From the Editor: The elephant in the operating room


Once again hospital administrators in their never-ending quest to reduce expenditures have placed vascular surgeons at a disadvantage. First they reduce the inventory of necessary items. Now they want to keep sales representatives out of the operating room. Their thought process is industry representatives will seduce us to use an expensive product which we otherwise would not consider using. Further, companies build support into the cost of their devices. Thus they would be expected to reduce prices if their personnel were no longer required in the OR.

Administrators as well as many lay public must also wonder why a nonphysician representative of a device company should be present in the operating room. This is certainly a valid question. The answer requires an understanding of how the complexity of vascular interventions has evolved in the era of endovascular procedures.

The vascular surgeon of yore learned basic vascular skills of dissection, excision, needles, and thread which could be applied with equal skill throughout the vascular system. Although they used multiple conduits as grafts, the technique of sewing an anastomosis was a general skill. Then, as surgeons still do now, they needed to know the benefits and drawbacks of the various graft materials and sutures. However, they certainly did not require a company representative to be in the room nor to instruct them on how to sew in the graft or how to deal with a broken suture.

But now vascular surgeons use wires, stents, catheters, balloons, lasers, and drills. When I last counted there were at least eight different companies selling aortic endografts and promoting never-ending variations or replacements for their ‘last year’s device.’ Often the advent of a new device produced an expanded repertoire of new procedures each with their own specific nuances many of which were device specific. Accordingly, it is essential that a surgeon become experienced with the new device in order to prevent or overcome glitches that otherwise might result in serious complications.

However, only the busiest vascular surgeons or those specifically involved in industry-supported trials may ever achieve sufficient experience to be able to use all these products. Certainly, a surgeon may elect to become familiar with just a few of the available choices. However, occasionally a specific indication may require them to use a device they seldom utilized. For example only certain endografts can be used in short or angulated aortic necks.

It must be stated emphatically that surgeons should be completely comfortable with the device and its instructions for use. It would be entirely inappropriate for a vascular surgeon to enter the operating room so ill-prepared as to require the company employee to walk him or her through the use of their device.

However, since some surgeons may have limited experience it would be beneficial to have someone else present who has more familiarity with its use. It is true that most companies have technical advisers who could come to the operating room but they are far and few between. Accordingly, sales representatives are well suited to be the other knowledgeable individual.

Most companies train their sales persons to have the core knowledge to function as advisers. They are well schooled in their device probably even more so than most surgeons. They know all its indications and the dangers in using the device outside of the instructions for use (IFU’s) published by the manufacturer. They also know the subtleties that make the device work more optimally. Many will have witnessed complications and so they will have learned how to overcome them. In some instances their accumulated knowledge may forestall an incorrect insertion or manipulation of the device. Of course salespersons will not have performed procedures themselves but most will have learned by attending many procedures, usually far more than performed by any one surgeon. Is it a coincidence that ‘rep,’ the diminutive word for representative, is the same word for the shortened form of ‘repetition?’

Once a trusting relationship develops between the surgeon and the sales rep, having both in the operating room can mean the difference between life and death for the patient. The security gained by knowing there will be another experienced person in the room is reassuring and should be reassuring to the patient and to the hospital administrators as well. After all, what is worse for the surgeon’s reputation, the hospital’s bottom line, or more importantly the patient, than an unnecessary complication that could have been easily avoided by a few cautionary words?Even when I use a device I have used many times, it has not been unusual for the sales rep in the operating room to help me work out a difficult portion of the procedure. How reassuring it is to have another educated adviser in there with you. Professional tennis players have their coach in the stands. Dr. O. William Brown, our associate editor, makes the point that even professional golfers have their caddy with them on the course. The caddy does not hit the ball nor play the course just like the rep does not touch the patient nor do the procedure. However the caddy (rep) knows the course, the player, ball and clubs and can read the greens and knows the distance to the hole. Advice from the supporting caddy can make the difference between winning and losing. Advice from the rep can save a life.

I used an automobile analogy in one of my last editorials and there is one which applies here as well.

Almost all of us by the time we are in our 30s or 40s can drive safely. However, when we buy a new car the sales person drives with us the first few times so we may become comfortable with the new features. When it comes to driving so-called exotics like a Ferrari or Lamborghini, potential buyers (such as hospital CEO’s) will go to a special track where they will drive with an accomplished company driver before they feel safe to drive the car on their own. The company drivers know the limits of their car and they know the limits of drivers unaccustomed to advanced automobiles. Press the gas pedal too soon or push too hard on the brake pedal and the car will spin out of control with fatal results. In the operating room, press the wrong button or push too hard and the device may deploy too soon and the procedure may spin out of control also with potentially fatal results.

It seems to me the whole controversy revolves around the phrase “sales-representative” since it implies at all times their sole goal is to increase sales. Perhaps if they were simply called “representatives” there would be no issue. Yes, it may be true that in some instances the selection of a device may be based on the relationship a surgeon has with a company’s sales representative rather than the quality of the company’s device.

However, administrators are misguided when they consider excluding the sales rep from the operating room or endovascular suite will achieve cost savings. Usually the decision to select a company’s device was made many days before the procedure. If the rep was going to influence the surgeon, it would have been done prior to the surgeon entering those sacrosanct spaces.

Thus, in their never-ending onslaught on cost, administrators who restrict sales reps from the operating room may be impeding quality care. Accordingly, ‘“the elephant in the room” may not be the sales representative but rather the administrator in the office down the corridor.

Dr. Samson is a clinical professor of surgery (vascular) at Florida State University Medical School, is president, Mote Vascular Foundation, Inc., and is an attending vascular surgeon, Sarasota Vascular Specialists. Dr. Samson also considers himself a member of his proposed American College of Vascular Surgery.


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