David Holtz, MD

As a gynecological oncologist, I often see patients who want to be tested for cancer because a close family member has just been diagnosed. Understandably, they want to be sure they don’t have it.

But there is a misunderstanding of all gynecological oncology tests. We just do not have a good screening test, even for high-risk women with a family history of the disease. OVA1 is not even a screening test, just a $650 method for deciding if a gynecological oncologist should be consulted. (By the way, a consult with me usually runs about $350).

Even ACOG's opinion is contradictory: "Screening with CA-125 measurement and transvaginal ultrasonography every 6 months has been recommended for high-risk women by the National Comprehensive Cancer Network, although evidence is insufficient to demonstrate that current screening methods improve survival rates for these women."

So, if we cannot yet impact survival, why do it?

If a patient with a family history of ovarian cancer is uncomfortable with observation, annual ultrasound and CA-125 using the family history ovarian cancer (V16.41) can be done but may not be covered.  While risk reduction BSO could also be offered, I would send the patient to genetics counseling first.

 The role of the obstetrician–gynecologist in the early detection of epithelial ovarian cancer. Committee Opinion No. 477. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;117:742–6.

Articles

CA-125: What is it good for?

This week, I spent over 3 hours struggling with my chief resident in a clinic case doing a robotic hysterectomy and staging.  Granted, the patient was an obese, hypertensive diabetic who benefited from avoiding a big midline incision, but it did make me think of one of my mentors from fellowship.

Dr. R, a busy gynecologic oncologist who performs 7-10 hysterectomies per week, once turned to me and said he would not be able to practice if he had to spend the time needed for laparoscopic hysterectomies.  For him, the opportunity costs of switching to laparoscopic surgery was too high, and he would state boldly that he did not get paid more if a patient went home or returned to work sooner.

I do about 75% of my hysterectomies laparoscopically.  The decreased work of early return to home and fewer office visits for wound separations outweighs the extra time in the OR.

How do you balance your costs?  Do we have an obligation to consider costs like hospital stay and return to work?
  

This week, I spent over 3 hours struggling with my chief resident in a clinic case doing a robotic hysterectomy and staging. Granted, the patient was an obese, hypertensive diabetic, who benefited from avoiding a big midline incision, but it did make me think of one of my mentors from fellowship.

A Parable of Two Surgeons

The cost of health care has been a major topic in the news of late. The growth in public debt is due in no small part to inflation in the Medicare and Medicaid programs. As physicians, we always wish to do what we can to maximize our patient’s health. But is there any way to do this without increasing the price-tag of medicine?

One definition of cost is “The sacrifice involved in performing an activity, or following a decision or course of action.” There are costs associated with everything we do in gynecology, including inaction, so getting a true sense of what a surgery or medication “costs” is complex. Lucky for us, we are usually protected from having to decide what the cost of our care is unless confronted with cost of our time when we have to argue with an insurance company over a pre cert.

I wonder if doctors could help contain costs if they had a way of comparing their interventions. If you go to a grocery store, you compare costs by looking at a price tag (and the number of calories if you have food OCD).

Recently, my hospital system started to print charges for OR disposable instruments on the pick lists. I was thrilled – this let me compare the various laparoscopic gizmos and trochars that I use. At the risk of having the company reps tear up my business card, I think there is clinically little difference, so this addition of price let me do some comparison shopping.

How many of us have let cost considerations into the operating room? Is it imposed from the outside, or generated by the gynecologists themselves? Can we think about cost and still give good care?

David Holtz, MD

Articles

CA-125: What is it good for?

A Parable of Two Surgeons

The Cost of Healthcare and the Ob/Gyn