The importance of learning “the business of medicine”

Joshua Abrams

The rapidly changing healthcare environment poses a substantial amount of challenges. In the USA, this environment has shifted from surgeon preference and surgeon-driven expenditures to hospital mandates and, by extension, government-run insurance policies, as a vehicle for establishing a standard of care, writes Joshua Abrams.

What does this all mean? The bottom line is that we need to adapt and learn the “business of medicine”. You will begin seeing your peers use more innovative ways to cut costs and increase efficiencies. Additionally, we will move towards procedural standardisation to replicate these efficient methods, and publish more studies to support these new practices. A growing trend is for hospitals and physicians to manage cost-sharing and quality metrics. These “co-management” relationships work to improve the hospital’s quality and efficiency in specific areas that matter most to physicians. These areas tend to effect reimbursement and, ultimately, physicians’ ability to treat patients effectively. Hospitals also benefit from the added effort and participation of physician risk-sharing partnerships.

Cost containment of products and implants is one arm of cost efficiency. On a local level, this can be moderately efficient. However, on a national or global level, one could argue that this may hinder product development and future industry development. Rather, partnering with product industry can also provide opportunities to develop cost-containment strategies.

Within the operating room, there is undoubtedly an exorbitant amount of waste—commonly discussed among surgeons and operating room personnel. This provides an opportunity for improvement in time and cost efficiency. It is time to focus on the much harder, yet much more monetarily advantageous, process of increasing efficiencies in the operating room. This not only includes equipment, but personnel and, most importantly, processes that will allow for a maximum return on hospital investment. As a surgeon, that all begins with you.

How do I make myself more efficient in the context of the business of medicine? As I reflected on this ever-evolving question, I thought of minimising and standardising my implants and instruments so I could limit waste and maximise efficiency. What metrics could I use to truly see the difference? However, once I began planning a study on the topic1,  I quickly realised that time saving and efficiency involves not only the entire operating room staff, but also anaesthesia, industry representatives and even the sterile processing department (SPD). The cost of sterile processing per tray is approximately US$125, which varies among hospitals. Simply consolidating trays led to a chain reaction of paring down and standardising instruments and implants.

Our study and focus was placed on tray reduction on specific procedures, namely minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF), lateral interbody fusion with posterior instrumentation (LLIF-P), and anterior and posterior interbody fusion (ALIF-P). For each procedure, instrument reduction and tray consolidation led to substantial sterile process cost savings. For example, MIS-TLIF trays were reduced from 16 trays to four trays—a cost saving of US$1,500/case. These modifications were studies for each of these three procedures over six months. The collective tray reduction can be extrapolated to be 1,572 trays annually or nearly 20 tonnes of tray weight that the operating room must process and store. This also equals nearly US$200,000 in cost savings on processing alone. Tray reduction removed considerable strain to the staff, hospital and SPD.

“It is time to focus on the much harder, yet much more monetarily advantageous, process of increasing efficiencies in the operating room” – Joshua Abrams

During this study, time metrics were tracked across 12 different time stamped start and stop points. Instrument consolidation and tray reduction led to significant time savings including post-improvements. A reduction in “per case” time averaged 52 minutes for 12 time stamps, including operating room set-up time, anaesthesia time, cut-to-close, and clean-down time. This included an 18-minute improved set-up time, 17-minute clean-down time,  and a 17-minute cut-to-close time.

All this sounds intuitive, but it required a deep level of commitment by all. The best outcome of the study is that this is now the standard in my operating room.

The benefits to the hospital can be measured two-fold; not only less time spent in the operating room—which allowed us to do more cases in a day thereby generating more revenue for the hospital using exactly the same resources—but also the huge cost-savings in tray sterilisation on every case that I do.

So you may ask, where are we heading now?  There is still much self-evaluation that needs to be done as I take an even more critical look at exact instruments I am using, in what order, and number of passes, to continue and increase my own efficiency.

But, the much larger picture is how to work with industry to decrease the strain they put on the system to meet our requirements, and how to reconcile that in the larger hospital setting as a major advantage and cost-saving.

Industry, hospital and sometimes even surgeons seem to be on opposite ends of the table when it comes to resolving issues that impact all of us. At the end of the day we are all part of the healthcare continuum and need to find ways to more effectively partner on mutually beneficially projects which improve the quality of healthcare delivered to the patients, and at the same time being safer and more efficient when delivering that care. Understanding the business of medicine is a win-win for all involved.

Joshua Abrams is an orthopaedic surgeon from Phoenix, USA


1. J Abrams et al. Maximizing Operating Room Efficiency in Spine Surgery: A process of Tray Consolidation, Instrument Standardization and Cost Savings. Presented by J Abrams at the International Society for the Advancement of Spine Surgery Annual Meeting (ISASS17; 12–15 April, Boca Raton, USA).


This article was originally published in issue 44 of Spinal News International



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