Sponsored by

AAGLAdvancing Minimally Invasive Gynecology Worldwide

Honorary Address:

Everything You Learned in Residency

Will Turn Out to Be Wrong

HONORARY CHAIR

William H. Parker, M.D.

Professional Education Information   Target Audience Educational activities are developed to meet the needs of surgical gynecologists in practice and in training, as well as, other allied healthcare professionals in the field of gynecology.  Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.  The AAGL designates this live activity for a maximum of .25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.   DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS As  a  provider  accredited  by  the Accreditation  Council  for  Continuing Medical  Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification  of  CME  needs,  determination  of  educational  objectives,  selection  and  presentation  of content,  selection  of  all  persons  and  organizations  that will  be  in  a  position  to  control  the  content, selection  of  educational methods,  and  evaluation  of  the  activity.  Course  chairs,  planning  committee members,  presenters,  authors, moderators,  panel members,  and  others  in  a  position  to  control  the content of this activity are required to disclose relevant financial relationships with commercial interests related  to  the subject matter of  this educational activity. Learners are able  to assess  the potential  for commercial  bias  in  information  when  complete  disclosure,  resolution  of  conflicts  of  interest,  and acknowledgment of  commercial  support are provided prior  to  the activity.  Informed  learners are  the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME.   

Table of Contents 

 Course Description ........................................................................................................................................ 1  Disclosure ...................................................................................................................................................... 2  Everything You Learned in Residency Will Turn Out to Be Wrong W.H. Parker  .................................................................................................................................................. 3  Cultural and Linguistics Competency  ......................................................................................................... 12  

 

 

HONORARY ADDRESS

Everything You Learned in Residency Will Turn Out to Be Wrong

Honorary Chair: William H. Parker, M.D. Santa Monica, California

Address Description Medicine is continually changing and much of what you learn now will eventually be seen as incomplete, irrelevant or proven wrong. The moral imperative to give our patients the best care requires us to keep up. Constantly staying current with new developments is one of the most challenging, yet satisfying, aspects of being a physician. Networks encourage new ideas and out-of-the-box thinking. The AAGL, which includes nearly five thousand members from 90 countries, provides us a network to help foster the interchange of new ideas about minimally invasive treatments for women. As the first organization to understand and embrace the phenomenal potential of minimally invasive surgery, the AAGL continues to provide an academic and clinical arena of learning for practicing gynecologists. We look to the new generation of members further consider and expand the intent of “Minimally Invasive” so that we can provide the best, least invasive, care possible. Dr. William H. Parker is a Clinical Professor at UCLA School of Medicine and in private practice in Santa Monica, California. He is the former Chair of Obstetrics and Gynecology at Santa Monica-UCLA Medical Center and also at Saint John’s Health Center. Dr. Parker is a Past-President of the AAGL and was an editor of The Journal of Minimally Invasive Gynecology. Bill has more than 50 published articles in the areas of uterine fibroids, abdominal and laparoscopic myomectomy, laparoscopic ovarian cyst surgery, ovarian conservation and prevention of surgical errors using cognitive science and aviation safety principles. Bill is also the author of the acclaimed women's health book, A Gynecologist's Second Opinion – The Questions and Answers You Need to Take Charge of Your Health. He has been selected for Best Doctors in America and Top Doctors every year since 2000. Bill and his wonderful wife Rachel have three sons, Aaron, Evan and Brian.

Learning Objectives At the conclusion of this activity, the participant will be able to: 1) Recognize that medicine is continually changing; 2) identify mentors and colleagues who help provide avenues for intellectual and personal growth; 3) recognize cognitive barriers to good judgment in patient care; and 4) formulate minimally invasive options for patient care.

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PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop and have no conflict of interest to disclose (in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* Viviane F. Connor Consultant: Conceptus Incorporated Frank D. Loffer, Executive Vice President/Medical Director, AAGL* Linda Michels, Executive Director, AAGL* Jonathan Solnik Other:  Lecturer ‐ Olympus, Lecturer ‐ Karl Storz Endoscopy‐America  SCIENTIFIC PROGRAM COMMITTEE Arnold P. Advincula Consultant: CooperSurgical, Ethicon Women's Health & Urology, Intuitve Surgical Other: Royalties ‐ CooperSurgical Linda Bradley Grants/Research Support: Elsevier Consultant: Bayer Healthcare Corp., Conceptus Incorporated, Ferring Pharmaceuticals Speaker's Bureau: Bayer Healthcare Corp., Conceptus Incorporated, Ferring Pharm Keith Isaacson Consultant: Karl Storz Endoscopy Rosanne M. Kho Other: Honorarium ‐ Ethicon Endo‐Surgery C.Y. Liu* Javier Magrina* Ceana H. Nezhat Consultant: Intuitve Surgical, Lumenis, Karl Storz Endoscopy‐America Speaker's Bureau: Conceptus Incorporated, Ethicon Women's Health & Urology William H. Parker Grants/Research Support: Ethicon Women's Health & Urology Consultant: Ethicon Women's Health & Urology Craig J. Sobolewski Consultant: Covidien, CareFusion, TransEnterix Stock Shareholder: TransEnterix Speaker's Bureau: Covidien, Abbott Laboratories Other: Proctor ‐ Intuitve Surgical  FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the “best available evidence” from medical literature (in alphabetical order by last name). William H. Parker 

Grants/Research Support: Ethicon Women's Health & Urology 

Consultant: Ethicon Women's Health & Urology 

 

Asterisk (*) denotes no financial relationships to disclose. 

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Everything You Learned in Your Residency

Will Turn Out to be Wrong

William H. ParkerUCLA School of Medicine

Grants/Research Support: Ethicon Women's Health & Urology

Consultant: Ethicon Women's Health & Urology

Disclosure

Urology

Review the current condition of MIS.

Objective Current Condition of MIS

Good

Not Good

Not Good Enough

Paraphrasing – Martin Seligman – psychologist, TED talks

“GOOD”

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Good – Explosion in Information Perception

People see things

differently

We will get back to

“Good”

D i M di i

“Not Good”

Dogma in Medicine1978

Dogma in Gynecology

Postmenopausal Ovarian Cyst = TAH-BSO

2012 ObservationLaparoscopic Ovarian Cystectomy

4

1978Growing Fibroids (premenopausal) = Sarcoma

Dogma in Gynecology

TAH-BSO

2012 Observation

If Hysterectomy indicated

+ Oophorectomy

Dogma in Gynecology

~ 1978 - all Women >40 ~ 1985 - all Women >45~ 2000 - all Women >50

2012 - Maybe Never?

Fibroids & Infertility -1978 Mechanical blockage Poorly vascularized endometrium Act like an IUD Subacute endometritis

Dogma in Gynecology

2012 - HOXA 10

2020 epigenetic changes environmental factors molecular interactions

17 years for new

Medical AdvancementsNot Good

medical information to enter community practice

“Not Good Enough”Not Good Enough

Minimally Invasive Surgery

Patient (Customer) wants:Not see a doctor

The Job of Medicine

EVER

If sick:Treatment

Least invasiveLeast time consuming Least bothersome

High rate of successClayton Christensen, The Innovator's Dilemma

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Breast Cancer SurgeryRadical Mastectomy

Modified radicalSimple

Lumpectomy & Lymphadenectomy

Lumpectomy, Sentinel node MIS

NOT Hysterectomy Heavy Menstrual Bleeding

OCP Lysteda

Mirena

Minimally InvaSive

Mirena Ablation

Pelvic Pain Multi-disciplinary approach

Fibroids Myomectomy UAE ? MgFUS

Minimally InvaSive Minimally InvaSive

Minimally InvaSive Minimally InvaSive

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Count Hysterectomies # TAH, VH, LH

# Operative laparoscopy Ovarian cystectomy, endo, ectopics, tubal ligations,

Resident Review Committee

# Laparotomy Ectopic, myomectomy, ovarian cystectomy

Why don’t they count # hysterectomies avoided??

LNG-IUS, Ablation, Myomectomy, Tranexamic acid, etc

PredictionRobotic Surgery will increase

hysterectomy rate Less TAH - good

Minimally InvaSive

More Hysterectomies - Bad

Start with a small uterus – NO Simulator

What is Right for the Patient

MIS - Redefined

Not what is Right or Easier for the Doctor

Back to

“GOOD”

Classical : Great Individuals with Great Ideas . . .

Now : Many minds contribute to a

Good – Collective Intelligence

river of innovation

Collisions - different fields of expertise converge in some shared physical or intellectual space

That’s where the true sparks fly……

Where Good Ideas Come From - Steven Johnson

Welcome to the AAGL

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Created outside the box Open to anyone with an idea

% Abstracts accepted

AAGL - Innovative

Open to destructive technologies Hysteroscopy, laparoscopy, ….

We are not your Daddy’s ACOG

AAGL - Trailblazers

AAGL - Innovators AAGL - Educators

AAGL - Leaders

“serve women by advancing the

safest and most efficacious di ti d th ti t h i

AAGL Mission

diagnostic and therapeutic techniques that afford less invasive treatments for gynecologic conditions”

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“dedicated to the advancement of women’s health and the professionalism and socioeconomic

ACOG - Mission

and the professionalism and socioeconomic interests of its members…”

ACOG will not lead these changes, they follow

First Operative Laparoscopy Lectures - 2000

Young - don’t know dogma

that’s why they invent more

AAGL - Creativity

Old - find new challenges, think like the young

Creativity — a state of mind

< 1 ten-trillionth of electromagnetic spectrum visible to usUmwelt – perception limited by what we can experience

detects a shockingly small fraction of reality unobtainable information, unimagined possibilities Consider :

Human Brain

criticisms of policy assertions of dogma declarations of fact

Imagine the proper intellectual humility that comes from appreciating the amount unknown

David Egelman.This Will Make You Smarter

Requires simplification

New Understanding of Human Brain

We are limited by the science of our time

The student needs to learn what is known

The teacher needs to be clear about what is not known

Learning and Teaching

not known

9

The plural of anecdote is not data

The plural of opinion is not facts

Not Knowing

The plural of opinion is not facts

In the Future What we learn this week will seem medieval

Humility

Put people in a sterile room Put them to sleep,Cut them open Remove body parts Recovery - weeks

But, the challenges to our patients will remain the same

What is the goal of your job

Financial Challenges

What is the goal of your job What do patients want?

Restore health

Not $$$$

Helping Others

Predicting Happiness

We get this opportunity every day

How lucky are we?

Close Relationships and Family….

Be kind to us as we get old

Suggestions for the Young AAGL

but, do not let us get in the way

10

Keep Learning Find Mentors Keep an Open Mind

C id N P di

Your Responsibility – Get to “Good”

Consider New Paradigms Don’t be complacent with what you know today

It won’t serve you for long

Do not let technology seduce you away from simple innovation

Checklists, Time-outs, Patient safety

Challenge

Patient Care, Patient Relationships

Consider Least Invasive Treatments

Make healthcare for women better

We challenge you to be better than usWe challenge you to look at things in new ways

Challenge

We want you to be better than us, correct our mistakes

Lastly

Hold your own beliefs a bit more humbly,

i th h k l d th t b tt id in the happy knowledge that better ideas

are almost certainly on the way

Thank YouKathryn Schulz, This will make you smarter

Clayton Christensen.The Innovator's Dilemma. Harvard Business Review Press.1997

Steven Johnson. Where Good Ideas Come From. Riverhead Hardcover. 2010

References

David Egelman. This Will Make You Smarter: New Scientific Concepts to Improve Your Thinking. Ed-John Brockman. Harper Perennial. 2012

Kathryn Schulz.This Will Make You Smarter. Egelman.This Will Make You Smarter: New Scientific Concepts to Improve Your Thinking. Ed-John Brockman. Harper Perennial. 2012

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CULTURAL AND LINGUISTIC COMPETENCY Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as

the AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians

(researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which

recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP).

California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws

identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at http://www.imq.org

Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from

discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national

origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the

program, the importance of the services, and the resources available to the recipient, including the mix of oral

and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm.

Executive Order 13166,”Improving Access to Services for Persons with Limited English

Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies,

including those which provide federal financial assistance, to examine the services they provide, identify any

need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access.

Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every

California state agency which either provides information to, or has contact with, the public to provide bilingual

interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population.

~

If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills.

A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.

US Population

Language Spoken at Home

English

Spanish

AsianOther

Indo-Euro

California

Language Spoken at Home

Spanish

English

OtherAsianIndo-Euro

19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%

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