But, that still leaves 75,000 or so eager young men and women idling in your waiting room, if you choose to see drug representatives. (About one in four doctors do not see reps.) What should you do?

There are plenty of reasons to simply say no to drug reps. First, they can take up your clinical time and drive your office staff a bit crazy, even if they are willing to cart in donuts, sandwiches and chef salads to grease the wheels. But perhaps more importantly and insidiously, drug reps are master sales people, shined up with a veneer of useful clinical information. Rest assured that before any drug representative sets foot in your office, she or he has studied an enormous amount of data about your prescribing patterns, including how much influence sample acceptance has on your willingness to favor their company’s drugs. The drug rep knows exactly what you may need to hear to be persuaded to increase your use of their preferred products, based on both prescribing data and field testing. Plus, the rep has been meticulously trained in how to maximize the utility of their drugs and downplay any potentially negative issues surrounding them as well.

In the face of this roundly negative information, why anyone would entertain the notion of dealing with drug reps? Because they also bring some positives to your practice. The samples they supply can make a real difference in some practices. You can try out a medication without asking the patient to invest in a prescription. You can box up a prescription’s worth of the medication for that patient who simply can’t afford it otherwise or who will probably not get around to getting the prescription filled but may be willing to take medication that you place in their hands.

Although drug reps are trained to shine the best light on their products, they can also provide useful information that saves you time learning about the products. They keep you apprised of what’s in the pipeline, why their drug is better than a competitor and how doctors are using and evaluating effectiveness.

Should you or shouldn’t you make yourself available to drug reps?

Here are some suggestions for structuring the relationship to your benefit.
1. See representatives by appointment only. Frankly, you are doing them a favor. It’s a terrible waste of time to hang around hoping to get a few minutes of your time. Everybody wins if you guarantee five minutes at a time that’s convenient for you.
2. Recognize that some of what they say to you is crafted by their knowledge of your prescribing patterns. Ask them to share that knowledge with you; you’ll at least learn something about yourself.
3. Listen to the spiel and the info with the awareness that their first job is to persuade you to use their product. Use their information as a stepping stone to gathering your own information.
4. Accept samples if they will help your patients but be aware that the drug company is trying to make you feel obligated to favor their products. Don’t think of samples as gifts that must somehow be reciprocated; they’re sales tools, pure and simple.
5. Don’t accept the lunches and other freebies; it appears inappropriate even if you are not actually swayed by these tactics.

Above all, pay attention to your own prescribing habits. Are they in fact habits or are you keeping up with the literature and adapting based on clinical evidence and patient need? Be sure you know more than the drug rep knows about how and why you prescribe.

Susan Brissette
SB Cass Associates
East Nassau, New York

1. O’Reilly, Kevin, “Doctors increasingly close doors to drug reps while pharma cuts ranks”, March 23, 2009, American Medical News, http://www.ama-assn.org/amednews/2009/03/23/prl10323.htm
2. Ibid.

Many “best practices” are being developed as protocols and as we become aware of them we will post them on the PrivatePractice.MD website (probably under the “Resources” section). I list here just a few situations which call for planned actions, organized as a protocol:

1.) Patient Emergency in your office. Do you have a code cart? Is it fully stocked with necessary equipment and medications that haven’t expired? When was the last time its items were checked? Do you know which drawer holds the ambu bag? While you attend to the ill patient, did your staff call 911 for the ambulance? Is a staff member controlling the situation in the waiting room? Are other patients peering out of their exam rooms in response to the ruckus? Obviously you need to think through such a possibility well before such a situation arises, and run a “mock code” in your office just like you did in residency.

2.) What about fire drills? Does everyone know where your fire extinguishers are and if they should even attempt to use them? Do you smoke detectors have fresh batteries placed in them every six months? How will you get your old or very young patients out of the office to safety if there is a fire? You need to practice a fire drill once in a while also.

3.) How do you handle patients who might have TB, or chicken pox, or some other highly contagious disease as they come through your office? Do you meet them outside and put a mask on them before they enter your office? Does your staff know how you want them to guide these patients through their visit with you?

4.) The front desk personnel have their own full set of issues to handle, and protocols would be wisely prepared and practiced. What happens if a dangerous person shows up in the waiting room, perhaps an irate ex-spouse who just heard his child is there for an “emergency”? How do they process phone calls to you from other doctors? Are those calls prioritized, so that you’re interrupted or paged when a doctor calls to speak with you? How are faxes and mail handled? Who keeps the waiting room and bathrooms for patient’s use clean and tidy during the day? How are urgent appointments scheduled? Are they squeezed in or are there “acute slots” available?

The list of situations needing protocols is a pretty long one and we’ll be discussing it on an on-going basis. Just be sure to think about developing protocols when starting your practice, and as a repeating exercise as you go through your private practice day. Keep thinking, “How can I automate and delegate” this task so I’m most efficient and utilize my expertise best?

Just because it’s difficult to measure something doesn’t mean you shouldn’t try because the goal is to always improve and to always provide better and better care. Running a medical practice well requires close attention to details, and monitoring details that ultimately affect patient outcomes directly benefits your practice. That’s why it’s so important to establish practical and reproducible policies, procedures and protocols based on logical goals, and rechecking the results so that appropriate modifications can be made in your practice. Every practice is a little (or a lot) different, with different physician personalities and practice styles, and different patient populations so what works in Boston may not work in Eureka.

For doctors to buy into all these new initiatives there’s going to have to be some tangible benefit for them. Less hours, better payments, more efficient use of their time. We’ll be asked to buy the equipment and pay the staff to input the data. This investment demands a reward.

Hopefully readers of PrivatePractice.MD will share good practice tips with each other here, so that we can all learn from each other. Medical practice advisors also can show us best practices used by others so we don’t re-invent the wheel constantly. No time for that!

These days I see far fewer representatives. The rules about giving samples and lunches and other perks to doctors have gotten much more stringent. Overall, I agree that there has to be rules and the changes have been good changes. Maybe I’m naive, but I’d like to think doctors don’t make decisions about medications or devices based on a nice dinner. But reading the literature, it’s pretty clear that I’ve been naive…

I believe that most representatives have something valuable to show me and perhaps teach me. I like the quick synopsis they present, and I read the articles they hand me, albeit with a skeptical eye. Doctors have a responsibility to filter any information presented to them to avoid commercial bias. That’s true whether reading a journal article, listening to a grand rounds lecture, or giving 5 minutes of your valuable time to the rep who bothered to drive an hour and then sit in your waiting room for another hour to have that 5 minutes with you. It’s the least we can do to be civil towards them. I do miss the scratch pads, however!

It’s penny wise and pound foolish, to quote Ben Franklin (I think), to try and micromanage your practice, in my opinion. Set up your systems and your protocols and procedures correctly from the start and you should have less headaches. To set your practice up correctly you need input from other, more experienced, doctors, and your business advisors, including your lawyer and your accountant.

Having an effective office manager and resources such as a medical billing professional, healthcare information technologist, and a human resources expert to guide you on issues such as billing procedures, EMR software selection, and payroll and staff benefit options will help you avoid big regrettable mistakes later. Where do you find these experts? How do you know who to trust? PrivatePractice.MD, as it grows, will be a superb resource for you.

We can’t ignore the fact that our medical practice is a business. It provides us our livelihood and provides jobs for our staff and paychecks for everyone including the ancillary team of experts we rely on every day. Our main focus is quality care of our patients, but we can’t provide the best care if we are worried about paying our office rent or making next week’s staff payroll. We owe it to our patients (and our staff, advisors, and ourselves) to be just as smart about our business as we are about the medical care we provide.

My goal for PrivatePractice.MD is for this community to grow to include many experienced doctors and other healthcare experts and advisors. This rich community will share ideas, challenge each other, and be a resource for the new doctors starting their own practices. Please be an active participant! RB