Dr John Short. Obstetrician and Gynaecologist Christchurch Women s Hospital Oxford Women's Health Christchurch
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1 Dr John Short Obstetrician and Gynaecologist Christchurch Women s Hospital Oxford Women's Health Christchurch 16:30-17:30 WS #125: Everything GPs Should Know About Gynaecologists 17:35-18:30 WS #135: Everything GPs Should Know About Gynaecologists(Repeated)
2 Everything GPs should know about Gynaecologists John Short Obstetrician and Gynaecologist Oxford Women s Health Christchurch
3 What is this about???
4 What is this about? Personality profiles Impact on practice The problems with gynaecology The Bleeding Edge
5 The average junior doctor
6 The average junior doctor Novelty Seeking: Harm Avoidance: Reward Dependence: Persistence:
7 The average junior doctor Novelty Seeking: low average Harm Avoidance: Reward Dependence: Persistence:
8 The average junior doctor Novelty Seeking: low average Harm Avoidance: low average Reward Dependence: Persistence:
9 The average junior doctor Novelty Seeking: low average Harm Avoidance: low average Reward Dependence: low Persistence:
10 The average junior doctor Novelty Seeking: low average Harm Avoidance: low average Reward Dependence: low Persistence: high
11 The average junior doctor Detached Determined Slightly Orderly Slightly Optimistic Slightly responsible Slightly helpful Slightly Altruistic
12 What about specialties?
13 What about specialties? ED Paediatrics Gen Med Psychiatry Gen Surg
14 What about specialties? Investigative Commanding Rescuers Dependable Compassionate
15 ED? Investigative Commanding Rescuers Dependable Compassionate
16 ED? Investigative Commanding Rescuers Dependable Compassionate
17 Paediatrics? Investigative Commanding Rescuers Dependable Compassionate
18 Paediatrics? Investigative Commanding Rescuers Dependable Compassionate
19 Gen Med? Investigative Commanding Rescuers Dependable Compassionate
20 Gen Med? Investigative Commanding Rescuers Dependable Compassionate
21 Psychiatry? Investigative Commanding Rescuers Dependable Compassionate
22 Psychiatry? Investigative Commanding Rescuers Dependable Compassionate
23 Gen Surg? Investigative Commanding Rescuers Dependable Compassionate
24 Gen Surg? Investigative Commanding Rescuers Dependable Compassionate
25 What about GPs? Investigative Commanding Rescuers Dependable Compassionate
26 What about Rural GPs? Investigative Commanding Rescuers passionate, thriving on novelty and unpredictable situations, persistent and co-operative Dependable Compassionate
27 GPs
28 GPs Rural GPs higher in novelty seeking, lower in harm avoidance
29 GPs Rural GPs higher in novelty seeking, lower in harm avoidance (curious, impulsive, enthusiastic/optimistic, outgoing, confident)
30 GPs Females higher in reward dependence and co-operativeness
31 GPs Females higher in reward dependence and co-operativeness (warm, dedicated/tolerant, empathic, constructive, principled)
32 GPs Older lower in reward dependence
33 GPs Older lower in reward dependence (practical, detached, independent)
34 What about OBGyn? Investigative Commanding Rescuers Dependable Compassionate
35 What about OBGyn? Investigative Commanding Rescuers Dependable Compassionate reliable, warmly supportive, nurturing, conscientious, highly co-operative, persistent, self directed
36 What about subspecialties Obstetrics vs Gynaecology Fetal Medicine Fertility Oncology Urogynaecology (Laparoscopic)
37 The 4 tendencies Upholder Questioner Obliger Rebel
38 Obliger Do things for others Can get overwhelmed and rebel (GretchenRubin.com) (happiercast.com/quiz)
39 Dependable Obliging
40 The problems with Gynaecology
41 The problems with Gynaecology Obstetrics Radiology The HDC The media
42 Why Obstetrics? Risky High expectations Leads to Risk-aversion More intervention, eg caesarean section
43 In Gynaecology fear of missing something
44 Groupthink
45 Groupthink Team meetings Guidelines Pathways One size fits all
46 In Gynaecology fear of missing something More investigation, eg ultrasound scans More diagnosis, eg polyps, cysts More Treatment, eg hysteroscopy and laparoscopy
47 Dependable Obliging Don t want to miss anything
48 VOMIT Victims Of Medical Imaging Technology
49 polyps Significance not clear 1% malignant or pre-malignant Possibly cause symptoms
50 polyps Ultrasound prediction v poor Hysteroscopy clinic population (mostly symptomatic bleeding problems) PPV 0.45 NPV 0.94 Incidence 14% (0% malignancy)
51 PMB- PPV 0.61 HMB- PPV 0.31
52 Hysterectomy for prolapse
53 Hysterectomy for prolapse 69 cases 10 with polyps (14.5%) All Benign All asymptomatic
54 Scan exercises
55 Clinical indications: Menorrhagia Age 53?endometrial thickness Findings: Uterus: anteverted, bulky 81x49x62mm. Volume 128cc Myometrium: heterogenous. 12mm ca++ within the fibroid There is a 53x43x44mm, volume 52ml posterior, submucosal fibroid Endometrium: Normal: proliferative. No focal abnormality or abnormal vascularity. Thickness 10mm Cervix: 6x9x7mm polyp Right ovary: 19x19x13mm. Normal Left ovary: 17 x 22 x 21 mm. normal Conclusion: Normal Endometrial Thickness. A cervical polyp is noted. Gynaecology review is recommended
56 Case 1 Postmenopausal Annual routine checkup) Bulky uterus with USS findings recommending gynae opinion USS- uterus 59x29x41mm 3x fibroids- largest 14mm Endometrium 6mm
57 Case 2 49yo Pelvic pain Worse with full bladder, eases when emptied
58 USS suggests cervical polyp Had hysteroscopy 3x polyps. Benign appearance + asymptomatic Returning for polypectomies
59 Case 3 Request for advice 45 yo, USS (TA, TV declined) done for?appendicitis concludes endometrium appears a little echogenic and focal within the body. A polyp is possible. A follow up scan should be considered. Patient asymptomatic. Is any action required?
60 Other info in scan report: (full report not in letter) endometrium 17mm Other patient info in letter: BMI 56, Diabetes
61 Referred 12 months later- 12 months heavy bleeding
62 Pipelle- complex hyperplasia with atypia Hysteroscopy- endometrial ca Hysterectomy- grade 1 stage 1a Might have been suitable for mirena
63 The bleeding edge documentary film that investigates the $400 billion medical device industry
64 Devices highlighted Essure Metal-on-metal hip prostheses Vaginal Mesh Robotic hysterectomy CT scan
65 Devices highlighted Essure Vaginal Mesh Robotic hysterectomy Other things mentioned including morcellation of fibroids
66 What is it about Gynaecology?
67 Essure Hysteroscopic sterilisation Metal coils placed in fallopian tubes Opportunity to avoid GA, abdominal surgery Possible outpatient procedure Problems with failure, migration, difficult removals, subsequent hysterectomies Withdrawn from NZ
68 Robotic hysterectomy Minimally invasive Quicker recovery Limited training High rate of vaginal dehiscence (Increased rate of vesicovaginal fistula) No proven advantage over vaginal or laparoscopic hysterectomy Greater expense
69 morcellation Facilitated laparoscopic removal of large fibroids 3/1000 fibroids malignant Difficult to diagnose pre-op Risk of tumour dissemination with morcellator
70 Vaginal mesh Disappointing results from traditional prolapse surgery Less invasive that traditional incontinence surgery Significant complications from transvaginal mesh for prolapse Relates to quantity of mesh in contact with vagina, route of placement (transobturator vs retropubic / abdominal vs vaginal), experience of surgeon.
71 over-use Poor training / technique Inexperienced surgeons Transvaginal mesh for prolapse no longer available in NZ Mesh slings for incontinence still available Mesh for transabdominal/laparoscopic surgery still available
72 The media No differentiation between different types of mesh All deemed bad No success stories- all bad news Advocates produce anecdote, medical societies produce data Science by press conference
73
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