The patient was a 77-year old diabetic with an ulcer on her big toe. There was almost no blood flow to the foot, and she was in terrible pain. Her podiatrist had sent her to the hospital. The nurses who initially checked the foot had seen cases like this plenty of times. If the woman was lucky, the surgeon might be able to amputate the foot and save the rest of the leg below the knee.
The vascular surgeon examined the patient and asked for an operating room to be prepped for surgery. But before he scrubbed in, he called Yvette Villa. “If you’re available, I would love your assistance with this procedure,” he told her. Villa jumped in her car and went straight to the hospital. She changed into scrubs and joined the surgeon in the O.R., where the patient was draped and prepped. The foot was grey, the color of ash. A radiographic scan showed a calcium block in the patient’s leg, in the area around the knee. The surgeon asked Villa for her opinion. Could they save the foot with a 1.5 solid? he wondered. She had seen dozens of these cases result in exactly that fantastic outcome. Villa helped advise the surgeon on the device used through the procedure, which lasted less than an hour.
Later that day, the patient went home. With her leg fully intact.
The story seems straightforward. But what may be surprising is that Villa, who played a key role in saving the patient’s foot, is not a doctor. Nor is she a surgical tech or a physician assistant or an O.R. nurse. She’s a medical device company sales representative, and like thousands of others around the country, she plays a vital — yet often hidden — role helping physicians determine which equipment to use and how best to use it.
Medical device sales representatives like Villa aren’t often discussed in healthcare circles. And when they are, they’re often misunderstood. Since sales reps also sell products, some may see them negatively. Others confuse them with the pharmaceutical sales representatives who often hand out pill samples in physicians’ offices. However, the truth is that sales reps like Yvette serve a critical purpose in healthcare, sharing a broad base of knowledge with physicians, introducing them to new products, helping them understand how and when to use them, and — most important — enhancing health outcomes.
In a 2016 study sponsored by Georgetown University, researchers surveyed orthopedic surgeons about their experiences with medical device sales representatives. The surgeons overwhelmingly said they found them indispensable — particularly when it came to educating them about complex devices, which they said O.R. staff weren’t equipped to do. “You can get information about a new cholesterol-lowering drug in the literature or at a society meeting,” said one surgeon, “[but] to learn how to do a new spine procedure you need industry to teach you how to use this new equipment they’ve developed.” ¹
Tom Fogarty, a cardiovascular surgeon who holds more than 100 surgical patents, says the pace of medical innovation necessitates that sales representatives play a teaching role in operating rooms. “In our training as doctors, we’re not taught to accommodate emerging technologies,” he told Stanford Medicine Magazine. That’s problematic, Fogarty said, because “Medical innovators and inventors are very impatient. They truly believe what they are creating is better than what currently exists. They want to get it to the patient as quickly as possible.” ²
At Cardiovascular Systems, Inc. (CSI) the company where I serve as chief medical officer, we make devices that treat peripheral artery disease (PAD), a condition in which plaque builds up on the inside walls of the arteries that carry blood from the heart to the legs and feet. Each year, physicians perform 160,000 amputations as a result of PAD. The cost of these amputations — both emotional and in terms of healthcare dollars — is incredibly high. Following an initial lower-extremity amputation, patients typically need additional reamputations. In fact, fifty-five percent of PAD patients with one amputation have their other limb amputated within 2-3 years. What follows is a prolonged period of visits to high-cost facilities, mental and behavioral health deterioration, and survival rates are abysmal.
Fortunately, amputation is not the only treatment for people with PAD. Peripheral vascular interventions (PVIs) including atherectomy, in which a catheter is inserted into an artery and used to clear plaque blockages, can be performed in less than an hour. When successful, patients who once suffered debilitating pain in their limbs can walk out of the O.R. the same day as their procedures.
However, as the Georgetown study showed, not every physician can stay abreast of cutting-edge technologies like this. Which is why physicians like Dr. Siddhartha Rao, an interventional cardiologist in North Carolina, says that Tim Staub, a district sales manager at Cardiovascular Systems, is a vital part of his practice. “Tim’s not just selling devices to me,” he says. “Tim plays an important part in making sure any staff member who needs to be trained is ready to work with the devices when the patient comes in the door.”
In addition, both Staub and Dr. Rao regularly host PAD awareness events for physicians, nurses and other practitioners who are likely to encounter patients with PAD but may not know all of their treatment options. At these events, Dr. Rao speaks about his experience treating patients with PAD, explaining how the illness presents and typically progresses. For Staub, events like this go far beyond a sales pitch. “PAD is an epidemic in central and eastern North Carolina because we have a lot of diabetes and smoking and kidney disease,” he says. “I work with physicians in the community who can get these patients revascularized so they don’t go down the route of amputation unnecessarily.”
Coaching and Guidance
The second role that sales representatives play is to coach and provide guidance to physicians as they perform procedures. In a widely read New Yorker article, the surgeon Dr. Atul Gawande wrote about his experience using a coach to improve his surgical technique. Yet, as any doctor practicing in a busy metropolitan hospital will tell you, their peers are much too busy managing their patient loads to spend time coaching them. ³
So, device sales representatives often step in and fill the gap — a role they’re uniquely qualified to play because they usually see more procedures than anyone else. Even a very busy physician who specializes in treating PAD may only see 250 cases a year. Device representatives often see ten times that number, and frequently draw on each other for advice and to share their own patient experiences. “The rep is another set of eyes,” one orthopedic surgeon told researchers in the Georgetown study. “They know the system and the trays—and when you’re not worried, that helps you focus on the patient more.”
Moe Nasser, a CSI district sales manager based in the Detroit area, used to work in pharmaceutical sales. He says that being a true partner to the physicians he works with is one of the factors that distinguishes device sales from pharmaceutical sales. “When I was a pharmaceutical rep, I got one minute of a doctor’s time in the office. With devices, I can spend nine hours in the office.”
Nasser often reviews angiograms with physicians and helps them know where devices may or may not be a part of appropriate treatment plans for patients experiencing symptoms of PAD. “You’re there to educate and help,” Nasser says, adding that a physician might ask him what size crown to use with a device or provide opinions on possible things that could go wrong during cases that physicians should anticipate and look out for. That said, Nasser says when the procedure begins, he is careful not to interfere: “I’m like a chameleon,” he adds. Nasser says that one of the benefits of having a device representative in the room to provide guidance is that it helps busy surgeons stay on schedule. “You’re the one constant that’s there to make sure everything goes smoothly, and the doctor doesn’t run behind.”
Villa says she’s assisted with thousands of patients in the twelve years she’s represented Cardiovascular Systems and that doctors ask for her to be in the room “because it’s all or nothing. We’re either gonna fix this or the patient will lose their leg.”
She notes that she’s seen cases involving severely diseased arterial tissue and shared her experience watching other physicians use low-inflation balloons to expand blocked arteries to make room for the catheter to pass through. “It’s great to feel essential and to know that physicians depend on your experience to help them make the best decisions for patients,” she says.
What Reps Don’t Do
As a surgeon and a healthcare executive, I’ve learned that the best device representatives are defined by what they won’t do: push a physician to use their product when it’s inappropriate. Villa says she sometimes sees patients who have blood clots in their arteries. “I will never recommend our product when there’s a clot because you can do more harm than good,” she says. “Ultimately, it’s up to the doctor’s discretion, but I’ll come right out and tell them, ‘I don’t know if CSI is the right product for that.’”
Just like physicians, device sales representatives have reputations to protect. A physician will recommend a helpful and knowledgeable sales representative to a colleague; but if the sales representative is clearly only interested in their bottom line — as opposed to the patient’s well-being — they’ll soon find that their calls go unanswered. For this reason, Nasser says he often finds himself advising physicians that his product isn’t appropriate for a patient. “You might not get the case,” he says, “but you’ll earn the trust of the physician.”
There’s a second — and more important — explanation for why these device representatives won’t push their products to boost sales. Simply put, that’s not why they’re in business. Nasser, for example, got into device sales after his father died of a heart attack. “I approach every case as if that were my family member and I ask what would be best for them,” he says.
“You can’t fake the passion and the caring you have,” adds Staub. “People see through if it’s just a business transaction.” Instead, he attributes his longevity to “engaging physicians in an educational way and getting across that you can be a partner in the care of their patients.”
When asked why she does her job, Villa thinks about the 77-year old woman she helped the day she drove to the hospital early in the morning. When the woman’s foot, which initially had turned grey, started to turn pink after the procedure, Villa says she was overcome with “a wonderful feeling. That patient had a fear of losing her limb and woke up knowing that her leg was still there. Saving limbs and saving lives. That's the beauty of our job.”
¹ O’Connor B, Pollner F, Fugh-Berman A (2016) Salespeople in the Surgical Suite: Relationships between Surgeons and Medical Device Representatives. PLoS ONE 11(8): e0158510. https://doi.org/10.1371/journal.pone.0158510
² White, T. Stanford Medicine Magazine, 2006, Fall Issue. Father of invention - Stanford Medicine Magazine - Stanford University School of Medicine
³ Gawande, A. The New Yorker, October 3, 2011. The Coach in the Operating Room | The New Yorker
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