“Look at every path closely and deliberately, then ask ourselves this crucial question: Does this path have a heart? If it does, then the path is good. If it doesn't, it is of no use.” ~Carlos Castaneda

Tuesday, May 15, 2007

He is dead to me ....

“Everything that irritates us about others can lead us to an understanding of ourselves.”
~Carl Gustav Jung

It is rare that orthopaedic surgeons know much about medications beyond the 2 antibiotics (Ancef and the other on when they are allergic). We occasionally know several NSAIDS and other post-op pain medication. If a patient is on more than Prevacid, we are likely to get a medicine consult because we have no idea what that new cardiac medication does. So, we rarely are visited by the well dressed pharmacy representative. (Well, ever since the who Vioxx debacle.) Orthopaedic surgeons are a high user of equipment, particularly implants. Therefore, we are always being visited by implant representatives, Zimmer, Styker, Medtronic, Biomet, Depuy. They bring their bagels and their new fancy devices just approved by the FDA through X amount of clinical trials. They keep scheduling you meetings to talk to you about new technology; take you to dinner to wine and dine you with a "special" lecturer. They smile and talk to you like a stripper wanting a 10 dollar tip. So, how should choose your implant company? My opinion is you choose the one with the best representation. Let me explain.

I do spine cases. Spine implants cost a lot of money and the rep gets a percentage of the money from each case. Let me give you an idea of dollars. A pedicle screw costs about ~$400-1000 per screw; a rod cost ~$500; and a cross-link~$1000 . I do scoliosis cases. On average, I will use 15 screws, 2 rods, and 2 cross-links (~$15,000-20,000/case). The rep gets 5-20% of that amount depending on where they are in the food chain (~$750-4,000/case). Because of the amount of money and the number of companies, they are always trying to get you to use their implant.

Now, I can tell you that most of the companies have the same "stuff." The fancy doodad and the whoosie whatsit will be on everyones implant set. The companies have become so big that even patents don't mean much and if they really want something from a small company, they will just buy the company. What separates one company from another, besides having a specific new device, is the representation. The representative must be knowledgeable, courteous, prepared, eager, unbiased, and the all important, not annoying. The rep has to be cautious as not to hurt anyones eqo as well as providing information that is helpful. It is a fine line. Let me tell you what puts a rep on "probation" in my OR. Saying you are prepared and you are not.

Today, I was doing a tibial osteotomy. I decided to use a company that I had used previously but had not for sometime. I was approached by the new reps who where eager an knowledgeable. They even brought their "specialist" in for the case. I check the set the day before, they assured me they had everything.

The day began, same as usual. Talked to patient. Walk the patient to the room. Checked with the rep and my staff to make sure we had all of the equipment. I began the case. Life was good. Pins were in place.

"OK Don, where is the whoosie whatsit?"

"Dr. P it's right over here." Pointing with his laser pointer.


Eve hands me the whoosie whatsit. I place it on the external fixator. I start to use it.


"Hey, Don. Is it says template on it? Is this the right one?"


"Sure is. That's the one you use."

"OK," I say. I put the next pin in place. Wouldn't you know that whoosie whatsit held that pin like a BB in a box car.

"Uh, Don. This doesn't fit. Do you have something else? Another whoosie whatsit? Maybe in you car or at the office?"

"UUhhh no, we don't have any thing else," he says.

Silence.To my scrub tech,"Get me the Ilizarov trays."

I didn't speak to him the rest of the case. My scrub tech, Eve, and I put together a new fixator. And the case turned out beautifully.

The leg looks FFT (Fan-Fu&@*ng-tastic).


For now, he is dead to me.

For all of you going into practice, don't be fooled by the fancy equipment, the nice dinner, or the pretty representative with the low cut dress. When you are choosing a total joint, spine, or fracture implant company, choose them based on the companies equipment and their representative. If you have a good rep, you can make almost any system work; with a bad rep, you may not have the equipment you need even if the company makes it.

Oh and by the way, always have a back up plan.


"Judge a man by his questions rather than by his answers"
~Voltaire

4 comments:

Midwife with a Knife said...

Wow. It's good to know that issues happen in other people's ORs also. We were doing a fetoscopy (laser ablation of communicating vessels in twin-twin transfusion syndrome) the other day, the rep was with us, and the F*#king 3mm bipolar cautery forceps didn't have an accompanying cord that fit (even though it was labled that it should fit.. the cord the rep brought somehow got labled wrong). It took us 30 minutes to get the right cord, and that resulted in more anesthetic time, and seems like it could increase the risk of complications. I wanted to scream.

Someonetc said...

you know, the reps make so much off the surgery we do, you would think that they would care and always be prepared. but, not so much.

i found that when you put them on punishment, they sometimes learn a lesson. but, not always.

Denise said...

I didn't really realize the relevance of this issue until I heard about the day my boss had when he went to do cases with an attending at another facility (with their Biomet rep). It was a giant clusterf*ck. Wrong sizes, wrong instrument sets, and not enough backup equipment. Each problem added hours to the day. A good rep can make or break your OR day. Our rep knows more about what is going on in the case than many residents, and he knows which cases might need special stuff. Perhaps it is just through years of working with someone so perfectionistic that he has learned what he needs to do in order to avoid pain. You would think companies would want their reps to be well trained so as to maximize physician satisfaction (and ensure their product gets used). That would mean a heck of a lot more than which fancy restaurant the rep is willing to take me to.

Someonetc said...

you know a good team of people makes the day go so much easier. that is why working with residents can be challenging because it is always like ground hogs day. "i do this because of that." over and over again.

i tell my residents when you choose a job and you choose a implant company, choose the one with the best rep. it will make your life so much easier. your rep should be thinking of things that you may have not even thought of. "doc, i know you didn't ask for this, but i brought it just in case you may need it." have one or 2 instances when your rep forget something and you will quickely fire them from your OR.

when i was doing total joints, i had one case, a revision, where i told the rep that we would need big cups yada yada yada. we ream, and i say, "ohh, we are going to need like a 70mm cup." he says, "well, see doc the company is redesigning this and ..." me, so you don't have them." him, "no"

flames off the top of my head. call mike (my usual rep). he brought them there in 30 minutes. he was my hero, and i never strayed from him again.