EndoWest Arrington
EndoWest Arrington 26 signatures

As a practicing, fellowship trained MIS gynecologist, I am well aware of the need of adequate care and treatment for endometriosis patients.

I started out as a general OB/Gyn with advanced laparoscopic training in a group practice. Over the course of my 12 years in practice, the need for minimally invasive surgical options for patients began to grow.

Eventually the patient need became so overwhelming that I had to stop obstetrics to provide the services that patients could not find elsewhere. That continued to progress, due to patient need, from general and surgical gynecology to an endometriosis focused practice.

The need is large. I no longer have time available for preventative gynecology or simple gynecologic problems that my colleagues can take care of. Literally I am the only gynecologist in Utah and the Intermountain region with the training, skill and expertise to recognize and excuse Endometriosis throughout the pelvis and abdomen.

My experience is highlighted in Contemporary OB/Gyn. The large majority of endometriosis patients have been severely mismanaged for years. They are prescribed medications as treatment, that by ACOG admission in Practice Bulletin #114, are only palliative. They are shuttled into incomplete surgery after incomplete surgery only to be told that they need a hysterectomy as definative treatment. Definitive treatment that ignores the language in the Practice Bulletin that states hysterectomy can be considered as part of a surgery for endometriosis. All too often patients are told that their only options are GnRH agonists to "kill" or "get rid of" disease or hysterectomy. Too many women are treated by removing a completely normal uterus while leaving invasive endometriosis in situ. Removing a normal organ to treat a disease that by definition occurs outside the uterus. This makes absolutely no sense and does not fall in line with what we see in actual practice.

Too many women are ignored, told they are crazy and that there is nothing more to be done. Many women with persistent deep endometriosis are told that their pain can't be due to endometriosis because they have had a hysterectomy.

Usual and Customary "standard of care" surgery IS NOT SUFFICIENT! Standard of care should not be limited by a shortage of surgical skill or expertise! It should be based on outcomes. Deeply infiltrating endometriosis often involves deep pelvic sidewalls, pararectal spaces, hypogastric nerves, ovaries, appendix, diaphragm and intestines. It is unacceptable in our day to treat these by the typical "peek and shriek" followed by hormone therapy that does not treat the disease or "prevent it from progressing" (Practice Bulletin #114). Portraying medical therapy as anything but palliative is misinformed and inaccurate.

Due to the length of these complex surgeries, it is clinically impossible to devote the time needed to treat these patients under current coding criteria. I am well aware of the years of petitions made to ACOG to lobby in behalf of benign gynecologists update CPT codes to reflect the advanced surgery required for endometriosis. Complete and appropriate surgical excision increases every aspect of RVU determination. There is incrementally more work in clinic with appropriate evaluations, imaging and surgical followup. There is a significant increase in the malpractice risk portion of the RVU with oncologist-like dissections including bowel, bladder, ureters and pelvic nerves.

To treat these cases of endometriosis that often require 4+ hours to complete using "usual and customary" operative times would require 8+ operative experiences of 30-45 minutes each. This is ethically unacceptable.

"Nothing more can be done" is simply not true. In the correctly trained hands there is more that can and should be done.

The current standard of care does not provide the care that our patients deserve and need. The current standard of care simply IS NOT SUFFICIENT!


to comment