(Opening Remarks)
We have been having a lot of fun on this one and I have been learning an extraordinary amount about the medical practice here in the Boston area.
We have an unusual place, Massachusetts.

You are not originally from here?
Oh, I am. I am. I have traveled a little bit. I have been in the military. It is a difficult place to practice, Massachusetts.

So I have heard. How long have you been doing what you are doing? You are an orthopedic surgeon, are you not?
Yes. I finished my training in ’84, 27 years.

All in the…?
I was in the service for a while. I went to Kentucky for the first year and realized I missed home. And I have been nonstop since ’85, except for a couple of tours of active duty in the Navy. The Reserves called me up.

What originally motivated you to become a physician in the first place?
Well, a number of factors. You want to contribute and you enjoy the lifestyle and want some level of graduate studies. So with time, I realized that this is where I wanted to take my career. Initially, I wanted to be a physician and then my love of sports and sports medicine and fracture management took me into orthopedics.

You have been doing this for what? Almost a quarter of century now?
Yes. Well, I started training in 1980, so, in a sense, I have been doing it for more than that, a third of a century.

I imagine in addition to the scientific knowledge you have accumulated and some of the technical skills you have acquired, what are among the kind of the lessons, the life lessons, that you have learned as a physician?

Well, I think you need to understand what your patients’ needs are. I have learned that initially I wanted to do what was best for the patient. And then, with time, I wanted to do what I thought was best but the patient may not be aware. And in recent years, I have come more to want to give my patients the understanding or the belief that they are being helped. I want them to leave my office with the impression that I have helped them. Because many times, you know you are helping them, but they don’t know that.

You said you are doing things in the last few years. What are have you been doing to give that belief…?
Well, it is important to give them that perception that they are being helped so that they will be happy.

So how do you…?
I spend more time talking to them, explaining to them why we are taking different treatment courses. At times, I will even treat them a little differently than I might have done ten or 15 years ago because I want them to come away with something that has given them the impression they are being helped, even though it may not be in their best interest. For instance, a prescription for a pain medicine. I used to be so firm, no narcotics, no, no, no. In recent years, and we are told we physicians are not sensitive enough to patients’ pain. And so I find myself prescribing a little more narcotics now. And I coach them all, I spend more time trying to explain to them the risks of dependency and habitual use. So I have become a little more lenient, a little more compassionate. I find myself following up on patients more, calling them at home. So my practice has changed to some extent.

And at the same time you are doing this development and evolution of your own practice, this little thing called the Internet has sprung up.
Sure.

How has the Internet, if at all, changed your interaction with your patients?
Well, there is a lot more information out there and I find now that I will take a prescription pad and I will write down the diagnosis of what I think is going on with a patient with bursitis of the hip or something. And I will say, “I want you to research this. Google up ‘bursitis hip,’ and see the diagnosis and different treatment options.” Some of my colleagues will tell you a little knowledge is a dangerous thing. But I mean most of my patients are going to do that anyway. Of course, the older age group may not do it, they may not have access to it. But I use the Internet to educate my patients and educate myself.

We have heard from some of your colleagues as you just mentioned that they are not crazy about that level of self-education. But you don’t share that view?
No, I think you have to embrace it. And it’s hard, especially my age group, I am almost 60, when I trained, my early years of my practice, there was no such thing. And now it has come on the past few decades. And I am somewhat envious of the younger physicians who are so acclimated to it, who can carry their Internet on their hip. A prescription drug with risks of interactions and so forth, I haven’t taken it that far yet. But it is just a marvelous tool and I feel badly for some fellow my age, men and women, who have never even been onto to it.

Well, interesting that you mentioned that thing about the hip. My guess is that you were talking about, say, a mobile phone or like a smartphone, an iPhone or BlackBerry. Do you own a BlackBerry or an iPhone?
I do, but I don’t use it for Internet purposes.

Do you have an iPad?
No.

Would you be thinking about that for your practice?
I thought of it. I just don’t have time right now, there are so many things going on. But eventually I want to use it recreationally. I want to use it for so much, you know.

Because one of the things that I am sure you are aware of among your fellow physicians nationally is that the proportion I think that I saw in recent research of those who actually use a smartphone or a tablet computer within their practice has gone from something like 30% in 2001 to about 82% in this past year. Now, I understand and this is not to put you on the spot, why do you or what do you think they are finding, your colleagues are finding in their use of some of these newfangled mobile technologies?
They are finding the information they need immediately. They are finding, among other things, diagnosis and treatment of conditions. They are finding lab values on different disease processes. They are finding different types of drugs and side effects and interactions and dosing that would take us normally longer to find out of a textbook, out of a PDR or a textbook on infectious disease.

Your patients themselves have adopted some of these smartphone, iPad sort of things. How has, which I am sure you have seen as well, how has their adoption changed how you interact with them?
Well, more educated ones will come in with different ideas of treatment plans and concerns about differential diagnoses. And over the past few years, every now and then I will learn something from a patient. Some are more aware of the most recent treatments out there that I may not have adopted in my practice. Different types of maybe injection techniques for treating contractures of the hands. We used to always operate on them and now there are enzymatic injections to dissolve scar tissue, things like that. There are new types of injections for all kinds of bursitis and tendonitis. We used always inject steroids and now there is this phenomenon of PRP, platelet-rich-plasma, injections that the teaching hospitals are doing. So we are going to see cortisone shots for shoulder tendonitis and elbow tendonitis eventually go by the board as the PRP injections become more popular. And these are things that are documented, but…

And you are finding that your own patient community, the ones that you service, are becoming aware through their mobile devices of some of these…?
Yes, yes. The latest techniques are out there online and patients will ask me about it. And I will say, well, in my case, I don’t do a lot of joint replacements anymore. I used to, but if I did, still they might say, “Well, there is this new type of knee replacement prosthesis and I hear they are doing it at John Hopkins or something. Are you doing it?” “Well, we don’t do that here. We have something just as good.” And I have to spend time reassuring them. So a little knowledge can be a dangerous thing, but there is no question the patients have more time to look at the conditions that affect their problem, because I have a broad spectrum of diagnoses I treat. And they are focusing on one diagnosis, so they will read everything about it, some of them.

Another thing that I ran across was the frequency and almost universality of how physicians on a regular basis, perhaps maybe multiple times a day, looking up, consulting, reading articles from peer-review scientific articles, journals, rather. Is that something you do as well?
Oh, yes. I do.

How frequently do you actually read these articles from peer-review journals?
Almost every day I will jot down a diagnosis I want to research or catch up on. And that night, I will follow up on it.

Are there certain journals that you follow?
No. No, I can’t say that there are. I mean the most popular journal for orthopedic surgeons is the Journal of Bone and Joint Surgery. And I pretty much scan that every month.

Do you actually subscribe to the physical…?
I don’t subscribe. I read it in the hospital library or something, but I used to subscribe, but I have cut down on that. There is just so much information out there. You can subscribe online anyway.

How do you get a hold of these articles of interest to you? We will assume that they are pertinent to your practice.
Well, you can read the abstracts and the articles online. It is something you can download…

Are there certain sites or certain services that you have learned to rely on?
Yes. Yes, and sometime I will go directly to the article. Other times, I will go through Medline or WebMD or one of those sites. Usually, if I am asked to out my credit card and pay a fee for a certain article, I will pass on it. I will read the abstract and move on to something else. But for the most part, there are number of ways to secure these articles. The hospital librarian will always help you get it.

Reprints, I mean do they give you access to reprints? Is it the full text? Is it just, as you say, abstracts…?
Abstracts are sufficient. If there is a technique, a surgical technique, I will pursue the full text. But, again, if the information I need is really out of reach, then my computer at home in the evening.

It interesting that one of the things you just mentioned that is different from what I have heard is that everybody seems to have their A list of publications, whether online or physically, that they really make a special effort to read when they come out. And I was curious, do you really, as you think about it, do you have an A list of maybe impact journals that you make a special effort to keep up with?
Well, the journals that come into my office as a courtesy, I do scan them. And I will read an article a month.

Like what?
American Journal of Orthopedics or Orthopedics Today. I mean these journals that come in. I think they have my address, they just send them to me. So they send them to me, I will read them. Sometimes I get journals from the Mass General or the New York Hospital of Special Surgery. And they have their own mailing lists. They will send articles and I will read those. So I do read what comes into my office mail. I just hate to just throw it right in the trash if it is educational. I go to a journal club once a month and one of the orthopedic surgeons photocopies the more relevant articles from the most recent issue of…

Now, tell me about that because you are not the first one who has mentioned that. What is a journal club?
It can be an evening club, in my case, it is an orthopedic Grand Rounds held every Friday morning. And once a month, we will review the most recent issue of the Journal of Bone and Joint Surgery. And one of the orthopedic surgeons will pick maybe half-a-dozen relevant articles to our practices. We are not going to treat techniques for managing dwarfism, for instance. But if you are in general orthopedic practice, anything relevant to arthroscopy or pain management or something might be interesting. So we will take half a dozen of the most relevant articles and one of us will read it. Hopefully, we will all read it, but one will report on it with his findings there to the group.

Oh, I see.
We break for the summer, but we are meeting tomorrow, as a matter of fact. And later this month, in September, we will probably review maybe the June or July Journal of Bone and Joint Surgery.

How interesting. That clearly would be one way that you could get literally peer recommendations on, “Yes, you should read this,” and so on. As you think about it, are there, given the current sources of articles of pertinence, articles of interest, and, again, we will keep it focused on these peer-reviewed sorts of sources, are there more or different ways by which you can come in contact with these articles that you wish you had, as you think about it, but maybe don’t have right now?
Well, the Internet, I can, something right to my e-mail relevant to my kind of orthopedic work, I will read. And I do get them. They do come to me now. Sometimes I will open up an e-mail from WebMD or Medline or something and there will be a list of recent articles. And I will click on it and there will be an abstract. And I want to read a little more. And then they want me to go to my username and password. And I say, “I don’t have time for that. I got off on the abstract.” I will go back to my regular e-mails. But if it were right in front of me more, I would read it. And I mean they are getting what they want because they I can see the advertisements on the side, you know. “Prescribe Celebrex,” and all. So if it comes right into my e-mail…

Do you ever get any, I imagine you get called on by sales reps from various device manufacturers or pharmaceutical companies. Would you ever read the articles from them?
I read their articles. Usually it is touting their products, but that is okay. I mean it is still informative. And I am not going to say no to them. They are making a living, they are in my office. I receive all of them. I know some of my colleagues won’t speak to sales people, but I do. If it is for a medication or a drug and they give me an article, I tend to pass on it because the article they give me is going to support their drug over placebo or over Motrin or something, I’m sure of that. But if it is an article relevant to a surgical technique, I will hold on to it and certainly I will refer to it at a future time if I am using their type of hardware or prosthesis.

Under what circumstances would you actually share, we will talk about your relations with sales reps in a bit, but that prior article, under what circumstances might you share an article, a pertinent article, with a patient? Or would you?
I would rarely do that.

Rarely do that?
Yes. I just think that that is more knowledge, more information than they need. I don’t want to confuse them. I mean if the patient has an interest in it, I will share it with them. Sometimes I will do it for their health. Like I photocopy articles equating the increased risk of back pain or infection with smoking and I want them to stop smoking, so I will give them that article for smoking cessation or obesity or things like that. Just articles that address health issues, but I am not going to give them articles on surgical techniques or just things that are beyond their scope of interest.

I was thinking about that because moments ago you had mentioned that one of the things you have learned is you always want to have people, your patients, leave your office with the idea that you are helping them.
Yes.

I was thinking maybe that one of these articles from a peer-review journal might be a means by which you can say, “Here. Read, there is evidence, you can see what we are doing with your particular treatment.”

Well, if I gave it more thought, I would do it more often.

Remember the thought came from me.
The problem is some of these articles have alternate treatment plans in them and patients will see that and say, “Why aren’t we doing this or that or the other?” But certainly if I had a little more organization skills, I might have an article on the management of elbow tendonitis and every time I see a patient with elbow tendonitis, I would give them that article. I might highlight our treatment in here. I do think that that would be helpful. At the same time, most of the things you see online are geared towards patients. So if I tell them to Google up elbow tendonitis or tennis elbow syndrome. They are going to find nine out of ten of the articles are for their purposes. It is geared towards the patient, not the physician. At least that is my experience.

Let’s talk a little bit about the companies, the device manufacturers, the pharmaceutical companies. That, frankly, have you and other physicians, you know, you are their target. They are trying to reach you. And so let’s think about putting you in that seat of being an independent observer. I know I do it when, in my industry, I would see what people are trying, you know, I would see how they are trying to target me. How they are trying to advertise to me. And some stuff works, some stuff doesn’t. From your perspective, when you think about the range of, we will just call them, promotional activities that are directed at you and your fellows, what works? What are among the more effective promotional techniques that any company trying to sell its wares would experience if it was targeting you?
Well, I am more accessible when I go to a medical conference. I should point that out. So if you are at a medical conference and you are looking at the different tables, that is when I am more open to trying new types of techniques and new types of hardware. In my office…

Let me stop you right there. What conferences do you go to regularly, do you attend regularly?
There are a number of Orthopedic Society conferences I go to. New England Orthopedic Society, Mass Orthopedic Association. The first one meets twice a year. Mass Orthopedic meets once a year. New England Hand Society meets once a year. I will go occasionally to the American Academy of Orthopedic Surgeons meetings. All these groups have large rooms devoted to this type of thing. And the sales reps who are at the tables are ready and prepared to show you their wares, their products. And I am more open to looking at new things at that time. In my office, where time is of the essence, I am less open to receiving new types of techniques and hardware and surgical apparatus and so forth. So 80, 90% of the time, the best way to reach me is, again, through the Internet. Articles online I tend to spend a little time in the privacy of my home or in my office…

So if a company wanted to send you an article, “Here is this,” I think what I heard you say moments ago was, “Look, I know it is from them. So it will probably be saying something positive about it, but I would read it.” Or did I hear that correctly?
Yeah, I would. If it comes into the e-mail, I would at least read the first page of it and if it is catchy enough and the image and the bold print and so forth, I might read it through. On a personal level, I also speak to salesmen and women in my office and I will look at their product. I think I am in the minority here. I think the vast majority of orthopedic surgeons will not do that. They won’t take the time to hear a person at length. They might say, “Hello. I will take your brochure, but I have to get back to work.” But I try to give them more time. And, again, because I am slowing down a little bit, I’m 60. I don’t cover the emergency rooms anymore. So I have a little more time in my practice to take the sales reps. So I would encourage sales reps to keep trying. It is a shame they can’t do the little perks, give us a pen or a calendar, like they used to. Because that would also attract our attention. They used to give us lunches. And during the lunch…

Why don’t they do that anymore?
They aren’t allowed to, I understand. This state, I think you can’t bring a lunch in and you can’t give a luncheon and market your product. As far as I know, I just noticed the gifts have dried up. In any case…

Sad for the pen industry, isn’t it?
Well, I mean it wasn’t a big deal. It wasn’t like we were going on junkets to the Bahamas, you know. And they were giving us thousands of dollars’ worth of things like I see the politicians getting all the time. But it was a nice exchange at their reasonable cost that would get our attention. But since they can’t do that anymore, they can’t even give us a pen, I still give them the time they need, a little bit, not so much as before. But I guess each physician has their own individual approach to things. But by instinct, we want to learn more. We want to stay up-to-date with the latest techniques. So most of us tend to scan through those e-mails and not trash them right away. Most of us will glance at the advertisements we see in the various journals and might read them through if they are a little more attractive, they catch my eye as some of them have over the years.

Let me find out a couple of things. You mentioned that, for example, at the conferences, when you are, as you say, you are more open to some of these things. A lot of the times they will be in a large room and you go up to various reps. They are going to be a variety of material and some of it is swag, but some of it is fairly substantive. How do you carry that material back with you? Is it in a three-ring binder? Is it on a thumb drive? Is it downloadable?
Well, for years, it was always 8 x 11 papers I would put in a briefcase. And more recently, it is more DVDs. I see the sales reps are taking not just our office phone number and address, but they want our e-mail, which we give them, which I give them. I give them my e-mail. So a lot of it would be on my computer when I get home from the conference. But the DVDs are helpful.

Is there any way you wish they would give it to you? Or is that sufficient for your purposes, the DVD and the…?
Yeah, the DVDs are sufficient for surgery, surgical techniques, the different types of hardware or prostheses. For medications, just a sheet of paper, 8 x 11, is helpful.

Now on the sales rep, let’s spend a little time on that issue. Because you are absolutely correct, I think the data that I saw was nearly a quarter of physicians refuse to see sales reps. But you are different, it appears that you are different. And you could either answer either side of this. Why do you think your colleagues don’t give sales reps more? Why do you invite sales reps?
Well, it’s personal choice. I mean I am a humanist, I like to help people, you know. And these people are making a living. And I don’t come from a family of physicians. I come from a lot of blue collar workers that are trying to do the same thing. So I will see them for their sake as much as for my own knowledge and education. Nothing personal, physicians are just too busy. They don’t want to take the time out of their busy schedule to meet with a sales rep when they know it is of no benefit to them in their practice. But I imagine any of my colleagues, no matter how busy, will meet with a sales rep when it is a product that affects what they are doing. Or a product in which they may have some future interest.

Give me an idea of a sales rep where the interaction is valuable versus ones where it is just not valuable? What are the key differences?
Well, it has got to be relevant to what you are doing. An orthopedic surgeon would want to know about just the latest techniques for treatment of tendonitis or arthritis or back pain. If there is a new drug on the market, I would want to hear about it. Especially if the salesman in the first sentence says, “They are using this at the Mass General now, the Brigham and Women.” And I know that perhaps other suburbs, they will be using it in a year or two. Sometimes the sales people have access to the hospital and the operating room and they will say, “I saw that you did a hip replacement the other day and you used a certain type of prosthesis.” I will say, “How the heck does he know that? He must have looked at the schedule.” And, “I want to show you our prosthesis, which is similar, but it has a certain advantage.” So some will get inside information. I don’t know how they do it. But for the most part, if it is a sales rep I have known from previous experience, I am more likely to hear from them. Which is unfortunate. I know there is a huge turnover. I mean a lot of these companies, every few months, every year or two, there is a new sales person. And if they are smart, the new sales person will say, “I know you worked with Jim last year. I am taking his place. And he tells me this and that about you.” And you just like to know there is a little more than cold and lack of interpersonal relationship with these sales people.

What differences, if any, have you noticed between the device manufacturer sales reps and the pharmaceutical sales reps? Is it how they come across to your or the quality of the interaction or the quality of the people?
They are basically the same types of people. I mean the pharmaceutical sales reps can sometimes leave samples, more likely to request a signature on something. But they are basically the same people. I mean they all seem to know their products quite well. They seem to know what I am doing or what I am prescribing. I am not sure how they know that. Whether they speak to my staff or the hospital staff, the operating room staff. I don’t think they are different types of people. Though, I think probably the device manufacturer people are a little more knowledgeable. They have been around a little longer because they have to know how the operating room works or something like that. But I suppose many of the people that promote pharmaceuticals a few years from now may be working for device manufacturers. Because there is a big turnover, right, in their professional. They are always moving around.

You mentioned samples. Is that something you request?
Yes, it is very helpful. Very helpful to have samples of drugs. And if I have them in my medication room, I am going to dispense them to patients and I am going to write them a handwritten prescription with it. I say, “If it helps you, here is a handwritten prescription.” So I know there is more and more limitations and curbs on it (inaudible). Once a drug goes generic, they don’t leave us the samples anymore. Other drugs, for some reason, they are just not allowed to leave the samples. But it is helpful to my practice and I think it is helpful to the company that is marketing them. The most common drug sample I seem to get now is Celebrex, a popular anti-inflammatory. I mentioned it earlier today in our conversation, which shows you that I am aware that I get these samples and I often give them out and prescribe it.

When a sales rep would send you a sample or deliver it, what would be your reaction if they also gave you, going back to the article question, that would be the means by which some of these articles or scientific support would accompany the sample?
It might be helpful. I mean usually a patient will take my word for it when I say there are articles that show that this is more effective than Motrin and won’t upset your stomach. If I had the article handy, I might give it to them. In most cases, it is probably beyond their level of interest or understanding.

Anything else in terms of what you would like to see either from the sales reps from these companies with whom you deal or from the companies themselves in terms of their general promotional activities that would be especially effective in reaching someone like yourself?
Well, I think the information brochures and flyers and articles are good for me. I suppose it might be helpful to have some for the patients, you know. “Why your doctor is planning to do this type of knee replacement, to use a Zimmer knee replacement,” or something.

I mean is that something that you would avail your patients of?
Sure. Something like that, if you are doing a hip joint replacement, you want to give them information. “Why your doctor wants a Biomet hip prosthesis.” And it shows a picture. And I say “This is the prosthesis I am going to use.” That is something a patient would have interest in, I think. And it would show the patient you are on top of the type of hardware you are using and you are familiar with it. And it brings them into the planned technique. Or from a pharmaceutical sales reps, “Why your doctor wants you to stop smoking. And that is why we are prescribing Wellbutrin,” or some of the others out there. And those are available. Sometimes I write a note to the pharmacists and say, “If you have anything on this type of drug.” I think the most popular one, Chantix, I don’t prescribe that, but…

Interesting. One of the things I have heard from your colleagues is some of them, there are differing views on whether or not, say, your waiting rooms or the common rooms in hospitals should or shouldn’t have some of this other material from manufacturers or drug companies and so on. But it seems like you have a different view. You don’t have a reluctance to…
I’m not sure what would be the objection of just a basic brochure for patients about protecting their new knee replacement and how to walk afterward and how to bathe and how to exercise. I can’t understand why a surgeon would have any objection to that.

Some of these companies also from what I understand also have areas on their public websites that would be for patients or just a specific patient for a particular treatment or a particular pharmaceutical that they maybe have had prescribed. Have you ever sent patients to those sites…?

I can’t say that I have. I mean if they want to learn about a drug they are taking, I will tell them, “You can find information on this particular drug online.” I will say, “Just type in the word, Soma, S-O-M-A, and you will see that it is habit forming and that is why I am trying to get you to cut back.”

Moments ago, you talked about some of the conferences that you attended. And I suspected, perhaps correctly, perhaps not, that they were also part of the package of the associations that you are also a member of. What professional associations are you a member of?
I am a member of a number of ones. Mass Medical Society, Norfolk County Medical Society, Mass Orthopedic Association, New England Orthopedic Association. Let me see, New England Hand Society, Society of Military Orthopedic Surgeons. Probably one or two others.

Your dues budget must be considerable.
It is, it is really high. American Academy of Orthopedic Neurologic Surgeons. It is high.

Why, what was the original impetus for joining these various associations?
Well, my colleagues were in it. You know, it is deductible from your practice to go to the meetings. Educational, I mean it is popular. I mean I think pretty soon I will start letting some of memberships lapse. I don’t do hand surgery anymore. But I do enjoy the meetings, the Hand Society, it is a nominal fee a year, so I may stay active with them.

You were mentioning moments ago about the fact that younger practitioners just coming in may have a different view on some of these issues. Most notably, I think we were talking about with the mobile devices, they have come to it, they have almost grown with it. As you think about it, Ron, if I may call you Ron, what would be your advice to those just coming out of residency, just embarking on their practices? What is your advice to them?

Well, I certainly am not going to advise them in a technological sense because they are ahead of me already. I would just advise them what I have learned after decades of practice, to think about your patient. Try and get into their mind. What are they looking for when they are sitting across from you? Give them the time they need. Many times, their paperwork, their disability form, is more important to them than their actual medical condition. And it took me years to realize that. Here I am trying to get them recovered and get them back to work. And that is not their priority. Their priority is what kind of financial security and to establish what is going on with them. So now I try to do both. I will be supportive but, at the same time, I am concerned about their medical condition. And I will tell them that. A lot of times I will hear, “My lawyer won’t let me go back to work.” And I gently try to remind them, “Well, I understand what you are saying but you understand my job is to get you recovered, treat your medical condition. So I will help you with that paperwork today, but I am only going to take you on as a patient with the idea that we are going to try and get you recovered.” And I will try to pass that concept on to the younger physicians who, if they hear that, they will say, “Well, I can’t treat him.” And they will send the patient out the door. That is an unhappy patient who will carry bad thoughts about you the rest of their life.

Well, that is a terrible, terrible thing.
Well, I mean if a doctor disagrees with a patient and says, “I can’t help you,” and discharges them. And I see a lot of these patients who come to me for alternate treatment, second opinion. And they have contemptuous things to say about my colleagues or are very upset about abrupt bedside manners. I try to always calm them down and say…

And that is what you are passing along to our newest physicians, that is what you are going to need to focus on?
Well, my personal experience, I want them not to alienate their patient population. I want them to stay close to their patients. I mean they have enough knowledge and many of them are ahead of me already in areas. So I mean I would certainly if I could assist them in surgery. I will show them things that I know. But I am also going to treat their interaction, their bedside manner, I think that is important.

You mentioned that maybe not as a direct one-on-one replacement but that the Grand Rounds…
Grand Rounds.

Grand Rounds or the journal groups is the way that practicing physicians in a particular discipline are congregating and talking and discussing and reviewing. How would you advise a pharmaceutical company, a reputable pharmaceutical company, a reputable medical device company, armed with that knowledge, to leverage that? Yeah, they are trying to promote their treatments, they are trying to promote their methods. You physicians are increasingly, because of statute, moving away from the old dinners and that sort of thing. How can they most effectively reach you, given this penchant towards these small group meetings?
They can sponsor the conferences and they do. I mean when I go to these annual meetings, the pharmaceutical companies and the other manufacturers are paying for the meeting, I understand.

So that the larger-scale events, they can continue to do that. But is there anything about these, if anything, it is a smaller, more intimate circle?
Well, they are doing that now. I mean sometimes a speaker at the Grand Rounds will be a speaker who is talking about his type of shoulder replacement and why he does it. And I will see the sales rep in the audience. And I know the sales rep has somehow brought this speaker in. I don’t know if the speaker is getting compensated, but I just think having a presence at these meetings is important. Because what is the alternative? Not having a presence? How are we going to see this product?

Very interesting. As I said, you have a somewhat unique perspective on the sales reps and that sort of thing, because we have had a very interesting discussion with some of your colleagues about you should do this and not do that. What I am sensing from you is that there is a far greater openness in your view. And maybe it is just because of the time issue.
My colleagues, they don’t even know the sales reps in many cases. They don’t know their names. They will go right by them. I mean they are an annoyance to them. But I mean I think you want to know what catches my attention and I am trying to tell you that. What would make me listen to what they have to say or look at their product. I mean if the same techniques were tried upon me tomorrow, I still may brush them off. I may have other things on my mind. But I think that that the sales reps that do persevere are the ones that get heard. Some of these factors to consider, I mean we were talking earlier, if you are well dressed, well groomed. Regrettably, it is a rough world out there, but if you are younger and more attractive, sometimes you will find you way in. The more you are received. And it shouldn’t be that way, but…

And you have to wear a tie.
I think if a sales rep wears a tie or has a nice suit on, I am more likely to hear them out, yes, regrettably.

Well, you know, I mean, heavens. I am going to have dust off what is in the, ordinarily, the dry cleaner. Hold on for a just moment. I have just to see if a couple of questions have come to the fore. Michael will regal you with all sorts of wonderful tales of growing up in Texas. I am so sorry, that is all we can provide for entertainment right now.
I guess I’m here to entertain, whatever you wish. I apologize, I didn’t mean to interrupt. I know that you guys were, because I am in the middle, and this technology. The camera ended up dying on me right then and there.

Do you have enough light?
Yeah, I know. It is surrounding everywhere. Hopefully it is not too much, you know, it is not too distracting for you, though. I tell you this would be better than having some big camera lights.

I wish I had a chair with arms, that’s okay, though.
That’s a good point, something with arms for next time.

Well, why didn’t you think of that.
Yeah, I know. Well, yeah.

I always, my patients always sit in a chair with arm rests.
Yeah, that’s a good point. Maybe it’s to, “Can I get your to move your arms,” you know…

Well, just flex a little bit.
Hey, they couldn’t stretch out. If you want, you can lay down and tell us how your week is.

You are wonderful, thank you. We are all set.
Okay. Hope I helped you.

You did indeed. I hope you didn’t go too much out of your way.
No, no.

To just trundle on back to the South Shore. And looky up here, it is has stopped raining.
Yeah. We’ll see, it is so unpredictable up here in New England. All right, good luck.

Thank you very much.

(End of Recording)