Thinking About Leverage

Leverage the Pharmaceutical Rep DOESN’T Have!

Yesterday I booked a lunch appointment with a large primary care office just south of my practice, with 25 employees, including 8 providers. It was a little “off script” as to how it actually went down, but this is a very important example of persistence and focus on the end goal which is to get into the office to sit with the MD or, in this case, the nurse practitioner. You want to build advocates from the inside and should look to the busiest practitioners. In today’s practice environment, it may be the PA or the NP (nurse practitioner), not the MD.

I have a patient that was involved in an MVA with the following significant findings:

C3-C4 and C4-5 disc herniation>

5-6 disc herniation with slight cord impingement and associated partial thickness annular tears

T6-7 disc herniation

T11-12 annular tear

Positive bone scan for post traumatic changes to the sternum

She is being co-treated with a spine surgeon and was released (in writing) for a trial of conservative care. She received low velocity procedures only to the cervical spine adjacent to the C5-6 level. I called her MD office to use this information to get into his facility. Here is how the conversation went. The NP had returned a call of mine from 2 days prior…

OFFICE – Good morning, _______ Primary Care. This is Janet. Can I help you?

Me – This is Dr. Owens. I was returning a call from Sara ______ regarding ________. Can you put me through to her?

NP – Just a minute, Dr. Owens. I will get her for you.

This took a bit of time. Be a little patient since they are working and probably in examination rooms.

NP – This is Sara ______.

Me – Good morning, Sara. This is Dr. Owens, [patient name]’s chiropractor. Thank you for returning my call. As you are aware, [patient name] has some very significant findings in her neck, middle back and sternum. The area I am most concerned about is the cervical spine; she has a severe disc herniation from her accident.

NP – Oh my! Does she have a neurosurgeon?! (She actually asked that!)

Me – Sara, I specialize in the triage and care for traumatically injured patients and work very closely with Dr. ______(surgeon). [Patient name] was examined some time ago and is being co-managed. Her condition has been released for conservative care, but I think she most likely will need surgery. Did you actually see the MRI imaging or did you just look at the reports? (I knew what the answer was before she answered.)

NP – I did not look at the images. I am looking at her chart right now and I don’t see the MRI reports either. I have a single surgical consultation, but that is it.

Me – So you don’t have anything from the remaining surgical consultations, the MRI reports, the bone scan results or the reports from my office? (I did not send my reports to her PCP office; this was found on the file review process that was put in on Consultation #2.)

NP – I don’t have anything…

Okay, so I helped her to realize that there was a problem. Now I offer the solution!

Me – Okay, this is what we are going to do. [Patient name] is a wonderful patient and her condition is serious enough that I am going to take the time out of my schedule to stop down at your office with all the reports and the MRI images. I want to show you what is actually happening. We can go through everything in about 10 minutes and get you caught up. I will bring lunch.

NP – I don’t take a lunch. I have the office book me right through. (Her exact words. Here is the persistence part.)

ME – I understand, but I usually bring really good food that is easy to eat while you’re standing or walking! Can you just put me through to the office manager to schedule a time?

NP – (Laughing) Okay, thank you. I am transferring you to Linda. She handles the lunches and can also access my schedule. Have her put you in and we can talk.

OFFICE – Hello, this is Linda. Can I help you?

ME – Hi, Linda. This is Dr. Owens. I was just speaking with Sara and she transferred me to you. She said you were the person that handles the lunch scheduling.

OFFICE – Yes, I do. Well…we only schedule lunches on Wednesdays and the next available lunch is the last Wednesday in August. Will that work for you? (Now remember, when they say “LUNCHES” they mean “SALES LUNCHES,” not clinical rounds type lunches. She was treating me as a pharamceutical rep at this point.)

ME – I have urgent findings on a patient in the office and it cannot wait until August. It has to be in the next 2 weeks.

OFFICE – (She is following office protocol and procedures that she was trained to follow, so I had to get her to improvise a bit.) Oh, this is not normally how we handle lunches, so I don’t know if I will be able to do that. (Remember, the goal is to get into the office and build a relationship.)

ME – Sara mentioned that you have access to her schedule and to put me in so I can review this chart with her. I felt bad for her. Apparently she does not actually take a lunch. (Laughing) You guys work her really hard!

OFFICE – (Laughing) Actually, she wants us to book her right through the day solid!

ME – Well, she is definitely an asset. We need to make sure she eats! Okay, how about we do this? I have to meet with Sara about some really important patient information. My mother taught me to never go anywhere empty handed, so…if I bring really good food for everyone at the office, what do you think the chances are that they will eat it? I’m talking REALLY

OFFICE – I can just about guarantee that it will get eaten up!

ME – Okay, can you look at her schedule? I need a Monday or Wednesday, as my schedule is filled with patients the other days.

OFFICE – How is May 10^th at 12 PM?

The rest of the conversation was about the number of people, etc…

The key to this consultation is that the PATIENT INFORMATION you have is what makes this process easier than the pharmaceutical reps’ process. This is your IN and you need to leverage that concept. When I go to see her, I will be reviewing the findings on MRI and giving her copies of ALL the reports and consultations. I will also present her with a binder showcasing the National Research Initiative to Promote Cooperative Spine Care in the Western New York area. It will contain the first consultation for MDs and patients and my CV (YOUR CV MUST BE CONTINUOUSLY UPDATED). I was sitting next to an orthopedic surgeon that I work with almost daily at this point and he was thumbing through my CV. You know what he said? “Wow, look at how thick this thing is!” That is the reaction you need to have. You are not an EXPERT until your CV says you are. I am going to point out that my training is specific and specialized in the diagnosis and treatment of the traumatically injured; it is what I do.

Finally, when I go for the meeting, I will ask Sara to introduce me to Linda, the office manager, so that I can make friends with her. That way I can be invited back 2 times per month to drop off research from the National Research Initiative to Promote Cooperative Spine Care.

Make calls and get into offices before someone else does! Educating them is sooooo important. Automatically, she thought NEUROSURGEON. This is important as they actually know very little about triaging patients with injuries.