Where the Sales Rep Fits In

Greg Rainey, a cofounder of Lighthouse Business Solutions, speaks with Scott about the role of the medical device salesperson in the operating room – a role that is ripe for change in a COVID-19 world. Successful sales reps today are showing that they understand the need to balance administrators’ perspective of wanting to reduce the number of people in an OR, with the need to have the right technical expertise available when timing is critical. You’ll learn how the rep’s role has changed over the years and how they can best help providers today.

Full Transcript

Announcer: It’s time to think differently about healthcare, but how do we keep up? The days of yesterday’s medicine are long gone, and we’re left trying to figure out where to go from here. With all the talk about politics and technology, it can be easy to forget that healthcare is still all about humans, and many of those humans have unbelievable stories to tell. Here, we leave the policy debates to the other guys and focus instead on the people and ideas that are changing the way we address our health. It’s time to navigate the new landscape of healthcare together and hear some amazing stories along the way. Ready for a breath of fresh air? It’s time for your “Paradigm Shift.”

Michael: Welcome to the “Paradigm Shift of Healthcare” and thank you for listening. On today’s episode, host Scott Zeitzer speaks with Greg Rainey, a co-founder of Lighthouse Business Solutions. Scott and Greg covered the role of a medical device salesperson in the operating room. That role is ripe for change in the COVID-19 world.

Scott: I just wanna welcome Greg Rainey to the podcast. Greg was never my vice president of sales when I was a sales rep. I was actually on my own when I was doing some work with Stryker, and Greg was the vice president of sales at Stryker. But, Greg, how many years have you been associated with sales? You know, either being a medical device sales rep yourself or managing medical?

Greg: At this point in time, it would be 43 years.

Scott: Yeah, see.

Greg: Which is probably older than some of the people listening, right?

Scott: It’s all good. And so you know, one of the conversations that Greg and I have been having over, gosh, a long time now has been the role of the medical device sales rep. So I kind of wanna bring everybody on board here for a lot of medical device sales reps who are listening, they’re gonna be nodding their heads, especially with big surgeons as well and spine surgeons. But from a really big picture a medical device sales rep is a lot different than the standard kind of pharma rep or drug rep that a lot of people know about. They’re much more involved with the surgeon, their customer, and they can be in the operating room, they can be part of the templating team. It’s really is a different type of relationship. But Greg, I was wondering if you wouldn’t mind kind of explain that a little bit.

Greg: Yeah, you know, it’s like everything, it’s undergone an evolution. I mentioned 40 what, 43 years. The first total joint I put in was it was a knee in 1978. And I actually scrubbed on the case and there was a point in time up until the mid-’80s where medical device reps, you know, and not just orthopedic medical device, but a lot of people knew about U.S. surgical reps, you were trained and qualified to scrub and go into the OR and in many cases you were first assisting or second assisting on the case. That eventually moved to a point of time where people wanted you in the room but they didn’t want you scrubbed. And so then it went from that into what a lot of people recognize as, you know, the rep in the back of the room with the laser pointer.

And that laser pointer and that rep being in the room was not so much for the physician, but for the staff because there were so many different systems out there. If you think of just the companies that are out there now, you have Stryker, you have J&J, you have Zimmer Biomet, you have Smith & Nephew, there’s four companies. And if you just take the number of knees that those four companies have, there could probably be 10 or 12 different systems on a primary basis, not even a revision basis. So it’s difficult for a hospital’s tech or hospital staff to stay current with all the changes. And that rep being in the room was a real member of the team, whether as you mentioned earlier, a pre-surgical templating part of the case where he made sure that all the implants, the correct implants are there, etc., but also then being interoperability to make sure that the staff was that one step ahead of the physician on what he was gonna need as the case went along.

Now, you know, if you think about it, it’s moved to where, and I think this piece is driven by the hospitals, they’re trying to get the rep out of the room. They want the rep out of the room because they see him. Yeah, they see him as another person in the room that could bring infection or whatever into the room. But they also feel that if there’s not a rep of the room, they can get a cheaper price, and that’s not necessarily gonna happen.

Scott: Yeah, that’s an interesting point you bring up. I know when I started in the ’80s, I was definitely helping…and so everybody understands, the orthopedic surgeon, the spine surgeon, etc., they’re quite qualified to do what they need to do, but it would be more have something of just reconfirming. So from a templating perspective, you might bring in your templates and you get the surgeon to pause for a second and say, “Hey, you know, I looked at this and it looks like we’re gonna go with the standard you’ve been using every…you know, before. And I saw that it was probably gonna be one of these sizes.” You didn’t pick it or anything like that. The surgeon would be, you know, taking a quick look and going, “Yeah, that seems about right. You may wanna bring this piece, that piece, maybe this instrument, etc.”

Greg: Well, you know, that’s true, if you think about that, and just templating itself, okay. When you templated those cases in the 1980s, let’s say it was a number seven, we’ll just pick a number seven, right.

Scott: Sure. The number seven.

Greg: You were trained as an orthopedic rep by the company whatever company you’re working for. You took one above and one below that seven, so you might bring a five and you might bring a nine, and you brought the instrumentation that would deal with that.

Scott: Yep.

Greg: Well, mid-’90s, all of a sudden the hospitals say, “We don’t want you carrying this stuff in and out. We want everything you have to be on-site.” And now you had millions of dollars’ worth of implants and instrumentation sitting in a hospital someplace. And then you got all the tracking issues and a lot of these hospitals at that time, because the orthopedic company has been slow to do this, they weren’t real good at keeping an actual audit of what was in the hospital.

Scott: You’re right.

Greg: You know, so you would find these huge write-offs from a corporate structure of, “Well, we can’t account for all of our inventory so it’s kind of out there.” So the rep played a really, really important part of making sure the right instrumentation, the right implants were available. Some of that went away when they just demanded everything being in the hospital.

Scott: Yeah, you know, along those lines, Greg, I remember being a rep in the ’80s and bringing everything in and taking it back out. Assisting all of the nursing staff and support staff on, “Hey, this is what’s next,” you know, to your point, you know, use the laser pointer and point out the next step so everything kind of went along smoothly. Even ran out and grabbed the appropriate components to essentially hand off to the appropriate people so they could open it up in a sterile fashion, etc., for implantation.

And then as the years went by, to your point, as more and more material was essentially requested/demanded, etc., into the hospital, I remember many times being the person responsible to go find it, as crazy as it sounds, because the hospital ORs are very large in a lot of hospitals. And so they would just store it somewhere and you’d be looking for it frantically, you know, the day before. Late part of my job.

Greg: Definitely making sure everything was there before the case and, as you mentioned, there the day before. And you were making sure it was in the central sterile area or outside the room or whatever it was. Because if for some reason something wasn’t there, whether it be a polyethylene liner or whether it was a cup or whether it was an instrument that the surgeon would need, rarely, but would need on that case, the hospital would take the fall on that quite frankly, the rep did. And every rep that’s out there and has been representative in the orthopedic industry has felt the wrath of his or her favorite customer for not having something there when he expected it.

Scott: Absolutely. And it was and probably still continues to be a big part of just making sure you take good care of your customers. And as you mentioned as financial, the hospitals took a look at it at two different levels, I think, when they tried to push the rep “out” of the operating room. One, they didn’t like the fact that the salesperson was such a part of the team so to speak. It made it difficult to negotiate with someone who was, I get it, not part of the staff, but still part of the team. That was one part of it. So there was that issue and then there was, well, maybe we could get a better price if we just don’t have this person in there.

There are intended and unintended consequences to not having that sales rep in the room. And this brings up, you know, COVID, where there’s a liability issue to having anybody in an operating room to some degree. As I joke, the surgeon coming into the operating room is a liability. He’s the surgeon, you know, it’s obviously a necessary liability but anybody extra, let’s not have them there.

And then the unintended consequence, which a lot of surgeons found out very quickly, was like, “Wow, this isn’t moving along as nicely as we thought it was going to be moving along.” I think that a lot of hospitals saw that and said, “Okay, what do we need to do now?” Because if I remember correctly, back in 2000s, ’90s, weren’t there a lot of larger companies that were even trying to sell a, “less expensive system” with no sales support whatsoever?

Greg: Yeah, I think the first company to really try it was Smith & Nephew.

Scott: I think it was.

Greg: It was late ’90s, early, early 2000s. And it might have not been Smith & Nephew. It might have been Wright Medical. It was White Box Orthopedics.

Scott: Ah, yes, you’re right.

Greg: And they marketed it. Of course, they forgot to tell their reps about it, which created a little bit of a problem because, guess what? The hospital said, “Well, we’ll just do the White Box.” But then what happens when they needed something? Then what happens if somebody wasn’t informed of it? You know, and every surgeon will relate to a story of, you know, that’s pretty universal. And that’s Sunday afternoon call to come in and do a trauma male, a gamma male or whatever and fairly regular procedure, but they wind up with an OR tech or an OR nurse who has no knowledge of orthopedics. And so who do they call? They call the orthopedic rep and he comes in and makes sure that everything goes right. But, you know, with White Box Orthopedics, you didn’t get that, you know.

So that methodology has failed miserably. Because, you know, if you go back, I mean, when I mentioned when I first started doing it, I was part of the team. And as you mentioned there, you were part of the team, whatever part of the year, whatever decade it happened, you were part of that team. Now, a lot of hospital administrators and again, this is just from my perspective, they want the rep out of the room. They don’t like the good relationship that surgeons and salespeople have together. But if you go back in time, and it’s not quite as prevalent now, but it certainly was 15, 20, 25 years ago, you know, many of these top reps in any company, were very close personal friends with their best customers.

And there’s a reason for that. And the reason was, is they both probably started out in their careers at the same time. The surgeon gets out of residency, he goes and starts to establish his practice. And he finds a rep who’s representing X, Y, Z product, who just happens to be about the same age. And as the surgeon gets busier, who does he deal with? He deals with the rep that he knows and he likes, etc. The next thing you know, they’re good friends. You know, their families are good friends and so that’s very difficult for a hospital administrator to break. That doesn’t happen as much anymore because the residency programs are a little bit different and the training programs are different. But you still see it. You still see where reps become very close friends with their best customers.

Scott: Yeah. And it’s not some sort of like evil plan I think.

Greg: Actually, no, it’s not that at all.

Scott: It’s exact opposite. It’s guys, I can’t tell you if it’s three o’clock in the morning and there’s a trauma case that’s coming. And there’s two nurses who are not adept at orthopedics. They’re certainly very well trained, they know how to be in an operating room, but they just don’t do a lot of orthopedics. So they know how to be sterile. They know how to set up the room, they know how to take care of the patient, but they don’t know of all the intricacies of all these different instrument trays, etc. And having somebody in the back go, “Now, the next step is to hook that thing with that thing up.”

Greg: You mentioned something.

Scott: How do you?

Greg: You mentioned something interesting there, Scott, you mentioned COVID, Okay.

Scott: Yeah.

Greg: COVID-19, which I affectionately remind people that there were 18 more before this.

Scott: Yes, there were.

Greg: But certainly the hospitals are going, some hospitals, some hospital systems are going to use this to say, “No reps in the room.” I’ve heard one story already where they said, “We don’t not only want the reps in the room, we don’t want the rep in the hospital.” And so okay, you’re not gonna have a rep in the room. I get that. Let’s say that goes fine. But let’s take a look at the latest development in all of orthopedics. What’s the biggest thing out there now? Robots.

Scott: Robots.

Greg: Robots, right, whether it’s a Mako, a Stryker or whether it’s a robot from J&J or whomever.

Scott: Yep.

Greg: There is a tech that’s assigned to that robot. That rep, that tech knows that robot in and out like nobody in the hospital does. They gonna let that guy in?

Scott: I cannot imagine that they will not. I also, you know, it’s interesting. I’ve seen a lot of conversation going on back and forth on LinkedIn and yet, a lot of the surgeons are the first ones to say like, “Hey, guys, like it or not, my surgeries go much smoother and much quicker with the rep in the room.” And so that’s that unintended consequence, so the intended consequence is, hey, let’s level the playing field, get everybody out of the room who doesn’t need to be in the room. And let’s just get our surgeries done. We’ll take the personal out of these conversations when it comes to negotiating price, we’ll take some risk out because there’s one less human being in the room and I get all that.

On the other hand, that OR time, which is quite expensive and now takes an extra hour because the surgeon has to stop what they’re doing and tell everybody in the room where to get what, what to line up, “No, I asked for A instead of B,” those are the unintended consequences that occur when that happens. And I have a feeling that certainly most orthopods, if they feel that they can have their room safe and their patients safe, most orthopods would prefer to have the rep in the room.

Greg: You know what, Scott? You know, the whole safety issue, okay? I’m sorry, maybe I’m just an old fart on this, okay, but I don’t buy it. Okay, for the last decade, or the last decade and a half, there’s been more scrutiny over the health and wellbeing of a rep with rep tracks and all these different things that they have to have just to gain access into the hospital. Do you mean to tell me COVID-19 is gonna not cover that, all of a sudden they’re gonna change everything? You know, they talk about getting…they meaning whomever, they talk about getting back to normal.

Well, normal, I don’t buy the concept of new normal, there’s normal and there’s normal. And all of a sudden you’re gonna cut out somebody who is at, whatever part of the supply chain that individual is, whether it’s a rep or the delivery guy, you’re gonna cut the delivery guy out, you know, who drops off the instruments to Central Sterile and makes sure that they’re taken care of, you going to stop all that?

I mean, the fact of the matter is, the system was pretty well set up, it’s pretty stable. And we shouldn’t be absolutely stupid because COVID-19’s out there and I get all the reasons why they did it. But at the same time, how many hospitals have been in trouble because of it? They cut out, you know, they flat out cut out all the elective surgeries nationwide for 60 days. How much has that cost the hospitals?

Scott: Oh, a tremendous…

Greg: I’ll tell you how much. We’ve laid-off 43,000 hospital employees.

Scott: Well, that’s another thing that it brings up, you know, there’s a lot of people have been laid off. It’s not that easy just to rehire everybody while, by the way, they have to take a lot of extra steps to secure the hospital and/or the ambulatory surgical center for that case you’ve got to make sure. We had a podcast about it about that what steps do you need to take, and it’s gonna be very dependent upon which hospital you’re in, which ASC you’re in but certainly getting the right people back. I always suggest to people when they’re about to have surgery that go ask a simple question of your surgeon, which would be, “Hey, how often do you do this? Do you do this a lot? And if the answer is, “Yes, quite a bit,” that’s usually a helpful answer.

And the other thing is, don’t see the surgeon the day they come back from vacation. I don’t think they’re gonna be bad the day they come back from vacation, but many studies have shown that we’re all better when we practice more. And so we’ve all got to get back in practice, and part of the team is the medical device rep. I’ll be very interested to see what the outcomes are over the next few months about how the reps kind of reintegrate themselves here.

Greg: Well, I think you know, if you think about the ebb and flow, this issue of moving the rep out of the room, okay, which as I said, has been going on for as long as I’ve been in the business and always the same thing—huge push by the hospital, “We’re not gonna let anybody in the room anymore.” A little while after that, you know, “We’re not gonna let anybody in the room anymore, except for this guy because he really helps make things go well.” Or, “Well actually, we’ve changed a little bit that we need you to cover some of the stuff,” you know. So it’ll all ebb and flow. My guess will be that, you know, in a matter of time, whatever, pick a time zone you want, 30 days, 90 days, I would think that within six months, the hospitals will be back functioning in a very similar fashion to what they were pre-COVID. Okay, only because they’re gonna have to, they’ll figure out their way around, and the reps will figure it out, too.

Scott: I agree. I do think that whatever that, like you said whether it’s three months from now, six months from now, a year from now, whatever that is, it’s gonna resettle probably to something very similar to what it was before.

Greg: Well, you know, I used the example of the robot technician. You know, if doctor A, at Motherlode University Hospital, is about to do five Mako knees on the first Tuesday of next week after everybody starts doing surgeries again. Are you really seriously telling me that they’re not gonna let the Mako rep in the room? That rep’s gonna be in the room.

Okay, so now there’s the crease, right? There’s already a rep in the room. I think what you will find is they’ll probably figure out a way to stop multiple reps in a room. COVID might be the thing that really stops multiple reps in a room and force surgeons to choose one or the other systems.

Scott: Yep, that’s a very valid point. I think that, like everything, you know, like you we’re making the point about there’s never a new normal, it’s just what normal is we continue to adapt and change, etc. I mean, I don’t think anybody walked around going, “There’s a new normal,” when talkies came out, you know, it was “Hey, sound is out now. So enjoy.”

I do think that change is always happening out there. And some of these surgeries, like when you talk about with robotics, requires a lot more attention to some really kind of cool and interesting stuff. But again, the surgeon still has to focus on the patient while someone’s got to focus on that robot. And as they work as a team, you’ll get a great outcome. That being said, I don’t see hospital employees being the “robot technicians,” not at all.

Greg: No. And you know, the one thing that orthopedics has always managed to hang its hat on is, you know, development and new technologies. Or if you stick around long enough, new technologies that have been here one or two times before.

Scott: Yeah, you’re right. Yeah.

Greg: But you know, the technology advancements, the robot’s a perfect example. So the question is gonna be, okay, now the robot when you think about it, it’s a decade old, right?

Scott: Yeah.

Greg: With Mako, and you know, all the other iterations.

Scott: From after a while, absolutely.

Greg: What’s the next technology that’s going to develop? And are you going to keep a rep out of the room in that situation? I don’t think so. I think there…I think we’ll go back to the norm of if it’s worthy, and it’s important enough for the rep to be in the room…

Scott: They will be in the room. You’re right.

Greg: But you know, two hospitals, which they’re famous for doing, they’re gonna throw up as many roadblocks as possible.

Scott: But I always joke with all my surgeons and friends out there. If you just let the medical people take care of their patients, everybody would be better off. Usually these conversations and these roadblocks are coming from people who aren’t in the operating room, aren’t taking care of the patient. They’re looking at bottom lines. And I get that. And that’s important and it needs to be done. But like I’ll say, beware the unintended consequences of some of these decisions.

Greg: And that discussion is another whole three podcasts.

Scott: You’re right about that. We kind of hit our 25 minutes there that we normally strive to. Greg, I can’t thank you enough. Forty-three years’ worth of experience, I think, you know, a thing or two about medical device sales. And I really, thank you for coming on.

Greg: Thanks. I enjoyed it very much. I appreciate it.

Scott: It’s my sincere pleasure. Everybody, have a great day.