A recent study sponsored Georgetown University and published in the journal Plos One examined the relationship between surgeons and medical device reps. The study detailed the extent that some surgeons rely on device reps in the OR and how this may influence surgeon choice of implants and medical costs.
The exploratory study involved focus groups with two groups of surgeons (orthopedists and ENTs). The study also included interviews with 3 current or former device reps, a director of a surgical residency program and a medical assistant for a multi-physician orthopedic practice.
Researchers found that device reps are fixtures in the OR. While some surgeons expressed concern that the surgical team sometimes relied on reps too much, most agreed that reps played an important role in the OR.
“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 rewrap instruments after each surgery.”
One rep estimated that for a total knee replacement there are typically 8 trays with 30 to 60 pieces of metal each. In the words of another rep,
“When the doctor comes into the room, [I can say], ‘We're ready to go with the instrumentation.’ That's one less thing he has to think about or worry about. And he has to be able to trust that I can say that with confidence.”
There was some difference in the way orthopedists and ENTs talked about reps. Orthopedic surgeons tended to talk about reps as dependable members of the team, while ENTs were more likely to refer to reps as “pests”.
The study noted that one source of concern is that reps are usually paid entirely on commission – thus there is ample incentive for the reps to recommend more expensive implants. In addition to cost concerns, there are also situations where reps may have incentive to recommend implants that do not have the proven track record of less expensive alternatives.
The reps confirmed the incentive to recommend expensive implants,
“...you can see how I have a direct incentive to get a surgeon to use something more expensive. . . .There was never a situation when I thought, ‘I know this is inferior and I’m going to sell it anyway.’ [It was more like] ‘I don’t think this is any better, but I know it’s more expensive, so I’m going to sell it.”
The authors admitted that the exploratory study was limited in scope and size (sample size = 19). More study is needed to gain an accurate idea of just how much surgeons rely on reps in the OR. The study cited a previous study of 43 reps that found that 88% had provided verbal instruction to to a surgical team during surgery, and 21% had direct physical contact with a surgical team or patient during surgery.
Ultimately, the researchers found that while it is clear that surgeons benefit from relationships with device reps, benefits to patients arising from that relationship are ambiguous. The perception among physicians and reps that reps increase efficiency and mitigate deficiency among OR personnel (including physicians) raises concerns about the competence of essential members of the surgical staff.