Comment & Controversy “ ‘NO-FAULT’ INSURANCE THAT Menopause of our patients. Some recent “improve- COVERS A PREGNANCY AND BIRTH” and cognitive decline ments” are making things worse. Physi- PAUL L. OGBURN, JR, MD (JULY) Staples, or sutures, to close the skin after cesarean delivery? cians and nurses spend more time trying REIMBURSEMENT ADVISER Many liability cases are Coding realities collide to document (based on ever increasing with new “opt-out” HIV screening guidelines result of poor medical care A DOWDEN PUBLICATION | VOL 21, NO 7 | JULY 2009 | WWW.OBGMANAGEMENT.COM rules and regulations) than they can I just fi nished reading Dr. Ogburn’s STRATEGIES FOR PRACTICE possibly spend at the bedside. Physi- thoughts on how to reform the medi- Chemoprevention cians spend more CME time and money of breast cancer cal malpractice system so that it works by Steven R. Goldstein, MD to learn the latest “new, improved” cod- Which of your patients can benefi t? The author explains at for everyone. Here’s my problem with obgmanagement.com ing changes than they spend on any real PLUS his proposal to off er an individual Dr. Barbieri’s call to action medical education. Th e 3MLI will at ObGyns must lead in policy for each gestation: As an “in- the battle against breast Ca least require each physician to partici- UPDATE ON ENDOMETRIAL CANCER house” reviewer for a major medical Survival advantage is dubious pate in a detailed review of the case of a with pelvic lymphadenectomy malpractice insurer and a consul- and external-beam radiotherapy poor outcome with a panel of experts so A “no-fault” plan to defuse the OB malpractice insurance tant for many defense law fi rms, I am crisis—could it work? that the case can go into the database of IN JAMAICA, TANZANIA How 2 US ObGyns cross borders overwhelmed by the sheer number of to care for the poorly served all poor outcomes and the physician can Only at obgmanagement.com med-mal cases out there—and many Follow us on Facebook and Twitter receive specifi c instructions on practice of them are legitimate. improvements, if needed (or be removed JULY 2009 When I began to review cases, from 3MLI eligibility, if need be). back in 2001, I expected the job to in- Patients taking out individual poli- volve mostly frivolous suits and mon- ›› Dr. Ogburn responds: cies is not new. What is new is that, ey-hungry lawyers. I was so wrong. We must® doDowden better than theHealth Mediaunder 3MLI, the physician or provider Many of the cases I have reviewed current system performs would pay for the policy, not the pa- are more than justifi ed, and many of Dr. Kramer raises some important tient. I want an insurance policy that them are “bad baby” cases. I Copyrightcan cer- points:For personal use onlywill take care of my patient and her in- tainly sympathize with the parents of Medical negligence is happening fant if they need it, no matter who is or these unfortunate children. and harming our patients. I agree. is not at fault. Th at is what I want; that What is needed is better training, Th is sad fact is as true today as it was is what my patients deserve. with more hours on call to follow the when we reviewed perinatal closed 3MLI is designed to help solve evolution of disease and course of claims in the mid-1980s.1 We found some of the problems that Dr. Kramer labor. Th e idea of being off so many that payments were made 50% of the raises even as it helps our injured pa- nights and working a shorter day in time when there was no negligence; tients. It can be instituted without tort- ObGyn just doesn’t cut it. Residents when there was negligence, payments reform legislation. For the sake of our are young; they can handle the work- were made 90% of the time. Th e current patients, we must do better than the load. We need to spend more time system requires someone to have been current medical-liability system does. with patients and learn more about negligent for the infant to get fi nan- Reference continuity of care. Th en, and only cial help. Th is leads to expensive (and 1. Ogburn PL Jr, Julian TM, Brooker DC, et al. Perinatal then, will there be fewer mistakes, wasteful) “discovery” and “expert testi- medical negligence closed claims from the St. Paul Company, 1980–1982. J Reprod Med. 1988;33:608–611. fewer cases, and lower settlements. mony” designed to convince a jury, not Th e idea of the patient taking out to get at the truth. Th e one person who an individual policy, as with airplane is not to blame is the infant. Under the “ COLPOCLEISIS: A SIMPLE, insurance, is not new. It was suggest- 3MLI system, the infant’s needs would EFFECTIVE, AND UNDERUTILIZED ed years ago but never made it to the be covered without the need to prove PROCEDURE” OZ HARMANLI, MD (JUNE) “big screen.” What we need are bet- fault. Th is fact alone makes 3MLI supe- ter, smarter, devoted physicians who rior to the current tort-based system. care more about their patients and Physicians need to spend more time Value of obliterative less about time off , vacations, how being trained and more time with their procedures for POP is their much they’ll make, and how quickly patients. Again, I agree with Dr. Kram- lower failure rate they’ll make it. er. Th e current system of health-care ed- I commend Dr. Harmanli on high- Barry Kramer, MD ucation and practice is not designed for lighting the importance of obliterative Bay Shore, NY overall effi ciency or for the well-being procedures for pelvic organ prolapse 16 OBG Management | September 2009 | Vol. 21 No. 9 For mass reproduction, content licensing and permissions contact Dowden Health Media. 16_OBGM0909 16 8/19/09 11:18:43 AM (POP). An obliterative procedure patients who might be candidates for should always be off ered to women obliterative and reconstructive surgery, From June 2009 who are certain that they will not be the success rate of over 90% reported in having intercourse in the future. all of the colpocleisis case series may Which strategy Dr. Harmanli states that “the be an attractive reason to consider this would be your top fundamental reason for choosing an approach for many elderly patients. obliterative procedure…is to treat the However, I kindly disagree with choice to reform prolapse with the least invasive tech- Dr. Valley about the lack of evidence in health care in this nique in the shortest time.” I disagree. favor of LeFort partial colpocleisis. As country? Th e fundamental reason my I stated in my article, the patients who patients choose an obliterative pro- underwent concomitant vaginal hys- cedure is because it has signifi cantly terectomy with total colpocleisis had a 19% 10% less chance of failure than the alterna- procedure that was 52 minutes longer tives. Dr. Harmanli suggests that hys- than those who underwent the LeFort 14 % terectomy in this setting “often adds procedure, and 5% of them required 30 to 80 minutes to the procedure” laparotomy.1 No one can dispute that 24% and argues that the LeFort procedure the longer operating time and poten- % is better than hysterectomy followed tial for laparotomy may add to the 33 by colpectomy. Again, my experience morbidity of this high-risk surgical is at variance with this position. population. Th erefore, it is incumbent Th ere is no evidence that vaginal on those who advocate hysterectomy hysterectomy followed by colpectomy and colpectomy over LeFort colpoclei- carries more morbidity than a LeFort sis to support it with evidence. None Reduce use of tobacco procedure when a regional anesthet- I failed to fi nd any data indicat- and alcohol ic is used. In addition, if the genital ing that this more time-consuming and hiatus (levator hiatus) is closed at potentially complicated approach im- None Replace fee-for- the time of colpectomy, a separate proved the success rate. Th erefore, for service reimbursement with a capitation payment system anti-incontinence procedure is rarely frail single women, I continue to rec- needed because the urethrovesical ommend LeFort colpocleisis, which can 10% Reduce capital angle is supported by the approxima- be performed in less than 1 hour—even investments in hospitals and tion of the levator muscle. In a LeFort with sedation and local anesthesia— the equipment they use procedure, the urethrovesical angle by any gynecologist who knows how to is pulled down by the procedure and do colporrhaphy using the technique 14% Institute a national may increase the risk of stress urinary described in my article. electronic health record incontinence postoperatively. Reference for all citizens When one of my patients opts 1. Von Pechmann WS, Mutone M, Fyff e J, Hale DS. for an obliterative procedure, I al- Total colpocleisis with high levator plication for the 19% Develop a national treatment of advanced pelvic organ prolapse. Am J most always choose to perform a Obstet Gynecol. 2003;189:121–126. effectiveness commission to colpectomy. slow implementation of costly Michael Valley, MD new medicines and equipment St. Louis Park, Minn “ HEALTH CARE, A GORDIAN that only marginally improve KNOT OF COST AND ACCESS, public health FACES REFORM” ›› Dr. Harmanli responds: ROBERT L. BARBIERI, MD For frail elderly, LeFort 24% Reduce the use of (EDITORIAL, JUNE) futile end-of-life medical procedure is best interventions I agree with Dr. Valley that one of the Single-payer system is advantages of colpocleisis is its lower the only option 33% Reduce administrative failure rate.