This chapter, and some of the following ones, deal with medical economics and logistics. Obviously, these topics are intertwined with almost every activity involved in surgery.

In this era of increased government involvement in healthcare, and with healthcare costs usually increasing faster than inflation, it behooves all of us to look for economies in the system. Every time a test or study is done which does not directly affect the management of the patient, we all lose. The present malpractice environment drives a hefty percentage of the tests and x-rays ordered by emergency room physicians and other practitioners. Our C. Y. A. (Cover your “you know what”) approach should be tempered with a modicum of common sense, however.

When I first started practicing in 1962. I repaired major complex wounds in the operating room. As time passed, I shifted increasingly to manage most of these wounds in the emergency room, trauma bay or at the bedside on the floor. There were several reasons behind this change. The environment where these wounds were repaired did not appear to influence the outcome and a significant delay could often be avoided by not using the operating room. The dollars saved by avoiding the operating room were astonishing. Occasionally a shortage of emergency room personnel would necessitate doing the case in the operating room.

The same philosophy is applicable to judgments regarding where to do minor surgical procedures. If the case can be done safely and without too much fanfare in the office, do it there. For more complex procedures a surgical outpatient facility should be considered, the latter usually being significantly less expensive than the regular operating room. In my experience, crossing the threshold of an operating room almost always adds $10,000 to the bill. Most of us have frequently seen cases such as excision of multiple nevi or closed reduction of a fractured nose scheduled in outpatient facilities or even in the operating room. I suspect that most of these cases could easily have been done in the office, at a great savings to the healthcare system.

Not infrequently, bedside repairs have been secondary to patients being transferred to the floor because of congestion in the emergency room or because the severity of the patient’s injuries necessitates careful monitoring. Working at the bedside, assuming adequate lighting, instrumentation and personnel are available, is essentially the same as operating in the emergency room or operating room, with the exception that the bed is significantly wider than a gurney. Consequently, bilateral wounds involve shifting the patient and drapes from one side of the bed to the other as the repair progresses. The final result appears to have much more to do with the judgment, skill and experience of the surgeon than the local where the surgery is performed, as noted previously.

One advantage of bedside repair is the teaching opportunity it provides. In the emergency room and trauma bay students are shifted from one trauma room to another and seldom have the opportunity to be with you long enough to receive any meaningful instruction. At the bedside, the atmosphere is different and if students and residents are not the around, you at least have an opportunity to discuss with the nurses and patient care technicians some aspects of postoperative care and reasons behind the orders. Also, the orders can be dictated to a nurse in attendance and later reviewed and signed by you, which saves a few minutes.

I have been criticized a few times for tying up a trauma bay too long, when dealing with extensive soft tissue wounds. The implication is that the case should have been done in the operating room. Often the trauma bay procedures were performed night or on the weekends and it could be argued that OR time should be prioritized for procedures which cannot be reasonably done elsewhere.

Physicians and hospitals have often been their own worst enemies when it comes to economics. The time is long past when either can ignore the cost implications of the way they function.

Some of our colleagues favor a single-payer system with complete government takeover, but most physicians prefer a free market approach. In those countries where healthcare is controlled largely or exclusively by government, the results have not been particularly good in terms of outcome or patient satisfaction.

The same government which continues to harp about the costs of healthcare, keeps contributing to the problem by imposing more inane, counterproductive and unnecessary regulations. Also, it has failed to address medical liability tort reform. Malpractice premiums may represent only 1% of America’s healthcare bill but the expense involved in unnecessary tests and studies because of the malpractice situation is astronomical.

Fifty years ago, physicians and lawyers who advertised were shunned and ostracized from their professional societies and generally held in contempt. Then the government, in its ultimate wisdom, stepped in, arguing that advertising would lead to reduced costs. Now the dollars consumed on ads in newspapers, phonebooks, magazines, radio and TV only add to the overall healthcare bill and the consumer is the loser once again.

In my opinion, in metropolitan areas, there is no excuse for not having hospitals devoted to particular specialty care. For example, having a hospital for trauma, one for orthopedics, one for obstetrics and gynecology, another for pediatrics, etc., could avoid each hospital having to purchase multiple, very expensive pieces of equipment. Also, such an arrangement would be much more convenient for physicians, who would not have to travel to multiple hospitals as now is often the case.

Physicians at long last appeared to have “broken the code” as far as the political area is concerned. They have come to appreciate that in Washington and in statehouses, money talks. Personal contacts are helpful but in the final analysis it is usually the color green that counts. Politics is a dirty game and always has been. Acknowledging this fact and not only living with it but making it work to our advantage appears desirable. The trial lawyers, who have the most powerful lobby in Washington, have long understood what makes politicians take notice.

Multiple factors are behind the upward spiral of healthcare costs-- new technologies, more expensive drugs, a massive amount of defensive medicine, the huge expense involved in the care of patients during the last month of life as well as the desire on everyone’s part to have the Cadillac rather than the Volkswagen version of healthcare. A dearth of common sense on both the part of physicians, patients and families are involved in this equation also.

The physicians who care for hospitalized patients are familiar with the “frequent flyer syndrome.” In communities of any size, there are multiple patients who are repeatedly hospitalized because of diabetes, obesity, dialysis complications, pressure ulcers, septicemia and a variety of other chronic and recurrent problems. Regardless of how stellar their care is with each readmission, which involves repeating a cycle of multiple consultations and “fine-tuning” of their status, it is almost inevitable that the patients will be presenting themselves to the emergency room again. There nursing home or home care situation is such that the same complications keep recurring. Often these patients are not seen in the same hospital, if there is more than one hospital in the area, on their next readmission, which further complicates the situation. How to best deal with this “frequent flyer” quandary is obviously a challenge. Having a physician or physician’s assistant monitor these patients with frequent home visits might be a solution. The expense involved in the frequent hospitalizations brought on by these patients greatly exceeds the cost of their frequent monitoring in the nursing home or at home.

In addition, in my experience, many patients are admitted who do not require hospitalization. Their problems could easily be managed as an outpatient. Having more precise criteria enumerated as an indication for inpatient care and more education on the subject might help. Also having an experienced physician and/or an emergency room admission office to clear all admissions might help.

In addition, algorithms regarding priority of tests or x-ray studies could lead to significant reduction in costs. For example, a CT of the facial bones is often ordered to rule out a facial fracture when two plain films of the head (a submental vertical and reverse Waters) will identify whether a significant fracture is present.

My belief is that whether the bureaucracy or the private sector is running healthcare, as physicians we have both a moral and financial interest in keeping healthcare expenses low. In the end, we are all directly affected, either through higher taxes and/or lower incomes. The government now controls a large percentage of healthcare through Medicare, Medicaid and the Affordable Healthcare Act. Hopefully, the latter will be repealed or significantly modified in the near future. In general, the government tends to have the reverse Midas touch - everything it touches tends to turn not to gold but to crap.

One rather indefinite aspect of the Affordable Healthcare Act and also of Hillary Clinton’s healthcare proposal was that if the study or procedure were denied by the bureaucracy it might be illegal for you to obtain it, even if you were to foot the bill yourself. Obviously one way to skirt this requirement is to seek medical care in another country. However, it is likely that only a small percentage of the population could avail themselves of this alternative.

Regulations such as the one referenced above, are in my opinion an absolute infringement on personal liberty and are to be abhorred. They constitute a type of government interference which sparks militias and which makes the right to bear arms so important. It is evident that I have very strong feelings on this topic but I would venture that a significant proportion of the population is an agreement.

The following chapters also will deal with logistics, e.g., the one discussing “instruments and items you may wish to carry with you.”

In community hospitals, it is often possible to obtain a surgical tech or nurse who has helped you frequently before and is familiar with your routine. Having such a person can greatly simplify the entire exercise of repairing wounds because such an individual knows your preferences in regard to room size, lighting, local anesthetics, sutures, etc. If you plan to sit during the repair, a padded stool is desirable. Two Mayo stands, one for your instruments and another for supplies, should be available. All these details, even down to positioning of the wastebasket, become part of the routine. Being assisted by someone who knows your preferences can significantly expedite the entire process and make your life much easier.