How do you define your self-worth? I realize that may seem like a question better suited for a college philosophy class than a urology blog, but I recently had an experience in the OR that made me think about this. I also think this question has implications for health care policy makers.
I had just completed a left hand-assisted laparoscopic nephrectomy for a 9-cm renal mass. The patient was a man in his 60s with a history of a car accident decades ago status post-exploratory laparotomy and splenectomy. The mass had a R.E.N.A.L. nephrometry score of 10p. The case certainly had its own challenges, but 3 hours later the specimen was in a bag and I was sitting at the computer in the OR entering orders while my first assist closed skin.
I was sorting through the paperwork looking for a pen when I saw the equipment list the OR staff used to prep for the case and noted that next to each item was a column listed as “charge to patient.”
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I was amazed. The 4-0 monocryl I used cost $139.11. The gel hand port $495.00. The stapler I used to take the hilum cost $934.98 (each reload $348.91), and the LigaSure I used cost $2190.00. I remember chuckling to myself and moving on. It wasn't until later that day when I was submitting the paper bill that I realized that the wRVU for a laparoscopic nephrectomy was 25.06 and when using the Medicare conversion factor of $35.8279, that means that CMS values my portion of the case at $897.77.
Which makes my self-worth just under one stapler (without a reload). Or 41% of one LigaSure. Really?
Now I realize there are various forms of financial compensation available to surgeons and there’s variation in the valuation of a wRVU (I’ve seen advertisements as high as 75 per wRVU for people working in Fargo), but 36 per wRVU is likely ballpark for the majority of us small-town plumbers.
What does this have to do with the health care system in general and why is asking this question important to the powers that be when it comes to thinking about how to design an efficient health care system? Think about the decisions that go into surgery.
For example, let’s take that same 60ish-year-old man with a significant abdominal surgical history and a 9-cm enhancing renal mass. Why me? Should I have referred the case to the tertiary care center about an hour away? I know they have a great hotshot surgeon who almost for sure could have done the case faster than me. That would have saved OR time and hence money.
What about the approach I chose? I chose a hand-assist laparoscopic nephrectomy but I know of guys in town who use the robot for just about everything. How about pure laparoscopic? I felt safer with my hand in the abdomen but his risk of incisional hernia is likely higher as a result. Why not do the case open? Think of the extra gear that I used (and money spent) by my choice do to this in a minimally invasive fashion.
Yes, a flank incision carries more morbidity, but was it worth the cost? Should I even be contemplating these questions or should I just declare that I’m the surgeon and I’ll do what I think is right?