Pharmaceutical Reps Are Not So Bad

I know these days everyone loves to hate a pharmaceutical rep, especially with news reports of them doing just about anything to get doctors to prescribe their medications...even using non-FDA approved indications as a selling point. Most of them are salesmen types with fake smiles and company cars, but here is the scary truth...some doctors could not survive without them, especially the ones who sell the surgical equipment. I recently scrubbed into an ACL repair (knee surgery) that was being done arthroscopically (as most are done these days). The representative from the company that was supplying the equipment to perform the repair was present, and to be honest, he should have been the one doing the surgery! Beyond the basics, the surgeon did not know how to use the equipment, and needed the rep to guide him through each step. It was stressful, scary, and 2 hours longer than it should have been. Most surgeons who use more than a scapel and some sutures will have a company representative in the OR with them from time to time...and some of them will have a rep with them almost all of the time. I also scrubbed a shoulder case with an orthopedic surgeon recently who decided he needed to use a certain piece of equipment to repair a tear in area of the shoulder called the labrum. The surgeon was looking to the scrub tech and the nurse to put the equipment together properly, but they did not know how. The rep was called, and rushed to the hospital so the surgery could continue. Perhaps surgeons should be forced into taking training courses before they are allowed to use this equipment on real patients...but that would be in the perfect world of healthcare, not the real world of healthcare.

Surgery Booking Day

We have clinic 3 days a week at a certain city hospital where the majority of patients are Medicaid and Medicare. As a result, we are told as residents that these are our patients, and we can treat them in whatever way we deem necessary. All residents need a certain number of procedures in order to graduate from the program. We are told that this hospital is the place to get our numbers by seeking out patients that we can book for certain procedures, and then performing those procedures on them. There is always an attending in the OR with us, so we are not actually performing the procedures alone, but these are clinic patients, and as a result, we are able to choose which procedures we want to do on the patients, and we are allowed to actually perform the majority of the procedure in the OR. I know that the idea of a resident performing a procedure on you is frightening, but this really is not the worst of it. We do need the exeprience in order to practice in future, and to be honest, a well trained monkey can perform most of these procedures. The difficult part of medicine is deciding which patients actually necessitate a procedure, and which procedure to perform on them. Unfortunately, residents always want to perform procedures because they need their numbers. Physicians are not going to let them practice on their private patients, so we practice on the clinic patients instead. We are told that one clinic day in particular is supposed to be our "surgery booking day." On this day, we are encouraged..well forced..to try extra hard to find patients to book for surgery, and if we do not book enough for that day, we are ridiculed by our attending for not trying hard enough. Something is wrong with this picture.

Defensive Medicine At Its Worst

On Friday I scrubbed a complicated orthopedic case that took about 4-5 hours involving the cutting of bone, and insertion of screws. Typically I order a post-operative x-ray while the patient is in recovery to make sure everything is in allignment and all of the hardware is in place. This is what I was instructed to do as a student and during my early residency training. I ordered the x-ray, and was beginning to preop the next patient when the attending physician approached me looking angry. "Never order a post-operative x-ray on my patients!! Do you understand?" Seeing that I responded calmly with an "ok, no problem," his tone softened.."you are just setting yourself up for a lawsuit" he said. "If you want a postoperative x-ray, take it in your office. There you will be the only person looking at it, and no one else will be able find anything wrong with your work." I am sure he thought he was giving me a good piece of practice managment advice..a tip on how to avoid a lawsuit, but in my mind, this was verging on the brink of malpractice. We are told that malpractice is anything that goes against the "standard of care," and the standard of care is to take a post operative x-ray in the hospital. We often hear about how doctors are scared into ordering too many tests on patients for fear of missing something and being sued, but here is an example of a doctor not doing something for a patient out of the same fear.