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In this episode, we sit down with vascular surgeon Adam Tanious to explore the complex relationship between “big business” and modern medicine. Drawing from his experience in the operating room and his deep dive into the influence of medical device companies, Adam sheds light on the ethical challenges faced by surgeons today. We discuss how sales reps can sway decision-making, the role of innovation in minimally invasive surgery, and how young practitioners can navigate these dynamics while keeping patient care at the forefront.

Adam Tanious is a vascular surgeon.

He discusses the KevinMD article, “Big business and surgery: Who belongs in your operating room.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Adam Tanious. He is a vascular surgeon. Today’s KevinMD article is “Big business and surgery: Who belongs in your operating room.” Adam, welcome to the show.

Adam Tanious: Thank you so much for having me.

Kevin Pho: So how are you? You are a vascular surgeon. Tell us about yourself.

Adam Tanious: Yeah, vascular surgeon. I practice out of Medical University of South Carolina in Charleston, South Carolina. I came here via undergrad in Baltimore, medical school in Michigan, and then trained in both Tampa, Florida and Boston, Massachusetts, and have been an attending vascular surgeon here since August of 2021.

Kevin Pho: All right, your KevinMD article is “Big business and surgery: Who belongs in your operating room.” So tell us the events that led you to write this article, and then for those of you who didn’t get a chance to read it, about the article itself.

Adam Tanious: Absolutely. So in my 10 years of medical training, and one of the reasons why I went into vascular surgery to begin with, was sort of my love for all things innovation. I’m sure you can agree that our world of medicine is on the forefront of innovation, because innovation in medicine usually means saving patients’ lives or improving their lives in some way, shape, or form. And so innovation, entrepreneurship, and medicine were always sort of things that grabbed a hold of me.

Vascular surgery in particular I think is just at the forefront of the innovation race, if you will. We are a specialty that has really progressed in the way that we treat and care for patients. And my background is that I have a father who is a salesman and was a fantastic salesman, and I have a wife who is an ethicist. And so this perfect storm of being involved with business in medicine, understanding things from a sales perspective, and then coming home and talking to my ethicist wife, who’s also an anesthesiologist, and getting her perspective on things, painted an interesting picture to me that sort of prompted me to write this article.

That really delves into this idea of, how do we mix the idea that for profit companies that are pushing the envelope with regard to innovation are interacting with a health system which is really patient first? And so you have two groups of individuals who seemingly have similar motives, because they can be mutually beneficial relationships, but really when you have a physician who is 100 percent patient focused, and then you have big business which wants to be patient focused, but obviously big business answers to their shareholders if they’re publicly held companies, or they’re privately held, whatever things they answer to in terms of their business plans and their spreadsheets and balance sheets and all those things, the numbers side of things.

So that led me to get my MBA and sort of really try to understand things from a financial perspective. And so I’m just trying to see how we really marry these two worlds as we move forward, to really try and advance medical care for patients.

Kevin Pho: So as a vascular surgeon, give us some examples of how you see that tension between technological innovation by for-profit companies with what you do in the operating room. How are you seeing that play out? What are some examples of that?

Adam Tanious: Yeah, absolutely. I mean, I think one of the easiest examples is that we have multiple ways in which we can treat disease, right? So in the vascular surgery world we’re talking a lot about peripheral arterial disease or aneurysmal disease, and so we have really pushed the boundaries of how we treat this disease. 15, 20 years ago everybody was getting some sort of open procedure, open bypass, lots of comorbidities, long lengthy hospital stays. And now, thanks to the advent of minimally invasive techniques, we can have patients in and out the door within 24 hours to treat these pretty severe medical conditions.

And so it is on the part of the physician to understand what tools and technology are available to help them treat their patients, but then it’s also on the part of big business to show the world of medicine what they have come up with in terms of innovation, so that the physicians use those products, right?

And so in our world in the operating room, you’ll have a lot of sales representatives from these companies trying to be involved in cases and trying to advocate for their device and the place for their device in treating the patient that’s on the table currently. And so it’s up to the physician to understand when and where to use particular devices.

But we also wouldn’t be as good at clinicians if we didn’t use the knowledge that these sales representatives have, because as a vascular surgeon I have to know every single device that exists on the market and how it can benefit or hurt my patient. But that doesn’t mean I’ve seen a particular device deployed 10,000 times like the sales rep who studies that one particular device has. And so it really is a marrying of the two worlds, and trying to really use all the information and tools that big business provides to us as clinicians, and really I think sort of set our own path forward on how we’re going to provide optimal care to patients.

Kevin Pho: Now what is the workflow that determines which device you see put in front of you? Is there certain criteria, is it like a department decision? So who decides what device you get to see in the operating room?

Adam Tanious: It’s really up to the clinician. As a clinician it’s up to me to decide what device I think is going to help my patient the most. And so let’s say that the hospital stocks five or six different devices that treat a particular disease, but I think device number seven has a benefit that only it can offer, then it’s up to me to go to my hospital and say I need this device to treat my patient for this particular reason.

I present why I think so, I present any of the economic data that needs to go with it to prove why it’s a benefit with that respect, or any patient safety data or whatever it is. And then the hospital will usually, if I can present good data, will acquiesce to my request, and then I get to use the device I think that’s going to best help the patient into the patient.

Kevin Pho: And you talk about that tension at the beginning of our conversation, that device is primarily being made by a for-profit company, and you have to balance that innovation with the improvement in patient care that it potentially can have. So how do you deal with that tension?

Adam Tanious: Really I think that’s sort of the whole goal of this conversation I’m trying to start, is how do we really move forward to abate that tension. And I think that it comes on the part of A, transparency on the role of the physician; B, transparency on the role of these for-profit companies; and C, always remembering that without improving patient quality of life or adding longevity to patients’ lives, neither us nor big business would be anywhere.

And so we have to start with the patient. Patient focus and patient-centered mentality I think has to be the driver of everything. And then I think as physicians we have to be sort of the champion for our patients, and then the safeguard when it comes to how we treat our patients.

And I gave a TEDx talk about this topic, and that sort of inspired the article that I wrote, and that was my main message to the medical community. And it was really awesome to see the positive response I got, not only from the medical community but from the sales rep community as well. Because the sales reps that are really out there doing their job, because they have a passion for improving patient quality of life or improving length of patient life, really also see the same role, that as long as everybody’s transparent in this interaction and trying to advocate to get the patient the safest and best treatment possible. I think that’s really where the conversation I’m trying to make happen between all parties.

Kevin Pho: So in general, what are you seeing across the country, or stories that you’ve heard? Are you seeing some less than scrupulous salespeople, and physicians for that matter, kind of not have that transparency? Are you seeing some implied pressure from companies to get physicians to use their devices? So what’s happening kind of outside your world? What kind of stories are you hearing?

Adam Tanious: Yeah, absolutely. And I think one of the things that prompted the TEDx talk was an article that was put out by The New York Times that actually spoke about sort of not great practices by some people in various specialties, where they were using the relationship with big business to drive more of a profit centered focus as opposed to a patient centered focus of care.

And that sort of sheds some light on what is going on in medicine in general, where I think as physicians we’re being pulled and pushed in a hundred different ways, and we’re being expected to do 10 different things as physicians, as surgeons, with our time. And we’re also trying to make a living, and so compensation is important. And so if people can augment their incomes by doing certain things, I think that that’s where the waters get a little murky.

And it’s becoming more and more of a topic of conversation in a lot of the literature, about things like office-based labs or outpatient hospital centers or surgery centers performing procedures, and what kind of procedures they’re doing. Are they the procedures that should be done? Are they using devices specifically because they can bill for using that device, even if it’s not a device that needed to be used, but it helps their reimbursement?

So that is what is going on in our current landscape. There’s a lot of people writing about this, and I think that it does take two to tango, right? I mean, it takes the physician to be willing to do those procedures, and it takes big business willing to sort of help those procedures get done.

And I think what I’m trying to call attention to is that we really need to be focused on making sure that everything we’re doing is to serve the patient in the end. And that if we are going to do that as physicians, I think big business is ready to get on board. They want to be the ones championing their device as the ultimate benefit to the patients. That’s why they’re coming out with these devices, and if the devices don’t work they don’t make money. I just think that we need to make sure that everybody is on the same page about what their objectives and their goals are.

Kevin Pho: So for those newer surgeons or proceduralists who may be listening to this podcast, tell us about some of the more concerning sales tactics by profit-driven corporations that they should be made aware of, so they don’t tip into that profit driven motive.

Adam Tanious: Yeah, absolutely. I think it actually starts before you become an attending. It starts when you’re in training. So if you’re in an interventional or surgical subspecialty, you usually are going to get introduced to these sales people, to the sales side of medicine, during your training. And you’re going to start noticing that as a trainee these companies are going to start offering to take you out to dinner, and they’re going to start offering to pay for meals and do things where they teach you and train you about their device.

But when you’re a trainee making resident salary and working resident hours, those free dinners with wine you can’t afford and steaks you would never buy for yourself really can seem very appealing. But I think, and this is what I think my MBA has really taught me, and understanding the world that my father lived in, there’s no such thing as a free cup of coffee, right? There’s no such thing as a free lunch. You have to understand that there’s a reason for that.

Now, is learning about the device itself a positive and a benefit to you as a physician in your future? Absolutely. You need to know about these devices, you need to know how they work, you need to know their pitfalls and where they triumph over other counterpart devices. But understand that there are sales techniques and there are sales tactics involved, right?

And so when you graduate and you are your own surgeon, interventionalist, somebody who’s putting a device in a patient, and you are in a situation where clinically the patient’s not doing well and you don’t have as much time to think as you did when you were a trainee, your mind is going to fall back to the company that you feel most comfortable with. And where did that level of comfort come from? Started from when you were a trainee, and when they started to teach and train you during your training.

And I would just caution everybody to really understand and watch for how these sales reps really interact with you, and what the motive is for their interaction with you. And so I think it starts early when we’re trainees, I think it continues on when we’re attendings, and young attendings especially trying to sort of figure out our place in the world of medicine.

And I have been really blessed and lucky to work with some pretty fantastic representatives from these companies who will literally hand me products from other companies if they think it’s going to be what saves the patient’s life or gets the patient off the operating room table. And I would just champion every physician to really make sure they’re working with people like that. Because at the end of the day our goal is to provide the best patient care, and it comes through in who you are as a person, whether you’re the sales rep or you’re the physician, in your actions and your words. And I think that as physicians we’re pretty good at reading and understanding people for the most part. And so when you’re interacting with the sales reps with these companies, just make sure that you’re interacting with people who hold the same values as you.

Kevin Pho: So if you’re a resident, fellow, young attending, is there a way to develop a relationship with these sales representatives without being taken out to dinner or wined and dined, and learning about these devices in a more neutral setting?

Adam Tanious: Absolutely. I think it’s up to the individual, right? I mean, you can very much just say and be very clear, I’d love to see the data, right? That’s my first response that I like to tell my trainees. The first thing I always want to see when I’m looking at a new device or a new technique or a new tool is, I’d love to see the data.

And thanks to Zoom calls and web conferences and emailing, I can get all that data sent to me via email. There are tons of web podcasts or webinars that have been recorded that they can send me. I think that these companies have really aggressively attacked this post-COVID era of using technology to their favor for getting information out there.

But at the same time, I don’t think we should be afraid to utilize the resources that big business has, right? Big business has deep pockets, and I frequently champion my trainees going to different courses that are hosted by these companies where they get to have hands-on experience with these tools, and cadaver labs that I can’t afford as somebody educating trainees to pay for my trainees. And if they can, why should they miss out on the opportunity to practice using a device in a relaxed, calm setting as opposed to in an operating room with a patient’s life at stake on the table?

And so I think that you just have to know what your values are, and understand that even though you are being bought a cup of coffee, even though you are being bought a lunch or a meal, as long as you understand what that’s in service to, and your true north is always pointed at patient-centered care, then I think that it’s OK to say yes to things, as long as you sort of know the forest from the trees.

Kevin Pho: Earlier on you talked about the transparency both on the physician side and the big business side. Give us an example of what exactly that transparency would look like, to make sure that interaction is solely focused on patients.

Adam Tanious: Absolutely. I think as a physician it’s our job just to talk about our needs, right? This is the patient I have in front of me, this is the disease that I’m encountering, and these are the objectives I’m trying to accomplish with this procedure I’m about to attack.

And then from the big business side of things, it comes to, well, our device offers these benefits, these are its limitations based on the patient that we’re looking at right now. I either A, believe that our device is the best device for this patient because of these reasons, or B, the particular limitations of our device are probably not suited for this particular patient. And as a great sales rep it’s also my job to know what my competitors are and to know what benefits they offer over my device in particular.

And so I think that’s where transparency and sort of openness in trying to achieve a common goal is going to come. And I think again that’s what I’m hoping to have happen as a result of all the conversations I’m having regarding this topic.

Kevin Pho: We’re talking to Adam Tanious. He is a vascular surgeon. Today’s KevinMD article is “Big business and surgery: Who belongs in your operating room.” Adam, we’ll end with some of your take-home messages that you want to leave with the KevinMD audience.

Adam Tanious: Yeah, first and foremost, just again thank you for having me. I’ve been a longtime listener and this is kind of a really big deal for me just to be here talking to you, so I just want to say thank you.

Take-home messages for the physician audience are fairly simple. Listen to your patients. Your patients are going to tell you what they want, as long as you’re open with them about what they’re signing up for with regard to any kind of procedure or intervention. They’re going to tell you what it is they’re looking for and the goals that they have for their care. Once you know their goals for their care, then it’s up to you to be their champion. And then just be open and direct and honest with the people you interact with. And I think that once you show yourself as that kind of person, everybody’s going to get on board with it, right? And so know who you are, know what your objectives are when you’re providing patient care, and people will get behind that.

And to my sales reps that are out there, I just continue to ask for your amazing professionalism that I’ve been experiencing ever since I’ve been a trainee. Continue to be experts in the devices that you are selling, because it’s your expertise that will get us out of bad and crazy situations that we haven’t seen, because we don’t use your devices or see your devices deployed as much as you all do.

And so I am just continuing to hope for this symbiotic relationship to continue to drive medical innovation forward, and to allow us to continue to be, I think, the forefront in this race of medical innovation around the world. I think that the U.S. has really poised itself as the champion of this race so far, and I think that if we can continue to grow this relationship the way we are, I think we’re going to continue to be at the front of that race.

Kevin Pho: Adam, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Adam Tanious: It was a pleasure.