My deep dive into this topic started after examining a New York Times article regarding the abuse of medical technology within my specialty of vascular surgery. The knowledge this article presented, along with my love of innovation and acquisition of an MBA focusing on entrepreneurship, prompted further probing into the field. Ultimately, my work led to an editorial in the periodical The Vascular Specialist and, subsequently, a TEDx talk: “Big Business in Surgery.”

Let us define our terms. When I say “Big Business,” I am referring to both the publicly traded and privately held companies that make and manufacture devices that sparked a revolution in minimally invasive surgery. These companies answer to shareholders and depend on profitability for survival. While it may seem that there is a symbiotic relationship between the success of “Big Business” and positive patient outcomes, that would be a naïve, simple assumption regarding a complex system.

The frontline workers for “Big Business” are the sales representatives who interact with surgeons and interventionalists daily. Reps are present for cases to offer their device expertise, as it is their job to know the “ins and outs” of the devices they sell. These sales reps see their product used several times a day, every day of the week, and often have real-world knowledge that practitioners cannot come by with the sparse use any individual practitioner experiences in daily practice.

Additionally, reps have access to resources above and beyond what educators are given to help teach and train the next generation of surgeons and interventionalists. Industry has the power to help fund conferences and educational seminars where experts are allowed to teach their clinical knowledge to a large forum of future practitioners. I can personally attest that these are invaluable teaching and training opportunities that individual training programs just cannot be expected to provide.

Now comes the hard part of this dynamic – understanding that having a sales rep present for a case where you have multiple device options to choose from to effectively treat your patient has the strong potential to sway your decision.

My question to everyone reading is this: should we put ourselves in a position to be swayed?

When I have predetermined the need of a particular product for a given case, I will always call upon a trusted rep with many years of experience to be present. It would be wrong of me to assume that level of experience with any device, as our jobs call for us to be experts in many different types of procedures using an array of different products. As a junior attending, newly managing so many different aspects of the OR environment, why would I not welcome additional expertise that is available to me when I have predetermined a specific tool I plan on using anyway?

What we as practitioners must understand is the strategy for sales. Anyone with a knowledge of sales and marketing understands that, more often than not, sales reps sell themselves, not just their product. While I truly believe that it is in the nature of every rep I have worked with to be extremely helpful and engaged in the OR, we must also realize that this is a sales tactic. The more buy-in we are given by reps during a case, the more we are likely to use their product. This extends to the cup of coffee, and the meals bought for us before, between, or after cases. Taking it a step further, there will always be more aggressive reps who try to “actively” sell you on their product. It has happened to me personally.

As I have grown as an attending, my ability to recognize the nuances of these interactions has evolved rapidly. Additionally, having senior partners who have good relationships with reps has also helped. Moreover, the earned confidence that comes with being the primary decision-maker responsible for a patient’s care cements the relationship between physician and sales representative.

My goal here is not to provide an answer for surgeons and interventionalists about how to interact with industry. Rather, my aim is to start a conversation. We, as practitioners, need to be better about controlling who belongs in the OR. While it is not possible to know every potential problem we will run into during a case, as practitioners, we should be better about deciding what tools and devices we anticipate using for specific pathologies and ensure that, no matter who is present during a case, that our plan for our patient is not swayed by individuals who are ultimately hired to support a particular product and answer to someone who is not the patient on the operating room table.

More importantly, we as attendings should actively engage in teaching our trainees about all the tools we use and be a sounding board for our trainees about the merits and pitfalls of these devices in conjunction with our industry colleagues. We must provide clear guidelines around the interaction between medicine and “Big Business” for the younger, more susceptible minds learning alongside us.

Adam Tanious is a vascular surgeon.