Friday, June 15, 2007

Details, Details

Having posted most recently about those bad -- if lovely -- drug and equipment reps (also known as "detail" reps), wouldn't you know I'd work with one today? It reminds me there's another side of the coin.

There was a scandal a few years ago when it was made known that salespeople for orthopedic prosthetics (hips, I think it was) were actually doing major parts of some operations -- fitting and inserting the joints because the surgeons weren't familiar with them. I never have, and never would allow such a thing (nor is it allowed anywhere, anymore), but there are times I've welcomed such detail folk into the OR. Most of them know their products very well, and when there's some sort of new wrinkle, it's nice to have them around. Here's the likely scenario:

Joe's Surgical Supply and Auto Shop comes up with a variation on a stapling device. Or an electrocautery unit, an adhesive dressing. They contact the hospital, or surgery center, and gain permission to show up with their device. Most often, they're hanging out in the surgery lounge when I arrive to do an operation. Sometimes, their impending presence has been announced: next week the rep from JSS/AS will be here to demonstrate a new foofratz. I look it over. In the case of staplers, which are extremely handy in certain situations, and which are quite regularly improved in terms of ease of use or extra features, I'm more than open to the latest innovation. If the demo looks promising, I'll let the rep know when next I'd be doing an operation for which it could be appropriate. They're there early the day of the operation, usually bringing doughnuts or pizza for the nursing staff. Who'd begrudge that?

I know how to staple bowel and when to do it. I know the various techniques, the tricks, the danger zones. But with a new instrument, I may not know how the re-designed handle works, or how to get it to bend in the newly-invented way. So the rep is there, in the OR (with the patient's permission!), and when the time comes he or she can give some instructions. From the sidelines: NOT scrubbed in. It's helpful, and I don't see it as any sort of breach of propriety. Sometimes I find the new item is no better -- and/or more expensive -- than what I've been using. Other times, it turns out to have major advantages, in which case I'll tell the OR it'd be nice to have them available (which may or may not happen!) It's even transpired that, after input from me and many others, a rep will get ideas of how their product could be improved and will take those ideas back to the shop. It is, I think, a mutually good thing.

Rants about over-use of staplers aside, I think I've made it clear I find them very handy in several situations; and I've always been impressed at the brilliance of the latest advances and the speed with which they occur. Reading about it isn't enough to decide; nor is it necessary -- given the fact that it's a trickle as opposed to a sea-change -- to take a course in the use. Having a knowledgeable rep around is just right.

One of the coolest improvements in a common technology of recent vintage is the development of "spray" mode for electrocautery. Electrically zapping something that's bleeding is generally quick and effective (assuming it's not the sort of bleeding you can hear, in which case you better have a big clamp handy.) But there's a problem: until recently it was usually necessary to touch the end of the cautery "pencil" to the tissue being cooked; and that tends to create a sort of black gob of charcoal glue, such that when the grilling is over, pulling away the pencil can pull away the char, and bleeding resumes. That's especially true for liver or spleen. You may have to try to control the bleeding with suturing, but those organs don't hold a stitch all that well. So when a rep hanging around the lounge approached me with his unit (should I rephrase that?), I was interested. It's perfect for liver and spleen, he said, because when you set it to "spray" and hold it close to the target, a broad electric arc jumps from the device to the bleeding area without the need to touch the two together. By golly, I had a gallbladder operation to do that very day, and it's not rare that a little bleeding needs attention where the gallbladder comes off the liver. It did, I did, and it did. Fantastic device, and I was glad to have the rep there to show the nurses how to set it up. Been using it ever since. And by the time I was finished that first time, all the doughnuts were gone.


Anonymous said...

All you guys got were donuts?

Francis Bacon took bribes when on the exchequer and his excuse was: "yes, I took them, but I didn't act on them." And that guy invented the scientific method!

Many doctors think that medicine entitles them to a high income as it did in the old days, but a bribe's a bribe.

Drug companies spent about 18 billion last year influencing doctors; you can be sure that doughnuts weren't the coins of the realm.

Bruce said...

Reps in the OR...

Positive example: We have a great rep that shows up for cases where we use hardware for mandibular reconstruction or facial fractures. It shortens the cases and decreases everyone's frustration level.

Neutral example: The reps for self-explanatory cutting devices ask you to try their new toy...only to find out later that the non-reusable clumsy device handle will cost each patient several hundred dollars should you ever decide to use it again.

Negative example: As the cuting device rep is leaving the OR, she tells your charge nurse to "put the XXX instrument on the doctor's preference list so he will have it for every case." Wrong.

Love that flamethrower image!

Anonymous said...

when people who are not part of the operating team are in the OR, observing or whatever, is it the surgeon who allows them in or does the hospital have to give permission?

Sid Schwab said...

In general, permission is required of the patient, the surgeon, and the hospital. That's how it is now: wasn't always that way.

Greg P said...

People get unnecessarily in a lather about all of this. This is the way the business world works and will continue to do so. Financial institutions make huge sums just by arranging for money to move from one place to another.

I recall hearing a story about Bishop Sheen, when someone asked him about how he could have a private limo as a Catholic priest. He said, "I never took a vow of poverty."

If one wanted to try to rigidly live their life this way, then you should never accept anything for free from anyone. Don't accept gifts even from your own family. Don't accept discounts on anything either -- they're just bribes. Don't buy anything from any salesman either -- he gets a bribe for selling it to you. In the hospital where I work, a medical equipment company gives out free newspapers to any patient that wants one -- I guess we better stop that.

To a large extent, doctors need the information they get from reps, doctors can give useful information in return.

Now "18 billion dollars" -- rather than simply trying to make as big a pile as one can, let's get realistic. I think we could say that 18 billion dollars includes things like ads in medical journals, sponsorships of various medical meetings, lots of free samples that patients benefit from, maybe even DTC advertising -- certainly not 18 billion dollars going straight to doctors. We're not in the corporate world or in government where kickbacks are rampant.

For many of the things I treat, finding a drug that helps is a trial-and-error process. Samples allow me to do that at no expense to the patient. And how else can I evaluate a new drug other than use it?

Anonymous said...

My original letter sounds aggressive. I'm sorry about that.

I am one of these fellows who is in a lather about all of this.

It's not like an NBA player who is paid to wear sneakers as a way to get Nike shoes sold. The consumer is still free to make a choice in that situation.

The doctor decides what is prescribed, and it is horrible to think that his decisions are sometimes based on bribes. Maybe he doesn't even take money from the company but reads the reviews from other doctors who have...

Why don't they make a nice website for each drug: quicktime lectures, mountains of technical data, detailed FAQ section, maybe in the background a picture of some golf course.

Dr Schwab tacked on glibly about donuts as if that was the typical extent of drug company influence.

Sid Schwab said...

Seems to me it takes the ignoring of my previous post and a pretty narrow reading of this one to conclude that I'm glib about drug companies and their influence. And the current post is about the maker of surgical instruments, not drug companies; I think I made clear how the relationship works.

Anonymous said...

Dr. Schwab:
Pay "Site Lover" no mind. I bet my left gonad he's of the "Pharm Free" ilk. They are the "PETA" of the medical community--everyone sees the bold examples of a single day of unity or the like but in the end, their tale is full of sound and fury, signifying nothing.

Also like PETA and similar, organizations, the germ, the nucleus of the original rationale makes sense, perhaps even is worthy of action, but it goes way too far.

What gives "Mr. Small Problem" away is the very fact that he keeps referring to "drugs" and "drug companies" when the post is obviously about medical equipment.

More on my thoughts on this in one of my previous posts.

And now a word from our sponsor...

Anonymous said...

Now that I got that off my chest, about the post...

I think this was a great topic. Writers' block, indeed! I only saw detailers in the OR twice in my observational time. Once was a standard "check-up," and it was very clear that it was a mutually beneficial way for surgeon and rep to chat, since the alternative would have to arrange precious (and always shifting) time outside the OR. It still smelled a bit "funny" (no, it wasn't the Bovie), though, having a complete outsider in the OR. I later learned that the guy was like a 1st-assist surgeon tech for years and years before he went suit-and-tie.

The second time, another guy was coming in to follow up on a prior meeting which I wasn't a part of to discuss some graft material they use for big vascular surgeries (when you can't simply harvest a vein, like an AAA or a large ileofemoral bypass or the like). They talked back and forth during an AAA repair and the rep was getting some real-time feedback on its use. I doubt that the company could have benefitted much more than that, since the surgeon would have otherwise had to remember all about the issues, write them down, etc.

I'm sure there are always those types in a slick suit offering some surgical snake oil, but 1) you're dealing with a pretty heady, no-nonsense bunch to begin with (surgeons of all varieties), 2) you can't bullshit a surgeon on the mechanics of a device that can be held,inspected, etc. in his/her hands like you can on a drug with dizzying tables/graphs, etc., and 3) even simple staplers are expensive--both sides have a mutual need to be no-nonsense--it's not like throwing a bunch of Avandia samples in a shopping bag and calling it a day.

OK, I've reached my comment quota for the day. :P

Anonymous said...

Per Anon's question: I work in a hospital, but in a job w/o patient contact. A while back (pre-HIPAA), I was able to ask surgeons to observe when they had interesting cases - and as a surgery neophyte, I thought just about anything was interesting. Or, I could just ask at the OR desk what was going on and get permission on the fly.

Fast forward to now: The last time I requested to observe I was told I needed persmission from the medical director, the head of the OR, the patient, and whomever would be on the surgical team that day. Too many hoops. I'm bummed, but forever grateful for the surgeries that I was privileged to observe in the past.

Anonymous said...

I am a disgusted now divorcing wife of a sales rep for medical equipment. I am appalled by the things doc's ask for in turn for promising to buy equipment. I have heard the reps will buy the docs drinks in topless bars, watches, drugs(they like their cocaine!) On top of it all they as for the reps to buy them whores. My husband is now a different person thanks to these disgusting so called doctors that take an oath to do what is right for the patient, not which company can buy them the best whore!! Its disgusting and the surgeons, MD's and sales reps should be ashamed of themselves ( Im sure they arent!) What a bunch of pathetic excuses for human beings!!