicing in a rural area, treat prolapse. That’s going to be a lot of your cases. If you’re appropriately medically treating patients, most of your hysterectomies are going to be patients with prolapse. People should be able to do the minimum and, or at least in a setting, someone should be able to. Maybe you don’t, but your partner does.

Stuart 41:03

Yeah, I think you’re right. I think learning to do those things and then just keep doing them, like I mentioned before, slings were a thing that I did. I just wasn’t doing that many of them and then I let them go, but because I felt like I was losing that skill. But I also didn’t have any partners who were doing slings and I was the most I don’t know most surgically aggressive of my partners. I would say and even now I’ll be honest like I have three great partners in my gyn-onc practice but I personally don’t do that many bowel sections.

41:31

I did a lot in fellowship and I’m close enough to fellowship where I feel like I could do them now if I needed to. But you bet I would call my partner in to help me. Or if my partner, for whatever reason, wasn’t there, I probably would call a general surgeon or a colorectal to come in there just to help me. And maybe I’ll do a few more as I practice gets busier, maybe I’ll get more complicated patients and that sort of thing. But I agree with what you said, Howard, that your partners and the mentorship that you get from partners or if you don’t have a partner, then another specialist like a general surgeon or something really can be helpful.

Howard 42:03

Well and again for people who are thinking about job opportunities or what they’re going to do post training you need a practice mentor.

42:09

Even you, a fellowship trained doc, are just saying basically that you can benefit from having a seasoned partner come in who has more experience with certain types of cases and you learn from that. You learn post training, you learn post residency, you learn post fellowship, you learn post everything but what you need a practice mentor. And that’s where a lot of, as I said, that training has traditionally taken place, but the current academic model doesn’t promote that, the current economic model doesn’t promote that. Residency programs, honestly, should be filled with more experienced folks who have gone out, even people who’ve been in private practice for a long time and done these cases and gotten good. But instead we often just hire brand new grads who themselves haven’t gone through the learning curve to get into mastership. And now yesterday they were the chief resident who was barely able to do a case, and now they’re the attending who’s barely able to do a case, teaching residents something to do, something they don’t know how to do.

Stuart 43:01

Yeah, I know, for fellowship we had a rule where you had to. You can be faculty at our fellowship program unless you had been out on your own practicing for at least a few years.

Howard 43:10

It’s a difficult thing to do and I know that I’m a person who did that, but that was a mistake in many different ways. That’s a different subject, but I was able to pull it off in some aspects but not in others. And it’s a very difficult thing to do because you’re essentially giving all the cases away from day one if you’re good, and if you’re not, and you’re doing them, then you’re not really benefiting the residents that much.

43:32

So, people need experience and they need independence. The master ship model requires time to progress to independence, and I mean three or four years post training.

Antonia 43:44

Yeah, I think another frustration, at least in certain kind of training programs, is that if the subspecialty services happen to have a low volume for whatever reason, then All of those attendings need some kind of maintenance and hands-on operating time, and they might achieve this by double or triple scrubbing any given surgery, even if they ended up with a more generalist-level surgery that just got booked with them, maybe to fill their OR or something.

44:13

So in those cases even an upper-level resident that’s on their team barely even gets to assist, and I’ve seen this at multiple different facilities. I’ve also seen really high-volume facilities too, so I know there’s variation here. And of course the residents need to see how surgeries are done by these masters at surgery and learn what they can from watching a live surgery. But they also really want the chance to refine what they’re learning sometime before they graduate and develop some muscle memory. I know most people feel like that’s how they learn best is by getting to do some of it. They don’t want to feel like they’re an inexperienced graduate who then is suddenly expected to teach something that just a month earlier they weren’t even trusted to do by their own attendings.

Stuart 44:57

Yeah, I know, as a military guy I’ve been guilty of the double or triple, sometimes even attending scrubbing and some of that’s our own volume and trying to keep up with that. But also I’ll say to myself sometimes well, there’s no reason that a generalist needs to learn how to do some of these cases. Two months ago we had a really big debulking, Did diaphragm stripping and liver mobilization and a splenectomy, and those are not skills that a generalist needs to learn how to do.

45:21

And also we do two splenectomies a year, so all of my partners that run the hospital scrub that case with me because, we needed to do it together.

45:28

But I think that’s a unique setting and it’s still. Even. In that case I had my second year make the vertical midline and my chief pack the bow and set up the retractor and stuff. So you try to give little bits of the cases to as appropriate In the civilian world. I think this experience actually can be taken away sometimes by surgical assists on the other end of the spectrum and it’s all how you use those assists and training. I’ve definitely seen them used really well In fellowship. We had a couple of really good ones and I feel like I got to do more because the surgical assists were so good at keeping the cases going. We got to do more that way. But I’ve also seen it where the surgical assist close all of the cases so the residents don’t even have experience.

46:08

Close the intern. It’s a great thing for them to learn how to close ports. They don’t do that because the surgical assist does that. That’s a problem.

Howard 46:13

Or the surgical assist may put in the trocars or things like that. That’s what the resident should be doing, Everything the resident can do and everything the resident yeah, maybe not a splenectomy, Although good surgery is good surgery. As a resident, I would go scrub with it. As an OB resident, I go scrub with the general surgeons and do cholecystectomies and appendectomies and stuff like skills or skills. But yeah, the subspecialist is going to define eventually what the resident needs to do. And if the urologist or the Urogynecologist never lets them do a utererosacralcolpopexy or a sacrospinus fixation or a sling or whatever, or if the MFM doesn’t let them do the amniocentesis or if the whatever they’re never going to do those things they’re just being told like that’s the door, that’s the boundary, You’re not allowed to do them. So the attendings need to have that clear in their mind and then they need to let the resident of the appropriate training do those cases if at all possible.

Antonia 47:01

Sometimes it’s hard to figure out what is the best balance of this for operative learning, because it’s not nice having cases stretch really long over time, especially when we’re given limited OR time and then in the future they say oh, that hysterectomy took you so many hours, so next time you can only do one or you can do less.

47:21

We’re not going to give you that whole OR day. That’s at least how it was at my former hospital. And if it’s, if that’s all because we’re watching the residents or the med students tiptoe through their parts, because we’re giving them the chance to make incisions or suture or dissect, and they’re doing it at a snail’s pace, even if they’re being technically safe with their movements, even though they’ve had 24 seven access to a sim lab. They’ve watched all the surgical video tutorials and maybe they’ve watched all those other cases where there are other attending triple scrubbed and they were just watching the live surgery. I know that there’s something that only real practice can achieve, but then when you give the opportunity for real practice, sometimes there’s also some sacrifices with that. So my question is how much hesitance and hemming and hawing and readjusting should be allowed in a given surgical teaching situation, versus just taking the reins back and moving things along and then making it another passive learning experience for them.

Howard 48:17

We almost need to need to use a different word here. Rather than teaching we should say coaching, and there’s a lot of, I believe, sports psychology in teaching physical skills. The appendix in my vaginal strengthening book about teaching talks about some of this sports psychology and mastership and things we’re talking about. I’ll also put a shameless plug in clinical reasoning book about, there’s a chapter about when to call for help that talks about some of these issues too. In terms of shooting the elephant, this short story by George Orwell but it’s expression now in medicine where Stuart said if you send the person to the oncologist, they’re going to do the surgery. They’re going to shoot the elephant if you ask him to. But these learners need confidence and that’s something that requires coaching more so than teaching, and I think there’s a difference there.

48:56

I mean, as an example, I let a third year. I have a. Well, she’s a fourth year student now, but I’ve let a. This student has worked with me off and on for the last few months. She has now done five vag hysts and she’s done seven or eight C-sections and she’s done about 50 deliveries. She does vacuum deliveries, so I’ve done that a few times. I let the co-host of this podcast do a vaginal strengthening when she was a third year resident and but that student the other day.

49:22

the C-section took her less than 20 minutes. So yeah, the cases don’t have to take long just because learners are doing them, but it does require, I think, some coaching and teaching in expectation setting.

Stuart 49:33

And I think it’s part of it can be picking the part too. So I, for instance, one of my favorite mentors from fellowship was an incredible surgeon, super, super efficient, and I did my first debulking with him. He’s look, I’m going to do the laparotomy, I’m going to get everything set up because I can get in three minutes and then we can spend the time. She’s, I know, you know how to make a vertical midline, but let me do it the way I want to do it. Then I’m going to let you mobilize the colon, which is the learning goal that I had for that case, and so sometimes, just which is an interesting way to do it. Now, granted, he was just working with me, we didn’t have residents a lot of times, and with working with residents, you have the intern, do a skill, then the second year do a skill, then the chief do a skill.

Howard 50:10

That’s where you can really add that time to cases, but that’s another technique that you could maybe use as a teacher and modeling is a teaching technique and that attending sounds awesome because I would love to watch him set that patient up in three minutes. I will learn from it and watching him do that is more valuable than me doing it Absolutely.

Antonia 50:27

Yeah, well, whenever I’ve, a lot of times when I’ve stopped C-sections, it’s usually with a full compliment of trainees like third year, second year, first year and a student usually. So usually I would take a more distant role, just watching that for the safety and intervening as needed, but otherwise just watching and talking them through it. And sometimes doing that and they’re the whole team of, I’d say, very patient upper level residents try to give as much opportunity for suturing the skin to the little med student and then that step alone takes 20 minutes. So it, yeah, it’s. It sounds like you’ve found some more ideal ways.

Howard 51:04

Well, speed and surgery obviously is a huge issue. It’s the greatest gift you can give your patient is a short surgery, and both of them. I don’t like to take long in any surgical procedure.

51:14

But I do think that I do think that I can take almost anybody who has merit to be a surgeon and encourage them or coach them to do it faster. But that does. It involves modeling. It involves them seeing that this can be done quickly. It involves specific coaching and teaching allowing them to know it’s okay to go fast and to not stutter and stammer and hymn and haul and things like that, to not be overly critical about every single bite and to give the right feedback so people learn on a progression. When they first do a case with me, I have very minimum expectations of what they can do. I just want them to get the big parts done and then I’ll add an expectation each time. And if I treated them in the 10th case the same way I treated them in the first case, they would implode.

51:57

So it’s about graduating thing. But yeah, the senior person in the case whoever that is it might be a chief resident, it might be a third year resident, something like that with an intern or vice or whatever they should be able to drive and dictate how long the case takes and get things done, or they shouldn’t be the senior. You might need to relieve that senior and take their place. If a skin closure took 20 minutes, then the person wasn’t giving the right feedback and may have been creating unnecessary anxiety for that learner. They may have been hesitant or functioning poorly because on the Yerkes Dodson curve their anxiety is too high and so they’re not learning anyway. So if somebody was taking that long, I’d take the needle out of their hands and show them how to do it and then I’d talk to them about it later. I would encourage how they can simulate it privately and then and it would be clearer that I expect you to do this in under five minutes at that level under a minute if it’s Stuart.

Stuart 52:41

But it’s that Keith need all that, Keith need all help you out. But yeah, I agree, I think the modeling part is a really excellent point and you have to individualize it to your learner. Some people do really well if in in the moment criticism, and some get nervous from that and benefit more if you tell them afterwards and I’ve found that a lot recently where I’ll say, okay, I’ll watch the video. Somebody will do something from start to finish and then say, okay, here’s my feedback for how you could have done that better. Or, like you said, Howard, here let me take the needle. Look you watch me and see how I can do this. So yeah, modeling is a great point there.

Howard 53:14

Well, different training models or structures promote this sort of thing in different ways. So both of you have been in the military, and the military, I know, sent Antonia overseas when you had hardly operated at that point, but independently at least. And then most of your patients there were young and didn’t need hysterectomies. And of course, you were there during COVID, when the ORs were mostly shut down anyway, goodness, yeah, so.

53:39

So then you go two or three years and you’ve not done a lot in that master ship level of training. Maybe you’ve not done as much. And survey residencies, in the same way, are full of junior faculty members who were, as we said just a minute ago, a chief resident and they still have a lot to learn. But now they’re all of a sudden in charge and they feel, of course, a pressure to not take cases away from their friends who are now their lower level residents. So we should have a more rigorous and realistic way of assessing whether or not people are competent at surgery before we allow them to teach it, realizing that graduating a residency program doesn’t mean you’re competent at surgery, and we probably need to limit surgeries in all settings to people who do a minimum number of cases a year. So, Stuart, if you’re only going to do three slings a year, then you consult that out.