Assume the Position: Memoirs of an Obstetrician Gynecologist (17 page)

     One year when reviewing the annual statements provided by the ‘real’ accountant, who had my computer generated paper trail to follow each month, one figure stuck out above all the others. Office overhead was 38% that year.  Meaning the other 62% was available for the partners.  This was exceptional efficiency of which I was rightly proud for such a large operation.

     When I was finishing my residency prior to leaving for Phoenix, one of my future partners asked me to visit a physician in Philadelphia who was one of the original clinical investigators performing a new in office female sterilization procedure under an FDA (Food And Drug Administration) approved protocol.  He told me he, too, was going to become an investigator and wanted me to observe and ultimately perform the procedure with him after my arrival to Phoenix.  At the time, I knew nothing about clinical investigation, but I was eager to learn the new procedure.  It was done by inserting a hysteroscope through the cervix after administration of a local anesthetic, a small fiber optic scope through which one looks into the interior of the uterus to view the opening of the Fallopian tubes as they enter the uterus.  Once visualized, the Fallopian tubes had a small catheter inserted with the silicone rubber instilled into the tube through the catheter to block the tube and prevent conception from occurring.  Most exciting about the procedure was that it had the potential to be reversed since the newly formed plug had a loop on it for retrieval.

(Formed in place silicone plug with retrieval loop resting in the tubal ostium as seen through the hysteroscope.)

However, since the patients had been told it was permanent sterilization, the reversal was only a potential future possibility also ripe for exploration.  No one knew if the tubes would actually work if the plugs were removed, or even if the plugs could be removed.  Also no one yet knew exactly how effective the plugs were in preventing pregnancy.  This is why the research was being done under an investigative protocol with FDA approval.

     When I got to Phoenix my partner and I got involved in this procedure in a big way.  It was new to me, but very exciting and cutting edge for us both.  The patients paid nothing for the procedure, would come to the office over lunchtime, and 30 minutes later leave sterilized and go back to work.  No major anesthesia, no major surgery, no cutting, no trauma, and sterilized with potential reversal.  We were careful to only recruit women who wanted permanent sterilization since there were no guarantees either about sterilization or reversal, but such was the nature of an investigative protocol and an as yet unapproved device. The company conducting the study and owner of the patent rights paid us for successful completion of the procedure and follow up according to the protocol.  Over time, we did somewhere close to 1000 of these procedures in the office and followed the patients for years, as one would have to do to determine sterilization effectiveness. We accumulated massive amounts of data that I decided to publish in the major obstetrical journals and textbooks, also an unanticipated, time consuming, but interesting venture.  My partner and I travelled and lectured.  We learned how to videotape the procedure for educational purposes.  From a medical standpoint, it turned out to be very effective and safe.  From a reversibility standpoint, it was in fact reversible with successes that we reported over time.  From a safety standpoint it was indeed safe without long-term consequences.  From a financial standpoint for our practice, not just in terms of immediate financial gain but also in terms of the notoriety it brought us, it was also a success. From the standpoint of the FDA, they insisted on long term further animal studies to document safety and efficacy, and the sponsor simply ran out of money to conduct that part of the ongoing investigation. As a result, the sponsor pulled the study from the US and moved it to Europe, where the FDA did not exist, so it never got approved in the US for eventual use, an unfortunate outcome since it proved to be safe and effective.

    (Formed in place silicone plugs in the Fallopian tubes as seen by X-ray post procedure.)

     The experience for us whetted our appetite for further clinical investigations. We were able to propel our expertise, publications, and experience into establishing Women’s Health Research of Arizona.  Over the ensuing years, we participated in over 35 investigative studies in the field of Obstetrics and Gynecology, testing FDA approved protocols on new medications, new contraceptives, and new medical techniques for the treatment of abnormal uterine bleeding in lieu of a hysterectomy. We were in the forefront of investigative clinical medicine testing devices not even used in teaching programs at residency programs throughout the US, so we commonly had both attending and resident visitors to our office for teaching and learning.  I had little time for the management of this part of the business and was fortunate that my partner ran the research end.  He enjoyed the notoriety that it brought, the travelling, and the business of making Women’s Health Research profitable, which it clearly was.  We got to the point where large pharmaceutical companies and device manufacturers would seek us out.   New studies just began to appear for us by reputation only.  I enjoyed the medical, clinical and investigative part of the work that kept us far in advance of other practices in town and on the cutting edge of new and exciting medicine.  In fact, some of the more astute local practitioners got wind of what we were doing, and we had no problem with them coming to our office to observe and learn.  Teaching was just part of the experience.  This side venture of the practice, all self taught and conceived, satisfied our inner need for academic medicine and clinical investigation. It was fun to build from scratch, it was innovative, and it was indeed entrepreneurial.

     Being on the staff of a hospital came with admitting and surgical privileges. If that is all one wanted, nothing else was required.  But since my primary office was adjacent to the hospital, and this was where we planted our stake, I chose to get actively involved in hospital politics, initially as preceptor for the family medicine program, a member of the OB GYN committee, and then membership on the credentials and residency advisory committees.  Eventually I was elected as chairman of the OB-GYN committee for four years.  In this capacity as chairman of a department committee, I was also required to sit on the hospital executive committee. So I became intimately involved with all aspects of hospital committee work and hospital politics. There were many meetings to attend, often into the evening hours. There was no remuneration that came as a result, but a great opportunity to serve the hospital and help it grow, expand and remain successful.   It also gave me the opportunity to push for my agenda to modernize both the nursery and the Labor and Delivery facilities, which were in need of expansion and modernization.  During my tenure as Chairman, we created a new labor and delivery suite, new Cesarean section operating rooms designated just for OB GYN staff use apart from the general surgical suite, new post partum rooms, new on call rooms for the physicians, and a new outpatient surgery suite, all of which I was active in planning and helping to design.  I actively pushed to get the nursery upgraded by the State of Arizona to a level II facility so that we could keep most sick babies in the nursery without having to transfer them, and getting neonatologists on staff.   I helped establish an in house epidural service under the tutelage of nurse anesthetists supervised by anesthesiologists.  Clearly obstetrical care and facilities was upgraded from when I first arrived. I was most proud of helping to get our hospital to this point.  There was no financial gain to our group other than seeing the hospital more successful and welcoming to our patients, and those of the other attending physicians on staff.

     From my first day of arrival in Phoenix, I was asked to be the Obstetrical and Gynecologic attending and supervising physician for the family medicine residency program at our hospital. This required me to go to their weekly OB-GYN clinic, attend their deliveries, allow them to assist and occasionally perform Cesarean sections since many of these Family Medicine residents chose to go into rural health care and needed to learn the procedure.  Having just come from a high-powered residency myself, this was nothing other than just continuing what I had already been doing.  More importantly, it gave me the opportunity to get to know the residents well, and vice versa.  When they graduated from the program, some stayed on staff at the hospital, and they became a referral source for new patients for our practice.  At some point we got the idea that we should just hire one of the residents and purchase a local family practice if and when the opportunity became available, then set up our own ancillary family medicine practice from which we could cross refer medical patients, and the medical practice could cross refer OB-GYN patients.  Indeed at one point we found an interested, busy, well-respected local family physician interested in selling his practice and reducing his stress. We hired a new young resident willing to work with him and us.  The practice was relocated across the hall from ours.  Literally with the papers on his desk and ready to sign, the physician unfortunately died suddenly about one week before we were ready to consummate the deal.  It was shocking for us all.  I attended his funeral and was just simply astounded at how many friends and patients were there.  After an appropriate time period, we did finally purchase the practice from his widow, and set the resident up by himself in the practice.  He had fully expected to have a working partner and was a trooper the first year, after which we hired and recruited a second and third graduating resident, moved the practice to a larger location adjacent to another local hospital, and it was up and running and flourishing.  We maintained and operated the business part of that practice for a number of years before selling it to the hospital.  It was just a lot of work for me and I was glad to pass it off. 

     The business of medicine also involved the business of finding, recruiting, training, interviewing, and hiring prospective partners, then finding a way to make them busy and productive from their first day of practice.  When I first joined the practice as the third physician, we were doing 12-15 deliveries per month amongst the three of us.  They had plans for me to bring in new business, and to assist with their patient loads, particularly since one of the benefits of the group practice as they envisioned it was the opportunity to take time away from medicine to travel, pursue other hobbies or interests, and catch up on missing sleep.  Fifteen years later we were doing 150 deliveries a month, had four flourishing offices, 14 providers, and a mixture of physicians, nurse midwives and physician assistants.

     As we grew, we recruited and found new physicians who had complementary skills. Most important to us, however, was in addition to physician personalities and skills that they understood the corporate philosophy; how we practiced medicine, night call, patient sharing, group practice, vacation time, and days off. It was assumed that productivity would be equal and not become an issue.  We carefully screened applicants to ensure this would not become a problem in the future and that we were compatible.  The underlying theme was that salary and benefits would all equalize over time, after a period as an employee with increasing salary (now only 2 years as opposed to three when I started), a buy in as a partner would occur, financed by the practice if that was their choosing, but that one had to put in time first, be productive or at least equally so, and go to work hard from day one.  We never added anyone after me unless the volume and the work were already there to support the addition.  It had been a winning formula for me. We thought it would be for everyone else.