As a young medical officer in the late 1980’s I frequently did locum at different General Practice clinics. At that time, many clinics reused sutures soaked in antiseptic solutions. Sutures were expensive and so by re soaking excess sutures and reusing them, cost could be contained. I am sure most patients with skin injuries sutured with these sutures did well. I am also certain that this is not practiced nowadays since sutures have become cheaper.
Fast forward several years, when I started private practice in 1994, most of my patients were cash paying patients. Medical Insurance was not common at that time. There were very few disposable instruments. Most of the laparoscopic instruments I used were reusable instruments. Whenever I used disposable instruments during laparoscopic surgery, I would reuse them to contain cost. This was common practice at that time. Disposable instruments were expensive and it was considered a “sin” to throw them away after single use. Morever, environmentalists complained that we were creating more rubbish. So disposable instruments were cleaned and resterilized with Ethylene Oxide Sterilization. Only when it was not functioning well anymore was it thrown away. A pair of disposable laparoscopic scissors or trocar could be used up to 8 or 10 times. Later, manufacturers of instruments begin to learn that there was not much money to be made with reusable instruments.
Who decides whether an instrument is disposable or reusable? There are no governing bodies in any country to decide whether an instrument should be a disposable or a reusable one. The manufacturers decide that themselves. So they started making more and more disposable instruments. Any new innovation will be a disposable instrument because more money is to be made. Even some reusable instruments were later labelled as disposables. There is no innovation in reusable instruments. This has made laparoscopic surgery more and more expensive.
Reusing disposable instruments is not only common in the government and private hospitals in Malaysia; it is also done in the USA. There are 2 issues to be concerned about when reusing disposable instruments. The first is, the risk of infection and the second, the risk of performance. Hospitals have staff to access that the 2 issues are addressed before reusing these disposable instruments. These have been done well for many years in my practice. However, in some countries (eg USA) the process of recycling disposable instruments is taken over by third party companies. These companies buy the disposable instruments, check to ensure that they are functioning well and then resterilize them and sell them back to the hospitals at a cheaper price. I believe this is not practiced in Malaysia.
Another innovation by instrument manufacturers is “reposable” instruments. Here, the handle and shaft of an instrument is made reusable but the tip is disposable. A common reposable instrument is a pair of laparoscopic scissors, which gets blunt rather fast and has to be changed frequently.
Some instrument makers have become smarter by making instruments that cannot be reused. There are several ways they do this and three of the most common techniques are: mechanical use-limiting, single wire/electric limiting, and radio frequency identification limiting (“RFID”).
In order to show the public that they have quality management, most hospitals try to acquire accreditation from different societies. In Malaysia we have the MSQH (Malaysia Society of Quality Health) and there is the International/American standard called JCI (Joint Commission International). One of the criteria used by these societies is to not reuse disposable instruments. Sometimes I wonder whether these societies are sponsored and supported by the manufacturers of disposable instruments, so that they lobby for the ban of reusing disposable instruments.
In Mahkota Medical Centre, we had a team to handle the reuse of disposable instruments. Until December 2019 we were allowed to reuse disposable instruments after the instruments had been thoroughly checked for proper function, cleaned and re-sterilized. After we successfully obtained the JCI (Joint Commision International ) accreditation, we were no longer allowed to reuse disposable instruments. Many of us had to change our practice to accommodate this new policy. The cost of surgery skyrocketed because of this policy. I personally had to adapt to not use disposable instruments as much as possible but sometimes it is difficult. For example, we had a reusable morcellator for morcellation of fibroids after laparoscopic myomectomy. However, the company that manufactured this morcellator stopped producing this instrument and would not repair the morcellator that we had been using for 10 years. As such, I had no choice but to use an expensive disposable morcellator, which raised the cost of the surgery significantly.
I have always had instrument company representatives telling me that I should use their products especially for insurance patients, as this would make my surgery easier and faster. I am not denying that some disposable instruments are so well constructed that surgery becomes a pleasure to perform with these instruments but this comes with a cost. I am always weary of opening a package with such instruments especially when performing simple cases when I can get away with just using reusable instruments. The worst thing that can happen is that I get so hooked on to using these disposable instruments that I feel handicapped without using them. I try my best to avoid being a slave to such disposable instruments.
So what advise can I give doctors moving from the government hospitals to private practice.
- When in government hospital, one does not think of wastage of disposable materials such as sutures and disposable instruments. In private practice disposable instruments add to the final bill of the patient. Learn how to be frugal with usage of disposables. Learn to work with reusable instruments so that it becomes a habit. This habit will help you keep cost down when you move to private practice. You can be wasteful in the government hospital but not so in private practice
- You should never let yourself to be dependent on a disposable instrument in your practice. Always be comfortable with using basic reusable instruments,
- Choose to work in a hospital that does not have restrictions of re- usage of disposable instruments. You will have a chance to keep the cost down and offer your services to a larger group of patients especially patients who do not have medical insurance
- Even if instrument companies tell you that insurance will pay for usage of disposable instruments and you can use their products, be careful. Insurance companies are always watching and want to keep their cost down. By being wasteful in opening disposable instruments indiscriminately, your practice will increase the cost of the surgery and the insurance companies who are always watching, may “blackmark” you for having the highest cost of a surgery in your selected field.