progress in ob gyn 2019...progress in ob gyn 2019 james w. orr, jr. m.d. facog, facs medical...

2/25/2019

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James W. Orr, Jr. M.D. FACOG, FACSMedical Director

Florida Gynecologic Oncology

Regional Cancer Center

Past Chair, Florida Board of Medicine

Fort Myers

THE EVOLUTION OF SURGERY:A journey of opportunity,

invention and quality!

PROGRESS IN OB GYN2019





Fort Myers

Nothing to disclose!


ObjectivesA “whirlwind” tour of major historical events that shaped

surgery as we know it!

Fundamental prerequisites:1) Anatomy 2) Hemostasis3) Anesthesia/analgesia4) Antisepsis and aseptic technique5) “Instrumentation”

Evolution of Surgery

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41,000BC

1 BC

40,0000 BCNeanderthal cave drawings, stone figures

of the human body

37,000 BC1st depiction of

female genitalia

1800 BC

Kahun Papyrus:

Women’s diseases

3500 BC

The wheel :

Mesopotamia (Iraq)

2560 BCThe Great Pyramid at

Giza completed

Kahun Gynecological PapyrusEgypt 1800 BC

Discovered 1889

• Oldest known medical text.

• 34 sections, addressing specific problems.

• Addressed women's health:

fertility, pregnancy, contraception.

• Diagnosis and non-surgical treatment.

• Symptoms/Diagnosis/Treatment approach

• PROGNOSIS was not addressed!

• Egyptian written level of knowledge of medicine

surpassed that of Hippocrates (1,400 years later).

Page1&2

1800 BC

1700 BC

1750 BC

Code of Hammurabi:

Medical rules of operation

(Babylon)

1800 BCBronze metalworking: Europe

( Middle East -3000 B.C.)

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Code of HammurabiMedical laws and ethics of Babylon (1700 BC)

• 282 laws, dealing with all aspect of public life,

citizen's rights and limits the Babylon Kingdome's justice

system.

• Represents the initial INTERFACE BETWEEN MEDICINE AND LAW .

• In principle, the human body represents a forbidden existence in nature, saved and protected against violation which may endanger life.

• Allows violating the body integrity in treatment and surgery by CONSENT, on condition that this interference in the human body is limited specifically to those cases that would benefit HEALTH.

Code of HammurabiMedical laws and ethics of Babylon (1700 BC)

• 282 laws, dealing with all aspect of public life, citizen's

rights and limits and the Babylon Kingdome's justice

system.

• Described a SCALED FEE SCHEDULE for surgical services, LINKED TO THE OUTCOME* of the surgery with severe penalties if expectations not met!

• Required documentation of diseases and therapies, included PRESCRIPTION BENEFITS.

• The code fully explained PATIENT RIGHTS.• Surgical care was authoritarian; there were possibility of

LEGAL ACTIONS to insure justice and equity particular to each social class.

*3700 years prior to NSQIP

1650 BC1st reference to suture material;

Edwin Smith Papyrus (Egypt)1700 BC

1 BC

1500 BC1st reference to “adhesive” tape

(Egypt) [1960 1st micro pore tape]

1000 BCFirst “skin” staples: Decapitated Ants!

[Modern staple use 1960s]

250 BC

1st recorded references to nursing as a

profession (India)

400 BC

HIPPOCRATES: operative techniques

-PATIENT POSITIONING -LIGHTING

980 BCAlbucasis used hot iron to

stop bleeding [1854: Middeldorpf describes galvanocautery]

776 BC

753 BC Rome founded

50 BCPhoebe, (Romans 16:1),

1st “Christian” nurse

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Hippocrates (460-375 BC) *

• "Father of Western Medicine”• Under his influence medicine became a “profession”!• 1st to believe that diseases were caused naturally, not

related to superstition and gods.• Hippocratic medicine was humble and passive and the

therapeutic approach was based in "the healing power” of nature.

• CRISIS, a point in the progression of disease at which either the illness would progress and the patient would succumb to death, or the opposite would occur and natural processes would “allow” the patient to recover.

*2

30 1st reference to vessel ligation:

Soft and not over twisted (Aulus Cornelius Celsus: Rome)

1 AD

1200

33 AD Christianity

793Vikings raid

Ireland

550 Persians use windmills

to power irrigation pumps

1099The first crusade captures

Jerusalem

• Treatise On Medicine (De Medicina). • 1 – The History of Medicine (references 80 medical authors)

• 2 – General Pathology• 3 – Specific Diseases• 4 – Parts of the Body• 5 & 6 – Pharmacology• 7 – Surgery• 8 – Orthopedics

• Theory to medical practice and pros and cons of animal & human experimentation.

• Credited with recording the cardinal signs of inflammation: "Celsus tetrad": calor (warmth), dolor (pain), tumor (swelling) and rubor

(redness and hyperemia).

• Celsus who translated the Greek term CARCINOS (used by

Hippocrates meaning crab or crayfish, to refer to malignant tumors) into the Latin cancer, also meaning crab.

Aulus Cornelius Celsus* (25 BC – 50 AD)

*Roman encyclopedist? physician

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1 AD

200 AD

30 1st reference to vessel ligation: Soft and not

over twisted (Aulus Cornelius Celsus: Rome )

33 AD Christianity

100

Soranus: Described the uterus (human dissection):

- Packed the uterus for hemorrhage - Performed hysterectomy for prolapse

150

Anatomic detail vessel origin, incision placement

Galen (Greek in Rome) *14

175 Tendon repair with silk (Gladiators)

1st reference to catgut (Galen)

200SURGERY SEPARATES

FROM MEDICINE

200 AD

793Vikings raid

Ireland

1-500 ADNursing care palliative needs of persons

and families. Religious organizations were the care providers !

1175

Intestinal suturing over a hollow tube Warmed exposed intestine: covered with

the viscera of a dying animal. Primitive MURPHY BUTTON (1903) !

(Roger of Palermo)

1099The first crusade captures

Jerusalem

1200 AD

910

Rhazes (Persia)

- Urine analysis

- Identifies smallpox,

- Suggests blood as the cause of infectious disease

(900 years prior to Lister, Semmelweiss, Pasteur, Koch)

Murphy’s Anastomosis Button: 1903

two bowls inserted into the lumen of the intestine and clipped together, making an inverted anastomosis.

End to End anastomosis, EEA 1978

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1320

SEVEN BOOKS OF SURGERY Arterial vessel control;

Jehan Yperman (1st Flemish medical writer)

1200

1600

1215

England's King John signs Magna Carta No freeman shall be taken, imprisoned,...or in any other way destroyed...except by the lawful

judgment of his peers, or by the law of the land. To no one will we sell, to none will we deny or

delay, right or justice.

1300-

1600

Renaissance:

cultural bridge between the Middle Ages and modern history

1455Gutenberg

PRINTING PRESS

1348Bubonic Plague kills

75 million in Europe

Jehan Yperman (1260-1331 AD)

• Flemish surgeon and the first Dutch medical writer.

• Realized the “lowly” status of surgery during late medieval time.

• Advocated that surgeons know nature, philosophy and ethics and have “good behavior”. (Origin of Disruptive behavior)

• Raised the level of surgery based on reason and experience in an effort to take medicine out of the hands of barbers and “ignorant practitioners”.

1380 Arterial vessel control; SEVEN BOOKS OF SURGERY Jehan Yperman (1st Dutch medical writter)

1300

1600

1400

Honey & wound edge eversion

Chirugia Magna (Guy de Chaulic)

1530

Pare:

Control of hemorrhage (cautery renounced in favor of ligatures)

- Cervix amputation

1543

Andreas Vesalius: Detailed description of

anatomy. -Hands on education.

1348Bubonic Plague kills

75 million in Europe

1431Joan of Arc burned at

the stake

1455Gutenberg

PRINTING PRESS

1492 COLUMBUS

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Andreas Vesalius (1514-1564) *Father of human anatomy (Dutch)

• 1543: De humini corporus fabrica, a fully illustrated book on human anatomy body, based on observations from dissections (many animal), over turning misconceptions that had persisted for >1000 years (Galen).

• Book 1: The Bones and Cartilages*2: The Ligaments and Muscles3: The Veins and Arteries4: The Nerves*5: The Organs of Nutrition and Generation6: The Heart and Associated Organs*7: The Brain* *#6

1540

1600

1545 Pare: “clean” care of

traumatic wounds

1597A Discourse of the Whole Art of Chirurgery

1st English Surgical text (Peter Lowe)

1546

Verona theorized that small germs cause contagious

diseases (>300 years prior to

Semmelweis, Lister and Pasteur)

1592 Galileo: 1st thermometer

1541John Knox leads Reformation in

Scotland

1588 Defeat of the Spanish Armada

1628 William Harvey: Circulatory system

An Anatomical Study of the Motion of the Heart and of the Blood in Animals

1600

1750

1633Daughters of Charity of Saint

Vincent de Paul: Servants of the Sick Poor

1736 1st appendectomy: (Amyand’s

hernia [R inguinal hernia])

U.S. Population: 5,700


1730 1st small bowel resection for

gangrenous bowel (Ramdohr: 1 year survivor!!)

1607 Jamestown settlement

1743 Jefferson’s birthday

1645French nurse Jeanne Mance

established North America's 1st

hospital Hôtel-Dieu de Montréal.

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1750

1810

1807 Repair of enterotomy;

Samuel White


U.S. Population: 5.3 million

1809 REMOVAL OVARIAN CYST:

E. MCDOWELL

17941st successful Cesarean

section in U.S. (J. Bennett: section or craniotomy)

1750Benjamin Franklin:

Silver coil catheter (brother and himself)

1776Declaration of Independence

Ephraim McDowell (1771-1830)

• Father of abdominal surgery!• Studied in Scotland and Virginia:

never received a degree.• 1809: 1st successful removal of an ovarian tumor (Danville, Ky)

• Performed without anesthetic or antisepsis. • Tumor weighed 22.5 pounds (10.2 kg). • Operative time 25 mins!• His report: "scrupulously clean“ technique, removal of

blood from the peritoneal cavity and “bathing” the intestines with warm water.

• Uncomplicated recovery ……..Mrs. Crawford lived another 32 years.

1813 Phillip Physick (Penn) : “Father of American Surgery” demonstrates Nasogastric tube

1810

1825

1818 1st transfusion of human blood for post partum hemorrhage

(James Blundell; London)

1821

Ovariotomy: pedicle “dropped” back into the

abdomen (Nathan Smith: Yale)

1824 1st attempt to remove a

cancerous uterus via the vagina: unsuccessful!

1815 Napoleon Waterloo

1819UVA chartered

Alabama Statehood

U.S. Population: 12.3 million

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1826 1st U.S. Gynecologic Text: (William Dewees: U Penn)

1825

1842

1828 1st ligation of

internal iliac artery: (Samuel White)

1826

-1st Creation of colocutaneous fistula

(Physick)

-Lembert describes his serosal suture

technique (as a resident!)

1842 Anesthesia (Crawford Long)

U.S. Population: 17 million

1831Nat Turner’s

rebellion

Crawford Long (1815 – 1878)

• Cousin of famed gambler John Henry "Doc" Holliday!

• Performed his first surgical procedure using SULFURIC ETHER on March 30, 1842, removing a neck tumor from a young man. Later used it in his obstetrical practice.

• Never published his findings!!!• Six years later (1846), William Morton, unaware of

Long's prior work, administered ether anesthesia before a medical audience at MGH.

1842

1850

1843

1st hysterectomy: Clay (England)

1st successful BILATERAL oophorectomy in US

John Altee (Pennsylvania)

1847 AMA Founded

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1851 Puerperal Infection (Semmelweiss)

1850

1868


1863 Battle of Gettysburg

1865 Lincoln assassinated

1858 1st transatlantic cable

1851 Florence Nightingale

completes her nursing training

Ignaz Semmelweis (1818-1865 *)

• Hungarian physician:“SAVIOR OF MOTHERS”.• As an assistant (“Chief resident”) in the

maternity clinic in Vienna, he introduced HAND WASHING with chlorinated lime solutions for interns who had performed autopsies.

• Immediate reduction of the incidence of fatal puerperal fever from ~ 10 % (range 5–30%) to <2%.

• The concept of “cleanliness”, was considered extreme and was ignored, rejected and ridiculed, dismissed and harassed by the medical community in Vienna, which eventually forced him to move to Budapest. LATER COMMITTED!

*3

1851 Puerperal Infection

(Semmelweiss)

1850

1868

1852 Fistula repair

(J. Marion Sims)


1863 Battle of Gettysburg

1865 Lincoln assassinated

1858 1st transatlantic cable

1853 Florence Nightengale

Crimean War

1851

Florence Nightingale completes her nursing

training

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J Marion Sims (1813 – 1883)

• “Father of modern gynecology" • Repair of vesico-vaginal fistula,

"catastrophic complication of childbirth”!• Silver-wire sutures led to successful repair of a fistula,

after multiple procedures (30)!!!• He founded the Woman's Hospital (1855), later to be

named St. Luke's-Roosevelt Hospital Center and established America's first cancer institute, New York Cancer Hospital in 1871 (MSKCC).

• Hero or Villain?


(Semmelweiss)

1850

1868

1852 Fistula repair

(J. Marion Sims)

1863 1st American woman to

specialize in pelvic surgery (Mary Harris Thompson)

1858 Needle/Suture

wrapped “skewers” (Goffres)


1857

Pasteur: the growth of micro-organisms was responsible for spoiling beverages and cause disease!(900 years after Rhazes)

1853 1st successful TAH (Burnham)

1861-65American

Civil War

1854

Middeldorpf electrical current in surgical

operations ("galvanocautery")

(850 years after Albucasis)

1851

Florence Nightingale

completes her nursing training

U.S. Women in Medicine

• 1849: Elizabeth Blackwell: 1st woman to obtain a medical degree in the U.S..

(Geneva Medical College)

• 1855: Mary Edwards Walker: 1st U.S. female surgeon: Civil War, Medal of Honor. (Syracuse Medical College)

• 1863: Mary Harris Thompson: 1st American woman to specialize in pelvic surgery. Chicago Hospital for Women and Children!

(New England Female Medical College/Chicago)

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• 1864: Rebecca Lee Crumpler: 1st black woman to earn a medical degree (New England Female Medical College)

54,543 physicians in the United States, 300 of whom were women. None of them were African

American women!!


• 1889: Susan La Flesche Picotte MD: 1st Native American woman to become a physician in the U.S.(Women's Medical College of Pennsylvania)

• 1947: Gerti Cori MD: 1st woman to win Nobel peace prize in physiology and medicine.


Journal of Medical Regulation 2017

30%

47%

0.8%/year

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(Semmelweiss)

1850

1868

1852 Fistula repair

(J. Marion Sims)

1863

1st American woman to specialize in pelvic surgery (Mary Harris Thompson)

1858 Needle/Suture

wrapped “skewers” (Goffres)


1867 LISTER: Carbolic acid antisepsis

1857

Pasteur: the growth of micro-organisms was responsible for spoiling beverages and cause disease!

1853 1st successful TAH (Burnham)

1861-65American

Civil War

Joseph Lister: (1827 – 1912)

• British surgeon: “Father of antiseptic surgery"• Applied Pasteur's principles in microbiology,

introducing carbolic acid (phenol) to sterilize surgical instruments and clean wounds, reducing post-operative infections.

• Lister promoted the antiseptic system by stressing ‘principles’ and ‘professionalism’ and ‘performance’ (soaking surgical sponges and bandages in a solution of carbolic acid, spraying a

wound with an antiseptic solution during surgery, washing surgical instruments, rinsing hands before beginning an operation, and wearing appropriate surgical gowns).

• Procedural changes confusing, use of carbolic area was unpleasant, not easily reproduced and “germ theory” was certainly not accepted by all!

“Mister”*4(Orthopedic injuries)

1869Cesarean Hysterectomy: 3 day

survival!! (Horatio Storer)

1868

1881

1877 P. Bozzini: electro-cauterization

1879Gastrectomy for

cancer (Pean)U.S. Population: 50.1 million

1881 1st successful

gastrectomy for cancer (Billroth I)

1869Suture

antisepsis (Lister)

1881 Garfield assassinated

1881 Clara Barton becomes

the first president of the American Red Cross

1879

Mary Eliza Mahoney 1st African American

nurse in the U.S.

1868 14th Amendment

1871 Life expectance 43 years

1877 1st resection for rectal cancer (Von Volkman)

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1881

1890

1883

-1st successful operation for ectopic pregnancy:

mortality rate 90% to 4% (Tait)

- EDISON INVENTS LIGHTBULB

18881st HYSTERECTOMY

FOR FIBROIDS (Mary Jane Dixon)

1882

Koch's postulates

“microorganisms cause disease”

1886 Statue of Liberty is dedicated

Hysterectomy: Historical “Highlights”

HYSTERECTOMIES WERE PERFORMED SPORADICALLY AND ONLY FOR UTERINE PROLAPSE OR UTERINE INVERSION.

HOWEVER, URINARY INJURY WAS COMMON & PATIENTS RARELY SURVIVED.

120 ADSoranus (Greece) removed an inverted gangrenous uterus

50 BC1st reference to vaginal

hysterectomy Themison of Athens.

1000

Alsaharavius (Arabic physician) “if the uterus had

prolapsed externally and could not be reinserted, it should be

surgically excised”.

1507

1st authenticated vaginal hysterectomy performed by

the Italian anatomist Berengario da Carpi of

Bologna


• 1670: One of the first reported successful vaginal hysterectomies was self-performed.

Faith Haworth, a 46-year-old peasant suffered a complete uterine prolapse while carrying a heavy loadFrustrated by this frequent occurrence, she grabbed her uterus and amputated it with a short knife.

She survived for a decade, with a persistent vesico-vaginal fistula.

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1829

1st “successful” vaginal hysterectomy for cervical cancer.

(Joseph Récamier)

With deliberate ligature of the uterine arteries and broad ligaments. Operative time: 20 minutes.

Death due to recurrent disease!

1813

Conrad Lagenbeck of Gottingen performed the 1st

planned vaginal hysterectomy (reported 1817).

1843

Charles Clay performed the 1st

recorded abdominal (subtotal) hysterectomy in Manchester,

England. (postoperative hemorrhage and death)

Hysterectomy: Historical “highlights”

• 1853: Walter Burnham performed the 1st successful abdominal hysterectomy, in Lowell, Mass, by accident! (12/15 (80%) subsequent patients died)

• 1868: 1st Cesarean hysterectomy in US (Storer, Boston for “perfectly frightful” hemorrhage)

• 1872: Due to high mortality rate Abdominal hysterectomy was “formally condemned” by the Academy of Medicine in Paris.

• 1895: Clark and Rumpf performed “extended hysterectomy” and pelvic lymphadenectomy (Hopkins).

Hysterectomy: Historical “highlights”

1902Schauta performed radical

vaginal hysterectomy

1898Wertheim devised extended

hysterectomy and lymphadenectomy

1929

Richardson (U.S.) performed the 1st total abdominal

hysterectomy, recommended cervix excision, to avoid

cervical stump carcinoma.

1948Brunschwig reports “ultra radical” salvage surgery

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1890 Halsted1st to wear rubber gloves

1890

1896


1890Catgut

available

1891James Naismith invents

basketball.

1890

National American Woman Suffrage

Association (NAWSA) is founded,

“In the winter of 1889 and 1890—I cannot recall the month—the nurse in charge of my operating-room (Caroline Hampton) complained that the solutions of mercuric chloride produced a dermatitis of her arms and hands. As she was an unusually efficient woman, I gave the matter my consideration and one day in New York requested the Goodyear Rubber Company to make as an experiment two pair of thin rubber gloves with gauntlets.

On trial these proved to be so satisfactory that additional gloves were ordered. In the autumn, on my return to town, an assistant who passed the instruments and threaded the needles was also provided with rubber gloves to wear at the operations. At first the operator wore them only when exploratory incisions into joints were made.

After a time the assistants became so accustomed to working in gloves that they also wore them as operators and would remark that they seemed to be less expert with the bare hands than with the gloved hands”.

1890

1897

1891 Halsted: Radical mastectomy

1894 1st survival after

perforated appendix (Richard Hall)

1892 Silver wire readily available


1895

- Xrays discovered (Roentgen)

- 1st extended hysterectomy (Clark)

- Mackenrodt describes pelvic connective tissue

- Surgical mask – (Mikulicz-Radecki)

I Olympiad 1896

1890National American Woman

Suffrage Association (NAWSA) is founded,

1897The American Nurses

Association holds initial meeting

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1898 Operative Gynecology (Kelly)

1898

1912

1900 Pfannenstiel incision

19011st abdominal

“oscopy”


1900Uterine

hyperplasia (Cullen) 1902

Suture sterilization; Iodine


1903 Wright brothers 1st flight

1898 Spanish-American War: USS Maine

We have come a long way…….1901: Dimitri Ott, wore head mirrors to reflect light and

augment visualization and used a speculum in the a posterior fornix incision as access in a pregnant woman (Petrograd gynecologist)

1901: Kelling, described “coelioscopy,” filling the abdomen of a living dog with air and inserted a Nitze cystoscope to inspect the viscera using high pressure insufflation (German surgeon)

1910

1982

1910H.C. Jacobaeus: published description of peritoneal, pleural and pericardial cavity!

1911Bertram M. Bernheim (John Hopkins Hospital)

introduced diagnostic laparoscopic surgery in US

1918 O. Goetze: pneumoperitoneum needle

1920 Zollikofer (Switzerland) CO2

1934John C. Ruddock (Internist) : DIAGNOSTIC

LAPAROSCOPY, SUPERIOR TO LAPAROTOMY. 1938 Janos Veress (Hungary)

1944Raoul Palmer, (Paris) gynecologic

laparoscopy, Trendelenburg position

1953-9Rigid rod lens system: Hopkins (UK

physicist) Stortz acquires the patient

Laparoscopy: we have come a long way…….

1960Semm, (German gynecologist) :automatic insufflator

Steptoe (British Gynecologist ):sterilization technique

1982Clarke: laparoscopic suturing technique.

1st computer chip camera - Circon

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1898 Operative Gynecology (Kelly)1898

1912

1900 Pfannenstiel incision

1908

Stapler used for gastric and intestinal surgery

(Humor Hultl) 8#: 2 hours to assemble

(US Surgical 1964)

19011st abdominal “oscopy” (Ott)


1912 Basset describes Radical Vulvectomy

1900Uterine

hyperplasia (Cullen)

1902Suture

sterilization; Iodine

1911

1st Department of Urology

Bellevue


1913American College of Surgeons:

1st convocation

1912

1937

19161st Subspecialty Boards

Ophthalmology

1930American Board of

Obstetrics and Gynecology

1928PAPANICOLAOU’S

REPORT


1937- American Board of Surgery

- Catgut suture material

19131st EKG Chicago

Presbyterian

1929Penicillin

Fleming


1925Cushing & BovieElectrosurgery

1935 Foley catheter

1914-18 WW I

1933 Electron Microscope (Ruska)

1947Introduction of polyamide

Nylon

1947

1969

1953Obstetrics & Gynecology

(Green Journal)

1969SGO!

- Polypropolene

1948-Exenterative surgery

-Palliative care Cicely Saunders

1958 Mersilene (cerclage)


1968 TPN (Rhoads & Dudrick)

1953 Polio Vaccine (Salk)

1969 ARPAnet

1950Columbia : 1st

MSN

1964 Nurse Training Act

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1969

1979

1974 Polyglycolic Acid suture (Vicryl)

1976 Polyester suture (Ethibon)


1977Sentinel Node 1st reported (Penis)

1st Whole body MRI (Damadian)

1973 Computed Tomography (Cormack & Hounsfield)

1972Gynecologic

Oncology

1969 ARPAnet

1979 1st Nursing PhD (Case Western)

1980

1995


1980

Bayh–Dole Act or Patent and Trademark Law Amendments

Act

COI

• Ownership of inventions supported with federal funding

• Business interests influence the direction of cancer research and the adoption of new practices in therapy (Guidelines, CME)

• University projects which receive industry funding are more likely to produce research outcomes which favor their funders

• Pharmaceutical and medical device industry sponsored studies are more often favorable to the sponsor's product compared with studies with other sources of sponsorship

• “Funders” seek and court scientists to author papers and lend their person reputations to add credibility to research findings

• $13-18 meals influence prescribing habits

1982

- Polytetrafluoroethylene (PTEE suture)

- Polydioxanone Sulfate (PDS)

- 1st Lymphoscintigraphy

- 1st video camera chip!!!

1982

1995

1986-1st LSC cholecystectomy

-1st LSC hysterectomy (Reich)

1993Poliglecaprone 25

(Monocryl)

1992-1st LSC Radical hysterectomy

-SNL vulva (Barton)

1985- PET scan

- Polybutester (Novafil)


1994Polygloconate

(Maxon)

19931st use of

Morcellator!(FDA Advisory 2014)

1990BRCA 1

Mary-Claire King

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1996

2012

2000 HUMAN GENOME PROJECT

1996

EVIDENCE BASED MEDICINE(Sackett)

The conscientious and judicious integration of clinical expertise,

patient values, and the best evidence into the decision making

process for patient care.

1997FDA approves

daVinci

2001

CROSSING THE QUALITY CHASM: IOM

- ERAS

2010 Affordable Care Act

2006HPV

vaccine

2012Uterus

transplant

1998Herceptin approved:

“Targeted therapy”

2004NSQIP

“Outcomes based”

Where are we going????

Single site vs. Multiple?

Role of Mesh?

Transplant?

Sentinel node vs. Lymphadenectomy?

Cost?

Quality?

Doubled from 100 B.C. to 1700 (1800 years).Doubled from 1700-1900 (200 years).Doubled from 1900-1950 (50 years).Doubled from 1950-1970 (20 years).Doubled from 1970-1980 (10 years).Doubled from 1980-1988 (8 years).

Now doubles every 12 months.Soon it will double every 12 hours.

Knowledge

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“I think the biggest problem with healthcare today is not its cost or technology– which is a big problem – but for all that

money, it’s not an expression of our humanity.”

Jonathan Bush – CEO, athena health





Fort Myers

THE EVOLUTION OF SURGERY:A journey of opportunity,

invention and quality!


progress in ob gyn 2019...progress in ob gyn 2019 james w. orr, jr. m.d. facog, facs medical...

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