Other Articles

Elegance in Spine: Extracavitary Approaches
The delicate task of dealing with spinal problems is getting a bit less complex, says Dr. Francis Shen. Orthopedists can now remove a section of rib and approach the front of the vertebrae from the back in an oblique direction.

Endotec Beats FDA, Strikes Blow for Innovation
Endotec has struck a blow for every orthopedic surgeon who wants to develop a better device. See how the company’s founders took on the FDA and got a federal judge to charge the agency with “stymieing progress and technological advancement.” How did they do it? Read on.

From Obesity to Osteoarthritis, the Carpal Tunnel Connection
It’s certainly no surprise that Carpal Tunnel Syndrome (CTS) is an exceedingly common orthopedic malady. But, as PearlDiver’s data show, the linkage between obesity, osteoarthritis and other conditions to CTS is most surprising. Check it out.

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.

Systematized or random? Fair or unfair? These are some of the issues that arise when taking on the question of compensation in academic medicine. Explains Dr. Sanford Emery, Chair of Orthopaedics at West Virginia University, “Those of us in academics typically don’t spend time on the issue of how we pay ourselves. Compensation tends to be all over the map without any rationale behind it. It ranges from a straight salary with no bonus and no incentives to very formulaic plans that are highly incentivized and based on clinical productivity. Things have evolved because the industry has changed. In the ‘60s and ‘70s most academic groups were on a salary that perhaps included a bonus. They were not concerned about maximizing clinical productivity because they were being reimbursed at a higher level and had extra funds for research, personnel, and resident education. This began to shift in the ‘80s, and by the early ‘90s budgets started to tighten and you had practice plans in academics that started to lose money. Cold, hard reality came calling, and it provided the impetus to work harder and concentrate on clinical productivity.”

It was during his MBA program that Dr. Emery began to ponder these issues…then he decided to gather data and let it do the talking. “My research in this area, published in The Journal of Bone and Joint Surgery in 2006 (88: 2049-2056), grew out of an independent study project during my MBA program. My colleague and I surveyed 31 academic orthopedic programs regarding how they pay their people. We found that almost all programs had bonus systems in place. We specifically wanted to determine if these programs paid faculty for academic productivity, because that is what’s getting squeezed by the time demands for pure clinical work. We postulated that maintaining scholarly output might require compensation strategies which push in that direction. We found that slightly more than half of the programs did pay for academic productivity, and the rest did not. We also set out to learn that if someone was paying an academic bonus, how would they determine what it should be? Half of the programs that did provide a bonus did so by the Chair’s decision. It was rather random, although a few Chairs had criteria. The other half of the programs had a point system, some of which were quite complex and included things such as taking call, papers written, presentations, grants written, visits to the locker room, service on committees, and citizenship. Other point systems were shorter, with the major categories being scholarship, the amount of extra clinical work taken on, and contribution to resident education.”

After developing principles and guidelines, collecting data from all 31 programs, and conducting in-depth interviews with the leaders of eight programs, Dr. Emery and his colleague found seven major themes. “First of all,” notes Dr. Emery, “the importance of the academic mission was taken seriously by all of the programs surveyed. This is not just lip service—people running these programs are very devoted to education and the future of orthopedics. We also learned that clinical revenue is the primary driver of compensation. The revenue we earn by seeing patients and performing surgery is what fuels the success of an academic department, and we must conduct that work alongside our teaching commitments and research productivity. Additionally, it was interesting to find that flexibility is an important part of these systems; if it is too rigid the program will box itself in. This is true, for example, if you have a system where everything you can think of is assigned a point value. To create some wiggle room in their system, most people inserted a category such as ‘citizenship’ so that the Chair could comment on this. Citizenship may involve treating others well, taking extra call when someone is sick, or showing up at committee meetings.”

Additionally, they found that not only did the Chairs do their homework, but they also encouraged others to pull up a chair and participate in the process. Dr. Emery: “The departmental Chairs put a lot of time into thinking about how to pay their faculty. Even if they weren’t using a point system they looked at CVs, met with faculty, and took into consideration what the faculty member had done in the prior year. This is related to the next finding, which is transparency. Most Chairs developed point systems in conjunction with their faculty so that everyone would have buy-in. This is important lest you have individuals later say that such-and-such was too heavily weighted, or that such-and-such incentivizes clinical productivity over research time. We learned that it is important that people know and understand the compensation structure, the point system, and the entirety of how they are paid.”

“Another finding was that fairness is vital to any compensation program. In my paper I quote an article where the researchers found that as a sociological group doctors crave three things, namely: security, self-esteem, and fairness. I strongly believe these points to be true. If you threaten a physician’s security, such as their base income, operating room time, or clinic space, you’re essentially threatening their families. On the issue of fairness, if you compare academics and private practice, you’re paid less in academics because there is more overhead for your department, indigent care, and research expenses. Generally speaking, I think that if people in academics view their compensation as fair they will stay. If, however, they’re working 100% more than non-academic orthopedic surgeons and they’re paid at an average compensation level or less based on benchmarks, that level of compensation will be unacceptable to them. Lastly, we found that issues of culture and leadership come into play. Compensation strategies will vary from department to department and institution to institution based on culture and the type of person at the helm. For instance, one program didn’t have an academic bonus system because they had created a culture of terrific faculty who were highly productive because they were internally motivated. Those people were paid well.”

Assistant/Associate/Adjunct/Full…the caché accorded to certain levels of professorships sometimes goes out the window. Explains Dr. Emery: “I was surprised to learn that academic rank was given very little importance. If I had to guess why I would say it’s because clinical revenue is the primary driver and supersedes the idea of a full professor who can sit back, teach a little, and have a leisurely clinic schedule. In fact no one can cruise because the department loses money. And younger, harder-driving faculty need to be well compensated because they are bringing in cash flow. Some of what we are seeing is sociological, as with the younger generation that is not particularly interested in delayed gratification.”

Dr. Emery’s advice to those structuring faculty compensation? Keep it simple. “It is better to use a few major categories such as grants, teaching, presentations, and the like, as opposed to an exhaustive list that breaks down, say, publications into book chapters and abstracts, and grants into industry, foundation, etc. And as the one with the broadest perspective and most responsibility, the Chair should have some wiggle room because there are intangibles that need to be taken into consideration. Find out what motivates your faculty and let them do it. If they love to operate, let them operate, while, for example, you build a research program with Ph.D.s.”

Commenting on the winds of change, Dr. Emery notes, “We used to throw our hands up and say, ‘We can’t measure this.’ Things have evolved, however, and there are now legitimate ways to get data on the underlying issues that are related to academic productivity and compensation.”