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Dr. Holly R. Miller on In-Office Procedures

Holly Raass Miller, MD, of A Woman's Place, part of Florida Woman Care, has been performing procedures in her office for about 17 years. And she's very passionate about the topic.

Click the graphic to hear Dr. Miller discuss how in-office procedures help her optimize her time

COMMON PROCEDURES

Hysteroscopies – including polypectomy and myomectomy – are usually done in the office at A Woman's Place, partly because they take so little time to complete.

"It's usually 10 minutes or less from start to finish," she says. "They are such quick procedures, and it saves me a lot of time to do them on site rather than at the hospital or surgery center."

The practice's six physicians handle about 70% of eligible procedures – including hysteroscopic polypectomy and myomectomy, endometrial ablation, LEEP and early miscarriage treatment (suction dilation & evacuation) – cases in the office.

PAIN MANAGEMENT

Dr. Miller says one of the biggest challenges for a physician converting to in-office procedures is getting comfortable with pain management.

"You're now in a situation where you're the physician, the operating room and the analgesia team all in one," she says. "That's a benefit for the patient because it saves them money. But for the physician, you won't be able to look at your staff and say, 'Hey, she's awake, give her more.' You have to lead, and you have to train your staff to recognize opportunities to maximize patient comfort."

Dr. Miller says her team faced a few bumps in the road when they got started many years ago. "We weren't very fluid in how we medicated patients. It was a little challenging in the beginning."

She says it's easier to create a plan now, because there are plenty of existing pain management protocols to use for reference. But the surgeon must feel confident with the option they choose.

"You're going into a surgery where you don't have a lot of extra medications to give. If you begin and the patient is uncomfortable, your option is to stop – to terminate the procedure."

At A Woman's Place, a common protocol is to give surgery patients an oral medication, either an anxiolytic product or narcotic pain medication, that they take an hour before they arrive at the office along with a vaginal numbing suppository (compounded).

On arrival, patients receive an injection of Ketorolac. "The key to the success of the procedure is an excellent paracervical block" says Dr. Miller. "And we have the additional option of an inhaled nitrous oxygen blend that is self-administered by the patient," she says. "Your little happy gas! Just like when you go to the dentist. That has been a great addition, and we need a lot less oral medication."

They also use simple distraction tactics like talking to patients, playing relaxing music or tapping them on the shoulder. Dr. Miller says, "The tapping distracts your brain and makes the patient less likely to focus on any procedural discomfort. We make sure they are comfortable."

Ultimately the patient has to know that she is in control, says Dr. Miller. "We've told her what to expect. We've told her that she is in charge. She has the power." 

So far, she has never had a patient ask to stop during a surgery.

WELL-TRAINED STAFF

"The other big challenge is having an office-based staff that is fully trained and ready to support the surgeon, especially ahead of launch day," says Dr. Miller. "They need to be good.

"On a really busy surgery day, we'll have two medical assistants helping to alternate the patients and procedure room so we can do a procedure every hour. Staff will need to set up, prep the patient, bring the patient to the room, be with her afterward, tear it down, get it sterilized and turn it over."

In addition to regular staff trainings and onboarding, each year the care center hosts a surgical training day for the entire clinical team.

"It helps refresh everyone to walk through all the processes," she says. "We review all aspects of sterilizing equipment, sterile set up, troubleshooting all equipment, cleaning instruments and proper storage. We also review emergency protocols for any possible patient scenario.



"It's a small operating room, and we need to respect it as such."

TEACHING MOMENTS

The patient education aspect of doing these procedures is especially important and rewarding for Dr. Miller.

"I tell them – you get to see the inside of your uterus – isn't that so amazing?

"As I'm operating and shaving the polyp or fibroid out, I'll show her the screen and point out the normal or abnormal anatomy. I will educate her that what we are seeing is causing her bleeding, infertility, etc. Then they watch as my little instrument eats it up like a Pac-Man.

"So I'm educating her; I'm teaching her. I'm showing her a beautiful body part that she's never seen in her lifetime and that is so exciting."

Contact Dr. Miller if you have questions or would like to discuss in-office procedures.

Physician Perspectives is a new series featuring insights, opinions, resources and knowledge sharing from affiliated physicians across the Unified community. Have an interviewee or topic idea to suggest? Please email Rosemary Thompson.