OBGS): Past, Present, and Future: Part I
Total Page：16
File Type：pdf, Size：1020Kb
#1183 Wortman Galley - 02 Gynecology SURGICAL TECHNOLOGY INTERNATIONAL Volume 35 Office-Based Gynecologic Surgery (OBGS): Past, Present, and Future: Part I MORRIS WORTMAN , MD, FACOG CLINICAL ASSOCIATE PROFESSOR OF GYNECOLOGY UNIVERSITY OF ROCHESTER MEDICAL CENTER DIRECTOR CENTER FOR MENSTRUAL DISORDERS ROCHESTER , N EW YORK KATHRYN CARROLL , BS, RN CLINICAL RESEARCH COORDINATOR CENTER FOR MENSTRUAL DISORDERS ROCHESTER , N EW YORK ABSTRACT he gynecologist’s office was, historically speaking, the original setting for surgical practice. In 1809, Ephraim McDowell performed the first ovariotomy and removed a 22.5-pound tumor from Jane Craw - Tford in his Danville, Kentucky office—decades before the development of anesthesia or the aseptic tech - nique. Three developments—introduction of surgical anesthesia, improved operative techniques, and the evolution of the medical-economic environment—shaped surgical practice for over two centuries. The latter part of the 20th century also brought two dramatic changes that affected gynecologic practice. The first included social changes which created a demand for legalized abortion and elective sterilization. The second was a cascade of technological growth and innovations that created the field of minimally invasive gynecologic surgery (MIGS), allowing many procedures to be transferred from the hospital to the outpatient setting and then to the office. With the increasing demand for patient-centered care, effective operating room utilization, and the efficient use of physicians’ time, many gynecologic procedures are now being performed in an office-based setting. But, at least three important obstacles remain: the need for widespread accreditation, the availability of teaching in an office-based environment, and meeting the ethical obligation for adequate analgesia and sedation in an office environment. - 1- #1183 Wortman Galley - 02 Office-Based Gynecologic Surgery (OBGS): Past, Present, and Future: Part I WORTMAN/CARROLL INTRODUCTION ment for practice in most hospitals. gynecologic procedures to be trans - World War II produced a sea change ferred to the office-based surgical in the practice of medicine and surgery , (OBS ) setting as well . Soon, laparoscop - Gynecologic surgery did not originate while stimulating the dramatic expan - ic sterilization, diagnostic hysteroscopy, within the prestigious chambers of a hos - sion of the 20 th -century hospital system the treatment of vulvar cysts, and loop pital operating room; instead it began in and motivating the modern infrastruc - electrosurgical excision procedures the remote confines of an early 19 th cen - ture of health insurance. The post-war (LEEPs) were being reported in an tury physician’s office, in central Ken - years witnessed numerous technological office setting—but only by a limited tucky, where a bold and original achievements in medicine and surgery group of pioneering physicians. idea —removing a life-threatening along with a rapidly growing and well- The last 30 years have seen three intraabdominal tumor—came to insured population that soon exceeded major changes that are now motivating fruition . For most of the 19 th century, as the capacity of hospital beds and operat - many gynecologic procedures to move to operative techniques and anesthesia were ing rooms. The response to these short - the OBS setting. First, the technological developing , gynecologic surgery was ages spurred the development of achievements of the last three decades increasingly performed in an office or outpatient surgery centers beginning in have resulted in the unprecedented ease home setting. However, in the latter part the 1960s. With the advent of Medicare and safety of many commonly performed of that century , during the decades fol - and Medicaid programs in 1965 3 the gynecologi c procedures —diagnostic lowing the Civil War , enormous strides federal government adopted a central and operative hysteroscopy , as well as were made in surgery, anesthesia, aseptic role in financing the costs of American endometrial ablation —in an OBS set - techniques, and formalized nursing train - heathcare . ting. Second, the increased growth and ing that would affect the future of our The 1970s also witnessed another complexity of hospital systems has specialty. important social change—the legaliza - imposed many new insurance and The turn of 20 th century brought tion of abortion services in the United administrative barriers to the delivery many demographic and social changes to States .4 The management of a large of care to patients . Third, the major America . Simultaneously, a revolution in influx of elective pregnancy termina - healthcare payers, in an effort to reduce surgery and anesthesia, the development tions, requiring discretion and privacy, the cost of inpatient and outpatient of diagnostic and laboratory services, was ill-suited to the hospital or emerg - operating room services, have provided along with the modernization of medical ing outpatient department and stimulat - strong financial incentives for physicians education witnessed the hospital emerge ed the early growth of office-based to perform procedures in an OBS set - as a modern institution of healing and gynecologic surgery (OBGS) . A handful ting. In 2006 , The Medicare resource- teaching. In the years just prior to World of physicians soon recognized that the based relative value scale (RBRVS) War II, both the American Board of skills learned in this setting—gentle tis - dramatically increased the reimburse - Obstetrics and Gynecology 1 as well as sue handling, the use of local anesthesia, ment for endometrial ablation and hys - the American Board of Anesthesiologists 2 and intravenous sedation—along with teroscopic sterilization performed in an were founded and the imprimatur of the support of a well-trained nursing office-based setting .5 As recently as these specialty boards became a require - and administrative staff allowed other 2017, the Centers for Medicare and Medicaid Services (CMS) instituted a 237% increase in relative value units for diagnostic hysteroscopy with endome - trial sampling .6 The relocation of many gynecologic procedures , from the hospital and out - patient setting to the office , comes at a time when gynecologists struggle for improved reimbursement and better utilization of their time while seeking reduced administrative barriers to more patient-centered care . Patients are motivated by the inherent cost sav - ings of OBGS and the individualized care available in the already-familiar office environment removed from the complexities of an increasingly corpo - rate hospital structure .7 This article will trace the history of gynecologic surgery as it moves from its original setting—the early 19 th century physician’s office —to the increasingly sophisticated but complex environment of the late 20 th century hospital . We will Figure 1. Ether Dome (Courtesy of Massachusetts General Hospital Archives). examine how the advances in surgery and anesthesia and the changing medical - 2- #1183 Wortman Galley - 02 Gynecology SURGICAL TECHNOLOGY INTERNATIONAL Volume 35 economic environment have inter - known Edinburgh obstetrician, experi - definitely ascertained” and noted that twined and influenced the growth of mented with the inhaled vapors on him - chloroform was used in 72.2%, ether in OBGS. After examining the present -day self and two of his friends at a dinner 14.7% , and a mixture in 9.1% of cases. status of OBGS , we will also identify party on November 4, 1847. Chloro - Chloroform was likely the preferred the obstacles to OBGS practice and how form “and its effects were rapidly agent since it was non-flammable and best to overcome them. demonstrated by the three seekers after was associated with a quicker induction, truth falling out of their chairs and lying greater potency , and more rapid return unconscious under the table .” 13 With no to consciousness .20 Although various EvolEuVtOioLUnT IoONf AOFn eANstEhSeTHsiEaSIA unpleasant after-effects , Simpson adopt - inhalation devices were available at the ed chloroform as an obstetrical anes - time, most anesthetics were delivered thetic agent and introduced it to the by pouring the agent onto a handker - Anesthesia was arguably America’s world in a paper delivered before the chief, towel, napkin, sponge, lint , or first important contribution to medical Medico-Chirurgical Society of Edin - special cone .21 The merciful relief that practice. Josiah Trent, in celebrating the burgh. Simpson withstood withering anesthesia afforded the victims of the centenary of anesthesia, described sur - professional and religious criticism in Civil War was best expressed by Con - gical practice prior to 1846 as follows: mid-19 th -century England and was federate Army General “Stonewall” “The patients were few in number, for opposed by those who suggested “God Jackson after being wounded during the the fear of pain was a deterrent equally has ordained that women should suffer Battle of Chancellorsville. Dr. Hunter as strong as the fear of possible acci - during childbirth .” 14 After being sum - McGuire informed General Jackson that dents or of fatal errors by the surgeon; moned by Queen Victoria in 1848 to he would be administering chloroform many preferred to die rather than attend the birth of her sixth child, in order to amputate the general’s left endure the exquisite agony which was Simpson’s participation was strongly arm two inches below the shoulder. in store for them .” 8 opposed by Her Majesty’s medical