(Opening Remarks)

How long have you been a physician?
Twenty-five years in practice as a gastroenterologist.

Where did you go to school?
Harvard, then Johns Hopkins, then Auburn for residency, and then Faulkner Hospital St. Elizabeth for fellowship, and back to Long Island.

What originally motivated you to become a physician in the first place?
Oh, that was so easy. When I was 12, I asked my father, “Dad, if I was a boy, I’d be a rabbi. But I’m a girl. What should I be?” He said, “You be a doctor because then you can do something good every day of your life.” That was the start. Then my dad died of stomach cancer when I was in medical school, and so I devoted myself, trying very hard all my life to not have people die of what killed my dad, so a lot of people go into medicine for very personal reasons, and it’s like I am, I consider myself a funny looking marine on the battlefield against people dying unnecessarily of diseases that we haven’t had an ability to intervene in the natural history of a biology.

That’s beautiful. I’ve been among as a practitioner of medical arts, and obviously you’ve got a lot of things that you’ve learned over time technically or scientifically, but in terms of being a practitioner, what are some of the biggest lessons you’ve learned?
Time spent with a patient, even when you’re running late, with ribbon time, making time, is never for nothing because it’s amazing how much you can understand and get inside the person’s head, their disease, their body, by taking the time to learn about them, taking time to do the procedure if it needs to be, so I think there’s a tremendous push in this country to try to make everything faster, faster, quicker, cut the corners, do things too fast, and they think that, what I’ve learned is the more pressured I am, the more time I take to make sure that I’m not missing something and that the patient has a chance to explain what’s going to them. And I find that often that’s the answer.

We live in the Internet era as you just said, where everything is sped up. How has the Internet affected your relationship with your patients?
I love that patients can go on websites to look up their illnesses so they come to me sometimes informed, sometimes after maybe a diagnosis, they can go home and check things. So I love that there’s …

You encourage your patients to do that?
I very much do. I mean, I don’t require them to do it. I have handouts that I give them, I explain stuff, but I find that, and it’s kind of like an informed consumer when somebody goes to buy a car. If you know what you’re buying, or you know something about what you’re looking at, I find it’s, it elevates the person to the level of a colleague rather than like trying to teach a child, so I think having patient education is, I think, vital for patients understanding what they’re supposed to do. I just came from a Journal Club, and they said that something like 40% of patients in this huge setting were never told what follow-up they need for their colon cancer, family history screening, and it’s like, well, my patients, if they look, besides getting a written handout saying this is when you need to come back, patients who understand what their own disease risks are are then better informed and can take care of themselves. So I think it’s really helpful to have patients be able to access information.

But you are the trained professional. Would you not be concerned about your patients kind of misdiagnosing or rushing to conclusions?
No, I love discussing it with them. I mean, they don’t have to, like I had a patient come in and they said they had, oh, it was a phone call yesterday. She said she had H. pylori infection and what should she do about it. I said, “Well, how do you know you have H. pylori infection?” She said, “Well, my endoscopy showed duodenitis so I must have H. pylori.” And then I said, “Well, no, actually your H. pylori biopsies were all negative,” so understanding why, sometimes even when they’re completely wrong, understanding what it is that they’re trying to say helps me to explain what it is that I want them to learn so I find that even a bad question that they didn’t understand then gives me something to, it shows me if they do understand it, then it’s really great because then I can talk more as “Do you want a paper? Do you want an article?” If they don’t understand it, then it shows me what they’re lacking in terms of their understanding of their disease process, so it gives me an opportunity to educate them. So both ways I win.

Do you own a smartphone?
Yes. I love it.

Personally?
Yes.

How, if at all, do you use your smartphone? Do you have an iPad as well?
No.

How do you use your smartphone in your practice?
It’s interesting because we are encouraged at this point by our physician network not to do professional work that has any kind of confidentiality on it, I mean, not to do anything that would have a patient name or something like that.

Is that for HIPAA reasons?
Right, for HIPAA. So, I do my educational stuff, I look up articles, I read articles, I love it, the AGA, American Gastroenterology Association, you know, I’m on their list, a variety of programs that send me articles of the week, articles of the day, so there’s a lot that I will do on my smartphone, but I don’t do patient contact, patient information, I don’t try to store anything that would be private HIPAA, potentially HIPAA violation data or information on it.

But you look at articles. Now are these articles, are you actually using your smartphone as a means of obtaining the articles?
Yes. I mean, I read them. It’s like great. It’s like you standing, you’re driving, my husband’s driving down the Cape, I’m reading journal articles. I mean, it’s fabulous. I mean, it’s a miracle. It’s more than a miracle to be able to wherever you are access things that you really want to know, or I’ll look something up so it’s like easy to say, you know, how do I do this or what should I know about this? So I think it’s a great opportunity.

Do you ever find folks, colleagues, sales reps, others actually giving you articles that would be smartphone enabled?
I can’t think that I have seen that, no. They’ve given me articles and I’ve asked them for articles, so I will say like tell me, you know, find out something like the foods that can cause the Eosinophilia esophagitis and they might go ahead and do a literature search for me and come back with it. So how they searching, I can’t say. Maybe they’re doing it as an Internet search, so I do have reps bring me information, and I find that very helpful.

But to this point, but not to this point. Would you be open to that if they shared it with you?
Sure, yeah.

I’ll tell you what, we’ll get back to that sales rep issue in a few minutes. So, given this concern about patient confidentiality and let’s say that will continue in the future. Nonetheless, you have found this new found love affair with your mobile device. What apps do you think might be useful to you? Let’s use our imagination for a moment, that it’s like, now that I could actually see, says you, you know, using my device for.
Well, what I have found the most helpful is picking the organizations that I want to receive their daily updates or weekly updates and then I have already pre filled out or checked off what areas of GI I’m interested in so that then what comes to me is what I’m most likely to use.

So these are the organizations that you are already a part of?
Or connected to in some way. So I find that helpful. I mean, there’s WebMD and various things, but I find that the stuff I read the most are like the American Gastroenterology Association sends me a daily update, here’s the ten articles that you might find most interesting, and I might only read two or three of them, but I see the titles and I can scan a lot of information in a very short period of time.

What about a …
Now, I do actually go to the written articles when I’m very interested so that I can sit and underline and review.

Let’s actually, let me put the question I was going to ask aside for a moment and go into this, I think because it’s obviously something that you take a good deal of time and devote yourself to.
I can’t say how much time, but I probably spend 15 minutes a day scanning information that’s sent to me that’s academic that I’m interested in. So, I mean, the nice thing about it is I don’t have to do anything to get to it. It’s right there with me all the time.

Why? What are you trying to learn from these scientific articles, we’ll say from the peer review?
Standard of care, changes in standards of care, better ways to do what I love doing. I love it.

Now, would you be getting, do you have certain preferred journals?
Yes, Gastroenterology, the GI journals that deal with what’s considered luminal disease like colonoscopies, colon cancers, screening, Barrett’s, reflux, ulcers, H. pylori, gastric cancer, so there are areas that I really, really find interesting to read.

That’s interesting. So my guess is that you’re reading these because they are highly relevant to your practice. Do you find yourself also gravitating to journals that you might consider impact journals, just a practicing physician really just needs to be reading this or that journal in order to do it?
I mean, you could say New England Journal of Medicine, but then I’m reading usually the hard copy because it comes to the house, so I don’t have that coming, and I don’t check it online because I know I’m going to see it anyway, but the GI material comes from a variety of journals, so it might be journals that I’m not going to see.

Now are you just reading the abstracts, or are you actually reading the articles themselves?
If I like the articles, I’ll click on the articles so you can pull them up. So some of them I’ll read the abstracts, some of them I’ll read the articles. Not terribly easy sometimes with the smartphone because you’re going up and down and back and forth. But it’s fabulous.

Okay, so that’s smartphone stuff, I would imagine, perhaps correct me if I’m wrong, are you also reading this in your office, this material, these articles?
I do it less in the office on a computer than I do it on my smartphone, but the journal articles, I’ll read in the office or at home. I access a variety of things.

Hard copy?
Hard copy.

Do you prefer hard copy or electronic versions?
I prefer hard copy of articles that I really, really want to carry with me, put in my files, underline, study, really, really down to the nitty gritty, down to the details. For scanning a lot of information quickly and covering a lot of topics, I much prefer doing it electronically because I don’t have to keep anything. I can just bypass it, delete it when I’m done looking at it, store it in my brain computer. So if there’s something that I really want to be able to, for example, some articles I will save, underline, put in a drawer, and then when a patient comes in and he has that condition, I’ll offer them, “Do you want a journal article on it that I’ve read in the past few years and reviewed, you know, reviewed and underlined and marketed up?” And a lot of patients really do. I mean, I think it’s amazing to me that I would say 90%, I mean, I don’t have, my population isn’t like all Harvard professors, but I would say that 90% of my patients when I offer them a journal article, it’s actually like a little blurb, a little handout, like a one page thing that a lot of WebMD kind of stuff prepares, but real articles, they want to see it. They really do want to read it and occasionally people will say, “No, I don’t need to. It’s okay.” But I’m amazed that people really do want to read that, even if they don’t understand it. I say, “Read it, if you have questions, call me.” I like an educated patient population.

What would be the circumstances that would signal to you this person I want to offer X article?
If they have a condition that’s something they need to know. It’s highly precancerous. It’s something that knowing about the condition can help them comply with follow up or do the right thing for themselves. I think a patient that understands what the risks are is just much better enabled to comply with the follow-up recommendations. If somebody doesn’t know what they have or what they’re supposed to do or why we’re worried about it, it’s hard to get people to do what we tell them to do. But when somebody understands it from within, their disease becomes something that they then have control over. That’s what articles really do. I think that’s the empowering nature of knowledge and medicine.

Whether we’re talking about the content that you might find in some of these peer review articles, or journals rather, or the methods by which you are obtaining them, is there anything that you could say you wish you could see or wish could be done a little differently that would make it even more accessible or more easily obtainable, either the information or the articles themselves? This is kind of a blue sky question just to see if it’s, you know, anything comes to mind.
Yeah, I suppose it would be nice if there were a perhaps a, for example, in my field a GI website where you can say, “Show me all the articles or scan titles in the past two or three months that dealt with Barrett’s esophagus or Barrett’s cancer or proton pump inhibitors and osteoporosis. I can see that it would be nice to be able to, instead of having the journals sort of feed me what they want or the association is going to remember to feed me, if there was an easier way for me to look up like I had a patient today with anaphylaxis. I didn’t think to go into my smartphone and look up anaphylaxis, GI causes but actually, I wrote it on a piece of paper and said, “Okay, go home and do my research.” Again, the patient information, you know, go see this allergist and that, this, and the other thing. I did blood tests, but I gave myself an assignment and so the interesting question that you’ve raised is how am I going to fulfill that assignment that I put in my bag, and am I going to do it on my smartphone or am I going to do it in paper or in texts. It has changed how we think of looking for information.

A couple of final questions on this and then I want to move on to another topic. It’s obviously changed a great deal how you obtain information. Your patients also have adopted some of these same mobile device technologies. How has it affected, if at all, their interaction with you? And I’m looking at now coming back the other way.
I am always happy to have a patient come in armed with knowledge about either their symptoms or their questions. I read about this. I read about that. The only thing I dislike is when somebody comes with an inch of printouts that they want me to review at the time of their visit when it’s not stuff that I myself have generated. So I particularly like giving somebody an article and saying, “Here, read this and come back, we’ll talk about it.” I don’t like it when somebody, which occasionally happens, is sometimes people will search the web and they will come out with inches of pages and pages and pages that they want me to review. It really isn’t, I mean, I don’t really have time in that hour that I spend with somebody to go over everything that I think and their symptoms and then review everything that they’ve printed out. But that’s not that often that somebody will come with, but it has happened, and I just cringe when I see somebody walking in with an inch of stuff that isn’t their own information but is something that they have printed out to review, like stool results and things like that. So that’s my only, I like an informed patient, and I do like it when I have read up on what they’re going to come and talk to me about with that caveat.

My assumption is that someone of your stature has been called on more than a few times by various company representatives or you have been the target of promotional activities either medical device companies or pharmaceutical companies.
I like being the target.

You like it?
I like being the target.

All right. Well, let’s think about it. Put you in the position of being a reviewer, an objective reviewer of all right, I see it all says you. What are among the promotional educational tactics, if I can use that term, that you would say are effective for reaching someone of your caliber?
I love it when a rep knows their stuff. Not just their stuff, but the field. So, for example, I saw a rep today who was dealing with pancreatic enzyme replacement. Well, they knew their stuff. They knew that the FDA had pulled all of the agents that were previously used for pancreatic insufficiency off the market and that they relicensed or approved two agents that had met their criteria so if somebody doesn’t know what the issues are in a current field, then it’s kind of like it’s a waste of time to talk to them. But, fortunately, at least the reps, most of the reps that I have contact with, they really know their material. They know their drugs. They know the FDA rules. One of the reps today, I said they have, I consider the most effective combo for H. pylori infection, but 80% of the time it’s not covered by insurance, so I said, “What am I supposed to do? How do I handle the issue that what the journal articles say is the most effective therapy, insurers won’t allow it because it’s more expensive than the alternate therapy that’s available?” So those are the things that I find very, or one of the reps, there was a woman that couldn’t afford the $1,440 charge for the antibiotic that she needed. They were able to get it. I mean, I don’t normally do samples, but in a compassionate use if somebody is really ill, they were able to figure out a way to help the patient. So I just find there’s a lot of bad condescension, I think to drug reps and the whole physician, pharmaceutical industry relationship, and I personally have had nothing but wonderful experiences with the reps and the companies behind them really trying to help my patients. I realize that there’s, you know, obviously a motive to try to sell their drugs and stuff. I’ve never used a drug that I didn’t think was the absolute best drug for a patient, but when I can have a rep really go out of their way to help my patients either in obtaining information that is helpful for them, I just think it’s, I mean, I really think it’s a wonderful opportunity for physicians and the company to interact in a way that’s beneficial for a patient population.

Well, that’s interesting you say that because in preparing for our talk this evening, I came across some research and it appears that something like a quarter of all physicians actually refuse to see reps from pharma companies or medical device. What would be, why do you think that is? I mean, you use the word condescension.
There is a stigma. Right. There is a stigma attached to physicians seeing reps as if there’s something like dirty or sleazy or not nice. I mean like it’s sort of like, “Oh, well, they’re going to buy you off and they’re going to buy off your opinion.” The best story I have that I tell is there was a physician at our hospital who is no longer there who had that policy, absolutely wouldn’t see a drug rep that was beneath, you know, it was beneath him, he wouldn’t do it. Well, there was a patient who was leaving to go to another country. They desperately needed a vaccine to prevent a disease that that country had. I knew that the reps, that the company that made the vaccine had just made it available. I said to the physician, “Why don’t you call the rep. You can get this patient, who was our mutual patient, the vaccine.” I mean, I said, “I know, I’ve spoken to the rep. I know it’s available.” And he said, “I will not deal with a drug rep even if it means saving a person’s life” because it was something he didn’t do. I’ll never forget that. I mean, I really can get goose bumps to this day because it was more a matter of principle not to deal with a drug rep than to save that person’s life potentially if they got that disease. I’ll never forget it. It was like if that wasn’t the most eye opening expose to me of how narrow minded that thinking is, that I’m only going to do this because I think Harvard and Mass General and they say, “Oh, drug reps aren’t allowed in the hospitals.” I understand because I know the government like has, you know, except for that one patient that had an emergency was frowned on, physicians having any kind of samples because you have sign for them.

So you don’t have samples?
I normally do not take samples, I don’t want it. I tell the reps I don’t want, I mean, I don’t want to be responsible for keeping the log that if there was a recall then you’d have to figure out which patient got which bottle of Prilosec because somebody put poison in it or something. There’s a whole system. And I mean, I tell the reps that. I like meeting with them, I like learning from them, and I like whatever help they can provide my patients in any way, but I don’t keep samples because of the whole government restrictions on them.

You like meeting them. You like learning from them.
Yeah. So I mean they’ll tell me what’s the current status on approval of this drug, where is the new drug that’s coming out for constipation, how’s that doing, you know, what’s the information, what do the other companies think about it. So, I find it very, I like the interaction and it’s, one of the examples is they’ll often know how can I best write the prescription for patients so that the cost to the patient is less. For example, writing 30 of a certain prescription might be actually less expensive to a patient than writing 20 because it comes covered as a 30 and it doesn’t come covered as a 20. So, little things like that that I would have no reason to know, or they’ll know which insurers allow which agents so that, I mean, for a long three years back, I would say, “Okay, you tell me, you know your drug. Which tiers are the lowest that allow your drug as opposed to another so that I can then choose for the patient’s interest which would be the lowest cost to the patient?” I use, I would say I almost always use generic drugs if I can. If there’s a generic available, then I just say, I just use generics. If I don’t think it makes a difference why have the system have an additional cost, but if there is a reason for one drug versus another one, it’s nice to know what the best way to achieve that at lowest cost for the patient is.

What, if any, I don’t know if you happen to actually have medical device reps call on you.
Yeah, we do because I do GI so we do procedures, so they do.

What, if any, difference is there between in both the quality and the approach between a medical device sales rep and a pharmaceutical sales rep?
The device reps are usually seeing us in the GI unit, and they’re usually part of a company so they will come usually and demonstrate what equipment they have or we’ll see them at meetings. The drug reps are not allowed in the GI unit, so it’s sort of the device people we see in one part of the hospital, the drug people we see in another part of the hospital.

But what about how they come across to you? Do you see qualitative differences in the approach, in the quality of the interaction?
I think that, I find my quality of interaction with the reps to be equally pleasing to me, whether it’s the rep in the office talking about the drugs that they service from the drug companies or the reps in the GI unit talking about the different devices that are available. I think that in the GI unit, the device reps are really trying to teach us about their new devices, so it’s a little bit different because they’re actually trying to instruct us in how to use the device, what the best way to use a clip is or what the new clip is or how the APC probe that’s now the one that we might use is the best, you know, how to do it best, so they’re really a level above the drug rep kind of people. I mean, the drug reps know their drugs, but the procedure reps, they’re kind of more like dealing with the gastroenterologists. They’re like going to a meeting and having somebody show us a new technique and say this is how we do it. So it’s a different, it’s kind of a different relationship sort of.

We were talking earlier about your love of the articles. Are these reps ever the source of those articles?
Yes, they will, I mean especially like I said, the New England Journal or one of the other big journals comes out with an article that’s relevant to whatever drug or condition they have, they’ll bring it with, and I will read it and I often will find it interesting.

Reading it because, as you think about it, because they’ve given it to you or reading it because you just love reading this stuff?
Oh, I will only read something that is of interest to me, but if there happens to be an article that is relevant to my current practice and somebody is handing it to me, I love reading it, so.

Now, it also could be argued that gosh, sales rep is only going to give you articles that support that which they are selling. Wouldn’t you be concerned about wanting to get kind of an objective view?
I do so much reading that I can tell you, I think, the pros and cons of every argument for every drug that I’ve ever prescribed. I don’t, I mean, I probably don’t prescribe more than 5% of the drugs that are available, so most drugs, I don’t even know what they are, I don’t use them, they’re not my field, and I’ll tell people that. People will call up and say, “Oh, I want Compazine.” I’ll say, “Well, I don’t do Compazine. I don’t prescribe Compazine. I don’t prescribe narcotics. I never do.” So if it’s not a territory I love and am comfortable with, I say, that’s it, I don’t do that. But if it’s something that I’m really interested in like neurologic side effects of Reglan, therefore why I don’t use it, you know, it’s like that to me is a passionate interest, drug side effects and drug complications, you know, like do the drugs like Prilosec and PPS, do they break people’s hips? Inquiring minds really want to know. So, any article that talks about stuff that’s relevant, I am very thirsty for that kind of information. So I feel that whatever is given to me, I’m always balanced in how much else I read. It just is a stimulus for me to look up more.

Has a rep ever been a source of what you would consider a less than totally favorable article about that which they have …?
Not an article. I don’t think anybody has given me an article that I didn’t view because if it was an article from something that I wouldn’t normally read, I wouldn’t have read it, but I can say that I would say that probably 10% of reps that I’ve met in my career have been pushy in the way that you sort of would turn them off and just, you know, if somebody, if you feel that somebody is trying to push something or sell you something or not sell, not physically sell, but try to convince you to use something that you don’t want, you’re not buying their story, I would just smile and just close the brain.

That’s so interesting. The gentleman, the physician that came in right before you had his own telltale, okay, I know. What are your telltale signs for a rep that is pushing where you know you’re going to shut down?
That’s a good question. How do I know? It’s like …

What’s the Rubicon?
A lot of times you’re talking too much. I can think of one drug in particular that, you know, when the rep comes in, I mean, she’s smart, but I don’t, I know I’m not going to use her drug because it’s not the cheapest available of the drugs that I think are okay, like I said, I use a lot of generics and I try to use the least expensive because of all the issues of healthcare costs, so it’s almost funny when she said, “Oh, don’t forget.” It’s like, okay, I’ll just smile. So, no one can talk me into using an agent that I don’t want to use, even if I think it’s a pretty good drug if it’s too expensive because this country can’t afford it, no one can afford it, and we’re already the richest country there is, so, imagine the cost of healthcare in places in the world where there isn’t reasonable healthcare coverage, so, anyway, so, yes, when a rep is talking too much, pushing a little bit too hard, trying to get me to not consider the alternatives that are less expensive for the patients, then I just turn them off in my mind. I mean, my contact with a rep is probably three minutes.

Do they usually schedule appointments with you?
They’ll walk by the office. I mean, they do, but it’s my usual contact time.

So, I want to be a new rep. What do I have to do to get you to really give me, well, let’s say that I am supporting a drug or a device that would be a relevance, so we’ll already kind of cross that particular hurdle. What would I have to do, be, or say that would get you to meet with me the first time?
I just have, some of the reps will bring a lunch to the office which is okay by our hospital guidelines, occasionally they might bring a coke or something like that. There’s a room that is our sort of second room, so there’s no private information in it. If the rep is there when I’m done with my office patients on my way to the GI unit, I will take three minutes out to say, “Go ahead, tell me in a nutshell what is it that you’re representing.”

Three minutes?
Three minutes. That’s how my life runs. But in three minutes, you’d be surprised if you say, “I have three minutes, I have to run to the GI unit. I have a patient on the table. What do you want to tell me?” And they’ll tell me something.

No samples.
No, I don’t do samples.

Maybe an article.
Maybe an article or, for example, like there was a new agent that came out to treat a certain condition that was really interesting to know, even if I wasn’t going to use that drug because I didn’t really treat that condition, knowing that this agent existed or had just been FDA approved, that expanded my knowledge, so that’s the kind of thing, even if it’s something I’m not going to use, knowing that there is a treatment for a condition that I might be called upon to consult on is nice to, so I really enjoy the potential learning that I have.

And it sounded like for some of the reps that you have gone, that you have seen time and again, that in some cases you’ve actually asked them to research things?
Yes, I do, right. So I’ll say, for example, “What information do you have on this agent and pregnancy?” Like if I have, which I do often have young women with various conditions. They’ll go look it up, they’ll call their pharmacy, you know, they have the whole pharmaceutical, pharmacist backup for their company. They’ll print out 30 pages, send it to me. I stick it in a drawer and then if a patient comes in that there’s a contemplation of pregnancy and stuff, I can say, “This is the information the company has on the drug today.” I called up the pharmacy at the hospital to say, “I have a kid here who’s 17 with severe reflux. Is there any limitations of using Prilosec or omeprazole in a kid under 18?” That wasn’t a rep from a company, but that’s the typical kind of question that I might ask. There was another time, it was a young woman with Crohn’s. She was like 16 to 17. The question was, is Cipro okay? It wasn’t even the reps like company. I was just saying get me the information that I need to know, and it turns out you can’t prescribe Cipro for somebody under 18. So I’m saying I will often give little assignments that, you know, there’s a pharmacist, there’s a whole, or, for example, the colon preps. I mean I do that all the time, saying, “Go find out whether there’s any problem with this condition and this prep.” You know, in other words, what information is there about V-tach and the PEG preps, so that kind of information. And they have backup there. They’re big companies. They can do that kind of research and come back to me and say yeah, this is what information there is. So it’s not necessarily particular to that person’s drug but to the whole class of drugs. That’s the kind of information that I try to find.

When it comes to promotional activities, though, sales reps, although they may be the most obvious or the most clearly identified, are only one several promotional activities known, my guess is that in these days gift gifting and junkets are kind of …
Not even a pen.

Can’t even do it. So, again, when reviewing promotional activities that are effective, what comes across to you as being an especially helpful or educational or effective promotional activity?
Probably the most effective is people that approach me about conditions that I’m interested in and that I treat, so I think probably the most effective is for a rep to say, “What diseases do you like to see, what diseases do you regularly see, and how can we help you in any way in taking care of your patients?” Is there anything, for example, I mean I’ve asked for years, no one has done it, I would like one drug company to give me a chart of gentamicin dosing for patients depending on their weight. I mean, we have to do the calculation every time. It would be a very easy little plastic ruler. I mean, maybe they’re not allowed to do that, but it would be, I mean, there are things that could actually make care easier. I would love to just see. You know, a little nomogram. Just like the BMI, maybe they’re not allowed to do that either, these little wheels that you could do like dates of conception and delivery date or date, you know, weight and beyond. So there are different things that can be, there are things that would be actually nice, and I don’t think they’re allowed to have logos, but anyway, there’s information that if somebody comes to me and they have something of value that I find will be helpful, I’m happy to look at it or to consider. If somebody comes to me with stuff that I really have no interest in, I don’t want to waste my time.

Stuff that you have no interest in, just so I understand …
Like hepatitis C, I don’t like hepatitis C, okay? So hepatitis C, if a rep comes to me trying to tell me about the latest treatment in hepatitis C, I say, “That I can read online.” I don’t want to meet with somebody for that. So if I’m choosing to meet with, the most important thing I think a rep could do is find out what the interests are of the physician that they’re trying to meet with so that they can tailor which physicians they meet with or which drugs or treatments they are trying to teach about or promote.

So, in addition to, I’m going to keep going back to the promotional, in addition to anything the sales, we’ll put the sales rep stuff aside for just a moment. We’ll come back to it. Is there any other material, any other activities that you’ve seen, maybe it involves creative uses of mobile devices, that some of these companies have done that says, “Now, that’s a clever way. I like that. That helps me.”
One of the things that sometimes they’re sponsored by companies but not the drug companies anymore, but they’re sponsored by universities, one of the things we really miss as physicians, we used to go for dinners in which some of the local experts would speak. I hope that’s turned over. I mean, it was, it became illegal, I don’t know, about four years ago I would guess, four or three, something like that, and I can say as a physician who regularly went to sessions like that, I really miss that I could go store up six people that I wanted to discuss with this expert from the Brigham, go to the dinner, and then ask about my six patients without having to have the person actually go see them. Those were things that drug reps would have known about and said, “Do you know so and so is going to speak on such and such at such and such a place, just FYI in case you’re interested.” I thought that was fabulous. I mean, I really, my patients benefitted tremendously from that, and it was such a nice informal way to do it. It’s not allowed now. It’s a little bit allowed because there are certain programs that are presented, but that’s the kind of information that to me was invaluable because I could make the decision about whether I wanted whatever exposure to the topic and I could choose whether to go. So, I think the rep coming across as your ally in fighting disease, that’s what I find, those are the reps I interact with the most.

It’s interesting that you, we’ve talked to several of your peers today, and every one of them has talked about that that’s something that they all miss.
Oh, terribly. I mean, really.

And I don’t think it’s the dinner either.
No, no, because with the dinner, you can eat anywhere, but it was when you get to meet with the people that you go to their lectures at meetings once a year, but you can actually hear them talk and interact with them on a regular basis, that was such an opportunity. It was an opportunity we miss because, you know, I have gone to 10,000 person meetings and asked questions, and I remember the ones I did because it’s embarrassing to ask a question in front of thousands of people, but when you’re in a room with 30 people, you know, you don’t sound like, you don’t sound silly asking a question that’s like, “Well, how many bottles do you use for your colonoscopy biopsies on colitis patients?” That was like a question I asked a few months ago because our hospital had a policy to cut back the number of bottles to two per patient if we could. Well, the people at the BI and the General said, “That’s ridiculous. You’ve got to have at least five.” You know, I mean it was actually a really practical question and answer that one hospital says, “We’re going to cut costs, we’re going to do this, we’re going to do that.” And then the other institution says, “Forget it. We don’t do it that way.” How much value could you put on that if it’s a person’s life at stake?

What, if any, this is in addition to the sales reps, but what if any marketing or promotional or educational material, in addition to those articles you told me about, do you regularly make available say in your waiting room?
Not much. I don’t like having named, I don’t have anything in my waiting room that is, maybe magazines, I don’t know if magazines, you know, things like that have the drugs in them, but I don’t have handouts. I mean, I don’t have anything.

Is that a principle as …?
Yeah, I mean, I don’t want to feel as if I’m pushing any particular drug on a patient by suggesting it by having the name there. So I just, I don’t feel comfortable with that. I mean, I feel extremely comfortable meeting with reps, but I’m the one making the decision about what I’m going to do with the drugs and dosing. I don’t want a patient to say, “Oh, I saw this drug, this name lying around. What about that drug?” I don’t want to, what do you call it when it’s subconsciously sort of lead a patient down the path to say they need something that maybe that isn’t what they need because they’ve seen it in a doctor’s office, so I don’t do that. Whereas, I ultimately will explain to patients that I do meet with reps and I don’t, nothing bad to say about meeting with reps. I don’t think it’s a bad thing but some of the institutions have…

What professional organizations are you a part of?
AGA, American Gastroenterology Association, American Society of Gastrointestinal Endoscopy, intermittently, so various areas.

Not a duh question, why did you join?
Oh, I joined in the beginning of my career, and you know, after 20 years became a fellow of the AGA, things like that, so you join to go to the meetings, stay involved, to some extent. I’m not one of the more involved people. I don’t like the politics of things, but I love listening to people present their research, and I love hearing the changes. You know, as we evolve through taking care of patients, things that we used to absolutely believe, you then go to meetings and it turns out what you always believed isn’t true anymore. And then sometimes it’ll swing back, so I tell people, “Ten years ago, we believed this. Five years ago, it turned 180 degrees. And now we’re back to where we were ten years ago in terms of the thinking. So I like those. I like the panel kind of discussions where they will present the different approaches to handle a problem.

And are there named conferences that you make a special effort to attend?
Yeah, I usually go to the Digestive Disease Week. I sometimes go to the American College of Gastroenterology. I like going to Pri-Med which isn’t GI, but a lot of the local, same reason, a lot of the local GI people, when they have a GI topic, they do a great talk to the internists, and so I like to, it’s not that expensive, and I like to go if I have the time to listen to somebody talk about fatty liver or hepatitis C, even if it’s a topic that I might not treat all the time, but it’s nice to hear an expert talk about it.

When there is material presented, educational material, I’m not talking about swag or the bags or any of that kind of stuff, how do you like to take, what’s your preferred mode for taking away…?
Oh, I take notes. I mean, I will take notes.

Right, you take notes, but I was thinking of things like, I mean, was it downloadable or it was on a thumb drive or other approach?
I think if I had my druthers, I would say wouldn’t it be nice if there was a website that you could go to and download what, something like the current treatment of alcoholic cirrhosis decompensated coming in the hospital. That would be, I mean, it would really be a fabulous, instead of like having to glean it from one lecture after another, really, if there were algorithms or one page summaries. It would even be nice if the diseases had one page summaries. I have a lot of patients with a condition lazy stomach called gastroparesis. Well, I’ve gone through ten different texts and I haven’t found a single one page kind of article, you know, just a general, not a journal article as much as just a sophisticated enough page to hand out to patients that’s not seven pages long that just kind of summarizes, so it’s like on my to do list is to find a nice one page, you know, physician level summary of this disease that I can mail to patients when I diagnose them with a condition. So that’s the kind of thing that some of the WebMD stuff is a little bit too sort of cushy.

Cushy?
Yeah, it’s like not as detailed as I want it to be for a patient, so I sort of like something of the quality of a journal article introduction where the field might be introduced and the issues discussed. That’s the kind of quality that I want.

And that’s what you would want to send to a patient?
I’d love to, yeah. Or to tell them, you know, here’s a website. It would be nice if there was a website that I felt had that kind of information on it.

So, in the final analysis, you have been most helpful in getting me to understand how you as a practitioner go about doing what you do. You’ve given me some, frankly, inspirational notes about how it got you started. What would be your advice to kids coming out of medical school now?
(Inaudible) as a resident. Just finish. Talk to GIs. My husband’s terror was if you go into internal medicine, we’re disinheriting you. And he meant it.

Okay, let’s get him out of the advice business then.
All right. So, the bottom line is try to find something for people coming out into medicine, find something that really means something to you because then, even if you’re working hard and even if it’s frustrating, at the end of the day you feel like you’ve done something good. I mean, I know I have a passion for things, not everybody’s happy with everything that I do or time or all the constraints of healthcare, but if at least you feel like you’ve picked something that you’re good at and that feels really good when you do it, that you really enjoy doing it. It’s really, I like to say I carve in flesh because what I do, it’s like an art form. Or I like to tell patients it’s kind of like a video game that I get to go play every single day and I understand why when kids are addicted to video games and they can do the same game over and over and over, that’s how I can do 25,000 colonoscopies in my lifetime, and every one is just like the very first one because it’s exciting. It’s like I have to look and see where are the aliens, where are the monsters. You know, it’s like, so the adventure, you have to pick something I think for people coming out that it’s not just a job. It’s a passion. It’s an art. It’s a career in which you really feel like you can make a difference. I think that makes the stresses of practice, it minimizes. At least when I’m in the procedure room, the world can’t touch me. It’s just me and my screen and what I’m doing and I feel as if I’m above the world. I mean, not above in like a more important, no, but the rest of the world, the beepers, the phone calls, the messages, the bills, all the everything, all those issues just vanish and then it’s just me and the patient and that’s a beautiful feeling. It’s focused. It’s like somebody made an analogy once I heard of a trapeze artist doing the tightrope walk and like the focus has to be right there on a moment, right at what they’re doing, and that’s the beauty of medicine, and if I can share that with students, with residents, with physicians, how that kind of focus really is what inspires me and I think inspires us to take great care of people, that’s what I like.

Okay, I wanted to follow up on a couple of things that you had mentioned, and I want to start with the sales rep one that you were going on and on about what the good ones really do and how much you appreciated them and you would visit them. But there are bad sales reps, too. What do they do? What are some of those habits that if you were Queen you’d say …?
Annoy me. I hate it when a rep, I mean, they don’t get, if somebody annoys me, they don’t …

Yeah, but, what do you find annoying?
Oh, pushy, like trying to push a drug when they know there are five other drugs in the same class including generics. I mean, there’s no point to try to convince me that one drug that is the same as all the other drugs and more expensive is going to be something I would consider prescribing.

So don’t be argumentative, don’t push it.
It’s not even argumentative. If what they’re telling me isn’t the truth, I mean, what I want somebody to come to me with is the truth. If somebody comes to me with what I know right away isn’t the truth, it’s automatically my brain is turned off, so if they’re trying to push something that isn’t true, and it’s one thing if somebody says this particular treatment for H. pylori is by recent studies the most effective, and I have articles and they’re not done by pharmacy companies, they’re done, you know, by different companies, not companies, different researchers on the globe, then that’s something that really means something to me. Somebody comes and they say, “Oh, my PPI is the best PPI.” I mean, I don’t believe it. I know it’s not true before they walk in the door, and then it immediately invalidates what they say to me because I don’t believe it. So if I can’t believe what somebody is saying to me, I don’t want to hear what they have to say.

Okay. Enough about sales reps, but I am curious under what circumstances might you actually recommend a branded versus a generic drug?
Oh, easy, when the generic fails. If somebody says I have tried omeprazole and it caused me belly pain, do I really believe it caused them belly pain? I don’t know but then it’s an easy thing to say, “Well, why don’t you get some over-the-counter Prilosec? Why don’t you get some over-the-counter Protonix. See if one agrees with you more than another, try this one, try that one. If you find that one really works better for you than the others, I will try to get that for you.” And that’s the reasonable approach I think that is very cost effective and fair because maybe for one person this particular drug is better than the others, or maybe, you know, I’ve had people that one colitis medicine didn’t work and another one did work, and there’s no reason why one should have worked and one shouldn’t have worked. So if one doesn’t work, that’s what, that’s how I use branded names which is to say if what’s the, the caveat. There are certain branded drugs that I think are better than the generics. If it’s one of those, then I will use the branded. So, I try to use generic if I can.

So it’s now a theologic thing?
No, no. The colitis medicines, I think the branded ones are better than the generic that’s available. If the generic were equally good to the branded ones, then I would always use the generic. Some of them, it’s the number of pills a day. I mean, certain drugs, it’s like the timing is easier, more convenient for the patient. So there are a lot of factors. But in terms of a rep, if a rep comes and tells me something or tries to encourage me to do something that I know right away is garbage, it will never, they have to use an argument that I’d reconsider not saying something that I wouldn’t consider because I don’t think it’s true.

You liked your mobile device.
I do.

Is it an iPhone?
No, it’s an Android.

Okay. You thinking about an iPad?
No. I went in and I tried them out, and they’re heavy. And I just find it, I mean, I walked around the store with the Galaxy, with the iPad, and quite frankly, it was heavier than I could comfortably carry with me so I found the smartphone, and I really made, it was a decision I really tried hard to, there was even a little Galaxy, I think a Samsung, a little one that was like an in between, but even that, it was just, it was an issue of weight. I mean, I know the reps love the iPad. I mean, they just love being able to pull up ….

Can you see, I’m not pitching you anything for Apple, but can you see doing one of those tablet …
Yeah, yeah, I mean, if it was lighter. It was just a question of the weight of carrying it around with me all day.

So, in other words, if we can get the engineers at Apple to kind of figure out how to do this and not make it a weightlifting exercise.
Right, right. I tried it, and after ten minutes, I could feel it in my back and it was like, “Do I want to schlep this around with me all day?”

You have been an absolute delight to be with.
Oh, thank you so much.

Thank you. It was a pleasure meeting you. Thanks for coming out so late in the evening.
Oh, my pleasure.

(End of Recording)