Podcast Transcript: Ambulatory Workup of Endometriosis Patients

[Dr. Mark Hoffman]
Hello, everyone, and welcome to The BackTable OBGYN Podcast; your source for all things obstetrics and gynecology. You can find all previous episodes of our podcast on Spotify, Apple Podcasts, and on backtable.com. This is Mark Hoffman, and I'm here with a friend and incredible guest, Dr. Ted Lee. How are you, Dr. Lee?

[Dr. Ted Lee]
Right.

[Dr. Mark Hoffman]
Can I call you Ted for the show?

[Dr. Ted Lee]
Please, please. Thank you. Once you're not a fellow anymore, you can call me Ted.

[Dr. Mark Hoffman]
For our listeners, Ted is a legend in our field of MIGS, minimally invasive GYN surgery. He is a clinical professor of OBGYN at Magee-Womens Hospital, UPMC in Pittsburgh. He is the director of the Division of Minimally Invasive Gynecologic Surgery, a past president of AAGL, has won the Golden Laparoscope Award there, I think, six times. Is that right, Ted?

[Dr. Ted Lee]
Yes. I haven't break Tom Brady's record yet.

[Dr. Mark Hoffman]
I think if they haven't already, the award should be named after you. Is that how it works?

[Dr. Ted Lee]
No, I don't think so.

[Dr. Mark Hoffman]
I'll work on that. Also a member of the board at SGS, the Society for GYN Surgeons. Ted, thanks again for joining us on the show.

[Dr. Ted Lee]
Oh, thank you, Mark. Thank you for having me. I'm very honored to be one of your guests.

[Dr. Mark Hoffman]
Now, we're excited. This is a continuation of a conversation we had actually at SGS about things to talk about in the show. One thing you wanted to talk about, which I think is an extremely important topic, is the ambulatory workup of endometriosis for patients in whom we suspect endometriosis. Before we get started into the topic, tell us a little bit about your practice, how you got to be where you are because I think those of us who did the AAGL, MIGS fellowships, it was set up for us in ways that maybe not everybody had that. Talk to us about your current practice and how you got to be where you are.

[Dr. Ted Lee]
I think I fall into what I do currently accidentally, to be honest with you. When I was a resident, obviously, laparoscopic surgery at that time was very, very uncommon in academic OBGYN residency programs. You probably don't know this; laparoscopic surgery in our field was started in the private sector. There's virtually nobody in the academia that is teaching laparoscopic surgery, so when I was a resident my exposure was basically vaginal surgery. I had a very good mentor, Dr. Terry, who has obviously since passed, was very well-known in the vaginal surgery world.

Then I thought when I finished training, that would be something I wanted to do at that time. It was only probably a handful a year of gyna fellowship, and then I apply, I didn't get the position. I started out my job as a brand new faculty practice in a small OBGYN residency program in Baltimore called Union Memorial Hospital. It's next to the Hopkins undergrad campus. During that year, I wasn't busy. I had only about two, three patients, a half-day session sometimes. I have nobody because a brand new practice, I had nobody, I didn't know how to get patients.

[Dr. Mark Hoffman]
This was a generalist practice, obstetrics and gynecology?

[Dr. Ted Lee]
Yes, we have like two or three residents a year. Obviously, the residency no longer exists at this point, so I was kind of like, "Feel like I'm wasting my life away. I want to do surgery," and I wasn't getting any surgery. I borrowed a bunch of slides from Terry at the time, was teaching the residents about vaginal surgery, sacrospinous ligament fixation, and so on, but I wasn't doing any surgery, so I just feel like this is not going anywhere. That was the year I learned how to fly fish because I had so much time.

[Dr. Mark Hoffman]
Something good came out of that, for sure.

[Dr. Ted Lee] Yes. I had a lot of free time on my hand, I learned how to fly fish, and then I learned how to tie flies during that same year. One day I opened the OB/Gyn News. I don't know, most of the audience, the younger audience this day doesn't even know what OB/Gyn News is. It's basically an actual paper, newspaper, basically, that give you the information on what's going on in the OBGYN world. They will have summaries of different meetings. In the back of the OB/Gyn News, there's always some advertisement for some job positions.

One day I opened it up, and then there was this fellowship with Tommy Lyons and CY Liu, both of which, they're pioneers in our field. Initially, it was supposed to be a combined fellowship, but each one ended up taking their own fellows at a different timeframe. I ended up becoming fellow with Tom Lyons.

[Dr. Mark Hoffman]
He was in Atlanta. Is that right?

[Dr. Ted Lee]
Atlanta. Yes, he was in Atlanta. If you guys don't know, he used to play professional football at Denver Broncos.

[Dr. Mark Hoffman]
It's one of the most interesting biographies I've ever read in my life. I think he was a concert musician too and led the Denver Philharmonic, I think at one point, while he was a member of the Denver Broncos. Didn't he pay for med school?

[Dr. Ted Lee]
He was doing medical school at the same time too.

[Dr. Mark Hoffman]
These people are made of different stuff than I am. That's amazing.

[Dr. Ted Lee]
Yes.

[Dr. Mark Hoffman]
By the way, he's a pioneer in gynecologic surgery.

[Dr. Ted Lee]
Right, exactly. He was a big proponent of a laparoscopic supracervical hysterectomy. Back at that time, yes, he could do a total hysterectomy easily, but he really believed that if patient doesn't have any pathology in the cervix, the cervix should be kept. Then he was the first person I realized how beautiful dissection in laparoscopic surgery can happen. I also spent a lot of time with CY Liu because, back in those days, they were the big shots. They are invited to meetings all over the world, so one of them is always traveling somewhere.
Whenever Tommy traveling somewhere in Greece or Italy or somewhere, I would drive up to Chattanooga and watch CY Liu operate and vice versa. I learned a lot from both of them.

[Dr. Mark Hoffman]
What an amazing opportunity.

[Dr. Ted Lee]
Yes. It was very strange because apparently when the position was posted, there was over 100 application for one spot.

[Dr. Mark Hoffman]
Wow.

[Dr. Ted Lee]
I was obviously very fortunate. I don't know how I got chosen. The only thing I can think of is that I share the same birthday as Tom Lyons and we have the same initial.

[Dr. Mark Hoffman]
Whatever it takes, again, I think.

[Dr. Ted Lee]
Whatever it takes, yes.

[Dr. Mark Hoffman]
No, I think it's always fun for me to start the show with understanding how people got to be where they are. To think what a loss to MIGS it would be, had you matched into urogyn.

[Dr. Ted Lee]
Yes, it was meant to be.

[Dr. Mark Hoffman]
Yes. It wasn't your favorite day, but it was a good thing for patients with endometriosis and for the MIGS specialty as a whole. You were with Tommy Lyons and CY Liu for a year?

[Dr. Ted Lee]
One year. Back then, it was basically apprenticeship. Back in those days, it's like the people service. Those people in private practice are rock stars of our field. They were basically getting paid before service for everything. Not just for endometriosis surgeries, everything, they got to pay for service. I was fortunate he allowed me to perform some of the surgeries. I also practiced a lot on my own. I was his first fellow, so he didn't know what to do with me, to be honest. I was practice a lot on my own. He has a back room where he has a TV monitor, and so I construct my little pelvic trainer that's made of a copy paper box with a lid.

I put trocars on the lid of the paper box, and I carved out the end of the box. I used the colposcopy light as my light source, I put the camcorder that was a gift from my in-laws, and I put it on a tripod, and I connected it to the TV monitor. That was my pelvic trainer. I'll be basically getting the chicken thigh, getting all the fat off the chicken thigh, debone the chicken thigh, all laparoscopically, and then close the defect of the chicken thigh once I debone the chicken thigh. That was basically my training, my pelvic trainer, and it comes in handy. When he hand me the tools, and I was able to jump out and do a laparoscopic purge, paravaginal repairs without much prompting because I was pretty good at suturing by that point on my own with all the practice--

[Dr. Mark Hoffman]
That's something that I talk to my residents about a lot is I think when we're teaching open surgery, most of us know how to hold a pen, holding a knife and retracting. There's skill there, but I think we're used to using our hands. What I want our residents to show up to the OR with is the ability to use those instruments as extensions of their hands. That's something that you can do in the lab like you did with the cardboard box. That's something I did with a cheap trainer in a closet up by the post-op floor, just throwing stitches and just tying knots, and just doing as many of those kinds of little dexterity things, so when I got to the OR and had an opportunity to operate, I could learn how to operate, not how to hold the instruments.

[Dr. Ted Lee]
Exactly.

[Dr. Mark Hoffman]
That's a perfect example of how someone can make the most of their opportunity in that situation.

[Dr. Ted Lee]
Right.

[Dr. Mark Hoffman]
You were with Tommy Lyons. You were there for a year, and then did you go straight to Pitt after that?

[Dr. Ted Lee]
No. At that time, MIGS wasn't a thing. Most academic departments does not know what MIGS is. I was getting close to finishing my fellowship, I sent out maybe over 100 cover letters to various OBGYN chairs in the country, and I think I heard back from like three or four places. The first place that offered me a job was the Medical College of Georgia because Tom is very famous and people in Georgia respected him, so I got a job offer there. Then I interviewed at Wake Forest, and I interviewed at GW. GW was where I went. That's my first job after the fellowship.

[Dr. Mark Hoffman]
Okay. How long were you there?

[Dr. Ted Lee]
I was there for two and a half years. Two and a half years, yes. When I started there, what I do is I think most people consider me as a threat because I'm stirring up the status quo there. There's a lot of people at that time just don't want you to succeed, basically. You just have to prove them wrong, and you get better and so on, because they are always people who want to pick on you when you first start. Especially back then, laparoscopic surgery just wasn't so common. Then also when I started, I still had to do OB calls. I was doing a lot of OB calls.

[Dr. Mark Hoffman]
Yes, no, I did too. It's nice to see all these jobs that are being posted now for MIGS fellows. It would have been nice, but it's folks like you that laid the groundwork for the rest of us to follow. Then from there, it was Pitt.

[Dr. Ted Lee]
Was Pitt, right, yes. At that time, towards the last year of my tenure at GW, they were having some financial troubles. I just opened the back of the Green Journal. At that time, I had been always doing a lot of urogyn procedure laparoscopically, even when I was at Magee. When I opened the back of the OBGYN journal, they have a position posted for a urogynecologist at Magee-Womens Hospital, and I just apply. I was applying for a position at Yale at that time, but then Magee replies that "That position has been taken, but your experience is very, very different. My chairman still want to interview. Can you come in and interview you?"

[Dr. Mark Hoffman]
Who was the chair at the time?

[Dr. Ted Lee]
Rick White. He's an infectious disease expert, originally from the University of San Francisco.

[Dr. Mark Hoffman]
Amazing how much a leader with vision can make an impact and get someone like you to come and give you the space to grow and build something when most other people in that situation, in that seat did not. I love hearing the story of how you got to where you are because it's never the straight shot, it's almost never just the straight shot.

[Dr. Ted Lee]
Yes, it's very circuitous, it's not like a direct straight line.

[Dr. Mark Hoffman]
The other thing I wanted to ask you, endometriosis-related, but before we get into the workup, I think as a fellow who also went somewhere after training where I was the only mixed person, and there wasn't anyone really doing what I did, I found endometriosis surgery to be the toughest thing to learn how to do. I still feel like I have so much to learn. I watch your videos and talk to you about this and your colleagues and those who you've trained. Your interest, your skill set, your ability to take care of those complex endometriosis patients, how did that come to be? What did that look like in your early career?

[Dr. Ted Lee]
Yes, I think in the early career I was obviously still learning. To get to where I am obviously took many, many years. Also, back in those days, there wasn't YouTube, there wasn't any kind of things that you can watch online. Everything is you go to meetings and you see how the people does it. You're trying to go back and to see if you can do it and so on. That's how it was in those days. When I started, it was basically, I remember when I was in GW, anytime I get into trouble I had my good friend oncologist come in and help me.

Usually, if endometriosis is so severe, he will come in and open the patients, and he would do surgery with me. Obviously, in those early days, that's how it was, and then you learn and you get better. I think what got me interested in is not even patient with severe endometriosis, in actually patient who has actually relatively straightforward endometriosis surgery, relatively straightforward excision. Patient has seen many doctors and has have many procedures done, and they have no improvement of their pain. All of a sudden, you come in there, you find the endometriosis, you cut it out, and they are pain-free.

Then you feel special. You feel like you can do something that other people cannot do, and then you keep on doing it. I think that's how it all got started is just because just a few patients that you feel you can make an impact on, give you that motivation to continue to do more. Then as you get better known, then you get fed a lot of worse and worse cases, and then you either sink or swim. You get better and figure things out, and then that's how it works. I think a lot of times it's, I consider myself very, very fortunate that I was able to be able to take care of a lot of complicated patients early on in my career without causing too much complications and then be able to learn.

[Dr. Mark Hoffman]
It's a tight line to walk. I had that experience in many ways and actually, it was at a different hospital than our GYN oncologist. It was urology, it was colorectal for me for some of these bigger, tougher cases. I'm very, very grateful for the partners that I have that work with me. Also, yes, you get into too much trouble early on, that can be the end for your career in that place. It's a tightrope to walk, for sure.

[Dr. Ted Lee]
Yes.