#45 - Navigating change in Orthopedic Sales: a deep dive with Stu Brandon (149 mins)

Brought to you by Tiger Buford.

Welcome back to Inside Orthopedics. This is Tiger, your orthopedic industry insider and retained recruiter for early-stage orthopedic companies. This is episode number 45 titled Navigating Change Inside Orthopedic Sales, a Deep Dive with Stu Brandon. You'll enjoy this one. Stu talks about the changes happening in orthopedics. Stu will walk young sales reps through how to best start out their career. Then for those experienced sales reps in big organizations who are frustrated, Stu offers a way out, a way to achieve control and agency in their careers. Enjoy this discussion with Stu. Remember to subscribe and happy ortho. All right, I'm live with Stu Brandon. Welcome to the podcast.

Thank you, Tiger. I'm happy and excited to be talking to you today.

Great. Well, I'm excited too. This is— I have a million questions. I don't usually interview on sales leaders, so this will be, this will be interesting. So before we dive in, just tell, tell us about kind of your journey in the industry and where you started from and where you are now.

Yeah, so I started, uh, September 1st, so it's almost 30 years exactly my anniversary in orthopedics. Right out of college, I was fortunate enough to get a job as a junior rep with DePuy through the local distributor. And back then, everybody who's listening realizes orthopedics was vastly different 30 years ago than today. Just the amount of total joints done then was very small compared to today. So there was a lot more geography. So I was fortunate enough getting in. That the guy I was a subrep for, he was wanting to get rid of some of his territory because he had such a large geography. So I did about 6 months of, you know, quote unquote training with him, and then he gave me about a third of his geography, which then became the core of my, um, quote unquote territory for the, the 20 years that I spent with With DePuy, or sorry, the 21 years. And then towards the end of that 21 years with DePuy, so we're talking 2013-14 timeframe, our industry had been changing, as most people know. Average selling prices were going down, commission rates were starting to come down from what they were. But the thing that was helping out all of the ortho reps is that the volume was still— going up. But what it did create was a situation where myself and the 2 people that worked with me at DePue— I was the team leader and they worked with me— we were starting to have serious discussions about the way the industry was going as a, as a big company rep and team. And so we started having serious discussions with our surgeon customers just about the future of the industry. This is something that they saw coming as well because surgeons had been going through and still are going through what reps were for years. I mean, you talk about surgeons' reimbursement for total hips and knees, it just continues to decline.

In fact, Yeah.

my dad was an orthopedic surgeon and he told me in the mid-'80s reimbursement for total joints for Medicare was at $5,000. For the physician fee. And, uh, yeah, that, that is jaw-dropping when I tell some of the orthopedic surgeons that have been practicing for 15 years or less that their jaw drops.

But then in today's money, that's $10,000.

Correct. But at the same time, not nearly the volume was going on. And so it was different. It was a newer operation, all of that. And I have to imagine that, I mean, the average orthopod was not doing many, probably under 20 a year when it was really in the early to mid-'80s.

Right.

But as with anything in medicine, the more done, the less people want to reimburse for it. So obviously that came over to the rep side. And so we were looking at each other and say, like, how do we keep going as this? We enjoyed working with each other. Again, we were having conversations over the years with our surgeon customers. And so we just came to the realization that if we wanted to stay working together, we were going to have to make a move.

Okay.

So what we did was first of the year, 2015, we left DePuy and we went and worked with DJO Surgical. And we were excited about that because our geography got much bigger. We were excited about that because we could now pick up some other product lines. We were able to pick up a small trauma company. We were able to pick up some foot and ankle stuff for a couple podiatrists that wanted to work with us. But what, what we came to realize through that is that our evolution of thinking— we took a big step forward in our thinking by— we were understanding like, okay, we get multiple companies, a bigger geography. We can have a joint company. We have a trauma company. We have this. And then after a while, you know, a few years spent there, we realized DJO Surgical wasn't the end stop for us just because of some things that were happening. I really enjoyed the small company feel. DJO Surgical has a lot of Stryker influence and I'm not going to say that the striker culture is wrong. It's just, it's a very unique culture, as most people know.

Mm-hmm.

And it's, it's, it's not the culture I want to work in. And so we moved on from there. And when we did that, um, I joined up with, uh, Scott Lyon as a business partner, who— he's, he's another, um, left— he was the next Zimmer guy. He had or has Corrin as his total joint company. We showed our surgeons who were using DJO and they said, yes, do, it's fine, we would use this for you. And a light bulb went off for us and we said—

So we said relationship over product, relationship service beats the product.

But what we came to realize, Tiger, was instead of trying to force our surgeons to use what we have, why don't we find them smaller companies that they would be excited about using?

Mm-hmm.

And so for us, that's what got us to expand outside of thinking we have a joint company, we have a trauma company. change that till we find solutions that they would like to use.

Interesting. Wow.

And so we've been doing that for about the past 5 years.

Okay. So let's— so how did surgeons make— and the hospital make the buying decision back in 2003, and how do they make the buying decision today? And I realize it's different because there's ASCs now in the mix.

Right, right. Well, yeah, I mean, that's a great question. And the answer to that is, well, it depends what hospital systems and it depends where you are. There is a trend towards hospital systems reducing vendors because the hospital systems think that if they reduce vendors, they'll be able to get more aggressive pricing, which is true to a certain extent. However— What's the trend? What I have seen is across the country, I know of hospital systems that have gone sole vendor, and that didn't last. You know, it lasted a couple years, and really the hospital system didn't get as much savings as they thought they were. The surgeons weren't as happy because a lot of surgeons had to change what they were using, so they reverted back to a cap price. I've seen the same thing happen elsewhere where They don't go sole vendors, but they go limited vendors, and same thing, same thing basically happens. And so I think that this is something that's going to continue to happen. Hospitals and hospital systems are going to think, you know what, if we reduce vendors, we can really, we can really save price. But what everyone has to learn for themselves— I mean, it— this makes sense that We learn best through our experiences and mistakes we make, right, Tiger?

Yeah, absolutely.

And so why would we expect hospital systems— if one hospital can't reduce vendors effectively, other hospitals are going to say, well, yeah, but that's them, we can do it. Because human— humans are involved, right? It's just like us. We think we can do something that's other people couldn't because, well, you're Tiger, you can do it, right? And we have to learn by going through stuff sometimes.

So the goal in reducing vendors— I was involved in the Kaiser Permanente presentation way back in the day, and they were picking 2 knee vendors for all of California.

Yeah.

And it was crazy. I mean, it was just— and they already— it was a theater. They already had their 2 vendors picked out anyway. But so the thinking is that if you limit vendors, you can lower price.

Correct.

Your average price. But are they measuring outcomes? Are they measuring OR time? Are they measuring OR turnover? I mean, there's things that seem more important than— there's more important than the cost of the implant.

Correct.

Are they meant— revision rate, errors, all kinds of things.

I mean, those are great questions. And as you know, and most people listening probably know, is that every hospital judges all of these other things differently. Some people are just going to judge, no, we only care about the price of the implant. We understand OR time has a cost, but it's not something that that particular facility is like on top of what does this actually cost. Just like sterile processing. I've talked with people in sterile processing about ways to save money, and some people, you know, if you could reduce trays significantly, Some hospital systems will say it doesn't matter, we have staff there anyway, so the only additional cost is 4 additional reps. And they're almost unwilling to take into account the labor cost because they think they're going to have the same staff there whether they process those trays or not. And so how do you really quantify wear and tear on your washer, sterilizer, all of that? And some hospitals are able to do it, but there's a lot of hospitals that just want— we need to reduce price of the implant.

Yeah, I mean, there is an argument for the Southwest Airlines model where if you standardize equipment and the training on that equipment, then you can turn over the airplanes faster and run the airline cheaper. Right.

Right.

Interesting.

But to be effective doing that, you have to have a well-run machine, right? And I talk with people all the time, and it's something that is fascinating to me as I go across the country. It's very interesting. I've never found a hospital that the OR runs super efficiently, Anesthesia and pre-op and pre-op holding runs efficient— efficiently, and sterile processing runs efficiently, and turnover's efficient. What I find is that there are some hospitals where they're super efficient on one thing and awful on another thing.

Mm-hmm.

And it takes all— it takes all of those running together well to really Yeah, interesting. Yeah.

Yeah, all right. So fascinating. So what other— so let's talk about the changes in the industry that have gone on in the last 30 years. So we talked about price and volume.

Yeah.

What else has changed?

Well, it's interesting from my perspective. I think today we're on the 4th iteration or the 4th resurgence of unicompartmental knees in my career, which is interesting to me. I mean, we started— or when I started, polyethylene was still gamma in air sterilized.

Mm-hmm.

You know, now every company, it seems, has vitamin E polyethylene. I do feel that industry-wide, by and large, polyethylene wear is, is not something it was before. In fact, I cannot remember the last time I was in a revision hip or knee that there was massive polyethylene wear.

Yeah.

But when I got in, everybody was gamma sterilizing their polyethylene. Dr. Harris and Harvard, you know, the previous years before I got in the industry, they really popularized cementing the femoral stems and total hips. And then right about when I started is when— and I was fortunate to work with the Pew and the AML Hip. And it seemed like people were moving away from that. If you're gonna move away from that, just have a fully porous-coated femoral component. Don't worry about cementing. And so a lot of revisions from that. And now it's interesting. There's a, over the past few years, there's a huge resurgence in the interest of cementing. Femoral stems, particularly in hip fracture patients. So just kind of like this change, but going back to old things that are tweaked, even going through metal-on-metal is— there were significant advantages in the lab of having metal-on-metal articulation for the hip. If components were placed where it needed to be for each patient.

Yeah.

And through some, through some of the stuff, everybody listening to this probably heard, uh, has heard of Russell Bodnar. Dr. Bodnar was actually a customer of mine when I was back with DePue and a friend. And just the research and education and his passion for that. And I've talked with him specifically about the ASR implant. And he joked because back when that was around, people— spinal pelvic dynamics and how your hip moves, you know, from sitting to standing to gait, et cetera, is something that it's amazing to me that it wasn't thought of very much until the past 5 or so years. I think it really has become popular. We were, we were chuckling when we talked last about he had just done the contralateral side of a patient that still had an ASR in because he said by chance it was put in correctly, the version, the, you know, the version and inclination that was right for that patient.

Yeah, but metal, metal has less tolerance for I mean, you can put a polyethylene— you can put an all-poly cup in and the head almost anywhere, it doesn't matter. But metal on metal's really— the error bar for alignment's really small, and then things can go bad when you get edge wear.

Yeah, but that was something that, you know, I remember telling the surgeons that ASR was going off the market and they were not happy because, you know, the huge heads that they were able to use, you know, dislocation was correct. They were stable as can be and they loved it, uh, until, until they didn't love it as, as their follow-up got longer.

I remember way back, you know, the McKie-Ferrar was the first metal-metal, and they were— I think they came from Germany. They were— the good news is they were matched pairs, so they actually polished the femoral head and the cup together so they fit perfectly. The bad news is they only came in like one size.

Right.

And there weren't many instruments. But they didn't have the metal-on-metal wear problems back then. Right.

Well, it sounds like we should bring back McKie-Ferrar if there weren't many instruments, because people like reducing trays these days.

They do. They do. Well, that's another topic. Are there— aren't there just more and more trays all the time? Um, and, and, you know, I haven't been in a case in a little while, but There's 5 or 7 trays in the OR, and then there's backup trays that are sterile somewhere.

Yes.

I mean, especially for joints, 'cause any joint can turn into a revision really quickly.

Correct.

So are there just more trays all the time, or is that maxed out?

Yeah, I mean, I— This is what happens as new products come out. I mean, let's just take total knees here. You take something like Sigma or NextGen, you know, Sigma with 6 or 7 AP femoral sizes to where now Persona has, I think Persona has 13, 12 or 13 AP femoral sizes. So obviously the more options you have, the more trials are needed, the more trays to fit the trials.

Yeah.

And yes, there's ways to make, you know, your inserts modular for trials. The problem with that is I have seen a lot of people who don't like that. So the more options that you have, the more instruments that you need for the most part. A company has not been able to come with a way that has been uniformly accepted that everybody likes to reduce that. And truthfully, if I was an orthopedic surgeon, I would want as many options as possible.

Right. But here's this dirty secret. He's not paying for it.

Correct.

The hospital, the hospital or the manufacturer's paying for all, all that.

Correct. But even from a sales side, Tiger, is you're right. He's not— they are not paying for it, but They are an advocate for their patient and they want, they want what they need for the case, which I don't blame them. I would want, I would want the same thing. So that's kind of where, you know, unless custom implants become the norm, which there's even with 3D printing, there's a lot more logistics involved. And this is something I'm not totally Qualified to talk about. I like the idea of custom implants, but I'm not qualified because on the rep side, I can help a surgeon get what they want, but then I don't follow up the patient. I don't—

Mm-hmm.

I can know in theory what features and benefits may, you know, help most surgeons just from hearing them talk, but I'm not seeing patients afterwards. I'm not Dealing with their frustrations of the, you know, what is it, 20% of the knees are not extremely happy, which I even hear people debating that. So, my point is, is it makes sense that the more options that you have, the better fit that you can match your patients outside of a custom implant. And the— But there's—

Yeah, go ahead. There's a law of diminishing returns. I mean, if— yeah, I mean, you can't, um, have an option for every— I mean, if that were true, we'd all have like a helicopter and a snowmobile in our driveway, you know, just, just in case, right? Um, there's a cost to that.

Correct, there is. But, but to date, I mean, let's just take this price being equal Would you rather have 12 options for the size of the femur on your patients or 6?

Or use a computer planning software that tells you you need to bring in size 3, 4, 5 only.

Right. And the way I see it is, you know, people are bell-curving things now, and where it is really an issue is In lower volume facilities, if you have 1 or 2 cases, even if you think they're going to be a size, you're going to bring in full sets. Where if you have 7, 8, 9 cases in 1 day, you're much easier to be able to bell curve those for that day.

That makes sense. Is that, is that another trend? Are there more Or the volume of joints going to the big teaching hospitals and the high-volume ASCs?

Well, I think from my experience over the past few years, what I'm seeing post-COVID is that everybody is busier. The community surgeon is busier than they were a couple years ago. The You know, the bigger volume places are busier than they were a few years ago, and more, more cases are going to ASCs, so the ASCs are busier than they were a few years ago.

And this is just— this is just elective surgery was put off for a year or two, you think?

Honestly, I don't know the answer to that because that doesn't make sense to me because And this is again from my experience through COVID. It was really only a few months that, that volumes were really lower. And then what I have found that is cancellations are more now than they were, but we've made up for more than just, you know, 3, 4, 5 months of decreased volume. Does that make sense?

Yeah, yeah. Because you would—

yeah, yeah, you would think that, that over, you know, the last 2 years it would be pretty quick to make up just a few months where you were doing half the volume or 40% of the volume. So I think, I think people are just getting busier.

Interesting.

More patients out there that need replacements.

Maybe so. Maybe it's obesity or I don't know. It's— there's got to be a reason for that.

Right.

Maybe the marketing, maybe the surgical practices are marketing themselves better.

Right. Well, that is one change that I have seen as a rep is when I started, I saw a lot more patients that were smaller than they are today. Today, it's an anomaly when you see a small patient.

Yeah, it's just, that's an American thing. It's happening to the whole world now, but we're the— we started it all.

America's on the forefront again, this time.

Exactly. So what, what else has changed? Um, so let me, let me give you a little backdrop.

Yeah.

So in the '90s, I did a— with a camcorder, I did a video called A Day in the Life of a Rep. And it was— we followed an instrument for 24 hours. And we like picked it up at the hospital, you know, after it was cleaned, and then it went to the warehouse, and then sat in the warehouse. And then the next morning it got scanned, and then it went on somebody's Bronco, and it went to the hospital, and went down to central cleaning. And then we watched it being used in surgery, you know, and then went back, you know, this full cycle.

Right.

But what my takeaway on that was, the sales rep was basically a materials handler. Well, it was his biggest job, just shuffling stuff back and forth. He might get 30 seconds in the hallway to say hi to another surgeon, but I mean, it was Really blew me away.

Right.

So that was 30 years ago. What's— what is it like today?

Correct. And I would say that there's a lot of similarities today from that, except the average rep, the reps that work for the large companies, the big ortho reps, it is drastically increased their workload. So again, we talked about this a little bit earlier from the standpoint of reduced reimbursement to our physicians and facilities has been gradually going on for years, and the same is happening on the rep side. And the reps are just working more and more, taking care of, taking care of the cases, longer hours. And truthfully, there's a lot of frustrated Orthopedic reps out there that are just in the daily grind of moving trays from hospital to hospital, covering cases. Um, supply chain issue is legitimate. It is something that is— our whole industry is dealing with backorders.

Um, I've heard—

Uh, well, both, but it's It's a bigger deal with implants than it is instruments, because most of those instruments are, you know, getting moved around, used day to day, unless something breaks. But I talked with an orthopedic rep a few months ago that he spent 5 hours at the end of one day tracking down backordered implants for cases the next day.

Wow.

And that's the, that's the type of thing a lot of, a lot of reps are having to do to make sure that they have everything. And it is, like I said earlier, it's an industry-wide issue right now because I believe there's only 2 suppliers of polyethylene for the orthopedic industry. The orthopedic industry, all companies are using some of this same third-party vendors to manufacture some of their implants for them. And, you know, a lot— COVID changed a lot. It changed a lot of the attitude of some jobs, some, you know, pay-level jobs. I know people in sterile processing, COVID was a mind shift on people like, why am I stuck here doing this frustrating job. I could go somewhere else and make the same amount very easily. And so all of that puts strain on things. But one thing people don't really think about is what happens when that happens at a, you know, a manufacturer that is supplying things for the orthopedic industry.

Hmm.

That can have an effect on all companies. Yeah. And so while it had an impact, impact on the whole industry, there were some companies that it had a bigger impact on just because they choose to run leaner, which exposes it more than other— some other companies that maybe they have more inventory on hand that they could weather it a little better.

Oh, I see. Interesting. Yeah.

And so, so I mean, what I, what I would say to that is the companies that are really concerned about their stock price and, and inventory and how they look on paper, those are the reps that are running around constantly trying to have— trying to fill their backorder holes.

And they're— and they don't get a lot of help from the manufacturers. They're doing horse trading with other distributors and Correct.

Other reps, or even if they're on the same team. You know, there's a trend with some of the larger companies that they'll have what I call mega teams, where they'll combine territories just because of proximity and then have 10+ reps that are covering the whole area. And the thought behind that is Which there is truth to this. The thought behind that is they're spreading the risk amongst their team. Is if they lose a customer, it hurts less because it's spread out amongst a bigger base of sales. But the reverse of that is true also, is as they gain customers, it's not as big of a win for everybody.

Yeah.

And that's kind of a tension that our industry has been going through. is with, with the commission structure for the large companies is when you get a significant new customer, almost all of that revenue is replaced by additional help to cover cases.

Wow.

So they're working more, working more and more, and sometimes just to make the same or less than they were the previous year.

And so the many— the Big 5 are not helping in that case? They're just trying— even if it's a direct employee sales rep or distributor or a 1099, they're just having to figure it out themselves?

Uh, that— I mean, that would change from situation to situation, Tiger. I mean, and that's— that is what I've, over the past few years, just the Literally hundreds of conversations I've had with reps across the country is still you could work for, and I'm not picking on any of these companies, but you could work for Zimmer or Stryker in one part of the country and love it because of your managers and just the culture and atmosphere that they created for the for the sales reps, where you could work for that same company. under a different distributor or different manager and have it be miserable for you.

Yeah, it's such a local business. I mean, you know—

Correct.

Yeah, Zimmer creates a new knee design for the whole world and they make thousands of them and they market it, but in reality, it's certain, you know, the service And the delivery of the services, it comes down to a zip code or a couple zip codes.

Yeah, which you're absolutely right. And even on the service side, this is something else that I talk with reps all the time about, or anyone I'm talking about with orthopedics, is what our customers want from us as the rep is different with every customer. Some customers, really all they want and need, just make sure you have the implants I want, instruments and implants ready to go for my case. They want to do their own templating. They want to, you know, they know what they want to use for that case. Where other surgeons want us to go template the cases, and talk with them about the case. And so it's just— it is all over the place. And even in surgery, what certain doctors want are different from what other doctors want. And if you think about it, why would we expect it to be any different? Because that's— Our doctors are humans, and as humans, we all want different levels of service when we're, when we're doing something, correct?

Yeah.

When we go to, when we go to, when we go to restaurants, does everybody want to go to a high-end where everything's attended to and, you know, you constantly have a, have a waiter or a busboy, you know, wiping the crumbs off the off the tablecloth. Some people would think that that was kind of obnoxious, that they're always hovering over them, where some people really like that. And so my point in saying that is not to say that that is wrong, but it is different everywhere we go.

Yeah, yeah, it makes sense. Man, that makes it even more— everything, services, Completely. Even within the same hospital, 2 different surgeons in the same operating room may have different needs.

Exactly. And then, Tiger, take it a step further is— and this is something that I've really come to appreciate over the past decade or so— is our surgeons want different things from, you know, Surgeon A wants different things from me as Surgeon B. B does. And okay, you understand that. But then as we talk to reps all over the place, they're saying, well, I bring a lot of value to the hospital. I bring a lot of value to the surgeon. Well, is what you perceive as value what your actual customer perceives as value? Because If you are doing something that Dr. A finds really valuable, but Dr. B could almost care less about it, Dr. B, he may not think that you're providing good value for him, even though you are doing things that you assume he wants.

Yeah, that's a really good point. Wow, it's always got to be— the value has to be measured by each surgeon. That's crazy. Correct.

And, and even from that same— I mean, we assume as an industry, I mean, we would default to assuming that, okay, every doctor is going to care about this. Well, every doctor may not care about it. It may be something that they're not having issues with, and which is another—

Yeah.

Which is something that is Yeah, it's something that has fascinated me about our industry is as I see, you know, thousands of joint replacements over the year, what's fascinating is that you can have 2 extremely talented surgeons with great results. Patients love them. And if you watch them in the operating room, yes, there's a lot of basic principles that they both adhere to. But what's fascinating to me is that some surgeons say, okay, this is, this is the important part of doing a knee replacement. And another surgeon, not that he's ignoring it, but he thinks, he or she thinks something else is the important part of the procedure. And that is just fascinating to me. Or even from the standpoint of You know, balancing a knee. What one surgeon thinks is, you know, a tight knee or a snug knee like they like is looser than what other people like. And so how— I mean, that's what's fascinating is that you can have great results and it can appear that they are doing things slightly different.

Yeah, yeah. It doesn't matter how they get there. That makes sense. That makes sense because I know a lot of salespeople shun the big company sales training programs because they have to standardize sales training. You know, here's the 10 important things when you put in a need. You got to make sure they do this and make sure that this fits in here.

Yep.

I have a different experience from you. I've been I've done every kind of procedure in the world, you know, in different countries— trauma, sports medicine, everything, spine. And I've seen a lot of diverse ORs, but I haven't done a lot of volume.

Yeah.

Sometimes the sales rep that is there is a problem solver, and the surgeon is relying on them all the time, every—

Right.

Every minute to sort of predict what the surgeon may need the next minute and point, you know, with his laser pointer. And then I've seen other ones where this sales rep just pops his head in the OR and says, all right, you good? Thumbs up? And the surgeon says, we're good.

Right. And I would say, I mean, that sort of thing, even in the US, that sort of thing would be an accurate statement. Is just the different level. There are some places I have been where the surgeon, like, look, your job is to make sure that you keep them one step ahead of me. Don't kind of— don't worry about what I'm doing up here. You just keep the scrub tech one step ahead of me.

Yeah.

I've had, I've had other surgeons who say, no, don't tell them what to do. They need to learn it.

Wow, wow, interesting.

And they, you know, and maybe they would, they would want me to have more of a, you know, be there for, hey, we need to go to Plan B, and my purpose of being there is to efficiently and quickly go get the Plan B trays.

Wow.

You know, run into something unexpected.

And yeah, I've seen a huge disparity in the OR staff. I mean, I've seen OR staff that literally is mind readers. They know, they know exactly what the surgeon's thinking before he or she thinks it. And then I've seen OR people that came, they don't even know orthopedics, and they come in.

Yeah.

And the guy's asking for, you know, for rongeur, and they're going, which one's that?

You know.

Correct.

Well, I, I was having a conversation with a physician, uh, I think at Academy, and we got some time to go talk. And, and I was telling him, I said, because he was talking about frustrations in the OR, and I was telling him, you know, so-and-so who you don't think is very good and is a frustration for you I said, I would take that scrub tech in 90% of the places that I go, because when I am there, I have to tell him very little, and he for the most part has everything lined up, which is not the case in other parts of the country. And this surgeon's jaw just dropped. It was like, are you kidding me? Like, How can they even do— how can they even do surgery there? But, but as an example, another part of this hospital was struggling compared to what other places I go, which gets back to that. I haven't seen— I haven't been in one hospital that has it completely figured out. Yeah, yeah.

I was in— the most impressive place I've ever been was Mayo Clinic. in Rochester, it was like clockwork. I mean, everything was perfect, on time. And then the next day I went to HJD in Manhattan and it was, it was a total zoo. I mean, I mean, not only the, the OR door was just opening and closing, there's just people pouring in and out.

Yeah.

Everybody, everybody in the operating room speaking a different language. The surgeon was Colombian. The the the the fellow was Czechoslovakian. The nurses were Korean, and I forgot, and nobody understood anybody. And they kept. I mean, it was. I was like. I couldn't believe my eyes. I mean, it took twice as long. They fumbled around. It took twice as long. Man, there's so much. There's so much. It's such a difference in. And the quality of the procedure and, and the quality of the service, it's unbelievable.

Yeah.

And the— and on the implants are all kind of the same now. I mean, there's not, you know, like I said, there's, there's a couple— there's only a few polys now. Vitamin poly is kind of a new thing. Yeah, everything's cobalt chrome on the femur, you know, and Titanium, and I mean, it's— they all— everything's off patent now. They all look alike, right?

I mean, I would agree with that for the most part. And I think here's the way I phrase it to people is the implants do look very similar. Are they the same? No. I mean, but it's the tools.

Yeah.

If you talk to mechanics or woodworkers, they have a certain set of tools that they prefer. And while implants may look similar, the instruments for doing it do look similar, but they have their own feel. And what I tell everybody is, I mean, if you look at a set of Persona instruments, They have a different overall feel than Attune instruments and a different feel than Triathlon instruments. Every company has a slightly different look and feel of their instruments, which is a big deal for the surgeon.

Yeah, it's— I remember when the PCA instruments came out, they were the first sophisticated knee instruments, and everybody in the world tried to copy them. They were They were very well thought out at the time. So let's go back to the career of a salesperson.

Yeah.

So, so what would— let's talk, help me with this too. If you were a 25-year-old salesperson starting out, what would you do? And let's talk about it if you were 35 and you'd been with a couple companies or carried a few lines and then go to 45 and so on.

Could you rephrase that again?

So let's just— if you had to coach a young salesperson today, you know, you're 25 years old and you're starting out today, and then let's talk about what if it's a 35-year-old or 45-year-old.

Yeah. Who's been in the industry or both?

Yeah, who's been in the industry, kind of bounced around. I've talked to people at all phases of, you know, and the young excited people, they can't wait to get started, you know, and then I talked to the people that are 60 years old and they've gotten battle scars, you know, wounds and everything.

Right. So this is the conversation I actually have quite frequently. I talk with a lot of reps who are frustrated and have been, you know, quote unquote, on the job for, you know, 3 years or less. And this is what I tell all of them is— and most of these people are working with the big companies because the big market share leaders in orthopedics, they have majority market share. So the majority of people are going to be reps for them.

Right.

But this is what I tell them. The big ortho companies are a great place to start your career because of the volume of cases that they do. I believe that reps will get trained quicker and better working for those companies than the vast majority of smaller companies because they're going to be exposed to a lot more cases to go to, exposed to a lot more learning opportunities. The bigger companies do have better education departments to get the reps up and going quicker, but ultimately it is the amount of cases that they can see and even having to be thrown into the fire quicker just because of the sheer volume of cases to people able to service those cases than a lot of the smaller Smaller companies. However, that comes with a significant downside that these reps are reaching out to me and are frustrated because they don't see a future potential for their career. And this could be for multiple reasons. One could be that they were sold something like come here. Work and grind for a few years and then you'll get your own territory, which there's a lot of people that for all practical purposes are being lied to by people who are trying to bring people into the industry because there's so many people that have been around that are in these geographies as team leaders that are not going to give up that position.

Yeah.

So there's great place to start with the big companies. But once you learn, once you start establishing relationships, it's not, it's not the career trajectory that you want. So someone that's been in the industry for a while maybe has the relationships with, with surgeons and hospitals to be able to look at something different. The biggest thing that they have to worry about is how do I make a transition from what I'm doing now to perhaps work for a smaller company or smaller companies carrying their products because they have a non-compete to deal with or other contractual obligations. I know there's a lot of talk about non-competes going away. I think that these companies are big enough, smart enough, that if it's not a non-compete, they'll try and tie people up with a non-solicitation of their certain customers or, or whatnot. So it really is kind of a dual-edged sword. The best place to get your, to get your training is to work for the big companies, but after that, you're seriously limited.

Yeah. So how many years, 5 or 10 years at a big company and just get a lot of times at bat? And—

Yeah, I mean, it's different. It's different for everybody because one, one thing I tell people also is, you know, there, there are a lot of extremely talented salespeople out there that have had a tremendous amount of success one place. But if they got plopped into a different geography, they may struggle because of just the existing, you know, the existing marketplace. So to say a certain amount of years, that's, that's hard to say because it's not the 10-year, it's the—

It's the relationship. They can't, they can't bring the relationship with them. They'd have to start all over again.

Correct. And that's, that's a big reason why people are, um, not willing to, to make a move. And it— I do understand it, but there are still people out there that have the ability to do it, and there's a tremendous upside for, for the future because I do— I believe strongly in this.

Yes.

Is that the future of orthopedic sales and the way I believe our surgeons are going to want to acquire implants are through the vast majority of time— this isn't everybody because some doctors like dealing with multiple reps, but I'm seeing a gradual trend towards one trusted rep who is able to pick up a lot of different companies or implants for their surgeon. Their surgeon may see something at Academy or AUKUS and be intrigued by it and say, hey, go talk to them.

Okay, so let's— so we're at 25, start with a big company, get a lot of surgeries under your belt, Learn the anatomy and the procedures inside out. And then 35— we're just picking round numbers here. Yeah, yeah, go to a smaller company where you can maybe move into, uh, where you can, uh, have a territory. And I guess you get a piece of the sale from the sub-reps, so you can— you have a higher earning potential.

Correct, right?

And then maybe at 45, that starts the time to start looking into being more of a broker. And we can, we can talk all about brokers, uh, you know, later on.

Yeah. And, and you, as you said, those are round numbers, but it's more about building relationships with the customers. And again, back to every customer wants something different. So building a relationship with them that is not just products, it is— and we stumbled into some of this, don't get me wrong, but we have come to realize like what we were successful about doing with some of our customers is they were buying implants from Stu and his team. They weren't buying implants from— Yeah, from the shoe.

And I understand that. Yeah, totally understand that. Right.

But that's, that's not everybody. A lot of people are positioning their company's products as, as what it is, is, you know, Persona is the knee. Persona is the knee because of A, B, C, and D. And they're, they're positioning Persona as kind of the hero. It's the product, it's the product, it's the product. Where, as you said, there's a lot of truth to it. There's— the knee systems are very similar, hip systems are very similar. It's building the relationship and trust with the surgeon and not just being the service person, but being the all-around, you know, I have a problem or I need something, I call Stu and he will He will bring me what I need.

Yeah, you're the— so what I've seen historically is the really strong reps can change products with the surgeon easily. They say, hey, we're dropping, you know, we're dropping Zimmer and we're going to Stryker, you know, in a few months, and I'm going to train you and your staff and it's not going to be a problem at all. And the surgeon will go along with that. They'll obviously have to do a little research, but the really strong reps can do that because it's— they're buying Stu the service, they're not buying the implant. Yeah, right.

And, and to situations like that, I would— if, if they have those relationships and surgeons are open at looking at something different from what they're doing, because there are surgeons who come out trained on a certain company in their residency, fellowship, etc. That just want to use that product, and there's almost nothing that's going to convince them not to use that. And there are some that are all about, look, I love this rep, whatever he wants to do, if it's a good product and I can use it, I will, I will use it. And then there's a lot of people in between somewhere. Um, but, but the key there is if you have a big company rep that is able to do that, they— I would encourage them to look outside of the big companies because the big companies are run very similar. And if they are frustrated with where they are, they're probably going to end up frustrated if they go to another big company.

Hmm.

Because they may be in the exact same place they are right now within a couple of years. And that's why—

loss of agency, that's like territory cut, commissions cut, more higher volume, more for the same money. Is that— those are the problems? Correct.

Or, I mean, we all think the grass is greener on the other side, right? Well, there's a lot of the same problems. And what happens is, you know, and over the years before I left APU, I had talked with all the other companies You know, serious conversations. I almost left and went to work with Zimmer at one point. I almost left and went to work for Stryker at one point. But I was able to look at it through that and talking with some of my surgeon customers and some other people that I had, you know, speaking into my life, that as we talked it through, is it possibly was only a temporary increase of of income, and then I'd be in the back in the exact same situation. And I was— I was—

Yeah, yeah.

I wasn't wanting to do anything just for a temporary. I wanted to wait until this was a clear, better path for me and a clear, better path for some of our customers, the ones that would want to look at something else.

Interesting. So let's talk about the device broker or agent. I don't know the right words, but—

So the way we explain it is, you know, some people call it independent distributor. I call it a device broker only because my analogy and some others is is compare your Allstate insurance agent versus your independent insurance broker that you may have in your community. If you call your Allstate agent for a price quote on car insurance, you're only going to get Allstate quotes. If you call your independent insurance broker, he's going to give you 4, 5, 6 different quotes from different companies. Now, he's probably not going to give you Allstate or State Farm, but he has the ability to bring more options to you.

And that's probably better service for a lower price for you. Correct.

Yeah, correct. And that— so that's the same philosophy that we're trying to do, understanding that one company, Zimmer, Stryker, DePue included, Their knee system is not the best option for every orthopedic surgeon out there. And if that's the case, why not have multiple options instead of trying to convince Dr. Smith that this knee is the best knee, you have to use this. And if he— If he would like you and want to do business with you, but he doesn't like the product for some reason, You're stuck in the middle of trying to convince him to use it. Come on, use you know use this. It is it is the best blah blah blah. Where if you have someone who wants to work with you, I can take them a product total me show them it and have the conversation like look I'm starting with this company because based on your background I think the philosophies behind it are the most similar. If there's something that you like here, great. If there's something like, like, uh, it's okay, I can bring you other options as well. And that's—

that makes sense. Makes sense.

That's the thought behind the service.

You're selling the service and a broader selection of implants and instruments.

Correct.

So how do you— how do you get to that point? I mean, how do— if you're working for one of the big companies and you have a Non-compete, non-solicitation agreement. How would— how do you do that?

Right. Well, I, I learned the hard way. It, it is very difficult to do, okay?

It—

I would do it much different if I had to do it today. Um, we chose to, uh, fight our non-compete Because talking with my, talking with my lawyer, he said, Stu, we believe your, your previous employer violated your contract. Now what he also said is they're going to say that you violated your contract, and so they probably will go after you. So we believe strongly enough that something had to change that we were willing to take that risk. And ultimately, we walked right in and we competed. We did get sued and ultimately came to an agreement between the 2 parties. But I would do it different today.

This was the Pew to DJO?

Correct.

Okay.

Correct.

Yeah. So what would you do today?

Yeah. Yeah, the way I would do it different is we had a good plan. We knew what, what customers were going to come with us through our years of conversation and even talking with them after that. But what we would do differently today is figure out a way we could partner with someone to, to cover the cases so we wouldn't be in violation of the contract.

Oh, I see. Like a— ah, it makes sense. You're like a third party.

Correct.

Yeah, you're just— you're basically selling a service. You're not representing the implant manufacturer.

Correct. And that— I mean, this is quote unquote a secret within the industry. Reps change companies not all the time, but frequently in our industry. Okay, so when one rep goes from DePuy to Stryker, if some of those DePuy surgeons would switch and start using Stryker products, that they're not getting paid on that, on that service, correct? But Stryker has an increase in business which helps them pay for the new rep, correct?

Oh, I see. Interesting.

And so the violation of the non-compete is if you are compensated on your old customer's business, which nobody is doing.

Yeah, interesting.

And so that is, that is what we would do differently, is we would figure out a way that was not in violation of our non-compete That people would be able to take care of our friends until we were able to service them again.

Yeah, I like that. That is really interesting. And that takes a— what, non-competes are a year, year or 2 usually?

Uh, it, it depends from geography. I know someone, um, I know people with 18 months. I know a year is By far the most common that I have seen. Yeah.

Yeah. Yeah, that's really interesting. Yeah.

And I mean, another thing that I was not prepared for was just the— I had what I thought was a good relationship with our distributors until it wasn't, and I was doing something else, and that I was naive about a lot of stuff. It's amazing what a legal— one of, one of our lawyers called it a huff and puff that they, that they send out telling us that we've done all of these things wrong. Um, but so if I had it to do over, I would understand certain things are going to happen. And it can be intimidating because if you're getting sued by a company, they have deeper pockets than you do.

Yeah, they can write legal letters all day long and make your life miserable. Yeah, yeah, correct.

And ultimately, I mean, the— if a company is willing to spend $50,000 to make you spend $10,000, $15,000, $20,000 to defend yourself even really before anything of significance has happened, it is a great way to scare people into, this is never going to end until you, until you concede to what we want.

Yeah. So the other alternative would be to just— if you're— let's just say you're representing them or these in a territory mostly, and then just to switch to trauma or shoulders or something else, you know, or sports medicine in the same territory.

That's right? That's correct in theory, although if you do that, you're still going to receive the letters. You're still going to receive the stress. What, what the companies are trying to do, even if you have a legitimate reason to be there is scare you to death that you are, you know, going to be sued into oblivion and owe them everything that you have.

And let's go, go back to the beginning on the non-compete.

Did you—

do— there's a, uh, when a rep is a W-2 and maybe even a 1099, I'm not sure, do you have to sign the non-compete like your first First week or two of employment when they— you need to do all your paperwork.

So, so in theory, it— I mean, it, it is in almost everybody's contract that they're signing upon employment. And that, that is the— that is the thing I've made a couple mistakes on, is I thought a non-compete is mandatory. A non-compete is not mandatory. I don't have—

You can—

Non-compete with anybody today. Now, the reality is, is for a new rep getting into the industry, one of the big companies will probably just say, well, if you, if you don't want the non-compete, then if you won't sign the non-compete, we're not going to hire you. Right.

And— or you could— but you could make it— you could make it 6 months. I mean, you can— you can modify it any way you want and give it a try.

Exactly. And that's what I didn't realize, is I, I kind of was naive thinking a contract's a contract, it has to be that way. But it, it does not. I mean, you could— you can put all sorts of things in there if both sides agree to it.

So if you're a young salesperson and you're taking a new job with, you know, even a smaller company, but let's just stick with bigger company, you would advise them to maybe spend, you know, $1,000 or something on the front end, talk to an attorney, and modify the non-compete language?

Correct.

Correct.

And I, I am very much against non-competes, in part because I've never had a guarantee within our business. Even when I started, I was on, I was on straight commission. So the thought that I would sign a non-compete for never having been Uh, on some sort of guarantee was, was very odd, odd to me. Um, even, even though I did end up, uh, signing a few of them. But you are exactly right. You, you can modify, you can redline anything, but ultimately both sides have to agree to it and sign it.

You got to be willing to walk your Yeah, yeah, correct.

And that, that's the best way to put it, Tiger, is that I have, I have taken the stance personally that I'm not signing one. And I have walked away from companies that I actually wanted to sell some of their products, but I was not willing to do that because I had such a negative— I was not going to put myself in that position again.

Yes, that's good. in the long run. It's just painful. So I'm familiar with non-competes from people that work inside the device companies, you know, marketing, engineers, operations, and so on. And they, they, you know, you're right, they're— it's boilerplate non-compete language. But they— the courts say you have to give The company has to give some kind of compensation to the employee in order for the employee to give up that right.

Right, that's legal consideration. I know more about that than I wish.

And it's usually— they usually do it with stock options. If it's a public company, here's your stock options in exchange for that, you know, you agree to these non-compete terms.

Um, right. Now there's— there is all sorts of thought about what qualifies as consideration, but you are exactly right. I had a friend of mine who, in his contract— and funny looking at it, it says, in consideration of this, basically we give you this— and one was $50.

Ah, that's— that wouldn't hold up.

Well, okay, it wouldn't hold up, but how much money do you have to invest for to fight it not holding up? And that is my biggest beef with the whole thing, is that even though it wouldn't hold up, it could cost you significantly to fight it. And this is an interesting thing that I saw through my research of non-competes. a few months ago is non-competes are technically not legal in California, but I saw something that it was a crazy— like up to 70% of physicians in California have a non-compete.

That's because a lot of them are employees, like at places like Kaiser. They have a lot of employees.

Yeah, but if non-competes are not legal and 70% still have it, And my— from my research of doing it is when people leave, they still get sued even though they're not quote-unquote legal. There's still a— there's still a legal process that they try and drag people through.

That tells you how much money the surgeon's making for the hospital right there. Oh man, that is really interesting.

Right. And the same thing would be The same thing would be true for, for the implant representative. I mean, if someone who has several million dollars of business leaves, to the company, that's several million dollars of sales revenue.

Yeah, they're going to have a target on their back.

Exactly. As one of my friends told me, it's a math equation. If there is something they perceive valuable of trying to save, they will go after you. If if there's nothing left to save, they may not go after you unless they're trying to make an example to as a deterrent for other people, which is another very. very real thing is, think of all the thousands of reps that work for these large companies. If they don't make someone's life and give them a lot of headaches in their exit from the company where they think that they're competing, what is that telling everybody else?

Yeah, it's just, that's really, that's a really good insight. I've always said that Doesn't matter how you treat somebody when they leave, it's— but everybody else is watching how you treat them. It's, you know, the experience is for the survivors, not the person that leaves. So they try to make an example out of people, strong people that leave a company really get—

Yeah. Correct.

Really taken advantage of.

Yeah, correct. And I mean, I have— I believe in teamwork. I believe in being part of an organization that is, you know, really working together, benefiting everybody, functioning, love working with each other, etc. And where I have an issue is when someone genuinely has an opportunity to pursue something better for himself and his family And people are trying to stand in the way of doing that. I, I have a significant issue with that side of the non-compete and that side of the vengeance and going after them to make an example out of it so that you scare everybody else from pursuing something better for them. Because in my, in my opinion, part of employment is like me personally, our distributorship. I only want to work with people I like. And if I genuinely hire someone that I like and enjoy, if he or she genuinely had an opportunity to pursue something different that was better for them and their family, how could I stand in their way?

Well, you're talking that you— now you're into, you know, a strong leader. Will help the person make the transition in their career. A weak leader is scared that they're going to lose their boss.

Yeah, absolutely. But what kind of, what kind of leader is it or something that we want to train you up, we want to make you the best, we want to invest all of this into you. Oh, but you know what? We don't want you to progress past what we think is best for you. Yeah. And, and on the, on the leadership side, Tiger, I mean, now that I have no non-competes, and I'm hoping some of the companies I represent are not listening, just kidding, but I am more loyal now to them because I have the option to, to leave if I wanted to.

Yeah.

Because I don't have that. I don't have that holding over, over my head, and it can be a genuine relationship.

And yeah, it's a, it's a true win-win for both parties. If it's not, you can do something else. Whereas with the other situation with non-compete, you could be a win-lose situation, but you— the rep can't leave.

Correct. And that That is something that's frustrated me, and and I know people might be listening. And trust me, there is another side to it. I do think if if the company and striker used to do this, I don't know if they still do it, but I'm okay with a non-compete being upheld if that person is still getting the salary they made the last year. Or the income they made the last year. That to me makes sense, that you can't, you can't compete in this geography, but you're still going to get paid what you did last year.

Because then the question is, how— what if you make 80% of your last year's earnings? I mean, there's— well, it comes down to, you know, numbers.

Correct. And I under— correct. And that's why That's why there's all of these, uh, all the litigation over non-competes, right?

Yeah, because—

But, but that, in my opinion, is, is the way to do it. Um, and also on non-competes is another thing that I'm— I don't have a non-compete. I'm not going to sign one. But one thing that I would be open to is, okay, How about a non-compete that goes away with time served? And time served meaning, hey, if I work for you for 3 months and I leave, okay, maybe my non-compete is in full. But if I work for you for a year, it gets knocked down. And that could be a negotiation— a negotiated way to get rid of a non-compete.

Yeah, that would be a good way to redline Um, on day 1 of employment, right? Burn off— wait, have an option to burn off your non-compete.

Yeah, because I do that. Yeah, I do understand the company side. Like, look, what if we hire this person, pay them $80,000, $100,000, whatever the amount is, they work for us for 2 years, they didn't bring in sales, and then now they— now they leave?

Yeah. They've invested in the asset and then the asset leaves. Yeah, I understand that.

But when does that flip and they've become more of an asset than what they've been paid? Maybe for some people it never has, but for some people that was 15, 20 years ago.

Yeah. Interesting. I see this in recruiting. A lot of times people will relocate from one part of the country another and they'll get a large relocation bonus when they start, and, and they have to pay it back if they leave within the first year. They have to pay it back, or, or it's prorated. Yeah, and that, that's legit because the company, you know, wrote a big check. Yeah.

Correct. And so I am— even though I'm completely anti-non-compete, I can understand And understand stuff like that. But I do think that the way that the non-competes are, are litigated these days is completely one-sided.

Yeah, he who has more attorneys is gonna make pain for the other person.

And more money.

And more money.

That's true.

Correct.

And the other thing about that is that it is very emotional On the one side, and this is on purpose because it's a scare tactic, is when a big company is sending threatening letters to me, I personally am fighting it. There is a corporate lawyer who has nothing to lose, and I do understand why it's that way, but that that part continues to frustrate me from just what a lot these companies are allowed to do. And threaten this or that, and there's no recourse. In fact, I talked with my, my lawyer after I got one of these letters, and I said, this isn't true, this isn't true, this isn't true. And he basically said, Stu, it doesn't matter what they threaten until you start getting in front of a judge.

Yeah.

And then it becomes matter of fact. Like this, that you threatened, it's not happening. And it's just like there's no recourse for them threatening and accusing me or anybody of something.

Yeah, and they're hoping, they're hoping the first letters are going to be—

Exactly.

Change your behavior. And it's— they don't want to go to trial either, you know, um, even though they can. But, um, so All right, let's, let's go back to agents, brokers again. Um, so what are the, what are the advantages of a broker distributorship, and then what are the disadvantages?

So you're, you're talking about on the rep distributor side, correct?

Yeah.

So Yeah. So the advantages of being a broker over being a, what I would call a captive agent, which is someone who works for, or a captive rep, someone who works for one company. The biggest advantage is diversified risk. And from the standpoint of we have multiple revenue streams every single month. Some of this was very intentional, but the proportions or the percentages that we have was— happened a little by happenstance. About 8 months ago, I really started looking at percentage of income that our distributorship got from our our vendor partners. And it just so happens that we don't have more than a third of our revenue tied up in one single manufacturer. And what that allows us to do is, if that manufacturer called us tomorrow and said, we're terminating your contract in 60 days, or whatever my contract with them would say, it would sting. Don't get me wrong. But we would only have a maximum of a third of our business tied up, or a third of our revenue tied up with that. And common sense would say, if we maintain 67% of our income, we would be able to make much wiser decisions long-term for what's next for us than if all of our eggs were in that one basket with one company. company, and they decided they didn't want me to work with them anymore.

And total, that makes so much sense.

So on, on that side, the diversification. On the rep side also, the ability to offer surgeons multiple products because they may want to work with Stu or one of the people that works with me because they like us and trust us and No, we're going to have, you know, what they want. The ability to, if they're having issues, frustrations with something, be able to offer them something else or more options is just tremendous flexibility. And what I point to people all the time is this sort of thing has been happening As there's been consolidation with our industry, I've heard all sorts of stories from Zimmer reps or Biomet reps, or even farther back when, you know, J&J and DePuy merged, and even Stryker Helmedica— or sorry, ASEONICS Helmedica, which became Stryker Orthopedics— is stories of once that happens, the surgeons are all of a sudden trying to start, or they're, they're starting to try some of the other products that quote unquote the other company had. So Zimmer reps I've talked to said as soon as Biomet was acquired, they had their surgeons trying Biomet products because they had always been curious about it but never really wanted to do it and bring another rep into the equation.

Interesting.

And vice versa was happening, vice versa was happening as well. And so this is the ability to To always do that. And I think I alluded to something previously, is that, you know, I know of surgeons that have their trusted broker as their rep. And when they see something at Academy or AUCUS that they think that they would want to try or at least look at, what they can say is like, look, I've already got my rep in place. I trust him. This or that, you know, send us the inventory. First cases, sure, you can bring out someone from corporate to help. But as far as the day-to-day person, I've got them in place. And so that that allows them to look at different things that may fit their wants and needs, but in a way where they're not having to, you know, learn. a new set of instruments, implants, and at the same time learn a new rep? Because each of us are different, correct?

Yeah.

And so if you bring a new person into the equation, you're bringing a new, you know, a new set of— a new communication style, you know.

Yep. So the second benefit is the surgeon Has access to more solutions.

Our ability to, to bring more things to, to, uh, the surgeon outside of what, you know, outside of what one company has.

Yeah. Okay.

And there's, there's people that we, we work with that on the total joint side only use one of the companies that we represent. There's surgeons on the total joint side that use several total joint companies that we represent. But, but the bottom line for that is they are using what they want to use and have directed us even to find other things for them.

Okay. Interesting.

Yeah. So there's advantages to both sides. The big disadvantage is lack of name recognition as well as—

Brand. Brand. Interesting.

Correct. Correct. But that and, you know, it is taking longer sometimes to get stuff on contract. Some hospital systems won't let it. Maybe they've reduced to three vendors. What I always tell people is, well, if it goes down to three vendors, at least one of DePew, Smith Nephew, Stryker, or Zimmer is getting left out as well. So if you're if you're one of the big companies, reducing vendors could be significantly that could significantly impact your. your career as well. Yeah, that's true. But as far as— there's some misconceptions out there too, mainly around the quality of some of the smaller companies' products, which I have not found to be true. In fact, a common thing I'd like to tell people is if you walk in sterile processing There's still a lot of people out there using Sigma from DePuy or NextGen from Zimmer Biomet, you know, previous generation, not the newest knee system that they have. And the reality is, in surgeons' hands, those can still work very good. But what I like to tell people is if you walk through sterile processing and some of those old Zimmer trays For NextGen or old DePuy trays with Sigma. If those had a smaller company's name on it, a lot of people would think like, this is malpractice that a surgeon would use these.

Oh yeah.

But because they have Zimmer or J&J written on them, well, it's completely legitimate.

And circle Z. Okay, so you can't brand your The distributor name. I mean— Right.

So, I mean, there's a misconception there, but what I also like to say is let's take DePue and Corai, okay? DePue acquired Corai or bought the French company and turned Corai into the number one hip stem in the world. And yes, Corai is a very good stem. Don't get me wrong, but the brand of DePuy and putting it in a DePuy box made the perception that Kauri was a much, much better implant than if it would have still come in the other box.

Yeah.

And that— there is a very powerful thing there. I admit that. But it is a misconception.

Yeah. It's always going to be around.

Correct.

But I was involved in Intermedics knees, and they were great knees with Aaron Hoffman. Yeah. And I was involved with the Wright Medical medial pivot, which was another great knee. And I mean, they were both like, you know, 1 or 2% market share. But yeah, right.

But what I do like to tell people is Everybody's concerned about these vendors being limited in hospital systems, correct?

Yeah.

Which, which is true. However, how is it that the small companies, if it's not legit— a legitimate business opportunity because they're going to get locked out, how is it that these small companies are still gradually year after year grabbing a little bit more market share and the big companies are losing Well, it's because aren't there—

I mean, isn't there a clause that says even with the vendor lock-in, you can go outside the vendor list like 15% of the time?

Yes.

Certain requests.

Correct. But my whole point is, is people say that that is a reason why it won't— it can't work to work for the small companies because you're going to get locked out.

Oh, I see. Yeah.

But it's very— if it can't work and you keep increasing market share compared to the big players, it seems like a weak overall argument, even though that may be extremely true in certain markets, if that makes sense.

Yeah, yeah. No, there's always room for the ankle biters. You know, they've got better product. And they have, you know, decent service.

Yeah, and even the better product, decent service, what I have found is overall I do think that our orthopedic surgeon customers dislike, on average, dislike working with the big companies just a little bit less each year. Because for the same reason that Physicians like working with their hospital a little less every year because it's not what it used to be, right?

Yeah, there's a loss of autonomy, a loss of— correct. I always keep going back to this word agency, you know. Yeah, it's like everybody's agency is eroding all the time. That's correct. Having to do more volume for the same or Earning potential, right? Having less control over your commissions get cut a lot of times and your territory gets cut and you have no control over that.

Right. But, but look at it from this way, Tiger. When I was with DePuy, one of my first couple years, I forget what year it was, but DePuy Orthopedics went over $500 million in sales worldwide. What is Depuy Synthes today? Now I do understand there's been acquisitions, etc., but Depuy Synthes today, close to $10 billion, probably?

$10 billion, yeah, I was thinking $10 billion.

Yeah, I don't know the exact number, but, but that is 20 times what it was early on, and the surgeons are feeling more and more like a commodity to the companies.

Yeah.

Because a busy, busy orthopedic surgeon who may be $1 million worth of business or a couple million dollars worth of business to a certain company, if that, if that customer looks and says, okay, I'm $2 million of their $10 billion of revenue, they're not going to do anything. Anything for me, which they're not going to. And by doing stuff for them, I mean listening to their concerns, helping them out in a compliant way, such as, you know, does a community surgeon who has maybe a legitimate idea to one of the bigger companies, are they going to listen to him?

Oh man, don't get me started. I, I mean, sir, just because I'm a startup guy, I'm a— yeah, engineer, I get surgeons that call me all the time and they, and they go, they go meet with the big companies, they sit down with the engineers, they sign a contract, and then nothing happens. Nothing.

Correct, correct.

And, and they finally, then they have to go to an attorney and they have to Find out, find a way to unwind that contract they wrote. Yeah, it's just so frustrating.

Correct. And, and I eventually get to a small company where things happen. Correct. And I remember this, and I mean, as a caveat to this is I have seen enough, enough surgery where there are very high-volume people that I have seen at teaching institutions That I would rather— I would send someone to a community surgeon. And not to disparage that, but I— but my point is, is that I think that if you're doing a certain volume of total knees or total hips, and it's different for everybody, I think someone could be very proficient at an operation if they did it once a week, where someone else, it may not be once a week. It may need to be much more because there's different skill levels amongst different people, correct?

Yep.

And so I think that there's a lot of very talented people who are not in teaching institutions that have great ideas that don't have the opportunity to work with one of the bigger companies because the way our environment is today, And significant part of it is probably the way that the orthopedic industry has acted over the years. But a community surgeon has really no chance of being a thought leader within one of the big companies.

Exactly right.

Because the perception of the big companies is you need very high-volume people at teaching to help promote the philosophy's thoughts and products.

Yeah, if you're going to bring an invention, you have to have the podium presence to sell that invention. Exactly. Correct.

And the frustration that I, that I have, Tiger, is when, when I hear big company reps say, oh, that company, all they did was buy their business. By signing this person on to design something or help consult for something. And this is my, my response to that, is if they are doing it just to sign them up to get their, their business, obviously there's an issue with that. Make them a consultant just to get the business, that's, that's not ethical. But if Tiger Buford started an orthopedic company tomorrow Do you need help with designing a product? Legitimate help?

Absolutely, yeah, absolutely.

You need consultants that are physicians that know what other physicians want. You need collaboration with them because surgeons want to know who helped design something. Surgeons want to know who is using this, and there's legitimate reasons to have surgeon consultants for companies that are just starting, for, for every size company. You know this.

Yeah, yeah.

And that is a legitimate business need.

It is, it is. You have to have surgeons buy from other surgeons, or they buy from other surgeons that teach them something new.

Correct.

A lot of times, yes, it legitimizes— yeah, it legitimizes a new idea when somebody they admire, you know, is using a new product.

Yeah, yeah, correct.

Well, this is, this is great, Stu. We could go forever. Uh, do you— anything else you want to talk about, about, uh, brokerage Yeah.

I mean, just to close it out, anybody who's listening to this, is what I have found over the past few years is within orthopedics, you can truly create the business that you would like. And that is something that most big company reps don't understand. And this does not mean it's going to be simple. But if you know what you want, there is a path to get there. And, and what has been really exciting to me is I have never been more optimistic and excited about the future, my, my professional future. And that's 30 years in the industry. Anytime I say that to people I meet, most of the big company reps' jaws drop and It's not until I kind of explain what, what I see from my perspective is possible in the industry. And I like to relate it to this. Tiger, have you ever bought a new car and all of a sudden you see that same model, color everywhere you drive?

Yeah, yep, exactly. There's a principle behind that.

Yeah, correct. And, and the reason for that is that our brain is going to Our brain is automatically looking at it, standing out to us. And the same is true for our careers, is that the big orthopedic reps, because they have such a small geography, it is constantly reinforced into them the problems that they're having, because everything that they see is a problem because of how it's laid out for them, how, how it's structured for them. And this was a gradual process for us. Now, if I see a problem out there, I'm excited because I know that there's something I could do to solve that problem.

Mm-hmm.

Or I have so much available geography where I could go pursue something. There's opportunity everywhere. And because my situation allows that. And that does not mean it's easy. Obviously, I do have frustrations. But one of my frustrations is not that the industry is changing.

Mm-hmm.

Because what happens when there's change? There's opportunities for people if you're willing to embrace change and do things in a slightly different way. And that right there—

you're nimble, you're nimble enough to take advantage of the change.

Correct. And even from the standpoint of, again, if I lose a vendor partner, I'm not going to be happy that that happened, but it's not the end of the world for me. I can, I can keep going. I'm able to pivot and be nimble, as you said. But I I would just, I would just tell people is that, you know, our industry is still a great industry to be in. I honestly don't think that's going to change, about it being a great industry to be in. What I do think will be— will change, and that you have to be flexible to, is how, how we work as reps within the industry, because I do think that that could change over time.

Yeah.

And the best way to position yourself is to be flexible and nimble, to be able to move and change with the market.

Yep. Makes total sense.

Yeah.

So how would somebody listening to this learn more about the broker concept? Yeah.

So I would say that the best way is just reach out to me on LinkedIn, DM me. That would be the best and easiest way to, to get a hold of me. We, we do have a website that's www.asddx.com and repfreedom.com, but the best way would be just reach out on LinkedIn.

Okay. Yeah, well, thanks. Thanks, Stu. That was great. We may have to do a round 2.

Yeah. Well, I enjoyed it thoroughly, Tiger, and I have really enjoyed over the past— oh, it's probably a couple months since we first talked. I enjoy other people's perspective on our industry. You give me a different perspective than the sales side, which I enjoy as well because I want to understand where everybody's coming from.

Yeah.

You know, you understand certain problems, I understand others, and, and it's just that's the only way we can advance our industry, correct, is if we collaborate and figure out new and better ways to do things.

Absolutely. Yeah. What I've learned is the status quo does not apply if you don't want it to. Correct. There's always, there's always another way to do things.

Correct.

Yeah, well, thanks, Stu. This has been great. Thanks for all your time. We'll, uh, sure we'll talk again, and we may have to do a round 2 one day, right?

All right, well, I appreciate you inviting me on. I enjoyed it, Tiger.

Yeah, yeah, terrific. Take care. Thanks.

All right, thank you. Have a good day.

Yeah, bye-bye.

Yep.