The price of a cup of coffee

In the wake of the coverage of inappropriate vascular interventions in the mainstream press, guest editorialist Adam Tanious, MD, tackles the thorny issue of interactions with industry “reps”—particularly among younger surgeons. 

Many of us in the surgical community have had an emotional response to the recent New York Times article describing the questionable practices of some of the members of our medical community.¹ Against this backdrop, as I look to tackle the subject of interactions with our industry partners as surgeons/ interventionalists, a few disclosures: 

• I have many positive relationships with my industry representatives 
• I have never received any form of payment from any industry partner
• I have just completed my MBA, taking specific courses in sales and marketing

Next, I’d like to define our terms. When I say industry, I am referring to both the publicly-traded and privately-held companies that make and manufacture devices that sparked a revolution in minimally invasive surgery we have been enjoying over the past two decades. More specifically, I am referring to the device representatives at the local level who are responsible for knowing their devices and make themselves available to assist surgeons/interventionalists in using these devices correctly to achieve the best outcomes for patients.^2,3 

For those newer to the world of industry, there are two main people you will work with at the local level as it pertains to industry: your local device representative and your “clinical” representative. A device representative is, by and large, a sales representative. They are required to have expert knowledge of their device and are expected to meet certain sales targets, with one key goal of expanding the sales in their respective territories. A “clinical” is a local representative who carries expert knowledge of the device or product in question, and is immediately available to clinicians to help with proper use and troubleshooting of said device in a clinical setting. They are not held to the same “targets” as their sales representative counterparts. However, based on which company you are discussing, there is likely a mutualistic relationship between a territory’s clinical and sales representatives (collectively referred to here as “reps”).^2–4 

Let us delve into the relationship our specialty has with industry and how it affects surgeons in their day-to-day practices—with a particular focus on being a young surgeon/interventionalist. 

The relationship starts during training. Depending on your training institution, you are exposed to various interactions between your attendings and their industry colleagues. Reps are always excited and engaged when meeting trainees. These interactions usually happen over a much-needed cup of coffee bought by your reps. What proceeds is, hopefully, a very fruitful and positive relationship whereby your rep teaches trainees about the device they represent and its nuances, and appropriate instructions for use. Throughout our course as trainees, we become very familiar with our reps, and often engage them regarding cases where their device is going to be used. 

As a trainee, I did not appreciate at the time how much the way my attendings interacted with their reps influenced the way that I interact with reps as a young attending. This is something not discussed enough from an educational standpoint. We as attendings need to realize that trainees are watching not just how we operate or interact with the operating room (OR) and hospital staff—they are also looking to us for guidance on interacting with our industry partners. As a young intern and junior resident, I remember being incredibly quiet and simply observing the interactions of everybody in the room when reps and attendings were together. Even though I had grown up in a household raised by a rep in the world of finance, seeing this interaction in the field of medicine still did not add up—for profit companies side-by-side with physicians. 

After graduation 

Fast-forward to when trainees are ready to graduate: I recall this time in my life vividly as it is something you’ve been anticipating for the better part of a decade. Once you have decided on where you will go to practice, the inevitable invitations for a “handoff dinner” start to arrive from your local reps who are familiar with those at the location of your future job. These dinners are lovely and really a time to interact with people in a new city where you may have never lived. These dinners offer an opportunity to put a face to the name behind the person you will likely be calling on in the middle of the night during some aortic emergency, when you still have yet to figure out the hospital system, or the inner dynamics of the OR. Additionally, in most job settings you will need to be calling on your reps for a large portion of cases, as you may not have the necessary product available at your hospital to perform your desired procedure. 

While these practices may sound questionable to a layperson reading this article, everyone must understand that these interactions go hand-in-hand with our ability as a medical community to provide patients with a “minimally invasive” option for surgery. There are very few patients who, when presented with both an open and minimally invasive surgical option, opt for the maximally invasive option. Our relationship with industry is often necessary to provide the care that patients want. 

Additionally, reps have access to resources above and beyond what educators are given to help teach and train the next generation of surgeons and interventionalists. Industry has the power to help fund conferences and educational seminars where experts are allowed to teach their clinical knowledge to a large forum of future practitioners. I can personally attest that these are invaluable teaching and training opportunities that individual training programs just cannot be expected to provide.² 

Rep ‘support’ 

Now comes the hard part of being an attending—and the hard part of this article. What happens during the cases where industry representatives are not needed but can help “facilitate” cases? Reps often offer to be present for cases to “support” the case. This typically happens when you are treating a particular category

of disease that has a multitude of treatment options (i.e., peripheral arterial disease). Stated plainly, having a rep present for a case where you have multiple device options to choose from to effectively treat your patient has the strong potential to sway your decision.^2–5 

My question to everyone reading is this: should we put ourselves in a position to be swayed? 

When I have predetermined the need of a particular product for a given case, I will always call upon a trusted rep with many years of experience to be present. Reps see their product used several times a day, every day of the week. It would be wrong of me to assume that level of experience with any device, as our jobs call for us to be experts in many different types of procedures, using an array of different products. As a junior attending, newly managing so many different aspects of the OR environment, why would I not welcome additional expertise that is available to me when I have predetermined a specific tool I plan on using anyway? 

What we as practitioners must understand is the strategy to sales. Anyone with a knowledge of sales and marketing should understand that, more often than not, sales reps sell themselves, not just their product.^2–6 While I truly believe that it is in the nature of every rep I have worked with to be extremely helpful and engaged in the OR, we must also realize that this is a sales tactic. The more buy-in we are given by reps during a case, the more we are likely to use their product. This extends to the cup of coffee and the meals bought for us before, between, or after cases.^3,4,6 Taking it a step further, there will always be more aggressive reps who try to “actively” sell you on their product. It has happened to me personally. 

This is not to say that the majority of device reps I have worked with try to actively sell during a procedure. In fact, many of the device reps I work with are the first to pull other competitors’ products during a case if it will serve the patient best. What I am saying is that there is an interaction that occurs that has meaningful outcomes for all parties involved. More importantly, it may be harder to anticipate these interactions as freshly minted attendings than we give credit to during our training of future surgeons. 

Who belongs in the OR? 

As I have grown as an attending, my ability to recognize the nuances of these interactions has evolved rapidly. Additionally, having senior partners who have good relationships with reps has also helped. Moreover, there is an earned confidence that comes with being the primary decision-maker responsible for a patient’s care that cements the relationship between physician and rep. 

My goal here is not to provide an answer for young attendings about how to interact with industry. Rather, my aim is to start a conversation. What I think we as practitioners need to be better about is controlling who belongs in the OR. While it is not possible to know every potential problem we will run into during a case, as practitioners we should be better about deciding what tools and devices we anticipate using for specific pathologies, and ensure that, no matter who is present during a case, that our plan for our patient is not swayed by individuals who are ultimately hired to support a particular product. 

More importantly, we as attendings should be actively engaged in teaching our trainees about all the tools we use, and be a sounding board for our trainees about the merits and pitfalls of these devices in conjunction with our industry colleagues. We must provide clear guidelines around the interaction between medicine and industry for the younger, more susceptible minds among us. 

So, will I continue to have device representatives present for various cases? Yes. Will I plan on the particular device I want to use for each case before deciding on which rep to call? As often as possible, yes. Do I want my trainees to interact with and learn from my reps? Absolutely—with an attending present. If an industry representative asks whether they can come to my next case “to support me,” will I let them? I can honestly say that, in this regard, I am on the fence. 

References 

1. Thomas K, Silver-Greenberg J, Gebeloff R. They Lost Their Legs. Doctors and Health Care Giants Profited.pdf [Internet]. New York Times. 2023. 
2. Chung KC, Kotsis SV, Berger RA, Ummersen GV. The Relationship Between Industry and Surgery. J Hand Surg 2011;36(8):1352–9. 
3. O’Connor B, Pollner F, Fugh-Berman A. Salespeople in the Surgical Suite: Relationships between Surgeons and Medical Device Representatives. PLoS ONE 2016;11(8):e0158510. 
4. Lively C. The Dual Role of the Medical Device Representative. Voices in Bioethics 2020. 
5. Grundy Q, Hutchison K, Johnson J, et al. Device representatives in hospitals: are commercial imperatives driving clinical decision-making? J Méd Ethics 2018;44(9):589–92. 
6. Moed BR, Israel HA. Device Sales Representatives in the Operating Room: Do We Really Need or Want Them? A Survey of Orthopaedic Trauma Surgeons. J Orthop Trauma 2017;31(9):e296–300. 

Adam Tanious is an assistant professor of surgery in the Division of Vascular Surgery at Medical University of South Carolina in Charleston.