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Training the Next Generation of Endometriosis Physicians - Michael Lewis, MD

Training the Next Generation of Endometriosis Physicians - Michael Lewis, MD
Endometriosis 2023:
Global Patient Symposium
Together for Tomorrow
March 18-19, 2023 - Einhorn Auditorium, Lenox Hill Hospital, NYC

All right. Good morning. I hit the green button in order to advance. Right. Okay. The importance of training the next generation of endometriosis surgeons, this is usually a talk that I have with my residents and my students, usually not to, uh, families or patients. Um, but this is something that obviously is very important because I think patients need to understand more the importance behind education, teaching, and mentorship. And so one thing actually that just happened this past Friday was resident match day. So all, all across the US there were all the specialties. Everyone, the fourth year medical students found out where they would be matching. So our institution had our match, and we successfully matched four residents. Um, four categoricals and one prelim meet. Pretty much five residents are gonna be starting July 1st. So yesterday was a great day, and this was across the country. So again, the next bunch of residents to join us and to also be a ta a challenge in terms of educating them. And also I just want to thank Dr. Sk, uh, Kyla Mayer and Dr. Haas for inviting me. I think it's been a couple years since I was here last, but, uh, I'm so sorry. Yeah,

Sorry to interrupt.

I forgot to make an, an important announcement that we are not breaking into a breakout room. Um, we are gonna do all of the talks here, um, today. So it is on the schedule for everyone to go to a breakout room right now, but we've decided to keep all of our speakers in this room and we'll plan to break for lunch at 1230. Sorry, Dr. Lewis to interrupt. No worries. Okay,

So just a disclosure, I'm a speaker for AbbVie Pharmaceuticals, and so why is this such a important topic? I already saw a bunch of the hands go up in terms of patients here and people who've had surgery, but I dunno if any of you guys remember, you know, prior to going to the operating room, had you ever been approached by a resident or a medical student prior to going to the operating room? Any of you? Right. And so a little bit of anxiety that would come about, like, well, where's my surgeon? How come my surgeons and talk to me about the procedure and going their consent? Or what if a medical student came into the room first and wanted to gather some information? And it is so important that we start from the beginning. You know, we have both undergraduates, medical students, and of course our residents who are going through their training. And I always end up hearing some noise before I go into the examination room. Where is it, Dr. Lewis, or where's it, where is my doctor? It's so important to just allow them to start, allow them to try to speak with you. And hopefully when I go through these slides, I'll try to explain a little bit more about what is made up of all the teaching to our residents.

And so also, this is what's really important to me. Uh, do I have a pointer around here?

Yeah. So this one, this one, this one. Those are my three. The other two are my nieces. And we got another three more nieces. I only, there's only girls in our family. And of course the anxiety behind this is that I'm worried that one of them will have endometriosis. My oldest one who's 10, I know her period is gonna come at any moment. And I am anxious that she will have pain, you know, and my middle one will constantly, you know, cause I bring home work and I'm doing presentations just like this one they see. And she's always asking me, well, I guess dad, you're a teacher as well. And how important it is to teach not only my kids and my, I mean, my children know everything there is about endometriosis, fibroids. They've seen pictures, they can explain it to all their friends. So of course I'm very proud of them. But again, this is also what has become important. Not, I mean, before I was interested in endometriosis, I didn't have children, but now I see again, also what's pushing me more and more to help educate, not just those of my patients that are in their teen years and their adolescents, but really the younger ones.

And so let's go through some of the numbers just to understand how many, I guess, residents are, are across the country. And just like what we had match day, there's just over, just under like 6,000 residents across the US and through that, you know, the residency, what it is. So I'll back up a little bit. You have, in terms of what are, what is the training that is needed in order to make a, you know, a physician? And so they could do undergraduate, right? So that may be four years. The residency training is also about four years. And then they have the choice of whether or not to go onto a fellowship. That fellowship would be sort of a subspecialty, or they would specialize in whether it is minimally invasive surgery, oncology, reproductive endocrinology, urogynecology, oncology. So they have that choice afterwards. So it, it ends and fellowship arrange anywhere from one to three years.

So you're looking at least, you know, in terms of that initial training, about 13 years, which as I'll show you some, some residents at the end of their training, they don't have that interest in going into endometriosis training or they may not have any interest in anything at all. Just doing basics, obstetrics and gynecology. And what I have to remind you is also it's again, the residency training is obstetrics and gynecology. So they focus on obstetrics and they focus on gynecology. And in regards to the fellowship training, there's about 60 programs in us. There's some in Canada as well. Um, two major organizations that are out there in terms of the fellowship training is A G L, which has over 50. And on also the Society of Laparoscopic Surgeons, which Dr. Serkin also has a fellowship in which he trains, uh, one of the graduates as well. And, but with that also, there's only, what they say is about a hundred surgeons who specialize in endometriosis across the us. So, you know, we are good looking at, yep. You can ask the question, what's

The difference between residency

And fellowship, right? So the residency is the four years where they're learning obstetrics and gynecology. Okay? They're already in md. Once they get their md they go into residency training. So they do those four years. And then once the four years are finished, then they have that ability or choice whether or not they can, we would wanna subspecialize. So for instance, I did my residency obstetric gynecology, then I fellowship in minimally invasive GYN surgery. So again, that's not all residents will go onto that. Majority don't. There's 23,000 practicing OB GYNs in the us And like when you look at the numbers in terms of how many are treating endometriosis, it's very scary. It's so small. And so I was thinking about, okay, well what are the, the main issues that are affecting our training of our residents? And why are they not all experts in endometriosis training?

And so I say I, I try to pick just several problems to keep it simple, but the three were time and time, meaning that the time the actual resident gets to spend with an endometriosis surgeon, or even just in the operating room doing gynecologic surgery, the interests that they have or that they actually will develop during their residency training to not only diagnose and then refer if they, if they don't have that proper training, at least be able to say, that is endometriosis and I'm gonna refer you to a specialist. But that interest in terms of going forward once they finish residency training, am I gonna learn more about it? And then also in terms of compensation, we hate to talk about it, but you know, residents, when they come out and they graduate and they're finishing, they're gonna be getting a job. If they're not doing fellowship, they don't know where they're gonna go into private practice or work for an academic institution. And that plays a difference in terms of what some of their priorities are gonna be. Most of 'em come out with over a quarter million dollars in debt. Yes.

Um, um, medical, do you, uh, feel strongly about MPHs in any,

I don't wanna say anything like, I, I'm not gonna say that, oh, you should be doing an MPH in order to fulfill yourself. But I think, I think that probably what are the gonna be the advantages of doing an MPH prior to going to medical school? It help you besides learning about the disease in terms of how you can apply that globally or nationally to help other patients. But I don't think just in terms of from the education perspective, from the residency, um, that is gonna make any impact in terms of what will go forward. You know, I think it's gonna be once you finish your residency training, you know, are you gonna want to do, um, outreach? Are you gonna want to travel to help educate more about endometriosis? So I don't, I don't know if that'll be much of an impact in terms of your actual surgical treatment for it.

And so how do we climb this mountain? How do the, the, you know, prospective residents and the a, these medical students will then get to the top. And we always compare it to a mountain. This is actually one of my third year residents, Kiara, who rock climbs on our weekends. And, you know, it is a challenge because at every step, you know, residency training, even though now they're, they're blocked at almost like they have to be working less than 80 hours per week. But we used to be working about 110, 120 hours a week. Um, it is a challenge at each step in terms of besides undergraduate medical school residency training, uh, and at each point they sort of wanna slow down and decide whether or not is, you know, what are they gonna do next? What's their specialty, what's their interest?

And when I look at residency training, and I used to be the associate program director and program director for my residents, what does that really mean? It just means I was in charge of the education, the curriculum for the residents, and I was looking at, for our residents, we would only do maybe about, because there is a large curriculum in terms of everything you need to know about obstetrics and gynecology and all the subspecialties, there was probably only about one to two lectures on whether it was endometriosis or pelvic pain per year. Okay. And again, going back to that four years of training within that four years, again, it's split between the obstetrics part of the training and the gynecology. We also have the specialty of oncology, reproductive, reproductive, endocrinology, urogynecology. So they're actual, when I look back at our old calendars and try to break it down in terms of how many weeks our residents get in GYN surgery, looking at how many weeks that most of the patients with, or most of the residents will get with me during an endometriosis surgery is maybe about 20 weeks, because I usually, the first and second years, they're not doing any complex surgery.

They're usually doing some minor hysteroscopy. So that's just with a camera looking to the uterus, DNCs, suction, tage, they're doing minor procedures, maybe not until their second year when they start doing some basic diagnostic laparoscopy. And it's really only in their third and fourth year that once they become a little bit more proficient in the operating room, then more training that they're gonna be doing some more complex cases for me. So when you look back and, and, and I just realized sometimes I was only after making this presentation, the little amount of time that my residents have with me and how I have to sort of speed up in terms of, okay, I know if I see that there are certain residents, there are excellent surgeons, I'm pushing 'em to do more, I'm educating them more. I'm, for, I'm almost encouraging all of them to do a fellowship in a minimally invasive surgery. And if not, in terms of, if a lot of them in terms of really excellent surgeons may also want to go into GY oncology as well, who I think is also very good, uh, a fellowship to <affirmative>.

So this is our operating room. And again, besides the patient who has the anxiety of coming to these rooms, which are very sterile, obviously very cold, um, the medical students, the residents, they're also very nervous. So, you know, a lot has to go into the training before they actually come into the operating room. And I would say 75% of my cases are laparoscopic, but I do robotics as well, but I'm not gonna let, and this is the hard part of allowing your residents or your students to do any procedures or helping out with the procedure unless they're prepared.

Does anybody remember this in terms of your, your, your driving? I mean, I I'm trying to age myself about like 30 years, but you remember, you, you get into your driving's class and you got the guy next to you and or the girl and they're, they're driving and they can slam on the brakes or turn, just make you avoid a collision. Sort of the same thing happens in laparoscopic surgery or a minimally invasive surgery. And I think a lot of the changes that have happened over probably the past, like 15, 20 years in terms of, you know, resident education and training has made incredible leaps and bounds. You know, I c when I'm thinking about this lecture, I was thinking, I can paint this as very, something very dismal and very bleak, and that we're not doing it enough and we have to make it really, you know, we have to make so many improvements.

But at the same time, there has been so much innovation, you know, in the past decade that I think our residents, you know, for those who are interested in going into minimally invasive surgery, are getting better and stronger. And so this is what I thought was like in terms of our typical way that we sort of educate our residents. And now it's become this in terms of, as an example, with the robotic surgery, we can sit side by side on the console and I collect my resident, do a portion of the procedure. And while they're doing it, I'm able to actually show them on the screen where to go, where to avoid, we can review the anatomy. Like one thing that is very important with resident education is being very patient. I have to be so patient in the operating room. And ex the same thing goes with, with fellowship training.

I mean, my first laparoscopy is actually with Dr. Sta, can't believe it or not, he used to be at, in Brooklyn at Methodist Hospital. This was a little while ago. But you have to be very, very patient with who you're working with. And this is one way in terms of how we could work side by side in the operating room and even on simulation. What you don't know also is that with the robotic consoles, that there's a robotic simulator as well. So the residents have a full curriculum where they practice beforehand going into the operating room. And every single one of my residents has to go through this curriculum before they were to actually go to the patient side or even be at the console.

And these are just a couple of the pictures of the simulation that we do. I mean, we have probably once or twice a year we go up to Columbia for a, a live pig lab that we do in terms of laparoscopy on the, on the animals. And then we have in-house laparoscopic simulators. A lot of us, sometimes it's, you know, helped with industry that will give us some of our, their equipment. We did, uh, last month recreated pelvises to do, you know, replicate doing a hysterectomy on patients practicing excision, sidewall excision surgery. So this is something that, again, is really important for the residents. Also, part of their residency training, or part of actually them graduating, is that they need to do something called the fundamentals of laparoscopic surgery. And this is something that, it is really not a challenging exam, but at least it is some level in terms of what they need to do.

It's a test, a laparoscopic training test, um, that they have to do that they need to pass also before graduating. And even with that, they've made changes. So within the next year or so, it's gonna be switched to something through A A G L where there's, um, additional training that they're gonna be needed to do before they finish residency training. But again, simulation, most, and not almost all my residents and even we have the medical students using the simulators before they actually go into the operating room and practice, not practice, but are treating our patients. And so when I go back to that third problem in terms of compensation, one of the things in terms of after residency training, and I always have this talk with our third years and our fourth years. So the third years are now usually getting ready to apply for fellowship and are graduating residents or fourth year are thinking about if they haven't applied to fellowship or if they haven't already heard from their fellowship, what are they gonna do next?

And actually, out of the four graduating residents that we had this year, three are going into private practice, three are going into private practice, one went into fellowship, into family planning and all spread out throughout the country. But a lot of it has to come down to, okay, well are they prepared? Do they think they've done enough to perform excisional surgery, treat endometriosis diagnosis? And if not, like I mentioned, if they can't, if most, most of the ones that I've tr trained and treat, they, they know that they can actually identify endometriosis, perform at least the basics in terms of identifying exci. And when it comes to complexities involving, you know, thoracic or bowel, um, knowing when to say, okay, I'm gonna stop, or I'm not gonna do more, but I'm gonna get somebody who can and evolving, again, it's a multi-specialty approach when you're dealing with advanced endometriosis disease.

And again, once they finish their residency, it doesn't just stop there. Especially those who are interested in endometriosis, whether they're finishing their fellowship, uh, fellowship or whether they're going on to a private practice, because I have, again, two of my graduating chiefs right now are excellent joy insurgents. I know they're gonna do fantastic, they went into private practice, but what are they gonna do next in terms of making sure that they're continuing to be educated because the amounts of information and innovation that has changed in the past decade in regards to endometriosis research, it's always changing, though. You still have to, you're never stopping learning. And that's one important thing about this is that if you are not keeping yourself up to date in terms of surgical techniques, medical management, you're behind. So there's a lot of different organizations that are out there that are helping us.

I mean, I usually go to two, um, conferences a year, usually. One is the, um, A A G L conference, which is multi-specialty and has a lot of focus on endometriosis treatment, surgical videos. And it is, again, I think from all the different organizations is mostly from physicians in us, but also a lot from worldwide. Um, one of my colleagues, HOAs Ramon, who's in Northern French O opened up a, um, endometriosis institute in France, and they actually just opened up their second one in Abu Dhabi. So it really depends on where you're going in terms of that, I guess that interest. But you need to, as a resident when you're finished and as a obgyn, once you've graduated, to actually ensure that you're continuing to learn more and more, you're networking, especially in your community. And also nationally, what if you know, you're in a small community and you, you diagnose somebody with endometriosis, but you don't know where to refer the patient to. I mean, these organizations are also helping a lot with networking and, uh, provide a lot more information in terms of both medical and surgical management for endometriosis.

And so again, the, the three problems, the three solutions, again, more time, more time for the residents in terms of their educational training. There has been discussion for years through the American Board of OB GYNs and through abog to maybe actually change the length of our residency training perhaps at a year. Then there was a discussion of splitting off in of, if we knew from the get-go that a resident was more interested in GYN versus obstetrics, that that would actually fish, you know, would split into two where you'd either be focused more on obstetrics and more in joann. So I think there's still a lot more in terms of, you know, the, the amount of time that is dedicated towards, not only in terms of endometriosis training, but just gynecological surgery. You know, unfortunately GYN surgical volume, not only at our institution, which has shown decreases in the years, but also across the country because most people have been focusing on obstetrics.

And a lot of them who it either malpractice has gone up, costs have gone up, the obstetrics is what was paying their bills, and they were focusing more on that, unfortunately. But you need to have more time dedicated towards that training and more interest. Obviously, if you don't have a specialist who's working at your institution teaching the residents about endometriosis, there's less likely that they're gonna have interest going forward. And that interest comes from mentorship. So for instance, I have two residents right now. I'm their mentee, I'm their mentor. And you know, through the residency training, every year I get a new, I get a new mentor. But you need to have that one-on-one with a resident to help them in their career. But also those who are interested in endometriosis surgery or endometriosis or just minimally invasive surgery, I push them, I help them, I bring them to conferences nationally, internationally with them.

And we, we focus on their career and help them understand, you know, number one, if they're not interested in this to begin with, if they not, if they don't feel comfortable, if it's too, it's too much from, they're not gonna want to do it. So I've really taken, and there's been several residents over the years that I know would be excellent GYN surgeons and endometrial surgeons, and we've pushed them and they've all applied to AJ fellowships, they've all gotten them, and they're all practicing now. And my greatest, I guess the greatest treat to me is having a text or having a picture sent to me by a resident, uh, well future former resident, but now an attending. She's telling me what they've done or what they were able to do and change the lives of patients. And then also in terms of compensation only, I think it's only this September that's coming out where the ic, like in terms of how we diagnose endometriosis, uh, it's called the ICD 10 from a coding perspective, this is the only time that it's actually gonna change to actually give more details in terms of the amount or the details of the endometriosis surgery that we have.

If we do a surgery that takes us half hour, an hour for endometriosis versus seven hours, it's the same code, it's the same procedure code, and we get reimbursed the same. And so it's very difficult for a lot of the private GYN attendings to are not affiliated with an academic institution to say, oh, yeah, I'm gonna spend seven hours in the operating room when they can't, they have bills to pay and they, they can't afford it. So because of that, we've had focused endometriosis specialists at crotch across the country, but there's not enough of them. Right. So we need more.

When I was in fellowship training, it was probably the month before I finished, and this was Dr. Najat who's out in, in Stanford, California. He invited my parents, my parents are coming to visit, and we'd gone out for dinner and my dad had asked him, he's like, isn't this so hard? And he's like, what do you mean? He's like, isn't this so hard that every single year you get a fellow and then they leave, you know, you, because fellowship, it was six days a week from 7:00 AM to usually 10:00 PM at night nonstop. And we gr we, you know, you grow so close this person, you work with them all the time, but then they're gone. And it was only until I became an attending till I myself became mentor to my residents that you understand the importance of education and teaching and mentorship. And I always try to again, be patient with my patients, uh, but also with my residents that this is such an important part of resident education. And if we don't slow down and teach, then we're gonna be in big trouble for our next generation. Thank you.

And we have time for a few questions. Yes. Um, and I, I may have missed the numbers, but, um, when you said there are about a hundred endometriosis specialists in the country, what percentage of the, um, MIGS fellows are going into Endo?

That, that I don't know for, you know, but the good thing is that through like a L for instance, has a endometriosis special interest group. You see, you know, from the years that are going on, that there has been more and more panels. You see the videos, I mean, before it was usually the same surgeons that were always doing their talks or their videos or talk. Now you see the growth of it and you see that through Society of Laparoscopic Surgeons, through, um, society of Gynecologic Surgeons, all these organizations have grown. And I think the fact that we're seeing more and more endometriosis, one thing that I'm, uh, disappointed is through acog. I'm not seeing as much spread or as much awareness. It's there, you know, through acog. But I think, again, it's growing. But do we know the exact number? When I look, when I look at my, um, my former residents who've gone through a G L and have graduated, I mean, they don't only focus on that, they focus on everything. And, and myself as well. I mean, I do a lot of treatment for fibroids, abnormal bleeding, you know, there's a lot of other things that I treat. I'm not just specifically for endometriosis, and that's also part of what I have to do. I have to teach them everything as well.

Do you feel like you have the power to add more lectures in, or is do you feel pretty tied to like GME standards when it comes to lectures per year?

Right. I mean, we have, we have a set curriculum that we have to follow mm-hmm. <affirmative>, but again, with the residents, you know, sometimes the residents will say, oh, we don't get enough teaching or lectures on this topic or that topic, but they don't realize that every single time we're sitting to discuss a patient, a patient's case, that's education. Every time we're, you know, in the operating room and we're going over anatomy and we're going over, like in turn we go talk with the pathologist afterwards, that's all education as well. So the lectures is one thing. Them sitting down and reading about endometriosis, where, you know, our textbooks only have, there's maybe only about, I'm looking, trying to see which amount of textbooks that Beckham in and drug Mueller. There's very few of them where they may have one chapter of endometriosis. It's very, it's very little. They have to go elsewhere to find more information about it.

Yeah. Yeah. My last question for you, and then we'll take it to the audience. Over the past decade, have you seen a trend in obgyn, um, residents choosing to go into fellowship? And if so, what kind of trends are you seeing?

So th this act this past year was the first time that I had a no applicants going into migs, but generally every single year we've had at least one or two of the residents apply for, I think the popularity has increased drastically. And the amount of fellowship programs also through a G L and through s sls S SLS started off as like one or two. And now there's, I believe, seven fellowship programs. So there's like 60 fellowship programs across the country. And I think every year there may be, you know, another program that's opening up may not be official, whatnot, but the, it's, it's growing slowly. It's not growing fast enough, that's for sure. Um, the amount, when I think back in terms of this being over like a decade where I knew about the endometriosis foundation just been introduced to it, you know, the amount of buzz and the amount of more people talking about endometriosis has drastically changed. Awesome.

That's what I wanted to hear. Yeah. <laugh>. All right. Do we have some questions in the audience? Yeah.

Thank you. Um, do you know about how many thoracic, um, surgeons know how to remove endometriosis from the lungs

In terms of a total number? No. However, that, again, going back to being able to speak comfortably with your thoracic surgeons and you guys working together, like I, again, going back to our thoracic surgeon that we have our institution, there's three of them. There's only one that enjoys working with endometriosis. Same thing with my colorectal surgeons. There's only one that I choose and I find that enjoys to work with endometriosis. So I can't give you a number in terms of how many there are in the US or even in New York City. In New York City. There's definitely a lot, but it's finding one that's either had experience with it or has it ch has the interest or the challenge to actually helping

Tha thanks for a great talk. As a, um, former ob gyn and laparoscopic surgeon, um, I think it's important for the patients in the room to realize that, um, over the last 10 or 20 years, the number of different subspecialties in OB GYN has doubled or tripled. The first three subspecialties that existed were gynecologic oncology, which is cancer, reproductive endocrinology and infertility, and maternal fetal medicine, which is high risk obstetrics. Since then, and I'll probably miss one or two, there is urogynecology, which is, uh, pelvic four prolapse, whatever. There's migs, there's family planning, there's pediatric and adolescent gynecology. And, and I'm sure there are a few that I'm missing. So not only has, you know, the residency training gotten diluted, but the number of different subspecialty choices. And again, is that good or bad? I, I'm not gonna guess whether it's good or bad, but the number and, and, and I, I have to echo, when I, I was faculty member for four years at a medical school, and you know, general surgeons take five years to train in general surgery after medical school, OB GYN residents, it's four years. At least half of that is obstetrics. And I'm assuming everybody knows what obstetrics is. That's management of pregnancy and delivery. So at least half is obstetrics. Um, and as Dr. Lewis said, you know, in addition to that, the residents have to spend time in infertility, in cancer, in whatever. So there's maybe a year, if you're lucky, right, to train them in surgery, which is absolutely inadequate. It just, you can't do it. So,

And, and it's also with a lot of different surgeons, right? Right, right. They're not, their time is not just with one person. They may be with a dozen different surgeons with different techniques.

And I don't know the answer, although I've been a fan of separating the specialty. Right. Uh, I'm a minority voice. American College of OB GYN has been incredibly resistant to that. But, um, i, I think it would make sense to have, um, literally maybe a year of joint residency and then split splitting it.

Such a pleasure on this very critical topic. This is obviously above your focus of me, but it's important for you to understand. As much as there is so many minks, minimally invasive programs in the country, they are not trained init users as a focused, uh, specialty. They train and, you know, they are being trained in laparoscopic surgery minimally. So they, they can operate through keyhole. So they do a lot of fibroids, hyster domains, you know, bladder lift ups and things like that. And truthfully, endometriosis is a specialty. It's a super specialty endometriosis surgery. If you, I, I'm, I'm sure you will agree, endometriosis surgery is the most difficult, difficult procedure advanced in, in gyn. It's very, very much difficult dying cancer surgery. And every oncologist, they're the best. So, so-called surgeon, they run away from endometriosis surgery. They want, they don't wanna touch it. And you, I'm sure you may have experience on this, these are for advanced cases.

The problem is the minimal, you know, minor endometriosis, as they say superficial, we say it's the majority and it's not in us. In, in essence, it is, you know, the patients are unhappy because they're not being taken care of. They think in a manner that they should be. So the, there's high recurrence rate of the symptoms. That doesn't mean that endo is back many times. So it's not a discipline that's been established yet. And there is high degree of complication also with surgeries compared to others. So due to malpractice and fear and everything, nobody wants to touch by themself. We are as much as that two, two, uh, see driver, uh, console that you see. We, we are in surgery two attending physicians that are trained. I don't go to cockpit without two pilots there. I have two, two endometrial surgeon because surgeons surgery is long at times, there's surgeons fatigue, there's a lot of things that happen in that room.

So I make sure I have another doctor who's also trained by me. And through this specialty, it takes additional years to train in good endometriosis a specialty. There is really no endometriosis fellowship program in the country specifically, except I have one and maybe a couple others that does exclusively endometriosis surgery. The others are doing general endosurgery. And that doesn't mean the same thing. And I want people to know that I'm not saying this to, but I, this is the truth, this is the truth. And we are trying to change this. I think the institutions like Methodist Hospital or, which is part of Cornell, I think they will come up with one specific endometriosis program that trains people just for endo. There's a, we need a team GYN people are not enough. You need a colorectal guy, you need a additional thoracic guy that really works together. You have pain management group, you have, you need to have, you know, dieticians and everything. Everybody should be a team. It cannot be managed by one solo group. Okay. Thank you.

I have

One more question back here.

Welcome. Um, I'm a patient, I'll ask you surprised that I'm speaking. Um, this is just a more general question about a, probably a personal experience that many people in this room have experienced. Um, I am 26 and for, since I've got my period when I was 14, I had, you know, the whole pain thing. Every, I was like the stomach problem girl. I saw every single gastro under the sun. And throughout all of this, I had a gyno. And from 18 until 23, 24, I had the same gyno at home. And we were, you know, I was taking different birth controls because I was trying to stop my period because I was complaining that my period was causing me pain. She knew I had anxiety, she knew, um, I just, I feel like, you know, she gave me checkups so she knew certain fit contexts that I, that I had.

Then I saw so, and she knew I also was seeing many gastros. Um, and then when I came to New York and I moved here, I just went to see a, a new gyno so I can be more local. And she asked one question that essentially changed my life. Um, and she, I was just comp, I just was seeing a checkup and I was complaining that I was going to all these doctors. And for my pain pe my wasn't even calling it pelvic pain, I was calling it stomach pain. Um, and she said with my things, and she asked if I had painful sex, which was the first time anyone has ever asked me that. Um, and I said, oh no, I think maybe, you know, sometimes whatever. And she's like, oh, pain is actually, you know, abnormal. You're not supposed to feel any pain. And I was like, oh, I thought every girl felt this way.

Um, so going back and looking at all of the doctors that I've had, I was really blaming the male gastros, <laugh>, um, that I was seeing, sorry men in the room. Um, but I kind of forgot that I actually saw this guy know that was seeing me throughout this time, and I'm just cur and then I, you know, spoke to a friend of med school and she said, well, she, they don't learn everything and they don't learn the specifics. So I guess I'm curious if my guy know didn't pull together the clues. Am I, I didn't know what endometriosis was until nine months ago. So if my gyno wasn't the one to do this, and my gastros were telling me that I had IBS and my therapist was telling me that I had anxiety, like what? I know it's been a fun 15 years. Um, what

Do we do <laugh>?

Well, again, it, it goes, it goes back to, it goes back to the, the initial questions. And there has to be in regards to, you know, when you were first evaluated. And one thing that we have for our students and our residents when they have, now, again, everything is electronically going to take a wellwoman in a exam part of it. The first question, like one of the first questions beside them, I'm asking you, when was your last period is just an open question. Tell me about your periods. Okay. And this goes across from, and we have, it's called a, a clg uh, CLG group. It goes across all the campuses through NYP as well, which we're trying to standardize in terms of questions that when you go for your annual checkup, you're not just answering some basic que, you're asking specifically open-ended, but then also specific questions about your period.

But then again, going back to teaching the students and the residents to say, tell me about your period. Don't just ask when was the last period and going on to the next part. Okay, how many times have you been pregnant? Do you have any STDs? But really stop and focusing on that question. And I think if they do that and they give you a chance to speak and to express, and again, sometimes you don't know how to express it. And that's when they ask, do you have any pain with the period? Do you have specific, do you have any pain with your periods? Do you have any pain with sex? If you're sexually active, do you have any pain having bowel movements or urinating? Those four questions will come up automatically afterwards, you know, so again, it's going back to educating from the beginning. And this is the most important part. And I have a lecture on it with my students in terms of their well exam, wellwoman exam is asking that, just tell me about your period.