OBGYN.net Conference CoverageFrom First Congress on Controversies in Obstetrics, Gynecology & Infertility Prague CZECH REPUBLIC - October, 1999
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Dr. Mark Perloe: "I'm here with Dr. Chvatal from Austria, for those of us who in America who can't deal with the pronunciation. You're interested in advanced laparoscopic techniques in your practice. Can you tell us a bit about your practice?"
Dr. Radek Chvatal: "In my practice, I'm working in Austria but I come from the Czech Republic, and I live in the Czech Republic. I began with my laparoscopy, the first laparoscopy, operations in a clinic in Brno - it is the second largest town in the Czech Republic. I then took a position in Vienna, and I had a very excellent opportunity to be confronted with the best laparoscopic methods, thanks to Dr. Gill at this time. "
Dr. Mark Perloe: "When a physician finishes training in an institute, usually we have our techniques, our basket is full with the knowledge that we have but there have been a lot of new laparoscopic techniques. How do physicians learn these new techniques, and how do they get trained in their equipment when new procedures come out?"
Dr. Radek Chvatal: "I think, basically, a good laparoscopic surgeon must be born so it's inherited. That's my point of view because there are very good surgeons who aren't able to operate just watching the camera and the TV and operate simultaneously laparoscopically. This is a little bit schizophrenic work and for some people it's impossible to do. So I think those trainees who want to be good laparoscopy operators must at first, be convinced about it - I'm able to do it or I'm talented."
Dr. Mark Perloe: "Are there mechanisms in the training programs here that look at basic skills to make that determination? One of the problems we have in the states is that it's assumed that by the end of the four years, a physician will be competent when they get out into practice. The insurance companies assume that anybody graduating from a program has the same levels of skills as someone more experienced. But in your training programs, are there steps and specific goals that measure laparoscopic skills? I mean, you know that you say you're a good laparoscopic surgeon, and you know when you watch other people operate that that person is a good laparoscopic surgeon, but do you have objective criteria that lets the young trainees determine if they really do have the skills?"
Dr. Radek Chvatal: "I'm afraid there's not an objective system to judge and define a good surgeon because I can't compare those two systems in the Czech Republic and Austria. It takes a very, very long time to become a good laparoscopic surgeon because you need time and you have to operate and operate and nothing more than that. You can study whatever you can but the physical training - it's the basics. So you have to have patience but first steps are very dangerous. There are also some very dangerous…"
Dr. Mark Perloe: "As a teacher, it causes me anxiety when I'm doing…"
Dr. Radek Chvatal: "Many times for me, it's a catastrophe when I'm operating as a first assistant to some new guy at the first operation. So it's to me more stressful than to operate myself on some complicated operation."
Dr. Mark Perloe: "I certainly agree. We used to have animal surgery labs where we would bring residents in and operate on pigs to teach them some of the simple techniques so that they could develop hand-eye coordination. We don't have that any longer, too many people objected to animal surgery. So now the residents learn by doing those surgeries on humans, and it's an unfortunate situation that they're learning on people rather than pigs."
Dr. Radek Chvatal: "I've heard of some system that existed to operate at first on pigs. A pig is not a human being; it's an animal - so you haven't had to do distention for the operation. So I think one must start with some very simple procedures like saphenectomy, for example, or diagnostic laparoscopy - it's a first step to put a trocar in safely. It's the first basic step."
Dr. Mark Perloe: "One of the things that is important to develop is the hand-eye step. You said that there's some inherent talent but then there's also experience. We're finding that fewer and fewer women are getting to the operating room in the United States. So the experience that the residents have may be limited now as it may have been ten years ago. They're seeing far fewer cases during their training program."
Dr. Radek Chvatal: "I don't know how many cases a trainee sees approximately in the Czech Republic. There's a big difference between the great houses - clinics, and some smaller district hospitals. I'm afraid the situation in Austria is the same or nearly the same, that some young doctors in this trainee time have few chances to operate and to become skilled surgeons."
Dr. Mark Perloe: "When they get to practice after they finish the training, are they seen as junior physicians, and as such work under the supervision of a more experienced physician?"
Dr. Radek Chvatal: "That's questionable, there are some guys that don't have any problem with this - they are convinced about it, they are the best. They're very adventurous I think, and I think everyone of us needs throughout their whole life supervision from time to time. We make mistakes and we advance. From my point of view, it's very, very hard for me when I can assist somebody whom I find is a very good surgeon and who I can learn some things - to see how the typical operations are operated in some other hospitals. There's quite some similar steps to this whole complex problem of the operation theater, I think it's the basic precept that we need to see more hospitals and how other surgeons operate."
Dr. Mark Perloe: "I agree with you that we learn from our mistakes, by some others, and by watching other people work. Those physicians who decide that they can't learn anything anymore are bound to get themselves in trouble. You said before that you're from the Czech Republic and working in Austria. I know that my wife would be upset with me if I was working in a different country. Now I understand that it's not really as bad as it seems. How bad a commute do you have, and how often are you going back and forth?"
Dr. Radek Chvatal: "That's a very sensitive question and it's very sensitive to answer. It's not that easy to answer it because there are two points that I made for this decision to go to Vienna for 8-10 years. I had been confronted with the first laparoscopy techniques and I wanted to learn it. I was told it's impossible because of the economical situation in Czech Republic that we could implement such a tactic. It's a big surprise for me what a quick development has made Czech Republic's doctors and laparoscopy surgeons in those eight years. I think it's a surprise for the, for example, the American doctors too - how great do they operate, which operations are complicated operations, and what success do they have? The biggest surprise for me is that in smaller district hospitals in the Czech Republic, there are some really excellent laparoscopic surgeons. And now some eight years after from my position as an Austrian doctor, I am surprised that the layers are now equal, the same quality. The second problem, I am afraid it will take longer, the economic situation of the Czech registrar senior officer is a natural catastrophe. I'm very glad I can take this opportunity to endorse my Czech colleague to be a little bit louder to express those needs and economical status which don't belong."
Dr. Mark Perloe: "So their equipment and their skills improved a lot faster than their economic well being?"
Dr. Radek Chvatal: "Yes."
Dr. Mark Perloe: "That's a fair observation. What are the new and exciting techniques that you have seen in the last year or so that have been helpful in your practice?"
Dr. Radek Chvatal: "Urogynecology, colpo suspension, laparoscopic ultra suspension - I'm convinced about it. It's a really a great method especially for a lot of surgery so in some typical case you can perform pre-peritoneal colpo suspension with, for example, perivaginal repair. This operation could be done in two hours time if you're lucky, and the results are excellent and compatible with an optimal procedure."
Dr. Mark Perloe: "We had talked earlier and you had mentioned that most patients here are not operated on in one day or a day surgery unit. How would the difference be, seeing that people are going to be staying in the hospital anyway. What is the…?"
Dr. Radek Chvatal: "Uneasy, it's an uneasy situation for both the patients and for the doctors too, because the economical system is like that, that it brings any money for the hospital if the patient is dismissed from the hospital and the second day after the surgery. From an economical point of view it's not good for those hospitals. So we are forced, we have to do it a little bit in another way. So even if you had a successful operation and a patient could leave the hospital in the same day, we must convince them that they have to stay three, four, five days or longer - it will be necessary."
Dr. Mark Perloe: "But despite the fact that there may be an economic consideration, the laparoscopic approach or endoscopic approach still makes sense to you for a perivaginal repair?"
Dr. Radek Chvatal: "Yes."
Dr. Mark Perloe: "What other new techniques or opportunities do you want to share?"
Dr. Radek Chvatal: "I think laparoscopic surgery has two goals now, two main goals, that's access to surgery in small pelvis and urogynecology and pelvic repairs. It's a huge, very complex problem to consider for the younger generation. We can't forget that the approximate generation with some pelvic problem is no longer sixty-years-old, they're between forty and fifty. So that's the one huge problem for the next millenium, I'm convinced about it. The second one is oncology. As oncologists, oncology surgery is very sensitive because there are different sorts of abdominal techniques, there's the laparoscopic technique and there are some systems that have been developed especially concerning endometrium and cervical carcinoma. But a very sensitive problem still remains - ovarian cancer, in which, I think, the abdominal procedure is still the better solution but it's a question of time and how the situation will develop."
Dr. Mark Perloe: "Are you seeing any new treatment options for adhesion prevention here in Europe?"
Dr. Radek Chvatal: "No, I'm sorry. Adhesions are a problem per say, and I think it must be some infection process in the abdominal cavity like chlamydial or something like that because many times for me it's really a shock. For example, I operate on some patient with a frozen pelvis, and she gets pregnant in one year's time with no problem. For someone else with absolutely no problem, she has no problem with pelvic pain, and by some simple abdominal procedure we find very strong adhesions. So I think that adhesions are not as big a problem as we thought it was, and how to prevent it - I don't really know."
Dr. Mark Perloe: "Hopefully, we'll come back to future meetings and have some more of these tools to manage that. I want to thank you for taking your time and coming down with us. And I look forward to seeing you in the endometriosis mailing list, and participating on that. Have you been involved with OBGYN.net before, and what activities have you taken part in online?"
Dr. Radek Chvatal: "Because I got my computer last year, it's a new subject for me and the next goal for the millenium."
Dr. Mark Perloe: "What kinds of things have you done online as an ob-gyn physician? Are you participating in mailing lists or Medline searches? How have you found it helpful?"
Dr. Radek Chvatal: "Medline, I think. It's for me the Netscape in Medline, it's the main help but it's very new for me. So my computer is on my table three months with nothing."
Dr. Mark Perloe: "You said at home yesterday - do you have one at home and at work?"
Dr. Radek Chvatal: "Yes."
Dr. Mark Perloe: "We now have in our house five computers."
Dr. Radek Chvatal: "That's excellent."
Dr. Mark Perloe: "It's excellent when they're all working."
Dr. Radek Chvatal: "Time consuming."
Dr. Mark Perloe: "When you get to that stage, you spend more time keeping them working so that everybody has one to use than you actually spend on it."
Dr. Radek Chvatal: "…Picking, sitting on the table, watching the screen all the time, and having no time for a family and for all the others."
Dr. Mark Perloe: "When you travel that's a concern. My wife gave me a membership to a group called "Internet Anonymous" saying that I spend too much time, so I brought her along to see Prague and to see Vienna. We've been lucky on this trip, and I'll be visiting a clinic in Linz after leaving this meeting so they'll have an opportunity to benefit from the Internet too and meet some of our friends. So thank you so much, I appreciate your coming by."
Dr. Radek Chvatal: "You're welcome, thank you."