Taking Gynecologic Procedures Out of the Hospital

It allows us both to diagnose more accurately and often to “see and treat” at the same time, avoiding the courses of unsuccessful hormonal therapy and multiple visits and procedures that too often result from a reliance on endometrial biopsy and ultrasound alone.

Office cystoscopy is a routine part of urologists' practice. With hysteroscopy, we have the technology and capability as ob.gyns. to similarly diagnose and treat common problems in a cost-effective, readily acceptable way. We must more seriously ask ourselves, why not?

Are our reasons not to embrace hysteroscopy really good enough?

Better Fits for a New Era

Ob.gyns. are often at a loss to explain why they seem to be working harder and harder while not getting anywhere, or while losing control, income, and/or the gratification of strong physician-patient relationships.

In a 2004 survey of approximately 830 District III ob.gyns., 64% reported symptoms of burnout; 16% wanted to quit medicine, and 40% said they planned to retire early. To maintain income or prevent a significant decrease in earnings, many had increased patient volume by 20%–30%.

Part of the challenge we face stems from declining reimbursement and the loss of entrepreneurship that often comes with larger group practices. But we also have an inefficient specialty. Many of us leave our offices for labor and delivery and for long OR cases that are unpredictable, that challenge the flow and efficiency of our office practices and the stability of our family lives, and that bring us reimbursement rates that do not account for waiting and time lost between cases. Often the reimbursement we receive when we are away from the office will not cover the cost of office overhead.

This is something we ought to analyze now. Depending on our professional interests, personal needs, and surgical and labor/delivery volumes, such a mix may be gratifying and completely acceptable, or it may be taxing, inefficient, and a cause of burnout.

An office-based ob.gyn. model of care can give us greater control of our practice, our scheduling, our patient relationships, and our lifestyle. Given the elimination of unproductive time, and the fact that professional fees remain the same regardless of setting and that facility fees go to the physician, we can also increase our reimbursement.

Substantial time and financial savings, moreover, are passed on to patients and payers. There is no wasted time: no separate office visits, for instance, for preoperative histories and physicals. When it comes to procedures, patients can arrive 10-30 minutes beforehand and leave in less than 30 minutes. In many cases a patient will be responsible for the cost of an office visit copay, compared with a large deductible and percentage of hospital costs.

I recently saw an interview with Warren Buffett in which he was asked why he is so successful in choosing investments. How was he able to predict the future? He replied that he could not predict the future, but he could recognize what was becoming obsolete. The era in which the model of care relied on a single ob.gyn. who could provide equally competent general primary care, obstetrical care, and the full spectrum of gynecologic surgery to the patient is rapidly becoming obsolete.

The specialty of ob.gyn. is destined to change. Many of us eventually will need to discover and carve out or fine-tune our roles. Today's generalist model of ob.gyn. will evolve into three components in the future: the office-based ob.gyn., the hospital laborist, and the pelvic surgeon.

Greatest in number will be the office-based ob.gyns. who provide well-woman primary care, office-based obstetrics (prenatal care), and a range of office-based procedures, from hysteroscopy and endometrial ablations to incontinence procedures, ultrasound, IUDs, cystoscopy, LEEP cones, and perhaps some “lifestyle” procedures such as laser hair reduction and varicose vein treatment. Considering the demand for such services, they likely will make up about 70% of the specialty.

The ability to have one office, fewer partners, no hospital responsibilities, and control over one's schedule can provide a career that is interesting and rewarding.

Ob.gyn. laborists will be modeled after internal medicine “hospitalists,” and will handle routine deliveries and inpatient obstetrical management. The laborist will work a certain number of shifts each month and will have enough time to be able to balance his or her personal and professional life.

Pelvic surgeons will perform laparoscopy, operative hysteroscopy, and abdominal, vaginal, and robotic surgery. They will provide women with state-of-the-art surgical care and will not have to balance surgery with primary care.

Skills and Set-Up

Ob.gyns. who are performing endometrial biopsies and inserting IUDs are more than capable of doing diagnostic and minor operative hysteroscopy in the office.