As a part of my series about “The Future of Healthcare” I had the pleasure of interviewing Dr. Paul MacKoul, Laparoscopic GYN Surgeon and The Center for Innovative Gyn Care (CIGC) Co-Founder
Along with Natalya Danilyants, MD, Dr. MacKoul developed and perfected the DualPortGYN® and LAAM® fibroid removal for fertility techniques used at The Center for Innovative GYN Care. Paul MacKoul, MD is board certified in Gynecology and Gynecologic Oncology. As a leader in the field of laparoscopy, he has presented at major national meetings and been published in world-renowned medical journals. He is frequently sought as a medical expert on techniques for minimally invasive removal of non-cancerous, pre-cancerous, and cancerous tumors. He is a specialist in the treatment of gynecological cancers as well as benign conditions such as fibroids, ovarian masses, and endometriosis. Dr. MacKoul is Director of Gynecologic Laparoscopy at Holy Cross Hospital. He has also served as the Director of GYN Oncology at George Washington University Hospital and Washington Hospital Center as well as faculty at George Washington University Hospital. He was named a Center of Excellence in Minimally Invasive Gynecology Designated Surgeon in 2012. He has been named a Top Doctor multiple times by the Washingtonian Magazine as well as Northern Virginia Magazine. Dr. MacKoul graduated from Medical School at Tufts University, completed his residency in OB/GYN at the University of Maryland, and his fellowship in gynecologic oncology at the University of North Carolina.
Thank you so much for joining us! Can you tell us a story about what brought you to this specific career path?
In the U.S., the OBGYN generalist is the patient’s “go to” source for GYN surgery. It is understandable that a patient in the OBGYN’s practice, who has had deliveries for babies and office GYN care over many years, would believe that their OBGYN is also a skilled laparoscopic surgeon. That patient has built a “bond of trust” with their OB, and when surgery is needed, that trust translates into the same OB performing surgery. But is that OB really a surgical expert, and one that can provide the best possible care?
The field of Obstetrics & Gynecology is one of the most varied and disassociated in all of medicine. OBGYNs do obstetrics, office gynecology, surgery, as well as some fertility, oncology, and other subspecialties of the field. Regardless, the vast majority of the OBGYN’s work is in Obstetrics. OBGYNs are consumed with Obstetrics — their practice is centered around Labor and Delivery at the hospital, and the majority of their income is from Obstetrics work. So how does the OBGYN manage to train and develop as an expert in Gynecologic surgery? Simply stated, the OBGYN does not have the time, focus, patient volume, and training or financial incentive to become that expert. When you think about surgical specialties such as Orthopedics and others, the focus is 100% on surgery 100% of the time. This is not clinically or economically possible for the OBGYN. Despite this, 95% of patients requiring surgery have it performed by the OBGYN generalist, and for the above reasons the patients believe that their OBGYN is that surgical expert.
During my residency training, this problem became clear. Many OBGYNs, responsible for training me during my four years in a large University program, were having difficulty. A bladder was inadvertently injured — call the Urologist. The bowel was “stuck” to the uterus — call the General Surgeon. The patient had large fibroids and was bleeding during a myomectomy, or there was extensive Endometriosis making every pelvic organ including the uterus, tubes and ovaries adherent to each other — call the GYN Oncologist. GYN Oncologists had advanced training in GYN surgery for cancer and complex GYN conditions, and were the “surgical experts” of the field. The GYN Oncologist participation even extended into Obstetrics. Heavy bleeding during a complication with delivery also required a call to the GYN Oncologist. It was obvious that the GYN Oncologist was indeed the OBGYN’s surgeon, and was often “on call” for difficult cases that the OBGYN could not handle. As I began to see GYN Oncologists at work, I realized I had no choice but to try and become one of them. I focused the remainder of my residency on surgery as much as I could, and moved on toward a fellowship program in GYN Oncology. As a GYN Oncologist, Obstetrics is not part of the training program. The focus is entirely on surgery. For four years in OBGYN residency, I spent at least 75% of my time learning the field of Obstetrics, all of which was now discarded for a three year training program on the management of cancer patients and complex surgery. Now, as a GYN Oncologist, I am able to focus on GYN surgery 100% of the time, and have developed new techniques and procedures to advance the field of Minimally Invasive GYN Surgery to decrease complications and enhance recovery for patients.
Can you tell us about your “Big Idea That Might Change The World”?
It was clear that a change was necessary in the way patients underwent GYN surgery, and that change would require new techniques and procedures to allow for better outcomes, lower complications, and decreased cost. Laparoscopy, or minimally invasive GYN surgery, was the future, but there were definite problems with the way laparoscopy was being performed by the OBGYN. There appeared to be very few advances in the way the surgery was performed. In other words, the techniques and procedures were not changing as they were in other surgical specialties. There was a lack of “innovation” and application of any new techniques and procedures, but more an adoption of expensive “tools” to get the surgery done. The tools being used, such as robotics, would never allow for better surgical techniques, but would allow possibly more surgery to be performed at the expense of possibly higher complications and cost.
As an answer to this problem, I developed new approaches to minimally invasive GYN surgery by applying both known techniques performed in open surgery with new applications in laparoscopy to allow for a better way to perform hysterectomy, myomectomy, and other procedures to optimize outcomes for patients. These procedures had to be safe with much smaller incisions, with a procedural time that was much faster than the OBGYN approach, and resulted in better recovery times and lower cost. The procedures developed included DualPortGYN Hysterectomy and LAAM — Laparoscopic Assisted Abdominal Myomectomy.
It was necessary to publish the data, and prove that DualPortGYN Hysterectomy and LAAM approaches were superior to the standard and robotic procedures being performed for hysterectomy and myomectomy. A retrospective comparison trial of hospital based DualPortGYN Hysterectomy to robotic, open, and laparoscopic procedures in 3000 patients — the largest comparison study of its kind — revealed lower complications, smaller incisions, a faster recovery time, a cost savings of up to $5000 for this procedure. The same comparison for hospital based LAAM procedures revealed similar outcomes as compared to robotic, laparoscopic, and open procedures with a cost savings of up to $4000. This alone is a significant savings in the hospital setting, considering the number of hysterectomy and myomectomy procedures performed nationally in the U.S. The cost savings is in the hundreds of millions of dollars nationally. The same procedures were then performed in the Ambulatory Surgery Center (ASC) setting, and the data published. Comparison of DualPortGYN Hysterectomy and LAAM, ASC to hospital, showed no difference in surgical outcomes or in the profiles of patients performed at either site. This now proved that the same patients who had these procedures in the hospital can be done in the ASC, with the same clinical outcomes but with further cost savings.
To summarize, new techniques and procedures, or new procedural technology developed by CIGC proves that there is a better way to perform GYN surgery from both the clinical standpoint, as well as financial. DualPortGYN hysterectomy and LAAM procedures are safer, faster, and cheaper to perform in the outpatient ASC setting, and have higher patient satisfaction rates than any other type of hysterectomy or myomectomy nationally or internationally.
Was there a “tipping point” that led you to this idea? Can you tell us that story?
The introduction and adoption of robotic surgery by OBGYNs in the U.S. drove me to develop new and unique approaches to procedures that the OBGYNs were performing either open or robotically. I began to see the Davinci robot being applied to everything from hysterectomy, to myomectomy, to simple ovarian cyst removal. Every hospital for the most part has a Davinci robot, and GYN is their number one market for sales. The robot increases the time and cost of procedures, in an environment that is requiring and demanding value based care. The OBGYN sets the standard for surgical procedures in the U.S., and the robot is fast becoming the standard of care. This is great for Intuitive Surgical, the manufacturer of the robot, but maybe not so good for patients with known higher complications, and for cost control for insurers and hospitals. The problem is clearly understandable, as described above, in that the OBGYN generalist performs up to 90% of all GYN surgeries in the U.S., and their surgical training is such that a robot is needed to accomplish procedures in place of cheaper and more effective non robotic laparoscopic approaches that can accomplish the same result. The high volumes of laparoscopic procedures performed in the U.S. further exacerbates the financial impact of a more expensive robotic option being used for that surgical care.
It was necessary to develop new applications of existing technology with innovation to create a more effective, faster, option with lower complications, faster recovery and at a lower cost. Further, the techniques and procedures used had to be accessible to all patients, regardless of the size of the uterus or fibroids, and also had to be applicable to the outpatient ambulatory surgical setting. The ASC setting is the future for surgery in the U.S., and it is expected that more than 90% of all surgeries will be performed in the ASC by 2030. DualPortGYN Hysterectomy and LAAM — Laparoscopic Assisted Abdominal Myomectomy — are clearly the answer as shown by studies presented and accepted to peer reviewed journals. These papers support the superior outcomes and lower costs of these procedures in both the hospital and ambulatory surgery center setting.
What do you need to lead this idea to widespread adoption? How do you think this will change the world?
It all goes back to the beginning of this discussion, and training. Training is essential to develop laparoscopic surgeons that have the ability to perform DualPortGYN and LAAM procedures. Our direct experience is that even those MDs completing a MIS (minimally invasive surgical) fellowship program for GYN surgery are either not getting trained hands with the specialists and are not ready to operate autonomously, or are learning standard techniques and procedures similar to what they learned in residency, only at a higher volume. It is not the higher volume that will lead to success, it is the specific techniques and procedures learned that will allow that to happen. Even more concerning, and a significant barrier to learning DualPortGYN and LAAM procedures, is the use of robotics extensively in these MIS GYN training programs. It appears that these programs are an extension of residency, and not necessarily focusing on learning a new or better way to perform GYN surgery. Robotics is a hospital based approach to surgery. Learning robotics necessarily eliminates the outpatient surgical setting — the ASC — that provides a better and more cost effective way to deliver surgical care.
Expansion and development for better surgical care, specifically using DualPortGYN and LAAM approaches to surgery, requires extensive training, and a “paradigm” shift in the way GYN surgery is learned and mastered in the US. The Center for Innovative GYN Care will be expanding to the New York / New Jersey area in 2019, and will be bringing these procedural techniques to a second ambulatory surgery center in New Jersey, just outside New York City. Presently, many NY and NJ patients travel to Washington DC for their surgery. Development of new ASCs in this market and others will provide patients direct access to these successful surgical procedures, and will do so using their standard insurance. It is important that patients have this type of access without financial restriction. The recent growth of some laparoscopic specialists charging exorbitant sums, up to $20 to $30 thousand dollars for surgery, restricts access only to those who can pay. This type of financial constriction limits the ability of most patients from obtaining the best possible GYN surgical care.
It will be essential that GYN surgeons adopt this paradigm shift in surgical care — a new and better way of doing things — and move beyond the OBGYN training that has been the standard of care in the U.S. for decades. It is the goal of the practice, through training of surgeons and further development of ASCs in additional markets in the U.S., to spearhead this new and better way of doing GYN surgery. With this paradigm shift will come better clinical outcomes, decreased complications, higher patient satisfaction, and much lower costs — the true epitome of value based care for GYN surgery in the U.S. and the world.