Dr. David Hovsepian is an Associate Professor of Radiology and General Surgery at the Washington University School of Medicine, and an attending physician at Barnes-Jewish Hospital in St. Louis. Dr. Hovsepian was also the impetus behind the Washington University Comprehensive Fibroids Center, which he co-founded in 1998. Recently, Dr. Hovsepian has published important new research about standards of care for patients undergoing uterine fibroid embolization (UFE). He also serves as a member of the Standards of Practice Committee for the Society of Interventional Radiologists. In this article, he discusses the importance of patient education and his passion for high standards of patient care.
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Fibroids1: What prompted you to go into medicine?
Dr. Hovsepian: I have four or five generations of doctors on both sides of my family. In fact, when I told my parents that I was thinking about medicine as a career, I was encouraged to pursue other interests first; they wanted to make sure that I wasn’t falling to some kind of tacit pressure. I took five years off in the middle of college and worked in construction, worked for an architectural firm, did a number of things before completing college; and, ultimately, arrived at a decision to go into medicine out of genuine interest. I took a circuitous path following all of my interests, and arrived back where I started.
Fibroids1: It seems like many people who go into medicine follow a pretty linear trajectory. How do you think your own, less typical, career path affected you?
Dr. Hovsepian: When I first got to med school, I was worried about being older, and then I turned around and there was someone who was 10 years older than I was. In fact, there were a number of older people in my class. And frankly, the people who had come to medicine after another career, who had been writers or engineers, were more interesting and well-rounded people, and I thought it was obviously helpful to their training for them to have done all the things that they did.
In contrast, there were people who went through college and medical school as a 6-year combined program and barely had time to indulge in the non-academic things that you get in college, which is some very formative stuff. They were much better at memorizing long lists and sitting in a classroom for hours and hours — that’s definitely a faculty that fades with age — but it became very clear who was better equipped to deal with stress and make serious decisions under fire.
Real-world experience, and the maturity that comes with it, gives you knowledge about the world and how to make a living - important things to understand when interacting with patients. And there’s general factual and cultural knowledge — of literature, or theatre, things you’ve seen and done, places you’ve traveled — all of those things make you a more well-rounded individual and make it easier to relate to patients.
Fibroids1: How is it you chose to specialize in radiology?
Dr. Hovsepian: I really had a hard time making up my mind what I wanted to do. When I was in school, I liked almost all the rotations. But the thing I liked about radiology was that the radiologists had to know a little about everything; they interacted with almost all physicians in some capacity or another, and didn’t get so compartmentalized. And the imaging was fascinating to a gadget and technology person.
Also, radiology was specialty that made you the go-to person for so many other people in the hospital. Not only did you have knowledge about imaging that could provide a diagnosis that was otherwise mysterious, but you could also, in short order, say "And here is a solution for that problem." Interventional radiology looked like the future of medicine to me.
Fibroids1: In some ways, interventional radiology has proven to be the future.
Dr. Hovsepian: Well, the whole trend in medicine has been toward minimally invasive procedures. They’re better for patients. We’ve seen the same progress in surgery, in gastroenterology, in so many areas, towards the use of imaging for guidance, whether it be x-ray, or endoscopy, or something else. And then, radiology can also look into organ function. It tells you much more than a simple snapshot. I think a lot of the subspecialties in medicine that used to be cognitive, not really interventional, have learned from and applied the techniques developed by radiologists. We’ve taught vascular surgeons and gastroenterologists new ways of treating patients.
Fibroids1: Can you tell us about some of your current clinical interests?
Dr. Hovsepian: When I did my fellowship in interventional radiology, one of my mentors was interested in fallopian tube recanalization. It was an opportunity to reacquaint myself with gynecological disease. It was also a very gratifying procedure, because you were dealing with young, healthy, well-educated people who really were very interested in their own health and their options in the case of infertility. Women got pregnant with some frequency after we had unblocked their fallopian tubes, which was a pretty simple procedure, and we could make such a positive impact with the skills we had learned. When I left my fellowship and started out on my own, I made that an area of focus.
Then, when Dr. Goodwin presented his results for uterine fibroid embolization in 1997, it sort of blew my mind. The idea of embolizing the uterus and only the fibroids would succumb to irreversible ischemia seemed too good to be true. It was an idea born out of a simple observation made by astute physicians in Paris in the early 90’s. Like so many ideas that have succeeded in medicine, it was simple and basic. As interventionalists, our skillset enabled us to adopt this procedure readily and not only was UFE something I considered a real advance, but it so perfectly fit with what already interested me. I had collaborated before with our gynecologists on both clinical and research projects, and here was another opportunity work with them.
So when we first started to consider doing the procedure, I sought the help of two people. One was a reproductive endocrinologist, someone who deals with infertile patients, in whom fibroids are often present. The other was a gynecologic oncologist, someone who deals with cancer patients. He was seeing people with fibroids because those people were concerned that they might be cancer. I sought their help establishing the Washington University Comprehensive Fibroids Center. It was a way of legitimizing ourselves, for patients to get access to us, and a resource for them to learn about the procedure. We set up the Comprehensive Fibroids Center in 1998, and the first thing we did was create a webpage.
We then printed materials, so that when people contacted us they could get information in several media. They could come see us in consultation. So, previously, where I had to wait for physicians to refer to me — I do a lot of public speaking, mostly to physicians, to raise awareness — this was a complete paradigm shift, because now patients could look up fibroids, find our webpage, and find us. It opened up a new avenue for patients to pursue their own healthcare options.
I get a number of women who, it turns out, don’t even have fibroids. We rely almost totally on MR scanning to find out whether there are really fibroids, whether they’re responsible for the presenting symptoms, and what the likelihood of success of UFE is. I’m frequently sending patients back to the gynecologists with a change in the diagnosis or a new finding. And if a patient doesn’t have a regular gynecologist or is looking to change doctors, I often provide their referral. So the whole development of uterine fibroid embolization has really helped to make this much more of a two-way street.
Fibroids1: Some interventional radiologists have found that both gynecologists and insurance companies are slow to consider UFE. Has this been your experience?
Dr. Hovsepian: That’s changed a lot. When we first started, and only had short-term results, a lot of insurance providers were really reluctant to pay for UFE. The first people they sought opinions from were gynecologists...[and] as experience has grown, and long-term data is available, many gynecologists recognize that uterine fibroid embolization is a good option in selected patients. The American College of Obstetrics and Gynecology (ACOG) has issued a statement to that effect. So the problems with insurance companies are far less.
If I get a denial, most companies will consider reimbursement on a case-by-case basis. In the past, I would write letters, go to appeals, send articles, and I think the insurance companies realized that the body of evidence had grown to the point where the procedure was not really experimental, and had even proceeded out of the investigational stage: it was safe and effective and had very few complications. Results were durable, and compared favorably with myomectomy and hysterectomy. The complication rate also seemed to be very low. A registry was created that has over 3200 patients in it, and follow-up is ongoing, to answer some of the finer questions, such as whether there is an impact on fertility, what the recurrence rate is and other issues that only long-term data can provide.
Some forward-thinking companies, like United Health Care, were quick to institute a nationwide policy to reimburse for UFE, which takes the pressure off of local administrators. The Blues and other big companies have recognized that the procedure is effective, patients are out of the hospital more quickly, and they’re back to work quicker.
Fibroids1: Recently, you gave a talk to a group of physicians in Tampa, Florida called "What Everyone Wants to Know about Uterine Fibroid Embolization." What does everyone want to know? And what are the answers?
Dr. Hovsepian: What the referring doctors want to know is who are appropriate candidates for UFE. As basic as that sounds, they hear a lot of conflicting information. When they’re faced with an individual patient, they are often several conflicting issues—their desire for future childbearing, their age — that may make the decision-making process less clear. So I tried to demystify it.
Everybody wants to know what the impact is on fertility and pregnancy, and we really only have preliminary data, although much more information is now coming to light. I presented what is known to date. It seems that all the studies have shown that women have been able to get pregnant, babies carried to term, and without any deleterious effect, although many physicians would say that a Caesarian section may be preferable to a trial of labor, since the wall of a uterus studded with fibroids treated by UFE may not be as strong.
My hunch is that we’ll see that there really is no significant impact on fertility in younger women. If there is an effect, it’s a subtle one. Nobody’s noticed any problems with the pregnancy itself, carrying to term or a problem with the fetus, or premature labor. When the registry [of UFE patients] was organized, everybody was informed of their options, and women who were actively seeking pregnancy were not excluded from the registry. The data from their experience will provide very useful information to other women in their situation.
Three fourths of the people that I see have five or more fibroids, so they’re not myomectomy candidates. When faced with that, it really seems like there’s nothing to lose by doing UFE. I don’t know that we’ll get to the point where a woman who has only one fibroid will be considered an appropriate candidate but we can at least say that if you have multiple fibroids and are considering myomectomy, UFE may improve your chances of getting pregnant, with little downside.
Fibroids1: What do you feel is your greatest contribution to this field of study?
Dr. Hovsepian: Without being falsely modest, I’m not really sure I’ve made any great contribution. I’ve been working hard to educate physicians in the St. Louis community to help build my practice. I have also worked to educate interventional radiologists who are interested in adding UFE to their practices. I was the editor of an issue of Techniques in Vascular and Interventional Radiology [March 2002] which was devoted entirely to UFE. The chapters provided good basic information in all aspects of fibroid disease, performance of UFE, outcomes, and practice building. We included panel discussions with each of the chapters to discuss issues for which there is as yet no consensus. Many radiologists have told me that that issue has been a very valuable resource to them.
I think many women stand to benefit by the widespread adoption of this procedure by interventional radiologists. But I don’t want to see it grow too fast, so that patients don’t receive adequate attention. I don’t want to see it grow so fast that physicians aren’t adhering to reasonable standards: appropriate screening, taking complete responsibility for patient in-hospital care, and follow-up.
When a new procedure offers significant advantages and suddenly everybody wants it, the danger is that details will be overlooked and patients will get hurt. The UFE procedure can produce significant cramps and pains in the hours after the procedure. During that period and in the first week after UFE, physicians need to be skilled in pain management, and management of all the other post-procedural symptoms, not only for patients’ satisfaction but to reduce the risk of later complications. My eagerness to be involved with this process is due to the fact that I really want to make sure we do a good job.
If UFE catches on too quickly, and patients start complaining that they didn’t get adequate pain control or there was no one to take care of complications, that message will get back very quickly to their gynecologists. The criticism of interventional radiologists will be that they are dilettantes, not real doctors, and they will discourage patients from considering UFE as a reasonable option. We’re finally on the cusp where some gynecologists are even bringing up the possibility of UFE to their patients. All that goodwill will go out the window in a tenth of a second if we start doing a poor job. And that’s the area where I feel I can best put my effort. That’s something that one person can do.
Dr. Hovsepian's practice website is located at www.mir.wustl.edu/.
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