In the April issue of the journal Obstetrics and Gynecology, ob/gyn Julian M. Thomas published an editorial, “Vaginal Hysterectomy: An Apparent Exception to Evidence-Based Decision Making,” and questions why more hysterectomies aren’t performed vaginally rather than abdominally/laparoscopically – most are currently performed abdominally. Thomas asks, “With evidence showing vaginal hysterectomy offers most patients the best combination of results, cost, and morbidity for hysterectomy, shouldn’t that be enough for surgeons and patients to demand it?”
The most interesting pieces of this editorial and the follow-up letters, however, may not be the commentary on the procedure itself. Thomas notes a shortage of training opportunities in vaginal hysterectomy, and offers the following as a possible explanation:
“Why? Industry plays a valuable role in teaching surgical procedures to gynecologists. One set of vaginal hysterectomy instruments may last an entire career. Laparoscopic surgery requires single-use, moderately expensive instrumentation. Which type of training would you provide, if you were selling instruments? Non–industry-supported training opportunities are uncommon: In the latest ACOG advertisement on postgraduate courses, there are no vaginal surgery courses.”
In addition to the lack of training, I also have to wonder about the sensitivity of the (predominantly male) ob/gyns when this discussion of vaginal surgery descends into car talk. In a letter published in the July issue of the journal, ob/gyn Mark Vizer says,
“I asked a general surgeon about this and how he felt about learning to perform a vaginal hysterectomy. He looked at me funny. He was concerned about lack of visualization and exposure and wondered why we even did this. It made as much sense to him as changing spark plugs from under the car.”
Thomas responds in kind, asking:
“Regarding your general surgeon’s comments—again, two questions: How does he change his oil? Would he cut a hole in the hood of the car to get at the spark plugs or use the opening that the maker provided?”
Vizer also notes that Medicare pays more for abdominal hysterectomies and asks, “So you do something harder but get paid 15% less. Does this make sense to you?” Thomas responds that, of 53 emails he received in response to his editorial, “14 of those responders, [who] stated that being able to bill more for a transabdominal approach influenced their hysterectomy route.”
I suppose it’s too much to ask that the discussion focus on real benefits and risks to women, rather than Medicare payments and car analogies. Thomas closes with the following point: “Those who choose between a best practice and an extra $200 per case will have to live with their decision.” Although this perspective at least takes “best practice” into account, it makes no mention of the women having surgery who also have to live with these decisions.
In contrast, a recent Cochrane review on hysterectomy for benign disease concluded, “The surgical approach to hysterectomy should be decided by a woman in discussion with her surgeon in light of the relative benefits and hazards.” Ahhh, nothing there about money or cars.
For related information, check out this fact sheet on hysterectomy from the National Women’s Health Network.