Message from the Fellows Education Chairmen for DePuy Spine

Message from DePuy Spine Medical Education

• Are you almost done with your spine fellowship or residency program?
• Have you landed a job in a new area of the country?
• Do want to get to know your new DePuy Spine sales representative?
• Do you want to walk into your new practice with the tools you are most familiar with?

Message from DePuy Spine DePuy Spine Management Board

Ask the Expert

DGA: I have been interested in minimally invasive approaches to spinal problems since I began practice. In the last 5 years, I have seen my use of minimally invasive approaches to spinal problems increase. At the current time, most patients with disc herniations, spinal stenosis and spinal instability at 1 or 2 levels are being treated in a minimally invasive fashion. In addition selected cases of spinal trauma, spinal deformity and tumor reconstruction are also approached in a minimally invasive fashion. The biggest difference that I have seen with a minimally invasive approach to these common spinal problems is the quicker mobilization of the patient following surgery and the reduced incidence of wound problems and infections.

As more difficult cases have been tackled in this fashion, we have faced challenges with the existing equipment for MIS cases. Fortunately, the new VIPER 2 system has been designed to address the challenges of these more complex cases.

DGA: Minimally invasive surgery has been very popular with patients because they have no trouble comprehending the connection between a smaller incision with less soft tissue trauma and a quicker recovery. I routinely do lumbar decompressions as an outpatient procedure and most patients undergoing a 1 or 2 level lumbar fusion are able to leave the hospital by the first postoperative day. By the time of their two week visit, most patients are off narcotic medications and able to do light activities. Return to work is variable depending on the nature of their job but is generally much quicker than what I experience when performing the analogous procedure with a traditional approach.

DGA: The most exciting area for me is the use of MIS approaches to treat spinal deformities. As our experience has grown, we are routinely treating degenerative scoliosis with an MIS approach. This represents a major advance over the traditional techniques that were used for this difficult problem. Patients with degenerative scoliosis are typically older and the MIS approach reduces the physiologic stress of surgery making the perioperative experience much more enjoyable for both patients and their surgeon.

DGA: My preference with regards to MIS fusion systems is to use the VIPER system. I have found this system to be reliable and versatile. With the first generation VIPER, we did have some struggles with rod reduction for complex, multi-level cases. With the new VIPER 2 system, this has been markedly improved.

Surgeons Giving Back: Mission Trips

AM: I was presented with an opportunity to give back to society and I have the means to be able to do it. I also look at it as a learning opportunity for myself. I learn from the surgeons there that there are other ways to do things and we teach the surgeons there how to treat spinal deformity. I look at it as a win-win.

I am from Argentina and I am very aware of the conditions that surgeons outside the US are faced with. Lack of medical supplies and hospital conditions are tough. Nicaragua is an impoverished country and the people there are in dire need of medical care. This was my opportunity to help.

AM: The residents welcomed the training. We started working with the orthopedic surgeons who treat spine pathology. Soon after we began training the neurosurgery residents. One resident was selected for each surgery by their attending. The resident is responsible for everything regarding that case. The team reviews the case and the resident then prepares everything for the case. At first the attendings did not want the residents to scrub in for the case but we encouraged the attendings to allow them to. We felt it was the best way for the surgeon to learn. Until we got there, none of the residents or attendings knew how to implant screws. The one major hurdle we have is the language barrier. I speak Spanish so I spend a good deal of time translating from English to Spanish.

Before we got there no surgeon in the country treated spinal deformity. With our help these surgeons are being trained to treat this disease specifically in children.

AM: The hospital lacks the latest in technological advances. Much of the equipment that we work on [in Nicaragua] has been donated, including things such as a Jackson table and a C-Arm. I am coordinating the shipments of the containers with the donations and ensuring they get to the hospitals that need them. I work with the Department of Health in Nicaragua to get this done. You would be amazed at the way some of the big machines and equipment has to be shipped, first by boat and then by truck.

Initially when we got there we didn’t realize that the hospital did not have adequate pain medication for post op patients. Not only do they not have enough pain medication but also the post op rooms were not air-conditioned and the temperature was usually close to 90°.

Since we arrived they have installed air conditioning in the post op rooms. And we now bring all the medication we need with us. That requires us to work with Federal Drug Enforcement Agency to be able to carry this medication out of the country. We are working with the American Red Cross to get medication donations. Currently the medication is not donated.

AM: Welcoming to some degree. They are accustomed to visitors. Many times we will be there and there will be plastic surgeons working in the OR. We just have to remember that this is their home. We are polite and proceed with caution, sometimes it’s politics and sometimes there are egos to deal with. We try to adapt to the conditions, but they are not too bad. They realize that we are here to help. We need their help too. Much of the equipment is older and we are not familiar with how to use it.

AM: As I said, everything is donated. The implants they have are not considered state of the art. There is no national industry for implants and no access to high priced instrumentation. They simply can’t afford it. On the last day we were there we saw a little girl with a severe deformity. Dr. O’Brien told her we would treat her. Our team told Dr. O’Brien that we were out of rods and screws. Dr. O’Brien asked what they had at the hospital. They had only wires and Harrington rods. Dr. O’Brien treated the patient with this instrumentation and she is doing well.

AM: There isn’t just one patient who has touched my life. They all do. They live in a world so different from us. Many of the children are afraid to go to school because of the way they look. They feel like “monsters”. They come into the operating room sad and with no self-esteem. Some of them have even tried to commit suicide. Some of the hospital staff tell us we are “creating models.” After we perform surgery on these little girls they all want to be models! They feel so good about themselves and they gain self-esteem.

AM: I have learned a great deal about working with different people from all over the world. I have learned that you have to be open-minded and willing to try something new, like using less modern instrumentation and achieving the same results. Since my time in Nicaragua I have patients calling me everyday asking for my help.

AM: Yes, Dr. O'Brien has asked that I stay in touch and continue to work with the group.

Practice Nuances

JSP: It’s clear that marketing and advertising are effective. Every corporation practices some form of it, and even peer-reviewed journals accept paid advertisements to support the cost of publication.

Prior to the early 1990’s it was uncommon for individual practitioners or medical groups to advertise or actively contact their potential clients, customers, or patients. Physicians felt that practicing professionally and prudently would be sufficient to guarantee an office full of patients. The notion of marketing or advertising was considered unprofessional.

With the health care financing crunch, third-party payers sought to reduce contracts to providers and pit them against one another in order to reap savings through contract renegotiations. HMO plans dictated where patients could seek specialty care. Practitioners were considered interchangeable as long as care was delivered. Hospitals have also employed surgeons under contract, supporting them under a marketing umbrella frequently to the chagrin of private practitioners.

In the late 1990’s the Internet led to an information explosion, giving patients and referring providers numerous ways of instantly finding solutions to a given health care problem. Previously entrenched referral patterns changed rapidly as patients came to their primary care physicians with specific specialists in mind, and were less likely to accept the status quo. At the same time, payers and Congress had to contend with those same patients demanding more options for specialty care. Preferred Provider Organization (PPO) and similar networks expanded, along with Medical Savings Accounts to allow patients more choice and responsibility in spending their health care dollars.

Specific to spine care, the boundaries between orthopaedic spine surgery and neurosurgical spine surgery also began to blur. Spinal instrumentation and structural deformity was traditionally the forte of the orthopaedic surgeon, while intraspinal pathology and neurologic symptoms attracted the neurosurgeons. As neurosurgeons learned the benefits of spinal stabilization, and orthopaedic surgeons discovered the challenges of operating on back or neck pain in the absence of neurologic symptoms, both groups have learned from each other. The end result has been better care from either specialty for their patients.

Marketing your specialty skills has grown in importance as payers and patients more closely scrutinize their provider options, out of both necessity and ability to do so. Physicians who distinguish themselves as exceptional stand to benefit as patients from a larger catchment basin will seek them out. Conversely, those who insulate themselves risk contracting their patient base to undesirable levels.

JSP: There are three basic populations to whom a physician should market their practice: patients, payers, and other physicians. The size and desired catchment basin of the practice determines how wide a net to cast in an effort to reach these groups. For example, a large Midwestern multi-specialty clinic desires to (and does) attract patients from across the globe, but realizes they also need to retain the local population to maintain viability. They have established geographically based marketing circles. The local circle comprises their surrounding counties and home state. Beyond this exists a group who markets to the greater mid-western states and large cities. The next marketing focus is on the entire United States, and the last group aims to attract international patients. This clinic has dedicated a specific team to approach each region and reaches out to their patients, physicians, and payers, illustrating the reasons for traveling as little as 10 miles or much as 10 time zones to find world class care. This example may be too grandiose for the average practitioner but the lessons still apply.

Specialty physicians have traditionally marketed to referring physicians, especially since many insurance plans require referrals from PCP style generalists to access specialists. For a spine surgeon, this would include family practice, internal medicine, rheumatology, chiropractic, physiatrist, and emergency medicine colleagues. A personal touch is always effective, so visiting their offices to meet face to face will cement your personality and skill set with that individual. Be available to receive phone calls from them and work to see new patients on a timely basis. Supply ample business cards and informational flyers about your practice to make for hassle-free referrals. The hospital should have grand rounds or other educational programs in place that you can use as a forum to present yourself and your specialty knowledge to colleagues. Approach the administration and request to be featured in this venue.

Marketing to patients requires more of a broad-brush approach. The hospital may feature community programs that focus on your specialty and should advertise to attract that community. Newspapers, local magazines, radio, and television all offer mediums for contacting patients, but are very non-specific in who they get to respond. Be prepared to spend a significant amount of money to send your message repeatedly across those avenues. A single advertisement may not make a huge difference but if repeated will eventually strike a familiar chord. Also realize that only about 10% of those individuals responding to such methods will have surgically treatable pathology. Your practice should have a website with links to physician profiles, treated conditions, and directions to the office. More sophisticated sites contain detailed information about diagnoses; downloadable patient encounter forms to be completed before the visit, and occasionally allow email correspondence. If desired, a practice can pay web content providers for advertisements on their sites, or pay search engines to feature their practices more prominently after searches for certain diagnoses.

You may find more results from new patients referred by former patients. In some cases you might approach particularly satisfied patients with common conditions you treated, and obtain permission to have new patients discuss their treatment with them. This is particularly useful for reconstructive procedures such as scoliosis surgery or hip and knee arthroplasty.

JSP: You definitely want to establish how hard you want to work and what groups of patients you do or don’t want to see in your office. A hand surgeon friend of mine joined a suburban orthopaedic group and was eager to market his practice aggressively and work harder than the senior members of the group. They supported this philosophy except that they had a policy of all surgeons working four days per week and splitting income equally. The junior partner was told he could not schedule an extra workday nor would he get paid more if he generated more efficiency or income during the allotted four days per week. This did not sit well with him and he ultimately left the group. Such a problem could also occur if your ancillary staff cannot support additional workload. One needs to realize this type of mismatch before embarking on a vigorous marketing blitz.

Different insurance carriers and payors have various levels of desirability that changes across geographic regions and does not always depend on direct financial compensation. Labor and Industries (Workers Compensation) carriers are the best payors in some markets, but not much better than Medicare in others. Regardless of how well they pay, loads of paperwork accompany these patients for which you may or may not be compensated. Legal work including depositions and court testimony may also be required. Be ready for these aspects if you choose to court these patients or their case managers.

Some regions have a few large employers or carriers who insure much of the population. You will presumably want to care for these groups but be careful of relying too much on the big fish, because that gives them negotiating power during contracting. It’s good to support the smaller players in a market so the larger ones are less able to leverage their size in negotiations.

JSP: As an intern I assisted a plastic surgeon in a pannus excision where he cut out some 30 pounds of excess skin and tissue from a patient who had undergone gastric bypass. I asked him how this came to be a part of his practice and he answered with a question: ‘What do you get when you get good at something? More of it.’ The lesson is to decide in advance where you want to focus your practice, then publicly move in that direction. This surgeon realized that traditional cosmetic surgery was a very competitive market, so he decided to add lesser-known procedures to his practice to help build volume. However, he had to be comfortable doing procedures that were undesirable to most plastic surgeons. Once he developed a reputation for skill and interest in this arena, patients flowed into his office.

This is perhaps the best way to differentiate your practice. Determine what is missing in the marketplace and offer it. That may include “minimally invasive” procedures, adult deformity, pain management and interventional procedures, kypho- or vertebroplasty, and oncology.

You may want to partner with another surgeon or provider from a related spine care specialty to deliver coordinated care. Orthopaedic and neurosurgeons can work together on cases to streamline an operation and patients find this quite desirable when available.

Working with physiatrists or interventional pain specialists can generate referrals and provide outlets for patients who won’t benefit from surgery or who need diagnostic procedures. If potential patients or other referring providers realize this, they will frequently find the coordination desirable. However, one must be careful of associating too closely with related providers because it may alienate their competition and become a double-edged sword. If you are seen as too closely wedded to one referral source, the others may shy away.

Word-of-Mouth, Amplified: Surviving the New World of Online Physician Ratings

6 Steps Physicians Can Take to Improve Ratings

1. Assign staff to browse each of these websites (or browse them yourself if you do not yet have staff) and become familiar with them. Are you listed? Is all of your information correct? If not, correct it.
2. List yourself if you are not listed. Adding yourself to DoctorScorecard is easiest, while FindADoc and Yelp require registration first. If a WellPoint insurance company is one of your payors, ask them about the upcoming ratings system.
3. Make sure you are listed on practice and hospital websites before you begin at the new practice.
4. Challenge your FindADoc rating if you believe it is too low. One of KZA’s client-physicians already improved her rating 15 points by e-mailing contact@findadoc.com, supplying missing information, and arguing for a more favorable assessment of her Training.
5. Promote your listings to your patients, and encourage them to rate you and post comments.
6. Promote your listings to your fellow physicians. FindADoc gives credit for Doctor Endorsements. Identify physicians with whom you are friendly, who refer patients to you, to whom you refer patients, etc., and ask them to rate you on FindADoc.
7. Monitor Regularly. Don’t let an unhappy patient’s comments go unanswered. Another KZA client discovered a negative comment on his Yelp profile, registered as a Yelp user, and contacted the patient (through Yelp) to repair the relationship with her.

Practice Opportunities

• Base Salary plus RVU Productivity Incentive
• Medical & Dental Insurance
• Malpractice insurance
• Life insurance
• CME
• Short & Long Term Disability
• Flexible savings accounts
• Retirement savings options

A Look Ahead – Upcoming Education / Events

2008 Calendar
Date	Meeting	Location	Faculty, if applicable	Web
4/26 - 5/1	2008 AANS Annual Meeting	Chicago, IL
5/1 - 5/4	The Spine Study Group	Palm Beach, FL
5/5 - 5/9	Spine Arthroplasty Society (SAS)	Miami, FL
5/15 - 5/16	*DePuy Spine Deformity Tutorial	San Diego, CA	Peter Newton, MD
5/15 - 5/16	*DePuy Spine Introduction to CHARITE® Artificial Disc Workshop	Raynham, MA	TBD
5/16 - 5/17	AAOS and SRS Present Current Trends and Treatment Methods in Pediatric and Adult Spinal Deformity	Dallas, TX
6/19 - 6/20	*DePuy Spine Advanced Techniques in Minimally Invasive Spine Surgery	Chicago, IL
6/19 - 6/21	Spine Technology Education Group presents the 5th Annual Innovative Techniques in Spine Surgery	Las Cabos, Mexico

Must Read Clinical Articles – Suggestions from the Fellows Education Chairmen

DePuy Spine in the Journals

Spine Case Challenge #4

a) vertebral osteomyelitis and discitis
b) insufficiency fracture
c) multiple myeloma
d) metastatic adenocarcinoma

a) Pseudomonas aeruginosa
b) Propionibacterium acnes
c) Staphylococcus aureus
d) Mycobacterium tuberculosis

a) all cases
b) all but 1% of cases
c) all but 20% of cases
d) only half of all cases

a) rheumatoid arthritis
b) diabetes mellitus
c) advanced age
d) cervical spine infection
e) all of the above

Winners of Spine Case Challenge #3

Next Quarter...

• Ask the Expert – treating Osteoporosis
• Clinical Forum: Laminopasty vs. Laminectomy
• Practice Nuances: Academics vs. Private Practice
• And more………..