Academic OB/GYN

For the last 12 months, I have worked for a federally funded hospital.  When I came to this hospital, I immediately noticed that the GYN surgical equipment was very outdated, most likely because the primary focus of the hospital until fairly recently had been the care of men. Wanting to bring hospital up to snuff, I requested about $100,000 worth of new equipment, including a hysteroresectoscope, new hysterectomy clamps,  uterine ablation equipment, a laparoscopic morcellator, and a modern laparoscopic power source.  When I put in the order for these things I was assured that we could get these things in short order, as the hospital had upgrading GYN surgery on its priority list.

As time went on, the equipment never arrived.  It was held up in committee.  It needed further approval.  We needed more competitive bids.   After further investigation, it seemed that the hospital just didn’t have enough money to do anything non-critical.

All the while, I had noticed something else very troubling.  Every time I did a laparoscopic case, I noticed that a lot of disposable equipment was opened right at the beginning of the case, often going unused during the case – a $100 laparoscopic suction irrigator here, a few $200 disposable ports there, sometimes even a $1000 energy handpiece.  Despite my attempts to limit this, it kept happening.  I started keeping mental track of how much stuff was being opened and not used, and it seemed like an average of about $300 worth of equipment was being wasted in each surgery.  Given the annual surgical volume, this adds up (conservatively) to a million dollars wasted each year.  On one hand the hospital couldn’t afford the new equipment I wanted to really improve patient care, and on the other they were throwing away a million dollars a year in unused equipment.

So why did this happen?   It seemed there were lots of reasons.  The biggest one seemed to be that the OR nurses, being very attentive to surgeon’s needs, wanted to make sure that everything that was needed in surgery would be immediately available.    In some cases, they expressed that some surgeons had gotten angry at one time or another that something was available, leading to this behavior.  Minimizing the waiting time for instruments was prioritized over wastage.  In other cases, surgeon’s preference cards were not updated, leading to wasted equipment.

What bothers me the most about this is these are real dollars that are being wasted here.  We talk about spending money on ‘unnecessary testing’, but in most cases this is just unnecessary use of a fixed capital piece of equipment (ie a CT scanner), with very little additional real dollar cost; the scanner is already paid for and the tech is already at work, so while there is a bill generated for the CT, it doesn’t cost the hospital any more to do the study.  But this is different – its actually spending money on something and throwing it away.  And it is completely avoidable if we just care enough to address the problem.

Laparoscopy is to me the biggest problem, because it is in laparoscopy that we use the largest number of disposable tools.  If I am going to do a laparoscopic hysterectomy, most likely I will need three and possibly four ports.  If I put this on my card, when I walk into the OR there will be three or four ports open on the table.   But what if I do a pre-op exam and decide that I will need to open?   Three ports wasted ($300-$600).  What if I put in the first port and see so many adhesions that I won’t be able to finish laparoscopically?   2 ports wasted ($200 – $400).  What if they opened my favorite energy handpiece and never use it?  At least $500 wasted.  What if I get in and do such a wonderful job that I don’t need to use the suction irrigator at all.  $300 wasted.  Just by leaving this stuff on the side of the room unopened, hundreds if not thousands of dollars can be saved.  In my experience, at least $300 worth of stuff gets wasted per case this way.  But this isn’t the only reason we spend too much in the OR.

Sometimes we just spend extra money through bad planning.  If I know I will need an endocatch bag to get a specimen out and use three 5 mm ports to do the case, I will need to put in a fourth 10 mm port to use the bag.  One 5 mm port wasted; I should have used the 10mm for one of the ports in the first place ($150 or so.)  If I find myself in that situation after having done an open entry with a Hassan trocar, I can put in a new 10mm port and spend $200 or so, or I can just put a 5mm lens into a side port and pull the specimen out through my 10 mm Hassan trocar, for a additional cost of $0.  You could even use a sterile zip-loc instead of that Endocatch if you’re ridiculously frugal (I’m not quite there.)  One can even use nondisposable ports, but in my experience the only ones that are completely nondisposable are really sharp and leave large fascial holes, and the ones that have metal sheaths but replaceable dilating tip trocars are priced such that it isn’t worth it.

We also spend too much money through failure to properly negotiate.  There are at least four different port manufacturers that stock ports in my hospital.  I have used them all, and for all intents and purposes they are identical.  If I were the OR administrator I would be getting competitive quotes from each manufacturer and stocking 100% of the least expensive port.  Surgeons that got upset about that could kiss my ass.  Sure I have a preference, but they all do the same thing, and anyone can get used to any one of them.  6 months later the bid could go out again, and maybe the brand would change.   The same goes for suture.  Ethicon owns the world in most hospitals, but in reality Davis and Geck and USSC both make good products, except in the area of microsuture.  Hospitals could save big bucks by bidding suture out. And energy devices?  I understand the need to have the ones that the surgeon wants to use, and they are all somewhat different.  But if Gyrus were willing to supply a Omni for $600 and Ethicon wouldn’t match that price on the Harmonic Ace, bye bye Ethicon.

Another problem is defective equipment.   I have seen so many pieces of defective disposable equipment in my career. Each time one defective $500 piece of swag is found, a new $500 piece gets opened.  Does the first one get sent back to the manufacturer for a free replacement?  Nope.  Just goes in the trash.  $500 wasted, and in this case its totally unjustified. Forget $500, I’ve seen that happen with equipment that was over $2000 a pop.

The cost of medicine is destroying this country.  There are things we as surgeons can do. So here’s five things you can do tomorrow to help your hospital, and the cost of medicine in general:

1. Make an open statement to your OR coordinator that you do not want any disposable OR equipment opened until you are sure you are going to need it in the case. When they do it anyway, nicely remind them you want that stuff left closed until you need it.
2. Be good to your word by patiently waiting the few extra seconds it takes for your scrubs and nurses to get what you need when it isn’t right in the room.  If you bark, they will pre-open stuff forever.
3. Find out what every disposable piece costs your hospital.  When you have the option, make less expensive choices.
4. When the pieces you want are more expensive than alternatives, let your hospital know that they should negotiate the price down or you might switch.  Follow up, and be good to your word by actually switching if they cannot get a more competitive deal.
5. If you encounter a defective piece of equipment, don’t just throw it away.  Make sure they get a free replacement.  Better yet, call the rep yourself and make it clear that you expect prompt replacement of defective items.

If every surgeon did this, I believe every major hospital would save at least a million dollars a year.  Maybe then the next time we go to the OR administrator asking them to buy something we really need to improve patient care, the money will be available to do it.