Hugo D. Ribot Jr., MD, FACOG, is an obstetrician and gynecologist in Cartersville, Georgia, a suburb of Atlanta. Born in Buenos Aires, Argentina, he grew up in the Bahamas. After earning his bachelors degree from Dartmouth College, Dr. Ribot attended medical school at the University of Miami School of Medicine and completed his residency at Emory University. He was Emory’s first recipient of the annual American Association of Gynecologic Laparoscopists resident award in advanced laparoscopic gynecology. In his medical community, he was the first to perform total laparoscopic hysterectomy, laparoscopic removal of ectopic pregnancy, and laparoscopic bladder suspension and pelvic floor reconstruction. Most recently, he was the first to perform the TVT procedure for minimally invasive treatment of urinary incontinence. In 2006 he became the first gynecologic surgeon in the state of Georgia to routinely perform outpatient total laparoscopic hysterectomy, which does not require an overnight stay in the hospital. Dr. Ribot also became the first surgeon in Georgia to demonstrate the feasibility of performing endometrial ablation for the treatment of abnormal uterine bleeding in an office setting, providing women with a non-lifestyle-disrupting alternative to hysterectomy. He is now involved in training other physicians in this procedure.
Dr. Ribot also has been active in his community, serving on the board of the local battered women’s shelter and the local chamber of commerce. He is also the Chairman of the Department of Ob/Gyn at Cartersville Medical Center.
Uterus1: Why did you become an obstetrician/gynecologist?
Dr. Ribot: As far back as I can remember I have wanted to be a doctor. There is a lot of opportunity to help people. The field of ob/gyn offers a little bit of everything. We provide primary care to a lot of women so we get to see patients for a long period of time. We get to know them and their families and see them through many of their life events. One aspect I was drawn to was that the majority of problems that we see and treat are fixable. Even a lot of cancers in this area can be detected early so we can cure the patient and that is very satisfying. A lot of nonmalignant problems, such as pelvic prolapse and excessive bleeding, we can fix, making a big difference in a woman’s life. Obstetrics is a whole different world and to be privileged to share in a pregnancy and birth is always extremely rewarding. Since 99 percent of deliveries turn out just fine, it is a very happy field. In the past 10 years, there have been an incredible number of innovations so we’ve been able to help women get back to doing what they want to do without disrupting their busy lives any more than necessary.
Uterus1: Who are your patients?
Dr. Ribot: I see a wide range of patients. This is a fairly diverse community about 40 minutes outside of Atlanta. I have patients who are highly educated with graduate degrees and patients who are the poorest illegal immigrants. Many of my patients are increasingly educated and savvy about vaccines and procedures that could impact them. The more patients educate themselves, the better, but we don’t discriminate. I treat everyone as an individual and explain things in a way that anyone could understand. Although some patients will say, “You’re the doctor, tell me what you think is best,” most patients are capable of taking an active role in selecting the best option for them. There is no such thing as one treatment fits all. What’s right for one patient could be the wrong choice for someone else. It depends on their lifestyle, family, views on preserving their uterus and much more. I try to understand each patient’s needs and desired results.
This practice has never developed a formal, serious marketing program. Our business has developed by word of mouth. Once women (and referring physicians) started to realize which doctors in the community were capable of doing minimally invasive procedures, they started coming to us and referring their friends and family to us.
Uterus1: What are the most common questions you get from your patients?
Dr. Ribot: They ask about the minimally invasive procedures and how they work. We are fortunate in that we have a wonderful rate of patient retention. So, when a patient keeps coming back, you build a long-term relationship with her. That promotes a lot of trust. It’s amazing that some doctors just don’t get this. If you sit down and explain things to a patient, even brand new patients you’ve never met before, most will understand. Even things that seem outlandish, such as doing endometrial ablation in the office, if you explain how you go about doing this and why it is safe, most patients will accept it and trust you. If the patient has a positive experience, she will go out and tell others about it. It is dismaying, however, when you get a patient who says she has been going to a gynecologist for 10 to 15 years but has never had anything explained to her. Doctors can be their own worst enemy. Something as simple as making sure the patient’s questions are answered makes a big difference in their overall experience.
Uterus1: Why is it considered safe to perform laparoscopic hysterectomies and other laparoscopic procedures in an outpatient setting?
Dr. Ribot: One of our very prominent and well-known gynecologists, Barbara Levy, published a paper highlighting the feasibility of developing a protocol of vaginal hysterectomy and going home the same day. About 60 to 70 percent of doctors perform hysterectomies through large abdominal incisions. That is associated with fairly significant post-operative pain and discomfort. Pain and nausea from anesthesia are the main things keeping patients in the hospital. Dr. Levy’s protocol involves pre-emptive management of both nausea and pain. Patients are given patches similar to those worn for seasickness the night before surgery and medications that pre-emptively treat pain. We also use a numbing block before the procedure. All of these measures dramatically reduce pain. The patient experiences nowhere near the degree of pain that comes with traditional hysterectomy. Ninety percent or more of these patients have been able to go home four hours after surgery. When the numbing block wears off, the pain is nowhere near what it would be if the patient woke up without having had it. When you pre-emptively treat surgical pain like this there is almost no need for injectable pain medication for about 24 hours.
Uterus1: How did you feel after your first outpatient laparoscopic procedures last year?
Dr. Ribot: I felt relieved that the patients did well. Then I felt that there was a world opening up as far as what you can and cannot do. Less than one percent of doctors are doing this. A lot of what doctors do is based on what they were taught rather than evidence-based medicine. We used to keep C-section patients in the hospital for almost a week. There is nothing unsafe about sending them home within 48 hours. For minimally invasive procedures, we don’t make a big incision and we don’t disturb the bowels. If the doctor is careful, this surgery isn’t associated with a lot of blood loss or other problems.
After every delivery, we used to draw a blood count to check hemoglobin. But, very few patients had low enough hemoglobin requiring a blood transfusion so we abandoned the practice. A lot of things like that doctors are taught and do routinely but there is no compelling reason to keep doing them as far as patient safety and outcomes are concerned. I am trying to help patients and reduce the amount of poking and prodding we do.
Uterus1: Is it important to you to be a progressive, cutting-edge physician?
Dr. Ribot: Yes. That has been an overriding theme ever since I finished my residency training. In the late 1980s, another resident and I started doing advanced laparoscopic surgeries. At that time, most doctors were only using laparoscopy to peek inside the abdomen, maybe clip the fallopian tubes, and see what was wrong to plan for a later surgery. We quickly realized the potential. We were doing things even our own professors weren’t capable of doing, such as completely treating ectopic pregnancies through a laparoscope. Patients could go home with a couple small bandages the same day rather than open surgery and the associated discomfort and recovery time.
That made me want to always be on the lookout for the very latest minimally invasive procedures that could safely be offered to patients. My partner and I realized long ago that we didn’t have to be in the back of the pack – we could be the leaders of the pack. We did our first laparoscopic hysterectomies 13 years ago. It’s sad that the majority of doctors aren’t doing it even now. That led me to always be reading the medical literature, particularly the European literature. Surgically, Europeans do a lot of “firsts” and then pioneering doctors in the United States pick up the techniques.
Uterus1: How do you balance learning new techniques with your patient volume?
Dr. Ribot: It’s not easy. Our practice has expanded dramatically but we have three midwives and three physicians so that helps with handling the increasing patient load. It’s tough because having a packed schedule four or five days a week leaves only one day for surgery, so I’m booked several months in advance. We have become more efficient about surgical care and successfully brought several procedures into the office. For about 90 percent of procedures that used to require an overnight stay, the patient now can go home. That frees up a lot of time since I don’t have to check on them the next morning at the hospital. And, we don’t have to use anesthesia for some procedures. That is opening up more time. Also, we are in the process of developing a freestanding ambulatory surgical center in our office building, so that will mean even more procedures can be done away from the hospital.
Uterus1: How can more doctors be trained to do minimally invasive surgery?
Dr. Ribot: We hope to be more involved in training once we have our own surgery center. The greatest advances in minimally invasive medicine have occurred not in academic settings but in private practice. That includes new instruments and laparoscopic techniques. Few physicians graduating from ob/gyn residency programs have adequate surgical training, especially laparoscopy. When we were recruiting a new physician last year, I don’t know how many resumes I sifted through to find a doctor with an interest and experience in laparoscopy. It took a year and a half to find someone.
A lot of faculty members are only two to five years out of their residency. They aren’t particularly well trained in advanced techniques. The quality and availability of advanced surgical training in most programs is suboptimal. The American Association of Gynecologic Laparoscopists has certified several minimally invasive surgery fellowships but that doesn’t even come close to addressing the need to have enough doctors out in the community. So, we are going to try to develop relationships with the four residency training programs in the state of Georgia. When new doctors are doing their gynecological clerkship and learning surgery, hopefully they can do a rotation with us. Hands on is the only way. You can’t just go to a weekend course and learn to properly do these procedures on patients.
Uterus1: How do you feel about the technological advances you’ve seen during your career?
Dr. Ribot: I don’t think anybody ever imagined that we could do almost every single procedure that gynecologists do in a minimally invasive fashion. In my 16-year span as a doctor, I’ve gone from almost everything requiring abdominal surgery and a significant recovery time to less than one percent requiring these things. There is no reason to believe that that will not continue.