No-Needle No-Scalpel Vasectomy (NNNSV) Training for Physicians
Having dedicated my practice to vasectomy and office-based vasectomy reversal since 1999, not to mention having had a pretty brisk vasectomy and reversal practice when I was still seeing new general urology patients prior to 1999, I have gotten pretty good at those procedures. What surprises me is the fact that I feel more comfortable with vasectomy this year after 27,000 procedures than I did last year after 25,000 procedures. While no-one can understate the value of practice (after reading the book and watching the videos), there may also be value in hands-on training with someone who has already had a lot of practice, subtle things like patient relaxation and the nuances of hand and finger position.
Because 40% of American pregnancies are unintended, and because many of these occur within couples who are perfectly content with the number of children that they already have, and because other forms of contraception fail so frequently, and because vasectomy fails so infrequently, and because I hate to see the environment degraded by suburban sprawl and habitat loss due to never-ending population growth, I am an enthusiastic promoter of vasectomy. I would like to see the reputation of vasectomy (as an almost painless and simple procedure) soar to the extent that more men who feel they have enough children get vasectomies before they cause unintended pregnancies rather than after. By sharing what I have learned with present and future vasectomists, so that patients rave about the simplicity of their vasectomies, perhaps that goal will be achieved.
So I offer NNNSV training (for some we will call it "refinement") at my Tampa office. Here is how:
1. When you, the practitioner/trainee, decide that you want training, you contact me by telephone or e-mail (via my Contact Us page). Then, by phone or e-mail, we decide on a date that works well for both of us. In the Tampa office, vasectomies are routinely performed on Tuesday afternoons and on Thursday mornings and afternoons (see my schedule). On Monday mornings I still see a few long-established general urology patients, then do a series of reversal consults in the afternoon. Wednesday is usually an administrative day. When we have a trainee, we can schedule training cases on Monday afternoon or on Wednesday morning so that trainees can get 2 consecutive days of training (Monday afternoon and Tuesday afternoon with a reversal Tuesday morning; or Tuesday afternoon and Wednesday morning, depending on travel schedules). Typically, on the first half-day of training, the trainee observes 4 vasectomies during the first hour, then does 4 vasectomies over the next 2.5 hours. On the second half-day, it's observe two, then do two; then observe two, then do two. Most trainees have found value in having these half-day sessions on consecutive days rather than the same day to allow the first half-day's experience to settle in overnight. So Monday afternoon / Tuesday afternoon OR Tuesday afternoon / Wednesday morning have generally worked best. This provides for a total of 8 observation cases and 8 hands-on training cases over two half-days.
2. After you commit by paying for your training cases (see #3 below), I recruit patients for the training day(s). A link on the homepage of my website http://www.vasweb.com conveys an offer for vasectomies at $100 off the usual fee on that date (we increase the amount off as the day approaches if needed to recruit enough patients). Clicking the link (there could be one there now if anyone has scheduled a training day) brings up the page that explains the arrangement ... something like this:
Note: On Thursday, June XX, 2011 at his Tampa office, Dr. Stein will host a training day for Dr. John Doe, a [Specialty Resident] [Urologist] [Family Doctor] in Hometown, State or Country. Dr. Doe would like to learn to perform vasectomies in order to be able to provide the service for [his own patients] [a local Planned Parenthood clinic which serves men of all income levels] [his county health department] in the Hometown area. Observation is helpful, but there is no substitute for "hands-on" training. Vasectomies performed while Dr. Stein trains another physician usually will take about 30 minutes, whereas Dr. Stein's routine vasectomy procedure takes 10-15 minutes. So we are looking for men with patience and a desire to save $100.00 (20%) off the usual vasectomy fee. Since Drs. Stein and Doe will work together on each patient, there should be no increased risk of either complications or pain, but there will be more manipulation of the vas tubes as Dr. Stein shows Dr. Doe how to position and access the vas on each side. Patients will hear Dr. Stein explain the procedure. Some hardy men will even be interested enough to lift up on their elbows and observe, which is always fine with Dr. Stein. Because of the reduced rate and the need for men who are not likely to postpone to a later date at the last minute (Dr. Doe cannot learn on men who don't show up), we ask for a non-refundable deposit of $100 at the time that June XX procedures are scheduled. Thank you.
The recruited patients know beforehand that they are training subjects. They are very cooperative and patient.
3. Fees: There is never a charge for observing. You may come to my office anytime and I will teach you everything I know about promoting and providing vasectomy services. But hands-on training is different, because most patients do not want to be training cases unless there is something in it for them, like a reduced fee. So here is how it works: My usual vasectomy fee is $490, but I get less than this from most insurance companies with whom I am a contracted provider, from county health departments under Title X, and from Medicaid. So we get an average of about $400 per vasectomy. Although we routinely schedule 4 per hour, we usually end up averaging about 3 per hour because of cancellations and no-shows. So over the course of a 4-hour morning or afternoon, I will do 12 procedures at ~$400 = $4800. If I am training, we perform 8 vasectomies in 4 hours at either $390 apiece = $3120, or if we have to drop to 50% of the usual fee to fill the training spots, $245 apiece = $1960. So there is a potential income loss of ~$2000. I say "potential" because some insured patients will choose a training day for altruistic reasons and we will get the contracted fee from the insurance company. So the trainee is charged $250 per hands-on training case (for example, a full day of 8 training cases, or two half-days of 4 training cases each, is $2000). This fee, payable by check or Visa/MasterCard, is due before we start to recruit patients, and at least 4 weeks before the training day (so that we have enough time to recruit patients), and it is not refundable after a date 2 weeks before the training day.
4. If you choose, you may order a MadaJet and at least one set of instruments (the "Vasectomy Pak") from AMI for $999.00 and have it shipped to my office before the training day, so that you do not have to carry them on an airplane. That way we can use your own MadaJet and instruments so that you are totally familiar with their preparation and function. You may then return home with them or we will mail them to your home office if you are traveling to Tampa by air with just carry-on luggage. If you already own NSV instruments, you may purchase a MadaJet alone from either Mada Medical directly or from AMI.
With proper handling, sterile storage, and periodic (once or twice a year) maintenance by the manufacturer, a MadaJet provides wonderful service. Filled with your choice of anesthetic, a MadaJet can be used for ~5-7 patients before a refill (accomplished in ~30 seconds) is needed. And the same MadaJet can be used for as many cases as you have in a single day (I have performed as many as 33 vasectomies in a single day with one MadaJet). But after each day, the MadaJet should be emptied and sterilized by autoclave before the next day's use. So a MadaJet is most beneficial for a series of vasectomies and much easier to prepare than a whole bunch of pre-filled sterile syringes. But if you have just one case on a certain day, a needle and syringe are easier. So if you are using a MadaJet, plan to group your vasectomies on a certain day. And if you do that, perhaps you should have more than one set of NSV instruments, all sterilized and individually packaged, for "Vasectomy Days". I own 80 sets because I perform vasectomies at different "outfield" sites, sometimes during 3 consecutive days, during which I cannot re-sterilize my sets. I suggest that a vasectomist own at least 3 sets, perhaps more depending on your patient load and availability of staff to re-sterilize instruments while you work.
So, here is what I recommend:
1. A MadaJet and accessories: http://www.ameditech.com/vasectomy/2500v.php, if you want to go with the no-needle technique.
2. 3 sets of VE-21 Standard NSV instruments (http://www.ameditech.com/vasectomy/ve21.php).
3. 3 VE-6 Medium Clip Appliers (http://www.ameditech.com/vasectomy/ve6.php) and one box of VE-6-10 clips (http://www.ameditech.com/vasectomy/ve6_10.php).
4. 3 straight Halstead mosquito clamps (http://www.ameditech.com/vasectomy/ve5.php) and 3 Iris scissors (http://www.ameditech.com/vasectomy/ve4.php).
You may be able to purchase #4 from your local instrument supplier for less. But rest assured that AMI's quality is absolutely the best. I own 80 sets of these instruments, most from AMI, and I have never been disappointed with their service or quality. Don't be daunted by the expense. The instruments will pay for themselves very quickly when the word gets out that you do a no-needle no-scalpel vasectomy with virtually no pain and a quick recovery time.
Again, the AMI "Vasectomy Pak" (http://www.ameditech.com/products/special_vaspak.php) includes only one set of instruments and one hemoclip applier. If you think that your case numbers will be high, you should have 3 sets of instruments, so that you can do at least 3 vasectomies in a row without resterilizing. It depends on how you schedule, but if you have only one set, you need at least 20 minutes between patients to resterilize that one set. If you wish to own 3 sets on instruments, you will have to also buy 2 additional instrument sets (http://www.ameditech.com/vasectomy/ve21.php) as well as 2 hemoclip appliers (http://www.ameditech.com/vasectomy/clips_appliers.php) and some clips.
Another point about the "Vasectomy Pak" (http://www.ameditech.com/products/special_vaspak.php) is that it comes with the 4030 clip appliers. I actually prefer the VE-6 Medium Clip Appliers because the VE-6-10 Clips are easy to load with one hand and their cassettes can be resterilized so that you can do 5 vasectomies with the contents of each cassette at 2 clips per vasectomy.
You can buy all of these instruments with a credit card online before you come, and have AMI ship them to my office in Tampa:
3000 East Fletcher Avenue
Tampa, Florida 33613-4645
If you are coming from outside the US, you can take them home in your checked baggage to avoid overseas shipping charges and taxes.
5. You may also wish to equip yourself with a pair of 2.5x optical loupes. I purchased my most recent pair from Designs for Vision, Inc. for $1345.00. This may sound like a lot, but my most recent pair of prescription transition photo-gray glasses was over $450, about 1/3 the cost of the surgical glasses. For me, they are indispensable, so much so that I purchased a second pair, the 3.5x loupes. I actually prefer the 2.5x pair because they are lighter, and the field of view is brighter, larger, and greater in focus depth. The working distance of 17 inches allows me to stand upright in good posture. The magnifiers are mounted into bifocals which provide me with good distance vision and reading-glasses type magnification around the 2.5x lenses, so I keep them on through a whole vasectomy day. Even if you perform only a few vasectomies, they are also very useful for a wide variety of office tasks, including examining skin lesions and repairing or cleaning fine instruments.
6. Before a hands-on session, a trainee usually finds it helpful to watch me perform a few vasectomies at my normal pace in order to appreciate the nice rhythm that develops in the course of doing a series of vasectomies. You may bring your digital or video camera and take photos of my office setup and of the procedures of men who provide permission. You are welcome to take samples of my brochures, consent form, op report, and patient instruction sheets.
7. If my staff forgets to ask, please let us know your surgical glove size so that we may have them available on your training day. I wear size 7. If that is your size, we will have no need to make a special order.
Now, 2 frequently asked questions:
1.How many cases should I perform under supervision before I start doing vasectomies on my own?If you have good hands (fingertip sensation and fine motor skills), you may be comfortable with the easiest vasectomies (thin floppy scrotums) after 8 hands-on training cases. So you screen the cases for the first few months and choose only the easiest ones for yourself, referring the rest to more experienced vasectomists. As you gain experience, you take on the more challenging cases. As they say, you must know your limitations. Even after over 27,000 vasectomies, I find some quite challenging, so you will probably never reach the point at which every one is easy.
2.After the training, will I be able to handle complications?Almost all surgical procedures involve the two classic risks: bleeding and infection. With vasectomy, "bleeding" usually refers to the development of a scrotal hematoma, large enough, on very rare occasions, to require a trip to the operating room for drainage. Urologists can already do this. Non-urologists may have to recruit the help of a urologist to help with this problem. "Infection" can be a mild soft-tissue infection treated with antibiotics, or an abscess, also very rare, requiring drainage by a urologist.
Other than bleeding and infection, the only other complications of vasectomy are failure, requiring a repeat vasectomy, and chronic post-vasectomy pain syndrome (PVPS), requiring referral to a urologic sub-specialist for vasectomy reversal or neurolysis.
So no, you may not be able to handle all complications, but even general urologists who perform vasectomies regularly sometimes need help with problems.
To discuss training, please call my office at 813-972-1365 any weekday or my cell phone at 813-390-3032 any evening until 9:30 PM Eastern Time. If you would like to discuss the training process with a former trainee, please request a trainee referral list via our Contact Us page.