Uterus1: Did you know before you got to medical school that you wanted to be a surgeon, or was a decision made along the way?
Dr. Krotec: That was definitely a decision made along the way. My dad was a general practitioner and I always wanted to do primary care like he did, but also to have a hands-on type of practice. When I got to medical school, I found I enjoyed surgery and I had good hands for doing the things that surgeons do. I really wanted to do more - to give surgical care instead of just general care, and OBGYN was the one field where I could be a primary care physician – as we’re considered to be by most organizations – while still being a surgeon. I’m not just a referral type of person who gets his patients from an internist or general practitioner and just does surgery. I made my decision on my OB/GYN rotation as a student and decided that’s what I wanted to do because it offered me the chance to do both.
Uterus1: People who come from highly specialized fields often say they miss that more generalized, hands-on component, where there is a view of the whole history of a patient, and then there are people on the other side who have gone into general practice, and say that what they miss is the opportunity to delve deeper into one particular area. It seems that obstetrics and gynecology is one of those areas where you really do get to do both.
Dr. Krotec: Yes. These days, there is the general practitioner, the internist, and then you have your referrals – orthopedists, neurologists, oncologists and so on. General surgeons don’t do any primary care whatsoever, and in the more urban area where I work, you never see the specialists, any of them besides OB/GYNs, do any primary care in addition to their specialty.
Uterus1: And when do you think that transition took place between OB/GYN being thought of as general or primary care versus a specialty?
Dr. Krotec: Well, years ago even my dad did obstetrics and gynecology, though he was a general practitioner. Obstetrics and then gynecology became a specialty over the years. I think it’s been a constant transition. It was like a sine wave, where at the top you have the general practitioners doing everything; then it came back to where you have everyone doing their separate specialties,; and now it’s come down the other way to the OB/GYN being a general practitioner.
Uterus1: Do you get the sense that changing perspectives about women’s health in politics had any influence on that change, where perhaps women wanted it to be more specialized because they were feeling they’d been neglected by the medical profession at certain times?
Dr. Krotec: I definitely think it did and I feel it still does. As a matter of fact, one of the biggest disappointments in my career is that I have not yet seen women’s health get the attention from the government, from insurers, even from the medical profession that it deserves. If you look at specialties where men are the primary participants – orthopedics, the sports medicine boom, cardiology, urology as it is connected to prostate cancer – there are literally billions of dollars being thrown into these things, and insurance payments are relatively high. Most of the hospitals in our area are advertising orthopedics and cardiac care because that is what brings in the funding, and women’s specialties traditionally get less. Part what the American College of Obstetrics and Gynecology has been doing is becoming become more active and more vocal. This has worked to get some significant recognition for OB/GYN’s as primary care providers so that women do not have to go through any other doctor to get to us. I think that women have seen themselves as different and needing more specialized care, and in some ways this care has become more available to them as we have become more available as primary care providers.
Uterus1: In terms of keeping the field evolving and growing, what is your greatest contribution to your research?
Dr. Krotec: I think that my greatest contribution is my ability to teach and to help people understand different and less invasive approaches to women’s healthcare problems. I was instrumental in developing one of the second-generation endometrial ablation technologies, the Hydro ThermAblator®. I was an investigator in phase II and phase III of the study, and I have been involved in the continuing evolution of the procedure.
I’ve done some other teaching for laparoscopic or endoscopic work. ACOG uses my videotapes and teaching procedures. I also think my ability to teach residents and other physicians to abandon their long-head beliefs that "to cut is to cure" – that if a woman has, for example, endometrial bleeding, that if it doesn’t stop with birth control pills the next step is not necessarily hysterectomy or that if there’s a cyst on the ovary a huge incision is not the only way to take it out – is another contribution. Hopefully, besides being able to use these procedures in my own practice, I have been able to spread this knowledge and these technologies and the confidence in these procedures, and now young and old physicians alike are much more comfortable using these newer, less invasive, more modern techniques. They’re saving women major surgery with all the associated problems: side effects, risk factors and with post-op care. Women don’t have to miss days of work now, and they don’t have to lie around for six weeks post-hysterectomy, but instead can get back to work in a day or two.
Uterus1: The transition from inpatient to outpatient procedures in women’s health care seems to be a huge stepping-stone in innovative treatment techniques.
Dr. Krotec: Yes, and fortunately, I came along at the right time, having finished my residency in 1980. Obstetricians and gynecologists were the only ones using endoscopy at the time, for minor things like tubal ligation, which used to be done as an open surgery with an incision in a woman’s abdomen. She would have to spend a couple of days in the hospital. That changed the thinking about those kinds of surgeries. Then as technology developed, OB/GYNs started doing more things through the laparoscope, which evolved from the hysteroscope, and then it moved on from gynecologists who taught general surgeons how to do laparoscopy. Now of course surgeons are doing whole ranges of procedures with endoscopic surgery.
Uterus1: You say the trend began with laparoscopy and hysteroscopy, in particular. Were there important baby steps in the field of hysteroscopy that you can describe for us?
Dr. Krotec: Hysteroscopy has been around for years, but the biggest problem there was instrumentation. It was used exclusively for diagnostic procedures; a patient would be bleeding or would have symptoms and a doctor would just sort of look in there with this crude scope. But the hysteroscope, because of the size of the cervix, has to be much smaller than the laparoscope. A laparoscope was between ten and twelve millimeters, but a hysteroscope, even the first one, was five millimeters. Finding the light sources and optics that would allow us to see was a real challenge.
As hysteroscopy evolved, in the mid-eighties, doctors out of Detroit started passing a laser fiber through the scope to treat pathology. Now we’re using tools that allow you to actually remove fibroid tumors in the uterus, going in through only a slightly dilated cervix, with the patient under local anesthesia and some minimal pain medication. We can remove growths that once required hysterectomy. These advances in technology into the nineties and up through the present mean that we can now, in a space of fifteen or twenty minutes, help women avoid major surgery and go back to work the next day – it’s amazing.
Uterus1: Let’s turn to what’s new and what’s on the horizon in your field. What do you see as important trends that are starting to effect the community?
Dr. Krotec: For things on the horizon, I think the biggest are improvements in technology. In GYN technology specifically, I think there are several things. One is the advance in non-invasive diagnosis and for treatment.
For instance, we’re getting a 3D ultrasound machine into our office for trials. It’s a three-dimensional image, and you can rotate it. If I’m looking at a uterus and I say, "You know, you’ve had a miscarriage, and I don’t know why." Instead of doing an invasive procedure to figure that out, this 3D ultrasound machine would allow me to twist the image around as though I have it in my hand, and say "Ah-ha: there’s a little dent here, I can see a thickening in the middle and it looks like there’s a septum, so let’s go in and do a hysteroscopy and cut that away." I could do this instead of doing an operative procedure when I might not have had to because I didn’t know what was there. So this looks to be a very wonderful technology to help us improve our diagnostic ability for a multitude ofconditions.
There’s also a color Doppler with ultrasound, which gives us the ability to follow flow, and see where, for example, there’s torsion of the ovary or there’s not enough blood flow and tissue may become gangrenous and die, whereas we couldn’t tell these things before. It’s saving the patient another risk and giving us more data instead us of blindly going into the patient.
And as the technology improves, the safety improves. I remember one of the first procedures I was working on back in the eighties; it was a laparoscopy, and for some reason the woman had adhesions, very bad adhesions, and we were just going along with this very crude instrumentation. The optics at that point made it like looking into a room with the lights turned off at midnight, with a firefly floating around to light your way.
Other changes are in medications that treat very specific problems. These medications can treat fibroids, endometriosis and other common surgical conditions without surgery. I see great strides in this field also in the next decades.
Uterus1: It sounds like the goal is to increase safety while also decreasing patient suffering.
Dr. Krotec: Exactly - and to be able to treat a specific problem in a very specific way from the improved technology.
Uterus1: Are there questions patients should be asking, or treatment philosophies they should be looking for?
Dr. Krotec: That is perhaps the most difficult one to answer, and I think that this applies not just to medicine but also to education and to life in general. The most important thing patients can look for in a physician is someone willing to spend time and listen to them. You would be amazed at how often, if you actually spend the time to listen to what a patient is saying, they will make a diagnosis for you. The doctors that take the time to listen and to spend the time with patients are the doctors who are going to get to the bottom of things and make accurate diagnoses. They’re going to treat those problems for the patient in the quickest and simplest way possible.
In my office, we set one hour aside for a patient’s first appointment, and that’s almost unheard of. So don’t go to an office where they tell you the doctor has 50 appointments a day or they schedule 4 to 8 patients an hour. Ask the office how much time they allot for a visit. An office that devotes time to appointments and sees maybe ten or fifteen patients a day will give you the attention you need, and not use testing resources that may not even be needed. That’s one thing.
I think another important thing is to find someone who will offer alternative treatments and not be dogmatic about how conditions are treated. Patients have to be made a part of that process, just as they may help you make the diagnosis. Doctors need to be able to look at a patient and tailor the treatment to that patient’s lifestyle – their family, their work situation, their fears, their expectations. That’s very important.
Uterus1: Would you say that in your practice, teaching, and research, you generally favor methods that involve dialogue?
Dr. Krotec: Yes, exactly: an ongoing dialogue, which allows discussion, an opportunity to find the best option for care, which is why another thing I’d add to what people should look for is someone in a teaching situation; a physician who has access to other experts in other fields. It’s a good way to be sure that people are keeping up on the newest treatments available. Also, the organizations that doctors are a part of ensure that they are still actively involved – I’m involved in ACOG and AAGL, for example, and this ensures that I keep reading the research and stay up-to-date.
Uterus1: Are there any final thoughts you would like to share with our readers?
Dr. Krotec: Well, one thing that’s great about what’s happening now is that women are becoming more vocal, and as I mentioned, the American College of Obstetrics and Gynecology has become more vocal as a spokes-organization for women. ACOG is lobbying for better coverage for women.
Hopefully because of things like this interview, and because of sites like Uterus1, women will be encouraged to start demanding better care for themselves because now they see it as a possibility. Our continual striving to develop more comfortable, less invasive treatments which allow women to get back to their normal lives, back to family, back to work, are the sort of accomplishments that I hope to have underscored. I think a lot of people, even very well-educated people who just happen to be outside of the field of medicine, aren’t aware of the newest technologies. Access to the information will allow women to make more empowered decisions about their lives, and that is a real highlight.
Dr. Krotec's practice can be found on the Web at http://www.ccivf.com.
Last updated: 04-Jun-04