Finding out if sales reps and medical students are providing hospital care

If the time in a doctor’s office or the hospital isn’t  frightening enough already for most patients, some recent publications by MDs in prominent, peer-reviewed medical journals may ramp up that anxiety to new heights: Just who is skulking around, with institutional blessing, when you’re getting your medical care? And what role are these official-looking people playing?

A tip of the hat to Morning Rounds, the daily newsletter from the health news site Stat, for pointing out a newly published study on PLOS One that details how sales people for surgical device makers conduct themselves when they are routinely allowed into operating rooms. They are gowned, often wear badges like hospital staff, and they consult with the surgical team, as doctors allow. They bring laser pens that they use to point out instruments and anatomical features. They never touch patients or handle any part of the surgery.

But, the study notes that the sales reps:

Reported attending at least one surgery daily and having to be available, at least by phone, 24 hours a day, seven days a week. The reps are responsible for ensuring that all the instruments and components needed for each surgery on their schedule are on hand and ready for use. That may entail assessing and accessing hospital stocks, as well as bringing their own implant systems. They also anticipate the need for alternative sizes, instruments, and components, and they bring these additional items with them. One rep reported helping hospital personnel sterilize and re-wrap instruments after each surgery.

Surgeons say that the sales reps, in the best cases, know devices inside and out; they have worked with practitioners frequently and know common issues that they may offer ideas on as they arise during procedures. Surgeons, particularly when they are first using new devices, in effect, may be getting on the spot training from the reps. The sales people also say they steer doctors to company-sponsored training sessions or they get to know their clients better with OR time, followed by coffee, lunches, and …

Others point out that the reps also do what their companies pay them to−they’re selling stuff, even during operations, suggesting to surgeons various other pieces of their wares that they might want to use, talking up equipment at hand, and, as residents say, they’re scouting for new targets for more business.

The device makers pay their reps for going into surgery – they might stay for only an hour of a longer procedure and walk away with several hundred dollars from their company for their time; one rep said this added as much as $50,000 annually to his company compensation. The bigger the device or equipment, the more complex the procedure, the higher the sums the reps earn per surgery.

Their wording is careful and conservative. But the researchers offered this worrisome conclusion about what they learned:

Our study raises ethical questions about the reliance of surgeons on device reps and device companies for education and surgical assistance and practical concerns regarding existing levels of competence among OR personnel.

MDs and truth telling

Meantime, Anna Reisman, an internist at the Yale School of Medicine, has written an insightful but also jarring commentary for the Journal of the American Medical Association, about her bad surprise as to who performed a procedure on her during her pregnancy.

Almost two decades after it happened to her, she recalls the shock that she and her husband, also a physician, experienced when a young practitioner popped into a procedure room. The young doctor took more than the usual time and had great difficulty with the amniocentesis, in which a needle is carefully introduced into the uterus to extract amniotic fluid for testing for various inherited disease. He insisted all was well because, when asked “How many of these have you done?” he said he had “five years’ worth” of experience with the procedure.

The doctor broke a sweat after several stabs, including one in which the nurse present advised him to try lower. He left. An older, female physician than entered the room, told Reisman and her husband that she was the supervising, attending−and that they would need to return to get the procedure done because three tries in a day was the recommended limit.

They then realized they had been “bamboozled.” The young man who had worked on Reisman was a physician-in-training.

She later had an amniocentesis that went easily and flawlessly. The credentialed couple complained about their bad experience, got an official apology, and it all might have been just a bad memory for Reisman. But now, as a teacher, she said she sees all too many instances all during a doctor’s day when physicians must learn and practice truth telling, including disclosing when they are less confident and skilled or experienced with a technique or procedure. She has an eloquent close to her opinion piece, including the poetic language of Emily Dickinson with hard advice, and it should be required reading for all MDs.