Patients first hear about possible treatments from their doctors — and for gynecologists, open abdominal hysterectomy is also a deeply ingrained tradition. It’s their default recommendation, not because it’s a big moneymaker but because they’re comfortable doing it. And feeling comfortable with a procedure usually reduces the doctor’s chance of error — a big factor in a specialty in which lawsuits are a major concern.
Not surprisingly, most ob-gyns do what they know. "When residents first go into practice, most have a huge number of obstetrics patients," explains Barbara Levy, MD, coauthor of So You’re Having a Hysterectomy. After years of being on call to deliver babies, many settle into the saner schedule of gynecological practice. But their skills may not be as up-to-date or well-honed as they should be. "Since they’ve spent years performing c-sections, abdominal surgery is what has become most familiar, and that’s what they tend to do," Levy says.
The bottom line: Open abdominal surgery is frequently performed when another, less-invasive procedure could solve the problem, and the doctor’s skill level is often the reason. Vaginal hysterectomy — a decades-old, minimally invasive procedure that enables a physician to remove the uterus through the vagina — is underused because many ob-gyns consider it too difficult. And laparoscopic hysterectomy, a newer treatment, has not been fully embraced because most of the ob-gyns practicing today do not have enough experience in the required technology. "Many doctors talk their patients out of laparoscopic surgery and other [less invasive] procedures because they aren’t trained to do them and don’t want to lose the business to someone who is," claims Harry Reich, MD, who performed the first fully laparoscopic hysterectomy in 1988.
Not Motivated to Modernize?
It’s not as if doctors can’t retrain midstream. General surgeons crowded in for classes when it became clear that laparoscopy was the future of gallbladder surgery. Even though the procedure requires training and great technical skill, the market demand forced doctors to get with the program. Today, 80 percent are performed via the laparoscopic route as compared with 15 percent of hysterectomies.
Compensation may be a factor. Minimally invasive gynecological surgery is more difficult — and takes longer — than the open abdominal version. Yet insurance companies pay ob-gyns virtually the same fee — around $900 — no matter how they get the job done. Perhaps it’s not surprising, then, that most time-pressed practitioners choose what is, for them, the quicker, simpler and, from a doctor-liability point of view, lower-risk option. "Doctors face the question of, do I do a quick 90-minute abdominal surgery, or do I invest in training, increase my liability, spend three hours in hard surgery, and get not a penny more for my trouble? What’s in this for me?" Parker says.
For general surgeons, like those who remove gallbladders, the rewards of retraining are much more immediate. Because they rely primarily on referrals, they need to be more competitive, which means offering the latest treatments. "If you were referred to a general surgeon who said he wanted to remove your gallbladder the old-fashioned way, by opening up your abdomen, you wouldn’t think twice about finding someone else who could do it laparoscopically," says Franklin Loffer, MD, of the American Association of Gynecologic Laparoscopists (AAGL). "Women, on the other hand, have a relationship with their ob-gyns. They trust them and tend to stay loyal to them. That makes ob-gyns less motivated to change what they are accustomed to doing."