While there’s little debate about the benefits of pursuing minimally invasive surgical options, not all specialties enjoy procedural innovations with equal vigor. At times, this is attributable to a lack of viability for individual surgeries, but there are often other factors at work that have little to do with the state of medical advancement.
“My mission is to bring minimally invasive surgery forward in the field of gynecology,” says Mona Orady, MD.
A minimally invasive gynecologic surgery specialist with Dignity Health Medical Group in San Francisco, Orady is a tireless presence when healthcare professionals come together for professional development, especially due to her prominent role with the Society of Laparoendoscopic Surgeons. At the organization’s Minimally Invasive Surgery Week conference earlier this year, Orady’s name appeared on the schedule of educational sessions with mind-boggling frequency.
That devotion to advancing her personal learning and then sharing the knowledge among colleagues is a direct result of the an honest appraisal of the dynamics at play. Orady points out the fast-evolving nature of healthcare requires a committed approach.
“It’s really easy as a surgeon to learn what you learned in residency and just keep doing that for the rest of your life,” says Orady. “But in every field, including surgery, technology is advancing at a phenomenal rate.”
Because Orady focuses on gynecologic surgery, the educational opportunities can be more difficult to come by. Gynecology is usually coupled with obstetrics, and it can seem the latter gets all the attention, both in residency and by the American Board of Obstetrics and Gynecology.
That priority is misguided, says Orady. And she uses basic math and the calendar to prove it.
“Women only spend nine months pregnant,” she says. “While we spend half of our life menstruating. And menstrual problems are extensive.”
Orady notes that menstrual problems like heavy bleeding and extraordinary pain are often dismissed as “normal,” even though they are anything but. Beyond that disregard, there are many other reasons surgical innovations aren’t pursued.
“It’s such a neglected field — whether it’s because women don’t want to talk about it, doctors don’t want to deal with it, or because reimbursement in gynecology is ridiculously low. OB-GYNs are so busy delivering babies we never had time lobby and advocate for ourselves in government or in Medicare or in the AMA.”
Gynecological concerns are often categorized as primary care, even though there are plenty of issues that are surgical, like ovarian cysts, polyps, fibroids, and several others. There is little research enthusiasm or dollars invested in this area, and the neglect extends to weak training structures for emerging professionals.
As is often the case, much of it comes down to money.
“A hysterectomy is reimbursed much, much less than a cholecystectomy,” explains Orady. “A hysterectomy is a much more complicated procedure, it takes much longer to do laparoscopically than a gallbladder. And yet general surgeons — because they’re surgeons — get reimbursed more because they’re gallbladders that affect men or women. A woman who has to have a hysterectomy, however, gets far less reimbursed for her surgery, with little incentive to have it performed in a minimally invasive approach.”
The problem was compounded when hospitals started investing extensively in obstetrics, under the theory that it was one of the few medical circumstances in which patients made an active choice about which facility provided the care. Emergencies make proximity and specialty the chief factors in selecting a hospital. A decision around childbirth could be driven by characteristics easier for facilities to control, like the coziness of rooms or the warmth of staff.
That divide has ebbed somewhat. But even if maternity wards aren’t emphasized as profit drivers any longer, the mentality has spread to other areas of the hospital.
“The problem is — with the advent of managed care and the de-emphasis of education, and academic medicine including research and innovation — everybody’s looking at doctors as production machines, taking away the time to practice the art of medicine, or the energy to teach, to learn and educate, and thus to push the file forward and innovate,” Orady says. “Most physicians now work for institutions that expect us to produce a certain amount. If you look at the number of hours doctors have to put in every week to try to meet those benchmarks, it’s beyond what anyone would consider full time.”
The demand on practitioners’ time combined with dwindling funds for professional development and box doctors out of learning opportunities away from the hospital. Even as that is happening, technology continues its relentless advance.
“The environment isn’t supporting education,” says Orady. “So how do you throw technology at doctors and never give them the opportunity to adequately educate themselves as to not only that technology but how to use it and to research where it would be most useful.”
While it’s difficult to carve out the time, Orady emphasizes the value in committing to betterment in the OR.
“You have to be able to deconstruct a procedure and know exactly why the procedure work the way it does, and how every single component of that procedure leads to the good outcome,” says Orady.
“Surgery is not a recipe, surgery’s an art,” she adds. “And you have to figure out how you navigate the environment that you’re in in a way that’s safe and effective. You need to learn how to create surgery, not how to do surgery.”
