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Can a Low Volume Surgeon Survive in a High Volume Surgeon World?

Perhaps my current experience as a minimally invasive gynecologic surgery fellow is what set off so many mixed internal emotions when I read the lecture titled “Can a general gynecologic surgeon survive in a minimally invasive gynecologic surgeon world?” It may have been the additional $55 lecture price atop an already expensive conference registration fee that did it. However, more than likely, it was my fear at the titles implication about the future of gynecologic surgery and limiting access to patient care which prompted me to write this opinion piece.

Are generalists (general gynecologic surgeons) and MIGS providers (minimally invasive gynecologic surgeons) truly in such contention? In reality, their coexistence is of the utmost importance for covering the vast quantity of patients in need of surgical intervention for advanced gynecologic disease. Just as the orchestra depends on multiple string instruments coordinated together in synchrony to create beautiful music, we as a field should move to an understanding that the cooperation between these two surgical groups is an essential requirement for the advancement of women’s health. If the generalist is the violin and the MIGS provider the viola, only together can we master an elegant duet.

According the American Association for Gynecologic Laparoscopists (AAGL), there are only 390 fellowship trained MIGS graduates since the inauguration of the first fellowship class in 2001. Assuming there are approximately 400,000 hysterectomies and roughly 34,000 myomectomies performed annually within the United States, then every single MIGS provider would have to staff nearly 4.3 major cases per day operating five days a week. Even for the most ambitious and productive MIGS provider, this workload would likely prove too arduous and unyielding in practice. This is not even accounting for the time needed for the many other commonly performed gynecologic procedures or the valuable clinical time needed for preoperative evaluation and postoperative follow-up.  

Perhaps a more appropriate title for this lecture would have been, “Can a low volume surgeon survive in a high volume surgeon world?” Such a title would be less controversial and truly hit at the heart of the issue facing the future of gynecologic surgery. Fellowship training or not, the evidence demonstrates that the best surgeon for a patient is one who spends a great deal of time in the operating room. Gynecologic surgery performed by a high volume surgeon has been associated with higher rates of minimally invasive approach and lower procedural cost, while surgery performed by very low volume surgeons have been associated with higher intraoperative complications, medical complications, transfusions rates, prolonged hospitalization and even higher mortality rates.

Recalling on my anecdotal experiences from my residency training, much of my understanding of key surgical principles were imparted on me by amazing academic generalists. They taught me the principles of electro-surgery, the steps of laparoscopic and vaginal hysterectomies, and walked me through my first experience with a serious postoperative complication. They embraced the full extent of Obstetrics and Gynecology by working in clinic, labor and delivery, and still excelling in the operating room. They provided top quality patient care and possessed exceptional surgical skills all while teaching new residents how to operate. I personally believe that these generalists were able to maintain their surgical knowledge and skills in large part due to the rigors of academic medicine that kept them well engulfed in the surgical realm. They all attended weekly M&M meetings, participated in additional training on new surgical technologies, and maintained a respectable surgical volume for the purposes of resident training.

The occurrences during my residency training where I felt the standard of care was not being provided to patients undergoing surgery were thankfully few and far between. However, they were always during away rotations, outside of the university hospital setting, with practitioners with low surgical volume and scant surgical training in minimally invasive surgery. Uncertainty placing a Veress needle, incorrect utilization of electrosurgical instruments, difficulty performing laparoscopic suturing, and inadequate appreciation of the complex pelvic anatomy are some of the painful experiences I witnessed occur amongst these low volume surgeons. Generalist or MIGS training had nothing to do with these events, and everything to do with these provider’s surgical volume and comfort in the operating room.

I ultimately chose the path to become a MIGS fellow as I had a true desire to increase my surgical training, participate firsthand in clinical research advancing the specialty, and a desire to stay connected with the advances in biomedical devices; all of which I have been fortunate to receive during my current fellowship training. However, it never occurred to me that such a competition between generalist and MIGS providers would reach such a critical debate when planning the future landscape of gynecologic surgery. In my view, gynecologic surgery should be provided by those who have dedicated perfecting their crafts and maintaining their surgical skills regardless of fellowship training, otherwise face the reality of decreasing significant access to women’s healthcare.

It is true that not all board certified obstetricians and gynecologists should continue to operate, specifically those with inadequate training and low surgical volume. However, in my utopian gynecologic surgery model, the generalist who has dedicated their time towards maintaining their surgical skills and volume provides a great deal of surgical care to patients suffering from abnormal uterine bleeding, pelvic pain, and infertility. In this model, MIGS providers play a consultation role for providing surgical care to patients with advanced pathology, having large fibroid uteri, high stage endometriosis, Mullerian anomalies, or even due to a history of multiple abdominal procedures. In this model, no contention exists and the two surgical groups are seen as harmonious providers working together with the same ultimate goal of providing excellent patient care.  

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