Monday, May 3, 2010

To Be or Not To Be, That is the Question?

Recently, two of our readers responded to a post entitled, "Are These Products Truly Dynamic?" It was evident that one respondent was critical, accusing surgeons of being unethical and criminal in their behavior indicative of the climate that exists in our industry. To generalize is to convict the entire profession. Yet, one can understand our reader's frustrations. In fairness to surgeons, not every surgeon that is involved in a study or development of an emerging technology is on the take. This point counterpoint tete-a-tete is interesting in that some physician respondent's argument was did you go to medical school, residency, or fellowship and do you perform the state of the art? For many of us the answer is simply, NO. But unlike the current business model that exists in our industry, for those of us that are tenured, our experience and mentoring by your own peers has provided us with an intelligent level of knowledge about medicine. And contrary to those beliefs, many of us pride ourselves on the fact that we can have a conversation with a surgeon and provide an intelligent answer, or listen to a presentation on a specific products efficacy and evaluate its usefulness. Unfortunately, many surgeons opinions have been jaded because of the quality and dilution of talent in the industry. With that said, how do surgeons think we view them when it comes to running their own business or attempting to be a business person?

Just like physicians argue about our academic background and training to opine about their professional decisions, those of us in the business have every right to question their integrity
and commitment to their patients well being, as well as their business acumen. Just because you were smart enough to go to med school doesn't qualify you to be a race car driver. Some cannot execute their own state of the art and like to tell us how to run our business. Let's face it, just because you graduated from med school doesn't make you a great surgeon. Even the Major League Baseball has a place for .240 hitters. All one has to do is attend a motion preservation meeting, or, a spine arthroplasty meeting and look around the room as many of your own peers shake their heads in disbelief to some of the procedures that are presented. The difference between us is that we attempt to honestly critique a protocol, whereas your peers dare not question the professor. It is your professions omerta or code of silence. Ever wonder what would compell someone to perform a three or four level total disc arthroplasty? Would you even allow someone to implant some of these systems into your own mother, father, sister, brother or spouse? How cynical can we be when we look at some of the same names that would endorse any piece of shit concept or device. Just because some fool and his money believed in the potential of a financial windfall, doesn't mean that the product will succeed, nor, does it mean that some of these products will find an indication to substantiate its place in a spine surgeons armamentarium. Let's be honest, when an observer looks at the dais, its an old boys club that seeks to perpetuate its own existence within the industry, mentoring younger surgeons on the nuances of how to contribute yet manipulate the industry. These aren't TSB's views, these are the views of your own peers.

So in closing, just like Goldman Sachs, SAS and NASS need an image make-over. Before any surgeon goes on to cry foul when one of our readers expresses their first amendment right, maybe it would behoove you to monitor your own profession before you criticize ours. TSB wants to know what our readers think?


  1. Should the surgeons care what we think? I consider myself lucky to be able to be in this industry, give my two cents, and make a decent living. Thank you to the surgeons who allow me time and time again to contribute.

  2. I think it is beneficial to the system as a whole if we are critical of each others' profession in a professional manner. I wish we were just as critical of peers in our own professions.

  3. By the way, I was the one that wrote in the previous comment (defending surgeons) about medical school, residency, fellowship, etc. and addressing the previous comment's condemnation of surgeons as unethical and criminal. I am not a surgeon. I am in our business. I totally agree with Anon 6:42am post.

  4. It is really pretty simple to understand if one knows ALL of the details. As usual if you follow the money trail you will find the answer. NuVasive encourages surgeons to "interpret" the IOM data (SSEP, TcMEP, Ped screw stim etc...) for each other, and collect on the professional component reimbursement. This is why you find surgeons using the NuVasive monitoring on every spine procedure they do...instrumented or not!

  5. By the way, I am the one who wrote the condemnation of surgeons. Without giving away details, as for now I'd like to preserve my anonimity, I do have the necessary credentials to assess the state of affairs in the area of spine pretty reliably. Maybe I was unjustified in generalizing to the extent I did, but I maintain that a majority of spine surgeons' first concern is how much money they earn, and patients' well-being is second at best. Spine also remains one of the few fields in clinical medicine where exceedingly expensive and often unproven therapies are foisted on patients with diagnoses that still nobody really understands. Will he or she who knows the exact pathopysiological mechanism of 'discogenic back pain' cast the first stone? European data show that there exist non-surgical therapies for this condition that lead to the same, admittedly not very high, long-term success rates as the expensive and sometimes debilitating surgeries.

    And in response to the previous blog, because it illustrates the state of affairs yet from another angle: If one lists the names of Yuan, Hochschuler, Philips, McAfee and Blumenthal one automatically list the names that appear or have appeared as Member of the Board of Directors or Member of the Clinical Advisory Board for a plethora of companies at least 50 times. And we all know a few other names that could be added. FDA now at least is smart enough that they want to know about these connections when they review an IDE, unfortunately so far they do preciously little with that knowledge.

  6. As a follow up to my earlier post regarding the surgeons getting paid for their pseudo-interpretation of the intraoperative neurodiagnostic data. It is really very telling, because you find the most unethical and greedy docs using the NuVasive system just because they can make extra cash (illegally by the way if the surgeons are not trained in the interpretation of the data). I approached the NuVasive heirarchy of sales and marketing at a trade show meeting in Chicago and asked them how they slept at night.....Their response was "Medtronic also does it"

  7. The comment about remote interpretation by surgeon being "Illegal" is false. It would only be a conflict if the interpreting surgeon was the same one performing the surgery.

    There are recommendations from review boards and insurance companies which state that the supervisory component be performed by Neurologists or Phys Med MDs trained in the field, but this does not make it "Illegal" for a surgeon to interpret. Questionable...yes, but not illegal.

    It's as if a family practice physician wants to do surgery, it is not illegal, but not necessarily recommended and likely would not be covered on their Med-Mal policy.

    The comments that were made about greed are inflammatory and to a certain extent discrediting to any comments you make thereafter. It shows you have an ax to grind.

    You make it seem that the greed is ubiqutious on the physician side of the spine community. The reality is, this is a trait that is seen in a percentage of the population in every field, medicine, sales, auto mechanics etc..

    Check yourself, if you had a way to enhance your income and it was not illegal and within your reasonable scope of skills, you would do it and sleep very well at night.

    Nuvasive can sleep at night because it makes business sense to them and allows them to enhance surgeon income on surgical cases where insurance companies are routinely trying to deny or decrease payment for medical services.

    I do not agree with surgeons "supervising" neurodiagnostic data, but that is just an opinion.

  8. The "illegal" part comes in when a surgeon who is not trained in reading neurodiagnostic data, is seeing his or her own patients, not connected via telemedicine remotely, and is billing for a multimodality procedure on a CMS patient. The fact of the matter is not that a surgeon is doing the billing, but that the work being billed for is not being done!!!
    I am pretty sure that fraudulant billing is still illegal....check your local medicare LCD requirements for what is necessary in order to bill for and collect on IOM interpretation if you do not believe me. Most of them require that the data be collected and performed by a trained and credentialed technologist in addition to everything else.
    These surgeons falling for this model better well hope that CMS does not audit their billing. There will be lots of fines and money to pay back to the government as well as the possibility of losing their Medicare number.

    I am all for physicians making money because we all know the reimbusements are down and always shrinking, but this is unethical at the very least. What happens when a patient suffers a bad outcome and the surgeon has to justify his monitoring choices?? I would much rather be a prosecuting attorney on that case because it would be indefensible.

  9. Once again, I do not agree with this model.

    But as long as they can document that they were in possession of their remote hand held device for real-time supervision, it is not illegal.

    I am very aware of the CMS requirements regarding IONM.

    Anyone doing the remote this way would clearly want to steer clear of billing Medicare. Otherwise they would open themselves up to having to prove that they were monitoring 31minutes out of every one hour billed and that "remote supervision" was their sole purpose during that time.

    P.S - You seem like a douchebag