Nick Shamie, MD, co-director of the UCLA Comprehensive Spine Center and associate professor in orthopedic surgery at David Geffen School of Medicine at UCLA, discusses the importance of spine surgeons working with other specialists on clinical and policy issues related to spine care.
Q: Why is it important for spine surgeons to have a positive relationship with other specialists and primary care physicians?
Dr. Nick Shamie: There is still some confusion between patients about whether they need to see an orthopedic spine surgeon or neurosurgeon, because we do a lot of the same things. Sometimes primary care physicians direct their patients to neurosurgeons without realizing the problem might be more suited for orthopedic spine surgeons. I believe that spine fellowship trained orthopedic and neurosurgeons are becoming more and more qualified to take care of all spine patients.
I have a dual appointment in orthopedic spine and neurosurgery; when patients are asking which type of specialist to see, I tell them to find a surgeon they are comfortable with because either specialist could probably provide the treatment they need.
The other disciples we work with are pain management, anesthesia, physical medicine, rehabilitation specialists, neurologists and internists. They certainly complement the care we provide our spine patients. A spine surgeon must have relationships with several different subspecialists to provide multidisciplinary care for patients; whether or not a patient needs surgery or can be treated with non-surgical care.
Q: How can spine surgeons work with other specialists to provide higher quality and more cost-effective care?
NS: Physicians are dealing with more financial pressures from the payors and administrators on various issues; one of the biggest issues is implant costs. Is it worthwhile to have a focused spine center in the hospital or surgery center? For now, the payors are reimbursing well for spine and neurological procedures, but I think we are going to face downward pressure that will force us to prove what we do is effective and financially feasible.
We have to figure out whether we have the right data, whether we agree that we should be doing surgery or something else, and whether there is a way to control costs. There are articles in hospital journals that show collaborative efforts can save money for the hospitals, but we want to make sure we are saving money without affecting the quality of care we provide our patients.
That's a really important discussion to have because as reimbursements go down, quality can be affected. If we take quality as the main focus in our discussions, it will help us achieve more efficient and less costly care without hurting the quality we want to provide our patients. If there is division among subspecialists and the spine surgeons say something different than other specialists, it can become a mess. If we don't work together ultimately the patient care will suffer. Together we stand and divided we fall.
Q: When we look at the national and global efforts to promote spine care, where can the partnership between spine and neurosurgeons take us?
NS: Spine surgery is a relatively new field, which is slowly migrating away from orthopedic surgery and neurosurgery over the past 20 years. From that standpoint, we are at a critical time point where spine surgeons need to work together to define quality spine care and answer questions that are raised — appropriately so — about the kind of care that is necessary and cost-effective. In medicine, we still prescribe lots of treatments that aren't based on solid data; we know from anecdotal evidence that patients are doing better, but no good studies are available to prove it.
In medicine as a whole we don't have enough class I data on everything we do, which has been overlooked in some areas. But in spine and orthopedics, our treatments and implants are costly, so we are faced with more scrutiny. We have to come together at a national level to answer questions about cost-effectiveness and quality of care. It's critical for spine surgeons and neurosurgeons to work together on moving forward over the next several years. If we don't move together in this effort, we may lose the opportunity to innovate and work with new treatments to help our patients.
One of the biggest threats to our field — and medicine as a whole — is that financial pressures have put a major damper on R&D in the U.S. There is a general belief in the spine community (and the payors alike) that most new technologies are too costly and not beneficial. Furthermore, we are faced with more stringent requirements by the FDA which has escalated the costs of conducting pre-market studies in the U.S. These pressures have forced many clinical trials to either close or move overseas. The impact of this shift will be that new and innovative technologies will be more likely developed outside of the U.S. Involvement in international spine societies will help foster a more collaborative effort and I believe can improve the quality of R&D performed in the U.S. or abroad.
Q: What needs to happen at the national level in order to advocate on behalf of spine surgeons, specialists and patients?
NS: One of the issues we are facing today is that we don't have a strong society that focuses on representing the spine surgeon's voice. The big societies like the American Academy of Orthopaedic Surgeons and American Association of Neurological Surgeons have a major presence, but they both have multiple interests and spine surgery is a small part of these societies. There isn't just one group with spine surgeons as their main interest; spine takes a back seat. We're in a very interesting situation where we aren't really being represented in any society just for spine surgeons.
There are several societies that have formed and are evolving to speak to this need. I'm involved with some of them, but we don't have the critical mass yet to effectively represent spine surgeons. On a national level, we need to push for a betterment of spine patient care through evidence-based data, education, research and advocacy. Advocacy is important and I do believe that spine surgery improves peoples' quality of life.
Q: What are the biggest road blocks to becoming more involved in advocacy efforts?
NS: We are busy all day with our clinics and we don't see what is happening all around us and over our heads. In our current environment we all have to be more involved in how things are affecting us locally and globally. Physicians are the ones in the trenches taking care of patients; and their voice is critically important — and oftentimes missed.
I think it comes down to the initial topic we discussed — collaboration between specialists. We have to get leaders from both orthopedic spine and neurosurgery who work together on advocacy. These leaders must gain the respect of their constituents because it's hard to convince all spine surgeons nationwide to see eye-to-eye on all the issues. We have different environments we work in and teach in; we have to find the common denominator that we are passionate for, which will bring us together.
Q: What about different environments drives physicians apart?
NS: Not everyone agrees with every issue because some surgeons aren't initially affected by a change, but by the time they are affected it's too late. For example, there are some regions of the country where Medicare has cut rates significantly, and providers in those states are speaking up. In other states, surgeons have begun charging cash and have opted out of many insurance plans. Providers in those states aren't interested in advocating nationally for feasible Medicare reimbursement.
We have to talk to policy makers about our experience and they need to take our experience into account when making legislation. We need to educate our patients so they can also be our advocates. If we as surgeons go to Capitol Hill, we are self-serving and no one listens. When the patients who have benefited from our treatments speak up, everyone listens. We need to act now, after a bill is passed, it's hard to change it.
Q: What are the implications of an adversarial relationship between specialties?
NS: There are several challenges that could arise from various specialists taking care of our spine patients, with difference in philosophies. But, first and foremost, we have to be prepared to look at non-surgical treatments as critically as we look at our surgical treatments. That offers an even more complex challenge on how we can work and collaborate together.
For example taking care of spinal stenosis patients requires a comprehensive approach utilizing the expertise of surgeons, pain management specialists, physical therapists and others. However, at times, differences in philosophy can be found between the surgeons and other specialists taking care of these patients. As an example, when a pain specialist was recently asked how many times a procedure could be repeated if the patient's pain returns, he answered, "Ad infinitum." Compare this philosophy with orthopedic principles that support using progressive treatment modalities that not only relieve symptoms but also permanently address the condition.
If a paper comes out that says epidural injections don't help patients with lumbar spinal stenosis, what should the societies do? Should they say epidural injections shouldn't be done for certain diagnoses? Should the society say surgery is better? Or should they stay silent? In a perfect world the societies would say what's best for our patients. This isn't a perfect world, but we strive to get as close to perfect as possible.
More Articles on Spine Surgery:
5 Points on Benefits & Challenges of Spine and Neurosurgeon Partnerships
What Percentage of Spine Surgery Could be Performed in ASCs? 7 Surgeons Respond
5 Spine Surgeons on Responding to Coverage Denials
Q: Why is it important for spine surgeons to have a positive relationship with other specialists and primary care physicians?
Dr. Nick Shamie: There is still some confusion between patients about whether they need to see an orthopedic spine surgeon or neurosurgeon, because we do a lot of the same things. Sometimes primary care physicians direct their patients to neurosurgeons without realizing the problem might be more suited for orthopedic spine surgeons. I believe that spine fellowship trained orthopedic and neurosurgeons are becoming more and more qualified to take care of all spine patients.
I have a dual appointment in orthopedic spine and neurosurgery; when patients are asking which type of specialist to see, I tell them to find a surgeon they are comfortable with because either specialist could probably provide the treatment they need.
The other disciples we work with are pain management, anesthesia, physical medicine, rehabilitation specialists, neurologists and internists. They certainly complement the care we provide our spine patients. A spine surgeon must have relationships with several different subspecialists to provide multidisciplinary care for patients; whether or not a patient needs surgery or can be treated with non-surgical care.
Q: How can spine surgeons work with other specialists to provide higher quality and more cost-effective care?
NS: Physicians are dealing with more financial pressures from the payors and administrators on various issues; one of the biggest issues is implant costs. Is it worthwhile to have a focused spine center in the hospital or surgery center? For now, the payors are reimbursing well for spine and neurological procedures, but I think we are going to face downward pressure that will force us to prove what we do is effective and financially feasible.
We have to figure out whether we have the right data, whether we agree that we should be doing surgery or something else, and whether there is a way to control costs. There are articles in hospital journals that show collaborative efforts can save money for the hospitals, but we want to make sure we are saving money without affecting the quality of care we provide our patients.
That's a really important discussion to have because as reimbursements go down, quality can be affected. If we take quality as the main focus in our discussions, it will help us achieve more efficient and less costly care without hurting the quality we want to provide our patients. If there is division among subspecialists and the spine surgeons say something different than other specialists, it can become a mess. If we don't work together ultimately the patient care will suffer. Together we stand and divided we fall.
Q: When we look at the national and global efforts to promote spine care, where can the partnership between spine and neurosurgeons take us?
NS: Spine surgery is a relatively new field, which is slowly migrating away from orthopedic surgery and neurosurgery over the past 20 years. From that standpoint, we are at a critical time point where spine surgeons need to work together to define quality spine care and answer questions that are raised — appropriately so — about the kind of care that is necessary and cost-effective. In medicine, we still prescribe lots of treatments that aren't based on solid data; we know from anecdotal evidence that patients are doing better, but no good studies are available to prove it.
In medicine as a whole we don't have enough class I data on everything we do, which has been overlooked in some areas. But in spine and orthopedics, our treatments and implants are costly, so we are faced with more scrutiny. We have to come together at a national level to answer questions about cost-effectiveness and quality of care. It's critical for spine surgeons and neurosurgeons to work together on moving forward over the next several years. If we don't move together in this effort, we may lose the opportunity to innovate and work with new treatments to help our patients.
One of the biggest threats to our field — and medicine as a whole — is that financial pressures have put a major damper on R&D in the U.S. There is a general belief in the spine community (and the payors alike) that most new technologies are too costly and not beneficial. Furthermore, we are faced with more stringent requirements by the FDA which has escalated the costs of conducting pre-market studies in the U.S. These pressures have forced many clinical trials to either close or move overseas. The impact of this shift will be that new and innovative technologies will be more likely developed outside of the U.S. Involvement in international spine societies will help foster a more collaborative effort and I believe can improve the quality of R&D performed in the U.S. or abroad.
Q: What needs to happen at the national level in order to advocate on behalf of spine surgeons, specialists and patients?
NS: One of the issues we are facing today is that we don't have a strong society that focuses on representing the spine surgeon's voice. The big societies like the American Academy of Orthopaedic Surgeons and American Association of Neurological Surgeons have a major presence, but they both have multiple interests and spine surgery is a small part of these societies. There isn't just one group with spine surgeons as their main interest; spine takes a back seat. We're in a very interesting situation where we aren't really being represented in any society just for spine surgeons.
There are several societies that have formed and are evolving to speak to this need. I'm involved with some of them, but we don't have the critical mass yet to effectively represent spine surgeons. On a national level, we need to push for a betterment of spine patient care through evidence-based data, education, research and advocacy. Advocacy is important and I do believe that spine surgery improves peoples' quality of life.
Q: What are the biggest road blocks to becoming more involved in advocacy efforts?
NS: We are busy all day with our clinics and we don't see what is happening all around us and over our heads. In our current environment we all have to be more involved in how things are affecting us locally and globally. Physicians are the ones in the trenches taking care of patients; and their voice is critically important — and oftentimes missed.
I think it comes down to the initial topic we discussed — collaboration between specialists. We have to get leaders from both orthopedic spine and neurosurgery who work together on advocacy. These leaders must gain the respect of their constituents because it's hard to convince all spine surgeons nationwide to see eye-to-eye on all the issues. We have different environments we work in and teach in; we have to find the common denominator that we are passionate for, which will bring us together.
Q: What about different environments drives physicians apart?
NS: Not everyone agrees with every issue because some surgeons aren't initially affected by a change, but by the time they are affected it's too late. For example, there are some regions of the country where Medicare has cut rates significantly, and providers in those states are speaking up. In other states, surgeons have begun charging cash and have opted out of many insurance plans. Providers in those states aren't interested in advocating nationally for feasible Medicare reimbursement.
We have to talk to policy makers about our experience and they need to take our experience into account when making legislation. We need to educate our patients so they can also be our advocates. If we as surgeons go to Capitol Hill, we are self-serving and no one listens. When the patients who have benefited from our treatments speak up, everyone listens. We need to act now, after a bill is passed, it's hard to change it.
Q: What are the implications of an adversarial relationship between specialties?
NS: There are several challenges that could arise from various specialists taking care of our spine patients, with difference in philosophies. But, first and foremost, we have to be prepared to look at non-surgical treatments as critically as we look at our surgical treatments. That offers an even more complex challenge on how we can work and collaborate together.
For example taking care of spinal stenosis patients requires a comprehensive approach utilizing the expertise of surgeons, pain management specialists, physical therapists and others. However, at times, differences in philosophy can be found between the surgeons and other specialists taking care of these patients. As an example, when a pain specialist was recently asked how many times a procedure could be repeated if the patient's pain returns, he answered, "Ad infinitum." Compare this philosophy with orthopedic principles that support using progressive treatment modalities that not only relieve symptoms but also permanently address the condition.
If a paper comes out that says epidural injections don't help patients with lumbar spinal stenosis, what should the societies do? Should they say epidural injections shouldn't be done for certain diagnoses? Should the society say surgery is better? Or should they stay silent? In a perfect world the societies would say what's best for our patients. This isn't a perfect world, but we strive to get as close to perfect as possible.
More Articles on Spine Surgery:
5 Points on Benefits & Challenges of Spine and Neurosurgeon Partnerships
What Percentage of Spine Surgery Could be Performed in ASCs? 7 Surgeons Respond
5 Spine Surgeons on Responding to Coverage Denials