Other Articles

Using DNA to Predict Scoliosis
Six million people (estimate from the National Scoliosis Foundation) have scoliosis in one form or another. The primary age for onset of idiopathic scoliosis is 10-15 years old. Finally, there is a test which can reliably predict scoliosis. Fewer X-rays. Lower cost. Better outcomes.

New Capital, New Science for Cartilage Repair
$36 million invested in the last couple of months. TiGenix has more than that in the bank to fund market penetration. Then a new paper last week finds molecular cause of OA. Cartilage repair momentum is building.

Should I Become a Physician-Employee?
Large healthcare institutions are increasingly purchasing orthopedic practices. What does this mean for patient referrals? How beneficial can it be for orthopedists? The upside is more stability, among other things…and one of the downsides is loss of freedom.

Outrageous Whistleblower Lawsuit Challenged
Spine surgeons sued by whistleblowers in Boston are fighting back. Their lawyer is outraged and says the claimants are just shopping an old and settled case to another judge. Is this the proverbial lipstick on a pig? Find out.

Medical Education Under the Microscope – Is It Up to Today’s Challenges?
Where is the line drawn between what medical schools, residencies, and professors should provide to students and what doctors-in-training should reach for themselves? Here are the results of interviews with three senior surgeons, who opine on things such as attitudes, how people learn, and the possible effects on the field.

The Underlying Meaning of Zimmer’s Purchase of Abbott Spine
From the price paid to the timing, this transaction held an underlying meaning for the entire spinal implant industry. Zimmer, the $4.2 billion (revenue) diversified orthopedic company is now #5 in spine. More to come?

Resurging Lumbar and Cervical Total Disc Replacement Markets! New PearlDiver Estimates
Rumors of the TDA market’s demise were premature. Increasingly positive long term patient data is at the core of a resurging lumbar and cervical TDR market. Senior analyst Matt Menze tackles the TDA market and interviews one of the fathers of TDR, Dr. Scott Blumenthal from the Texas Back Institute. Where is this market actually heading? We think to the $2 billion range by 2015. All details here.

Six Days in June – Biomet and Zimmer Battle for Distributors in Kentucky
Documents filed recently in a Kentucky lawsuit pull the curtain back on an epic battle between Biomet and Zimmer. For six fevered days in June 2007, Biomet CEO Jeff Binder and founder Dane Miller went into the trenches to save one of their own. For all the details, read on.

Multicenter Clinical Trials: Do They Get the Respect They Deserve?
They’re not fast or sexy, but they are critical…large trials, that is. With multiple sites and principal investigators who donate their time, large trials are more complex—and normally yield more actionable data—than smaller, quicker studies. But large trials don’t always get the respect they deserve. And, says at least one physician-researcher, this could affect the future of the field.

Patent Wars: Medtronic Attacks NuVasive
MSD’s lawsuit came amid a period of declining spinal implant market share – from a peak of 60% in late 1998 (just prior to being acquired by Medtronic) to, we estimate, 36% currently – and a growing sense that MSD’s reign as the king of spine was coming to a close. What’s really behind Medtronic’s attack on its former senior exec? Read on.

Spine Gainsharing Through the Looking Glass
The feds have issued their first opinion allowing a spine gainsharing proposal. In Alice in Wonderland style, Through-the-Looking-Glass logic, they said the proposal was improper but would not impose sanctions. Who is the author of such a plan and what’s her secret? Read here.

PearlDiver Data Raises New Questions About Synovial Injections
Synovial injections for painful knees have been approved for use since 1997. If the goal is to improve the quality of life for the patient, is that being accomplished? The latest numbers from the PearlDiver Patient Records Database cast doubt.

Plantar Fascia: The Annual 3 Million Patient Market
“Plantar Fascial Fibromatosis (ICD-9-D-728.71) is right up there in frequency with pain in the shoulder joint, degeneration of lumbar intervertebral discs, pain in the lower leg joint, and carpal tunnel syndrome. As usual, PearlDiver has this market mapped out.

Orthopedic Incubators: Where Little Ideas Grow Up
Business incubation, also known as acceleration, can be a wild ride. Thus it’s best to approach it armed with the solid advice of experienced professionals. Who should take this ride? What can venture financiers bring to the table? These questions and more are answered by two seasoned VC professionals.

Just Say No to CMS Potential Coverage Decision List
Unless you want to be on the receiving end of a non-coverage letter, just say no to CMS’ proposed list of potential National Coverage Decisions. You’ve got until September 28 to make your case. Read what a leading industry consultant and analyst have to say.

Staking a BIG Claim
Alphatec, the company whose IPO collapse served as an object lesson for all medical device companies, has nearly completed its turnaround. The key? New management and new technology. Exhibit A: OsseoFix™—with it Alphatec stakes a claim to the next big spinal implant market.

Most orthopedists step into an orthopedic department and operate within the existing environment. A few fortunate, adventurous types have the opportunity to build an orthopedic department from the ground up. Dr. Richard Gelberman, Chair of Orthopaedics at Washington University School of Medicine in St. Louis, is one of those physicians.

“Establishing a department of orthopedics is one of the most rewarding and challenging undertakings a physician can have. It gives one perspective and solidifies one’s management style and can result in an outstanding unit that excels at patient care, research and education. In determining how to proceed with developing a department,” says Dr. Gelberman, “one must first understand the history of the department and the goals of the institution. Whether you are being promoted from inside or hired from the outside, you should develop a strategic plan that is consistent with the objectives of the medical school and of the hospital. In my view, that strategic plan includes two overarching objectives: recruitment and retention of outstanding faculty and the maintenance of a financially viable entity. How those objectives interact with the goals of a particular institution vary from place to place. For instance, it may be difficult to develop a flagship orthopedic research division in a medical school that does not have a record of excellence in investigation and does not have a dean that values development in this area. Part of one’s due diligence involves making several trips to the prospective institution in order to understand its goals and priorities. It is useful to make certain there are other departments and programs, like orthopedics, that have succeeded in the areas in which a prospective chairman has greatest interest. In addition, whenever I carry out an institutional assessment, I contact faculty who have left the institution and I ask them why they left. Often, I receive responses such as, ‘It is a difficult place to succeed for surgeons; I couldn’t get cases into the operating room, etc.’”

Continues Dr. Gelberman, “I build my strategic plan in the three key areas of clinical care, research, and education. The clinical care component is based on the financial support provided through careful negotiation. Direct discussions with the dean and president of the hospital are required to determine what is needed to succeed in clinical care, including the resources necessary to recruit outstanding faculty and, just as important, the ongoing resources for clinical growth and faculty retention. Obtaining sufficient operating room time for existing surgeons and allowing for the provision of block operating time for new surgeons is of utmost importance. Similarly, the provision of attractive outpatient clinic space and inpatient care facilities is critical. In 2008, many programs are focusing on establishing new models of efficiency in the outpatient arena, thus allowing orthopedic patients to be cared for in the most effective manner. At Washington University, we built our program on some of the principles outlined by Taiichi Ohno, the architect of the Toyota system. In doing so, we developed an emphasis on patient safety, clinical efficiency, and reduction of waste. In the end, one must make certain that the financial model that one creates with the hospital and medical school is one that will support these programs and others so that the growth of the department will be assured well beyond the first few years of development.”

Key to growing such an orthopedics department is the brain trust you bring in to forge new paths. “The overarching objective of an effective chairman, in my view, is the uncompromising search for outstanding talent. This means making certain that one recruits exceptional people—those who want to advance the field either in clinical care, research, teaching, or in all three. Taking the time to conduct the due diligence necessary to make certain that faculty will succeed in your environment is of utmost importance. In recruiting established faculty from another practice, it’s useful to take a look at their clinical track record in prior years. In other words, the numbers of total patients they’ve seen in a year, surgeries done, wRVU’s achieved, etc. is valuable information. A comparison of those data to benchmark data provided by the Medical Group Management Association with regard to work value units per specialty area can be very helpful. The average hand surgeon, for example, produces approximately 7,500-8,500 work value units per year; a sports medicine surgeon, 9,000; and a spine surgeon, 11,000. If a potential recruit is not achieving those levels, one should probe for the underlying reasons.”

Continues Dr. Gelberman, “Once the faculty member is recruited, the goal is to provide a principle-based system for faculty growth, financially and intellectually. The objectives that the group decides upon are applied uniformly—with an effort to avoid special arrangements that favor some faculty over others. We do not shy away from talking openly about financial incentives and rewards. Our incentive-based system of financial reimbursement, which is based on clinical, research, and teaching productivity, was decided upon with broad input from all members of the department.”

Once you’ve recruited the faculty, shepherding these talented orthopedists will distinguish you as a leader and mentor. An encouraging Richard Gelberman says, “You should feel good about having others do well under your leadership. Ideally, you will strive to have them become leaders. In order to build trust you have to be the type of leader who makes it clear that you care about them and demonstrate that you are fair about supporting people. And set a standard of openness. An informed group will make a better decision than an individual. Many times I have found that in the end, the answer is not one that I’d have come up with. In general, be interested in building a department and not one’s own future. Be willing to give to others and take a genuine enthusiasm in their achievements. Then people will trust you and be willing to learn from you.”

To be effective in establishing an orthopedic department one must be comfortable in both the OR and the boardroom. “A high level of financial awareness and effectiveness is critical to building and growing a viable orthopedic department,” states Dr. Gelberman. “You must have not only a terrific strategic plan, but also a realistic pro forma to support it. Twenty-five years ago it may not have been so critically important to understand medical economics. Today it is critical. In earlier years, the chair could make some mistakes and still survive. We are now in an era of diminished resources where every penny in support of one’s mission counts. One must make certain that he or she has a program that allows for the resources to last and be regenerated. Try to establish a sound program from the outset, and avoid going back to the medical school and hospital for additional resources for as long as possible. Take research development, for example. One knows from the outset that an orthopedic Ph.D. scientist is unable to earn more than 90%-95% of his or her income. Therefore, the resources necessary to support the laboratory long term must be established from the outset.”

As an example of how a department head negotiates with an institution, Dr. Gelberman cites the following example. “In my view it is most important to develop a goal and then to keep your eye on the target. While the path to achieving that goal may vary slightly, a steady effort to achieve it remains central. For example, recently we developed the goal of building a flagship outpatient facility. It took us three years to convince both the hospital and the medical school, but we successfully negotiated a new 60,000-square-foot facility with ORs, MRI, etc. We provided the strategic direction, the supporting financial data including data on the anticipated return on investment and net present value, and tried to provide a solid understanding of why this undertaking was important to the institution. As our prior record was one of yearly growth for 10 years, we knew we had accrued some of the political capital necessary to accomplish this major undertaking. We opened the new facility six months ago and now have our eye on the target of providing outstanding care to patients in the most efficient ways possible. We have to reach our benchmark financial targets in order to demonstrate to the administration that a lean facility of this sort, operationally based on the Toyota model of reducing waste and improving efficiency, can indeed work. We are trying to apply all of those principles used so effectively in business over the years to outpatient healthcare delivery. In the end, our goal is to build an exceptional, eco-friendly, energy-efficient, and patient-centered environment in this new facility.”

There is an old adage that it’s lonely at the top. In the case of an orthopedic department, however, that could be said of being in the middle. “In many cases you’re the middleman between the administration and faculty. You are expected to keep the faculty encouraged while relating effectively to the administration. This is becoming increasingly challenging as resources become more limited.”

So, while sometimes you’re working with personalities and other times with numbers, you’re always working with your overall strategy. Ultimately, that strategy will influence the success of your program. States Dr. Gelberman, “Most institutions are willing to have a joint strategic planning effort. That effort enables surgeons to be involved in developing a plan that they feel is appropriate for their program. As one goes through the process, one develops targets for research productivity, innovative teaching methods, and clinical achievement. To assess progress towards those goals, one develops the metrics necessary to demonstrate that progress is being made. Those metrics should answer the following questions: Are your clinical programs growing? Is the department producing innovative research; research that is providing answers to significant questions in orthopedics? Are we recruiting and retaining outstanding educators? These are some of the guideposts that keep us on track in reaching our target.”

So bring along your toolbox, orthopedists. It’s time to build.