All-female urology practice's mission is to give women choice in care

Lora Plaskon, MD, MS, is the co-founder of Athena Urology & Urogynecology, an all-female urology/urogynecology practice in Issaquah, WA. In this interview, she discusses the practice’s origins, how it differs from mixed-gender practices, and how her unique model fits into today’s economy. Dr. Plaskon was interviewed by Urology Times Editorial Consultant Philip M. Hanno, MD, MPH, professor of urology at the University of Pennsylvania, Philadelphia.

Q: You have the only all-female urology and urogynecology practice in the United States. Can you explain how that came about?

A: I always knew I wanted to practice female pelvic medicine and reconstructive surgery, but I took a circuitous path. In the early ‘90s, the field of urogynecology was in evolution. I was really interested in female pelvic surgery, and it was Drs. J. Thomas Benson and Doug Hale from Indiana University’s urogynecology department who really hooked me early on in medical school. I was fortunate to match at the University of Washington department of urology in Seattle. I came to Seattle by default; my husband is a general surgeon and that’s where he matched 2 years before me.

At that time, there was no clear path to urogynecology in Seattle. The OB/GYN program was focused on primary care and there was no fellowship training in female pelvic surgery. The field of female pelvic medicine is heavily dominated by urology in the Pacific Northwest, so I was fortunate to hook up with urologists early on in my training.

At the time, Dr. Tamara Bavendam was very influential in getting women on board at the University of Washington, and she mentored me in urology. She and Dr. Paul Lange, chair of urology, built a balanced urology training program that focused not just on male disease, but also included the full spectrum of female urology and pediatrics. Dr. Michael Mitchell was also there as chief of pediatric urology, and we had no pediatric urology fellow during my pediatric services, so I was privileged to learn reconstructive surgery under a true master. I trained before hours of duty and the inundation of fellowships, so overall, I had a well-rounded and robust case log.

By the time I finished my residency, I had more female pelvic floor cases than most female urology fellows, and the accredited urogyn fellowships were just coming out. I looked at the fellowships and realized I was at a crossroads to go academic or private. I really enjoyed clinical patient care more than writing papers, so I went ahead and hung my shingle. I took 6 months after residency to self-educate on how to start a practice, and had invaluable business mentorship from a successful colleague, Dr. Ernest Norehad. Mostly women showed up to see me and without any advertising, my patient mix was about 90% female and 10% male. I cut my teeth on the female pelvic reconstructive cases nobody else wanted to do-recurrent prolapse, failed grafts, sling revisions. Looking back, it was really naiveté on my part, knowing now that more experienced colleagues in the community would pass on the “difficult” patients. Vaginal grafts for reconstruction and mesh were coming out at the time, and I was a very early adapter. I tackled very complex pelvic floor cases pretty early on in my career. Thankfully, I had good surgical skills and was able to help my patients with good outcomes.

Q: Tell us more about how your practice philosophy came about.

A: Between 2002 and 2003, I made an effort to go to quite a few meetings. I read articles by surgeons I admired and would contact them and ask, “Can I come and watch you operate?” I paid my own travel expenses to have a day or two of focused apprenticing in a particular surgery or skill set. During that time, I attended an International Continence Society meeting and there was an interesting paper presented about what women want. The study polled women seeking care for pelvic floor issues, asking them, “What are you really expecting out of this appointment?” and the results indicated that it was all about being offered choice, a spectrum of therapies, and opportunity for improvement in their health and not necessarily a cure. We used that information to found our mission: to offer women choice in care. This really shifted our focus from offering women a surgical fix to offering women the complete spectrum of choices in pelvic health care.

Q: Where is your practice located, and what is its composition?

A: The practice is located in the Seattle suburb of Issaquah in the Cascade foothills of Washington. Currently, we have four physicians, two nurse practitioners, a nurse educator, and pelvic floor physical therapists. We have over 50 years combined experience practicing female pelvic medicine and reconstructive surgery. Last summer, we added a urogynecologist from the OB/GYN heritage, so we have both urologists and OB/GYNs practicing urogynecology in our clinic. We all plan to take the board exam in urogynecology/female pelvic medicine and reconstructive surgery at the first offering in 2013. The next specialty we plan to add in our service panel is colorectal surgery. We are also expanding our physical therapy department to meet the high demand for these services.

Q: Do you have any male physician assistants or nurse practitioners?

A: We don’t, and we’ve never had any men apply.

Q: If a male urologist, gynecologist, PA, or nurse practitioner applied to be a member of your practice, would you consider their application?

A: Yes, most definitely. I think the right person can do a fabulous job. I think women do seek women providers, but when there is a male provider who is passionate about his vocation, I think women would be open to seeing him as well.

Q: Your website notes that you serve a 100% female population. Do you turn away males from your practice, and if so, why?

A: We have, yes, and that’s been really difficult to do. When I first started out in practice, I did see men. They were only about 10% of my practice, and they were very loyal. I think they gravitated toward our practice because we spent more time educating them and offering choices in the spectrum of care. I no longer see male patients since I’ve designed our facilities to accommodate women’s diagnostic evaluations and procedures. For example, our exam tables are the gynecologic procedure tables and each room is set up for pelvic exams. I’ve sold off my prostate equipment, so I’m not set up anymore to do complete urologic care for men.

Q: So if new male patients come to the practice, would you refer them to another caregiver?

A: Yes. The classic example is when we’re on call. We still take general urology call, including male patients. We’ll commonly stabilize a male patient and then transfer his care to one of our male urology colleagues in our call group.

Q: Could you see an all-female provider practice like yours taking care of men as well, perhaps on a separate day?

A: Yes, definitely, with a focus on lower urinary tract pelvic health, reconstructive surgeries, and restoring pelvic function-that’s what we do best. We’ve envisioned a Jack–n–Jill concept for urologic care, sharing resources, but having different encounter experiences that are either totally male or female focused.

Q: How is an all-female urology practice different aside from the providers and clientele? What else do you do differently in terms of office design and atmosphere?

A: We’re very focused on service; our clinic has more of a spa-like feel to it. Our appointments are longer than average in our community. The colors and decor are more feminine, there are women’s magazines in the reception area, we have restrooms adjoining our exam rooms, we have beautiful art by local artists, and every exam room has a window for emotional reprieve. We have larger exam rooms with space where families and children can come in as well. We see many younger women who may not have child care, so we have accommodations for children in our clinic.

Our staff is very good at history taking and being able to elicit detailed intimate information from women. The average time that a woman will suffer with a pelvic health problem before she brings it to her caregiver’s attention is about 5 to 8 years, so just getting over that emotional hurdle of making an appointment is a big deal for many women. We want to make that first appointment a comfortable and safe experience for them. But even once they are in the clinic, they have a hard time talking about bowel, bladder, and sexual issues that are bothersome to them, so we strive to create an environment that enables women to open up and talk about their most intimate health issues.

Q: What advantages do you see in a single-gender practice?

A: I think it takes one to know one, so as women treating women I think we have more empathy than a mixed-gender practice. When I opened my practice, it was predominantly women who came to see me without advertising “women only.” Women are choosing women providers, so we focused care on what our clientele was telling us they wanted.

Being in private practice, we have that flexibility to basically give the women what they are seeking out of their encounter.

Q: It almost sounds like you could franchise this idea.

A: We’ve thought about it. It’s a model that we have developed with our business plan and are exploring our next site to offer complete-spectrum, full-service care.

Q: Do you conduct patient satisfaction surveys?

A: Yes, and we are very flexible and dynamic in responding to them. A nice thing about running our own practice is that we can change on the fly. If we see an issue, we can correct it quickly.

Q: Have you found the model to be successful overall?

A: We have, and it has been really surprising to me since I have no business training. Thankfully, I’ve had some great mentors, read a lot of books, and followed my instinct. Training in a university program, I was groomed for academics; I earned a masters in epidemiology during my research year and was set up to do outcomes research. Looking back, I think I may have been better served getting an MBA.

I’ve had on-the-job training on the business side. The AUA has been really supportive; I’ve used their resources a great deal and got involved in coding and reimbursement as a matter of financial survival. I’m currently chair of the American Urogynecologic Coding and Reimbursement Committee and liason to the AUA’s Coding & Reimbursement Committee. Keeping an open philosophy of letting our clients tell us what they want, being adaptive to novel new therapies, committing to the spectrum of therapy, and honoring the woman’s choice have been what’s made us successful.

Q: Do you predict we’ll see all-female provider practices around the country?

A: I do, and I think urogynecology is going to step into that role if urologists practicing female urology don’t adapt.

Q: Do you think these practices would be different if the providers were male and female, or does it require an all-female provider group to be successful?

A: A mixed-gender composition can work fine, but you need to be focused on the disease process that you are treating, be passionate about it, and embrace it as your vocational mission. It’s important to center the encounter environment around the patient so that you can meet her expectations. I don’t think it matters where you come from or what your gender is, as long as you keep patient centered.

Q: Five years ago, there were 80 board-certified female urologists in the country. Today, the figure I have is that there are over 200. Do you think men are more comfortable with a female urologist than women are with a male urologist or urogynecologist?

A: It depends on the individual. I have had many male patients who wanted to retain their relationship with me because of the empathy I had for their problem and the extra time I would take researching their particular issue. A good example is hypotestosteronism in the post-prostatectomy patient. I was one of the first in our community to offer testosterone to those men. I was out on a limb at the time since I had little medical evidence to stand on. We really went to extremes to go through the informed consent process and make sure these men understood that there really wasn’t any data (at the time) to support that that was a safe thing to do. I figured if a man had been 10 or more years out from his prostatectomy, he was cured of his prostate disease and he was suffering from hypogonadism, why not treat it to improve his quality of life? There are now studies supporting this mode of therapy.

It’s very similar to my postmenopausal patients having atrophic vaginitis and low libido dealing with their sexual symptoms from low estrogen. So the crossovers into sexual medicine were pretty easy to do between men and women. I don’t think it necessarily means you have to be a male provider or female provider to see a same-gender patient; it just depends on the doctor-patient relationship and how you address a disease process and treatment options with your patients.

Q: While I was researching this interview, I came across an article characterizing changes in student empathy throughout medical school (Med Teach 2012; 34:305-11). It found that female students had more empathy than male students. Why do you think this is? Do you think patients are picking up on that in your practice?

A: Possibly so; maybe it’s a little easier for women to acknowledge or discuss their own feelings. I certainly see this in my own experience, although there are exceptions for both genders of caregivers. I personally feel it’s a privilege to witness the human experience through my patients’ stories and embrace the emotions that come with that. I feel it’s part of the adventure of being a physician and maybe keeping open to those emotions is what patients feel as empathy.

Q: Do you think that the gender area is one we have ignored or dismissed too much? Recent articles suggest that we might have improved rates of colorectal and breast cancer screening if we took gender preferences into account.

A: Urology deals with very intimate parts of our bodies. These are the sorts of subjects that patients may discuss with a trusted friend but not necessarily something that just pops out to a complete stranger in a short, formal doctor’s appointment. I think sometimes that’s what the doctor-patient interaction might feel like. When you have 20 or 30 minutes for a new visit and you’re trying to get your EMR checklist filled out and in the litany of history taking you blurt out, “Do you have any sexual symptoms?” a woman may not be inclined to say, “I’ve never had an orgasm,” or “It hurts when I have sex,” or “I leak all the time.” I think you have to take into account the encounter setting, the doctor-patient relationship, and all the gender ramifications in order to completely serve a woman’s pelvic health needs.

Q: We are training more and more female urologists, and the general thinking seems to be that you should see whomever you are scheduled to see. But maybe we shouldn’t be doing that so much; maybe we should be offering people alternatives. What’s your view on that?

A: I think you let the patient choose the gender of their provider. I feel strongly about that. Patients need to be comfortable in their visit. Better care will come of it; there will be more interaction; and the physician will be able to elicit information that the patient may not have provided otherwise if they are not comfortable with the gender of the provider.

Q: How might that affect training programs for female residents? That’s always a potential issue.

A: That’s difficult. When I was a medical student at Indiana University, there was an issue with pelvic exams and our ethics committee got involved. Some patients didn’t want male students involved in their gynecologic care, and it went to the ethics committee to determine whether patients did have a choice in a state-sponsored institution charged with training caregivers. The policy that came out of it was that, at least in an academic teaching institution, the patient didn’t have a choice. That’s the societal burden of training the next generation of providers; if you go to that institution, you are going to interact with the provider that’s assigned to you. I think it’s particularly difficult in state-owned institutions, or wherever public funding is received, to bend to those issues. I think in the private sector, it’s easy to do.

Q: Should our ultimate goal be to make patients blind to gender when it comes to provision of health care or to accept the way it is and go with it?

A: I would say with that initial interaction, encourage them to be blind to gender, but if it’s not working out, give them the option to change.