Docs vs MBAs

In a Florida operating room … there’s an anesthesiologist alternating with a nurse anesthetist, an X-ray technician and a circulating nurse; … there’s the surgeon, a middle-aged orthopedist who has never performed this type of operation before.  And, at the foot of the operating table, there’s Chuck Bates, a guy who studied biology in college. … Come up one centimeter and make your incision there, Bates tells the surgeon. …

The job wholesaling hot dogs enabled Bates to get an MBA … which led to employment with Kyphon, a manufacturer of medical devices.  … Bates was the salesman in the operating room. … Sales representatives … in operating rooms … serve as simple reminders that medicine is a business, with all the potential that entails to promote efficiency, boost sales and extract profit.  But should they be there at all?  In an age of rapidly proliferating technologies, the salesmen may know more about their products than the doctors who use them do. … They speed procedures along, making time for more. …

Many medical devices could not be used — or used safely — without sales reps. … Richmond gynecologist Catherine A. Matthews said that’s a frightening argument.  “They’re not in any way motivated to recommend what might be the best thing for the patient,” Matthews said. “They’re there to sell their product.”  Doctors shouldn’t have to depend on reps for expertise, she added. … The presence of the salesman in the operating room has long raised concerns that it can put the interests of manufacturers before those of patients.

More here.  Can’t you feel the shame?  You pick a prestigious doctor to solve your problem, and instead he’s taking orders from some lowly MBA!  Horrors.  Such low status folks might, gasp, recommend things to make money, not like surgeons, who are far too high status and “professional” to care about such lowly things as money.  Riiiight.

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  • Phil

    “Doctors shouldn’t have to depend on reps for expertise, she added.”

    The logical consequence, of course, is that the doctor should have his license suspended until he takes a course to learn how to use the device at least as well as the sales rep.

    But I’m sure that’s not really what Dr. Catherine A. Matthews is getting at.

  • Do you really think there’s no reason to be wary of the influence of people with the incentive structures of the salesmen as opposed to the incentive structures of the doctors?

    • Phil

      It’s the doctor that decides whether to use the salesman’s product. If I wind up using the salesman’s product when it’s not really the best choice for me, that’s the doctor’s fault, as he could have chosen otherwise.

      As Robin points out, the doctor has status incentives to downplay the salesman’s value. There are two fears: (1) the doctor’s incentive to refuse the salesman’s help, and (2) the salesman’s incentive to convince the doctor that a product is good for me when it isn’t.

      On balance, I think I am indeed more wary of (1) than (2). Bad products tend to be found out and taken off the market, and, even if they’re not, we do have the doctor with some incentive to look out for us and not be taken in by tricky salesman.

  • quanticle

    I definitely think there’s a good reason to have sales representatives out of the operating room. The sales representative’s expertise is with the device only. They do not have the necessary expertise with the human body and its numerous biological systems to ensure that their advice makes sense in the context of the surgical procedure.

    That said, I wouldn’t have any problem with having sales reps in the operating theater if they were also doctors (or perhaps licensed nurses). Its the fact that they have little to no medical training that bothers me.

    • If the sales rep is just giving directions to the doctor, the doctor can veto any move that, in their understanding of the human body, will be dangerous. So it doesn’t sound like a problem.

      I mean, doctors are heavenly incarnations with god-like powers that depend on us respecting them, right?

  • Bill Gardner

    No, I can’t feel any shame. I have a pacemaker. When I see my electrophysiologist (EP), there is a rep from Boston Scientific there. Here is what I feel.
    a) I am concerned that when my pacemaker was replaced, the “upgrade” — which had many new programmable features but didn’t work as well — was chosen to increase revenue for both the provider and the manufacturer.
    b) I wonder what the hell the EP is getting paid for if he needs the rep there to do his job.
    c) But since I am well-insured, I don’t feel any of these too strongly.
    All of these are serious problems. But I don’t see where status comes into it. I didn’t “pick” a fancy doctor and there is nothing prestigious about having a bundle branch block.

  • Well, there’s a difference between an MBA with a masters in biomedical engineering and a quantitatively semi-literate MBA who specializes in office politics success and expressions of social dominance regardless of subject matter expertise.

    In my opinion administration and management professionals should be much higher status, or at least there should be a high status variant with rigor equivalent to an MD or a quantitative Ph.D.

    Perhaps a series of certification levels equivalent to the CFA or medical boards, and a standard, professional, 4 year program.

    Also, stronger quantitative analysis underpinnings (the same should go for medical credentialing, IMO).

    I think maybe things like sigma six and project management certifications are playing this role, but it doesn’t seem to me to be as formalized as would be useful, yet.

    • Matthew C.

      Heh. You mean Six Sigma, not Sigma Six. I’ve done the first, and my son has purchased the second.

      • Good wikipedia page. The bullshitty aspects of Six Sigma are interesting.

      • Matthew C.

        The bullshitty aspects of Six Sigma are interesting.

        Yes, and there are right many. . .

  • anon

    The article implies that Bates was in the operating room as a technical field rep for the firm, not as a salesman. Yes, he also sold the device, and his sales job required an MBA. But this seems irrelevant.

  • Eric Johnson

    If ya want objectivity. Buy an opinion from some expert who wont benefit from you getting the surgery (or wont get a commission on the sale of your house, etc).

  • Dentists should face a lower demand for status than doctors, since dentists deal with non-life-threatening problems where the demand for magical reassurance is lower. Aside from that, though, dentistry is a problem of medicine and biology that shouldn’t be different in principle from dealing with other organs.

    To the extent that you’ve attributed various real-world aspects of health care to the demand for magical reassurance / showing that you care, can you show that these aspects are different in dentistry?

    • Dentists are in fact lower status (see The Hangover), we are more comfortable with folks paying out of pocket for dentistry, we allow dental assistants to do more of dental work than we allow doc assistants to do doc work, and there is clearer evidence that dentistry is useful on the margin.

  • “They’re not in any way motivated to recommend what might be the best thing for the patient,” Matthews said. “They’re there to sell their product.”

    I would imagine that patients dying would lead to bad sales for their products.

    Sure, I can understand the worry in cases like Bill Gardner’s, where the sales rep influences the decision of which pacemaker to choose. But if they’re in the operating room, simply telling the doctors how to use their equipment?

    • I would imagine that patients dying would lead to bad sales for their products.

      Got any evidence of that? That’s not how things usually work in medicine.

      • Grant

        I would imagine that patients dying would lead to bad sales for their products.

        Got any evidence of that? That’s not how things usually work in medicine.

        It may not hurt as much as we’d like it to, but certainly doesn’t help sell their product.

        Professionals in the medical device industry can easily know more about how to use their product than doctors, and may know more about how to perform certain kinds of surgery. Of course this doesn’t mean they are as good at it (as they’ve probably never done it), but they can be a very good source of knowledge.

        The article is not painting the worst-case scenario, by far. Many doctors call tech support lines for help, sometimes needing assistance with general techniques (an example that comes to mind is how to correctly use a torque wrench to screw an abutment into a dental implant). The people answering these lines definitely don’t have MBAs (not that I see that as a problem; lower skilled people assisting in or performing medical procedures can easily be a good thing).

  • Jaffa_Cakes

    Hahaha 😀

    The best articles on here are the ones where Robin allows himself to get a little bit arsey and sarcastic.

    When a post is delivered in that hyper-rational tone he sometimes uses I am always tempted to comment “once more, with emotion”.

  • In related news, last year Overcoming Bias reported on a study that showed that physicians from top schools could lower medical costs.

    It looks like business schools are giving medical training and medical schools are giving business training.

  • Matt

    First, if a salesman has incentives to sell medical products even if they are bad for you, wouldn’t they also have the same incentives to sell medical porducts even if they’re good for you? I’m sure most (or all) medical supply companies strive to get a good reputation, even more so than they strive to get dead stock off their shelves (at least at the margins).

    Second, standards for Med students may be high, but they are not infinite. If a Med student spends 10 years learning hundreds of thousands of intricacies about treating humans, why wouldn’t you trust someone who had six months training on one specific treatment? By my calculations, that would make the sales rep more capable. And the rep wasn’t even doing the procedure. He was probably just repeating what higher paid doctors that work at his R&D department told him.

  • Weasel

    Much more basic than the questions about the sales reps motivation, I am alarmed by the apparent acceptance of the idea that the sales rep actually understands the technology he’s pushing. While my experience is admittedly all outside the medical field, rule number one, don’t believe anything the sales rep says about what the product can do or how it works, make sure to read and understand all technical documentation yourself or you will be sorry. They never understand it as well as they think they do.

  • Tree Frog

    I wondered about the feasibility of small hospital-subsidized “experimental divisions” – like some sort of medical Q branch, where seasoned docs try out different devices and techniques related to their specialty only.

    My vision: The patients would pay less money – due to the experimental nature of the care, the doctors would get a salary on the lower end with bonuses for upticks in patient survival and health that can be attributed to their recommendations, and the sales reps would have a known set of contacts for the hospital at large.

    I know the military has unofficial experimenters for just about every kind of gear possible and that process seems to suss out the better ones (with a pretty high failure rate for the unfit products).