COMMENT & CONTROVERSY

Mari-Kim Bunnell, MD
Brookline, Mass

Dr. Barbieri responds:

I appreciate the excellent and practical suggestions from Dr. Bunnell that will help smooth patient flow, improve the quality of the visit, and enhance the patient’s experience. The readers of OBG MANAGEMENT are a rich source of important and clinically helpful advice. Keep sending us your clinical pearls! We will share them with our readers, thereby advancing the health care of our patients.

“UPDATE ON URINARY INCONTINENCE”
MARIE FIDELA PARAISO, MD, AND ELENA TUNITSKY-BITTON, MD (DECEMBER 2010)

Consider economics when managing occult incontinence

The article on occult urinary incontinence was factual and of longstanding common knowledge: The worse the prolapse, the more likely it will mask urinary incontinence. In my younger days, I always performed a Burch procedure at the time of sacrocolpopexy. This, of course, was before slings were developed.

There are several reasons why physicians often don’t perform a prophylactic procedure for stress incontinence at the time of sacrocolpopexy, and one of them is never discussed: money. We don’t get paid fairly to perform a second procedure (50% of its value at best), and especially not a third procedure (15% to 20% at best). Further, a Burch done at the time of sacrocolpopexy is likely to be denied as same-site surgery.

I no longer perform the Burch procedure. I do a sling procedure if the patient has overt stress urinary incontinence, but not if her incontinence is occult. Even when incontinence is overt, however, I expect that a concomitant sling procedure is reimbursed at a much discounted rate—despite the fact that the repositioning that is necessary for a sling is a completely new operation. And cystometrics has virtually disappeared from private practice because the cost of supplies is frequently more than we get reimbursed for the procedure! (Thank you, American Medical Association, for the 2010 CPT changes, which killed cystometrics).

Do what is best for the patient, of course, but don’t go broke doing it. Perhaps money is not an issue in academic medicine but, in the real world, I expect to get paid for what I do.

No doctor will ever admit in a study that he held back a procedure because of money, but in these days of meager reimbursement I believe that it happens. Perhaps we need a purely anonymous poll to reveal the true influence of reimbursement on patient care. When a physician is penalized for doing a procedure, he will eventually stop doing it. I believe that is why the “wait-and-see” option mentioned in the article is the most likely to be selected.

The words of a wise physician, spoken to me in my youth, hold true today: “You must have a positive cash flow to be a professional. “

Robert Frischer, MD
Wichita Falls, Texas

“SKILLED US IMAGING OF THE ADNEXAL MASS”
ILAN E. TIMOR-TRITSCH, MD, AND STEVEN R. GOLDSTEIN, MD
(4 PARTS; SEPTEMBER-DECEMBER 2010)

Educational content is helpful

The four-part article on ultrasonographic (US) imaging of the adnexae is great, especially for recent graduates who had little to no gynecologic US training during residency. Thank you for publishing it!

Monika Hearne, MD
Rowlett, Tex

Thanks for the great article!

Thanks to Dr. Goldstein for continuing to write rather than retire (as I have urged him to do). Dr. TimorTritsch and he have produced a truly great article!

Regards from a resting ultrasonographer, now in Florida.

Donald Meek, MD
Bonita Springs, Fla

“THE DIFFICULT VAGINAL HYSTERECTOMY: 5 KEYS TO SUCCESS”
JOHN A. OCCHINO, MD, AND JOHN B. GEBHART, MD, MS
(NOVEMBER 2010)

We need more minimally invasive hysterectomies!

I would agree with Dr. Occhino and Dr. Gebhart that we need to perform more minimally invasive hysterectomies. Over the past year, we have been able to perform laparoscopic and supracervical hysterectomies in more than 90% of cases, including those involving a uterus as large as 16 to 18 weeks’ gestational size.

We use both myomectomy and hysterectomy technique during laparoscopy, as well as in patients who have a partially obliterated cul-de-sac.

We use retroperitoneal uterine artery ligation in cases involving a large uterus, and this strategy has helped us keep blood loss to an average of 100 to 150 cc.

Chauncey Stokes, MD Leesburg, Va

“HOW STEEP IS THE LEARNING CURVE FOR ROBOTIC-ASSISTED SACROCOLPOPEXY?”
CINDY L. AMUNDSEN, MD, AND AMIE KAWASAKI, MD
(UPDATE ON PELVIC FLOOR DYSFUNCTION; OCTOBER 2010)

Easier surgeries mean a steep learning curve

The slope of the learning curve is frequently misunderstood. A procedure that is difficult requires many cases to achieve competency. As such, the learning curve would be flat, not steep. In contrast, a procedure that can be mastered in a relatively few number of cases would be represented by a steep learning curve. Unfortunately, innumerable scientific papers equate difficult procedures with steep learning curves when it is exactly the contrary. Fortunately, Akl and coworkers got it right in their featured paper on robotic-assisted sacrocolpopexy.