Thursday, October 13, 2011

Thursday Op-Ed

Today, one of our surgeon readers opined about how this blog has "regressed into a dark place where former allies, reps and surgeons, hide in cloaked veils of anonymity to routinely lash out at one another.  Before we elaborate on this post and the state of our industry, one must remember that it is absurd to discuss how one hides behind an anonymous post, when the individual opining is writing anonymously themselves.  But let's be honest with one another, whether you like it or not, this blog has never regressed, it has always been a referendum on the state of our industry. As TSB has stated, "for years it was our dirty little secret," and contrary to what anyone thinks, it has taken some courage from some individuals, god bless you whistleblowers because sometimes it takes a woman to show a man that it takes balls to step up and call out the nefarious arrangements and greed that slowly has become the norm rather than the exception.  Thank you Blackstone, you set a great example.

Contrary to our commentator's opinion, surgeons and reps have always had a mutual respect for one another, at least our generation did, unfortunately somewhere in the journey, there was a change in personal and industry related dynamics. "If my mentor could do it, why can't I?  I'm just as smart, I'm just as talented. If they could start a company why can't I?  Some investment bank told me my company or IP is worth gazillions."  Could these individuals be part of the entitlement generation, could some people be delusional, maybe some of them are nothing more than dreamers? It is difficult to place one's hand on the pulse of how a once respected industry has become so scrutinized in the public arena (thank you Mr. Carreyou), considering that there are many hard working young sales people and surgeons that do their job in a professional manner respectful of one another everyday.  Unfortunately, the current state of the industry may sadly be a reflection of what our society has become, greedy.  There's just never enough.  Just like Democracy is for sale, spine has taken on the persona of its masters. There is never enough, because what were once vices have now become habits.  And contrary to what Gordon Gecko has said, greed is not good when there is no balance in your lives. TSB believes in capitalism, but one must understand life's priorities.  Today, company's still have unrealistic expectations when it comes to growth and market penetration.  20% is a thing of the past, of course unless you are dealing in a POD or POC. Zero-sum means zero-sum, unless you have breakthrough or emerging technology, the question becomes  where are you getting your growth from?  Your competition?  It's difficult to understand the present or the future, if you are stuck in the past.

Yes doctor, the industry is truly in a sad state, and you are correct that life can go on without a rep, just like life will go on without your existence, but before you cast light on the reps, one should look at one's own profession and accept the fact that the patient has a malignancy that has never before been seen in this industry. Maybe what some people need is a good old fashion whipple? Chemo will not cure this malaise. So, who's fault is it?  Is it the sales rep who earns on average $120-$175K, covers their own expenses, has a mortgage and family to feed, just like you and your peers? Free-markets means free-markets, not a specific set of rules that only benefit me and screw everyone else. Is it the surgeons fault, who has spent countless hours educating and honing their craft with the expectation of being compensated commensurate with their expertise, only to find out that enough is not enough? The reason this insanity exists is because of the lifestyle you choose, the personal decisions you make, and that you believe that you are the straw that stirs the drink. There's only so many LeBron James' or Kobe Bryant's and then the rest of you are bench warmers. But in the end, there's no special dispensation for you just because you are a doctor.  When the world suffers, you too suffer. We have become so consumed with money, that it has led people in both our profession and yours to conjure up more schemes and business models in order to make that almighty dollar.

So before you make an off the record statement, Doctor Anonymous, maybe you should look at your peers and wonder what in God's name are they doing?  Believe it or not, there are many sales people that are as disgusted as you are about the current state of affairs, the question is who and how are we going to do something about it before we get back to doing the things that made us all proud to be affiliated with this industry.  TSB wants to know, what will you do?


  1. I will vent in cyberspace
    Go to NASS
    Punch myself in the face
    And catch a bass

  2. I just had a conversation with a surgeon, 2+ MONTHS into practice tell me he is designing a pedicle screw for an anonymous company. ARE YOU KIDDING ME!?!?!?!?! Thanks Doc...just what the patient, industry, and society needs. another "tweak" on a screw and an instrument to do THE SAME THING.

    I'd personally love to see the DOJ & OIG get involved. I'd like them to set some kind of standard on consulting compensation based on the level of unique or breakthrough IP the surgeon brings to the table. Which means $0.00 for another pedicle screw. Pay them tens of millions for a breakthrough--because they deserve it for a truly game-changing implant/instrument/procedure. But do we really need company X shelling out dough to a nobody surgeon for another me too POS? Is that capitalism? Is it advancing anything? no, like TSB said.....

    its greed. the deadliest of the deadly sins.

  3. 2:53. shut it.

    if you can be a value beyond the description of your pedicle screw design, you can still win business.

    discipline and dedication.

    oh, and try to be humble once in a while.

  4. 5:51 Pedicle screws are pedicle screws, consolidation is upon us. Embrace or find a new job.

  5. Did you just blame this on physicians?

  6. 6:44
    Commoditization is upon us, not consolidation. If everybody has a pedicle screw, why would a company buy another company with a screw.

    Who are you to tell some dude that wants to make a pedicle screw that the input of a surgeon, or anybody else, is worthless? If you somebody has the nuts to get in the fray and compete with a screw, more power to 'em. Obviously, you are too chicken to do it. Are you working for a legacy company and think they invented everything? Think again bro. As far as I'm concerned, the more it get commoditized, the better. Because then, for the honest docs out there (and there are plenty) it comes down to the rep that provides the most value to the customer. And those reps will be sought after by the throngs of manufacturers. Sure, the prices go down with commoditization, but the points go up for the guys who bring it. What sheep working for Medtronic can stay in it at 7% when prices dive. If he can make 30%, then he can ke a living and hospitals get lower prices and as you say, a screw is a screw so patients don't suffer.

  7. 7:48 we are all dumber for having read your rambling nonsense.

    Thank you

  8. Life is short! Pigs get fat hogs get slaughtered! We r in this together believe it or not! Pods or distributors paying docs. It doesnt matter it is un ethical! Everyone call out distributors paying docs or doc in pods! Air it out. Lets put a list online of every distributor paying docs and those docs in a pod!!! Show some balls! We need to have a track record for OIG. If not we R just letting it happen and not reacting!!

  9. 2:53 is absolutely right. If my mentor could, why can't I? Unfortunately, there's only so many ways you can make a screw, and most variations mean nothing in surgery. After the true pioneers of the art, who with one or two exceptions now all are retired, the followers were more motivated by money and fame than by improving patients' lives. Unfortunately there is no single solution that will work to return spine surgery to where it should be: a specialty that focuses on helping patients.

    One radical option is to pay surgeons a fixed sum to see and treat a patient with back pain, whether the treatment is conservative or surgical. If surgery is necessary, he or she will be paid a fixed sum per hour. Lets play with some numbers: a fairly busy surgeon sees 60 patients a week, and performs 10 surgeries with an average duration of 1.5 hour per. For each patient visit he will get a fee of 150 dollars, per hour of surgery a honorarium of 500 dollars. The goal here is to make it about equally lucrative to treat conservatively as it is to do surgery, and the numbers will need tweaking. For insurance and general overhead of his outpatient clinic there will be a surcharge of 50%. The weekly revenues of our hypothetical surgeon thus would be 24,750 dollars, his income 16,500 dollars. Assuming he works 45 weeks a year, the annual revenue will be 1,113,750 and the income 742,500 dollars. Seems reasonable, and probably not much different from what the average busy surgeon earns make now. The main savings for the healthcare system will be found in the reduction of unnecessary surgeries.

    And last but not least, a minimum of 50% of any pre-tax royalties he receives for implants, whether he uses them or not, must be used to pay for the care of the uninsured. After all, most royalties in spine surgery come from Medicare/Medicaid patients, i.e. us tax payers.

  10. Sorry but i don't blindly agree with 2:53.

    The comment never said how much the doc is getting paid - or that they claim to be inventing. Not that it actually matters, the doc may be a really bright guy with some solid IP (I doubt it, but it possible).

    Regardless any company that doesn't get surgeons involved in the early stages of product design scary, a bunch of engineers in a lab cannot just churn out an entire pedicle screw set and hope to get everything right just bacause they copy someone elses system. It needs real world use by someone thats going to give you feedback - and as the company wants to make money out of it why shouldnt the person doing the work get their share too?

    Its just a shame that the patients dont get some kind of benefit from the increased risk they take in the earlier stages of product development

  11. Amazing,, another post & more of the same. More finger pointing, whining, crying, bitching & name calling from those posting.

    Any wonder that this industry finds itself to be in the state that it's in. The reps, companies, industry & surgeons are all to blame. There have been some great success stories in this industry over the years, but no everyone thinks that they have the next great idea or at the very least, the "here's how we're going to cash in" plan.

    The probloem is that there is so much corruption going on at this point, no one knows where to start to clean it up. The best analogy would be to compare the spine industry to the NCAA. Everyone knows that corruption exists, but while everyone wants to bitch & complain about it & point fingers, no one actually has a relly good idea of how to police it.

  12. This blog is starting to sound like "Occupy Spine Surgery".

    We as a community need to show value for our products and services.

    As a physician, I can only do what I hope is ethical and hope that no one offers me the deal that turns me into the "1%". I don't that will happen, as by being a prudent, conservative surgeon, I do not generate the volume that makes me the target of those deals.

    But the device companies need to consider change. The quota's are driving the deals to the docs.

    How about developing great products that everyone wants to use? How about training a great sales staff that treats all doctors as respected customers instead of a revenue stream? A sales staff that competes on quality, knowledge, availability, not just on capacity to "entertain"?

    How about setting prices that make hospitals pursue the relationship?

    You will lose the doctors that seek the consulting deals, POD's, and perks. But there is a vast majority of doctors that do want to do the right thing. It is just that the companies also know each and everyone of us have a price. And the companies are often willing to pay that price for our business.

    Surgeons are humans, and we behave just like anyone else. At a certain price, change of practice styles can be "rationalized". I would love it if companies stopped these practices, and terminate relationships with doc's that demand these arrangements.

    But do it silently. You do not need to bring down the whole community to flaunt your new ethical standard.

    Compete well.

  13. Old Spine Doc,

    I won't pay you use my products, but I will pay to move you into my territory. You and I would get along brilliantly.

    Old Spine Rep

  14. Hello Old Spine Doc( If you truly are) . Why the hell are you on this blog?With all of the other issues you have to deal with.. It is comical that you take the time to post here?

  15. Old spine doc. What does this mean and I quote from your posting?".Surgeons are humans, and we behave just like anyone else."

    So you are weak and can be bought? You have sold out because your friends told you it was profitable?

  16. A surgeon with 2 months in practice is consulting with a company to design a new pedicle screw? Can you say "kickback"?

    How willfully blind do you have to be to not see this?

    The surgeon and the company that hired him should be fined an amount larger than any "fee" paid to him.

    Let's face it, there's not much new under the sun at this point. A pedicle screw is a pedicle screw.

  17. Old Spine Doc,

    Thanks for your comments. I don't quite understand the abuse the last two posters heaped on you.

    I will say that I work for a company that is trying hard to "develop great products that everyone wants to use". The problem is that with the current 510K approval process, and all the IP that is presently locked up, it is increasingly difficult to find room to innovate.

    As far as "training a great sales staff that treats all doctors as respected customers instead of a revenue stream? A sales staff that competes on quality, knowledge, availability, not just on capacity to 'entertain'?", well, that would be a perfect world, now wouldn't it? But we don't live in a perfect world, and some doc's like to be entertained. And face it: you are a revenue stream.

    Thanks for the post though. I think it's valuable to hear from all members of this community.

  18. 7:48

    Thanks for your civility. And thank you for giving me this opportunity to discuss revenue.


    This Blog is one of many that I monitor. I am a spine surgeon, and often times the grassroots (Reps, Industry, patients, attorneys) have a better insight than medical journals. Besides,don't you think everyone else is also monitoring your comments?

    There are two "Dr. Revenue Stream"'s.

    One is the surgeon who uses your products because he likes the product, and like you as a person. You are dependable, and make sure that you appreciate Dr. Revenue Stream's business by always making him look good in the Operating Room. A smooth case is worth everything. This Dr. Revenue Stream would never ask you to find a consulting deal or ask for royalties on a product he never designed.

    Then, there is the other Dr. Revenue Stream. He is the rain maker. He always has a ton of surgeries. He realizes he is a revenue stream. He is the target of all your competitors. One day, Dr. Revenue Stream tells you that you are a great friend, but your competitor has offered him a sweet consulting deal, and he is thinking of switching to them. He thinks you will understand, after all, it is all about the revenue stream. Later on, this Dr. Revenue Stream decides POD's are the way to go. Don't worry friends says Dr. RS, we'll still have dinner won't we?

    Do you really just look at your Doc as a revenue stream? Should he look at you as one? What are you willing to do to protect your revenue stream? How ethical is your revenue stream?

    Compete well.

  19. It is obvious that things are changing. Everyone involved in the process is trying to preserve income flow - from the hospitals, to the rep companies, to the surgeons. There is nothing wrong with that, businesses want to keep their doors open.

    Implant companies face downward price pressures and the industry will be consolidated - fine. Everyone along the line will not make what they made in the 80s or 90s.

    Hospitals scrounge for their dollars, just like the implant companies. Ethically or unethically. Fine, they are the hospitals and let them run their businesses.

    Physicians in private practice run a business - they too face increasing overhead and decreasing revenues. While they treat patients, they have to consider the business side of medicine - if you don't consider this, you can take down your placards and sell out to the hospital (75% of all private practice ortho surgeons will be hospital employed by 2020).

    Unethical arrangements such as bogus consulting and, in my opinion, PODs, should not be a solution. The responsibility for this problem lies on both the physicians and business entities involved. Whoever is involved made that decision to be involved. Let them decide, and let them face the windfall from this, if that happens - fine. That is their business.

    If a physician has an idea to make a better product, even if it is incrementally improved (such as a slight change to a pedicle screw), fine. Let them help design that and negotiate a consulting deal with whatever company-fine. That company may be small, who cares? Let them have a run at it, and if they get swallowed up by a big company or fall off by the wayside great. That is business, that is entrepreneurship (even if it seems like a minor, useless change) who are we to judge them?
    Without clinician input, medical device development
    is hampered. This input has a value and shall continue to have a value and ETHICAL arrangements can be made to benefit the people with the ideas, and the company looking to EXPLOIT the ideas.

    If you want to impose stiff regulations on product development you risk hampering truly meaningful medical device/procedural development. If you really want more regulations, then you should also consider whether or not you want your business to succeed or have the freedom to develop new products.

    Stop the anticapitalist ranting here, or, as one person wrote on the thread, join the occupy wall street protest downtown. Stop whining and figure out how you and your company will succeed in the future. Stop pointing fingers at the hospital, the physicians, or anyone else; accept the fact that things are changing and position yourself and/or company to maintain or grow your business.

    Who knows, maybe that surgeon 2+months into practice will design a new pedicle screw that doesn't go anywhere. Who cares that this surgeon is talking to a small, noname company? Maybe that surgeon has another idea that will become the next breakthrough in spine implants and that idea is patented, 510k'd and sold to Stryker. Great! Who knows? Don't judge that surgeon from the sidelines. Get in the game, be innovative and figure out what your are going to do to keep your businesses open.

  20. Americans will always need spine surgery. A solid rep will always be able to make a living, either as a rep, distributor or a POD bitch. Most of the postings on this site lately sound like a bunch of wussies who feel entitled to 300k for opening boxes and writing up usage sheets, just like the old Medtronic-dominated days.
    Get over it! Obamacare will insure that everybody makes less money (even with M.D. after your name), it's up to you to navigate it and still be able to look in the mirror. Man up and stop whining.

  21. New to this site...

    Would someone explain how PODs represent such an evil relationship in the spine industry? I think people are confusing the issue of surgeons who will operate on anyone for any reason and are "outside the bell curve" with this POD situation. If a surgeon is in spine to make a lot of money, it is very possible to do so even without PODs. Lumping conservative surgeons into the category is to miss the point on all of this.
    Eye doctors, ENT and most primary care make "extra" money either in the office or with some type of ancillary service. This could include glasses, hearing aides, lab services, DEXA scans, Xrays, MRIs, PT, etc. What makes surgeons involvement in PODs so diabolical in and of itself as a business model ?

  22. 1:14,

    Are you kidding?

  23. Anyone who has worked within the healthcare industry during the last two decades has been witness to the growing metastatic greed. When 20% of GDP falls within one system, veiled corruption is inevitable. Everyone can point fingers; the truth is every facet holds responsibility. Justification is always viewed and filtered through the almighty dollar.

    Payers, providers, industry, physicians, attorneys, representatives, hospitals…legions all scrambling to siphon off their due from the source. Every day, more and more come to drink from the “bottomless” cesspool.

    A myriad of Medicare Fraud and Abuse Laws, Stark Laws, Anti-Trust Laws…all passed to protect the greatest healthcare system in the world. They are all worthless Congressional masturbation without proper enforcement. A Department of Justice only interested in enforcing laws with political expediency attached. The drunken suction and depletion continues; how will it end?

    It is time for healthcare professionals with a conscience to insist the cancer is revealed. The public deserves to understand the problem. The DOJ will only respond when enough people demand a cleanup. It is time to get organized and expose all of the dirty, greedy, shady, schemes on a public forum. Everyone reading this knows what I mean and knows of instances which should be eliminated.

    The simple fact: Money IS the root of all evil.

  24. No, 'The LOVE of money is the root of all evil!'

  25. 4:11

    No I'm not, please explain.

  26. Hey 4:36

    A historical perspective clearly demonstrates one thing counter to your point and it is that:

    "Religion IS the root of all evil"

    Not M$ney!

    More people have died in the name of religion than money by a long shot. Think about it...

  27. Religion is just the Vehicle to steer the masses to the part the power brokers really want to control.....the MONEY! Once in control the masses are not necessary.

  28. Globus何時將公之於眾?

  29. Hey, I want my royalty for that IP ;-)

  30. Amazing posts- as a non surgeon I can only gasp at the ignorance of some who think a minimal change in a pedicle screw deserves millions in royalties. And that someone in practice for two months really thinks the company is after her innate intelligence and amazing innovations. Spine surgeons are their own worst enemies. Look at the studies and reflect on what is really going on.

  31. 9:24, what is really going on is that half the patients operated on today would be better off without it. The show must go on in the name of the holy dollar! That however will change, long before Globas goes public.