The issues spine surgeons are advocating for outside of the operating room


Many spine surgeons do work to push for awareness and advocacy for their colleagues and patients. Ten spine surgeons told Becker's about the issues that matter to them.

Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. Becker's invites all spine surgeon and specialist responses.

Next week's question: What's something you wish non-spine surgeon colleagues in healthcare understood about your job?

Please send responses to Carly Behm at by 5 p.m. CST Wednesday, March 8.

Editor's note: Responses were lightly edited for clarity and length.

Question: What areas of advocacy are you involved with for surgeon and patient concerns? Are there any issues you wish more spine surgeons would engage with?

Brian Fiani, DO. Mendelson Kornblum Orthopedic & Spine Specialists (Livonia, Mich.): An issue that I am a strong advocate for and that I wish more spine surgeons would engage with is the total and complete lack of adequate and fair compensation for in-training physicians, particularly referring to residents and fellows. Residents and fellows are famously underpaid, especially when calculating the labor force it provides. Specifically when referring to how much a resident is "worth," there are hard facts and evidence that support a resident or fellow "worth" to be in excess of $300,000 annually. 

My favorite paper on this topic was published in the Journal of Neurosurgery in 2020 by William E. Gordon et al., from the University of Tennessee. The results found that "using the assistant surgeon billing rate for directly supervised activities and the Medical Group Management Association nationwide median neurosurgery reimbursement rate, the on-call activities of a single resident generated a theoretical billing value of $689,514 over the two-year period, or $344,757 annually. As a program, the on-call residents collectively produced 39,550 wRVUs over the study period, or 19,775 wRVUs annually, which equates to potential reimbursements of $1,668,386 annually." 

So explain to me why residents and fellows work 80 (loggable) hours per week, generate large work-related revenue through their duties and services, and are only being paid $50,000 to $100,000 before taxes, which certainly does not afford the cost of living, especially in regions of this country such as New York City or San Francisco. The above calculation for "worth" does not even factor in the roughly $100,000 to $200,000 per resident/fellow that the government directly gives to the hospital from Medicare to fund that one resident/fellow's training. I strongly suggest that this unsettling and gross misalignment of funds plays a harmful role in terms of resident/fellow satisfaction and wellness.

Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: I have been involved in advocacy for over eight years both in local, state and federal arenas. It became a matter of avoiding burnout to get involved. After getting tired of watching missteps by the federal government in doing anything to actually achieve a better and safer system, I felt the need to work on legislation and speak directly to members of Congress and assembly members.  

I am currently involved in two different political action committees that have mostly aligned goals. My job is to make sure that I am doing everything I can, in every space I can, to push back against the false narrative of the bad doctor that the insurance companies have been so good at pushing. One of the most satisfying things is to talk to educate my fellow physicians on how they can win back their efficacy and push back. We all too can learn how to build relationships with our representatives and senators and tell them our story, about how insurers and large for-profit healthcare entities and the corporate practice of medicine have made doing our jobs even harder.

Getting involved with our speciality and state societies is absolutely crucial to effect policy. But throwing up your hands, and demonizing the other political party and lumping and splitting is exactly why up to now we have lost and will continue to lose. We must be political opportunists and realize the survival of medicine is not a political battle, but one of principle. At the end of the day, we are the only ones that give a hoot about our patients.

Adam Kanter, MD. Pickup Family Neurosciences Institute at Hoag (Orange, Calif.): As current chair of the American Association of Neurological Surgeons/Congress of Neurological Surgeons section on disorders of the spine and peripheral nerves, it has been my pleasure to work alongside our Washington spine advocacy team in our appeal to CMS to maintain the valuation of lumbar interbody fusion and concurrent decompression codes. As appraisal for surgical services are continuously cut and bundled, it has required greater and greater time, data and effort to protect our surgical skills and labors. We must continue to support these efforts to ensure that our services remain accessible and patients receive proper reimbursement from insurers.   

Additional advocacy efforts we must support involve the creation and updating of clinical guidelines for evidence-based practices. I have now participated in both academic and community practice and remain discontent by the disparity in care across providers in both realms. We must work together to advocate for evidence-based care algorithms and pathways to provide patients with a minimum standard level of care regardless of institutional or provider biases or incentives. 

Jason Liauw, MD. Hoag Orthopedic Institute (Laguna Hills, Calif.): I think artificial discs are becoming more popular as patients seek alternatives to fusion, yet they have not been fully embraced by all spine surgeons. On the West Coast, I think there are more surgeons offering these advanced technologies as the patient population is highly educated. However, a lot of traditional surgical teaching programs have not been exposed to these newer technologies, which has hindered their adoption. I believe spine surgeons should engage in more education and peer discussion regarding artificial disc technologies that are only getting better and better. I think there also should be more advocacy by spine surgeons for artificial disc adoption by insurance companies, as many commercial insurance companies still deny patients artificial discs claiming that they are experimental technologies when in truth, they have been around for over a decade and are not necessarily "experimental" anymore. Essentially, newer technologies that allow more mobility and have the promise of preventing additional surgeries should be advocated for by spine surgeons as they will only continue to improve. 

Luke Macyszyn, MD. DISC Sports & Spine Center (Newport Beach, Calif.): I wish that spine surgeons in general would engage with patients, health systems, payers and societies at a much larger scale regarding the importance and priority that conservative, nonsurgical care should play in our decision-making when treating patients with spinal ailments. There are certain conditions, such as acute unstable fractures or compressive tumors, where surgery will always be the mainstay treatment. However, a large majority of patients' symptomatic complaints should first and foremost be addressed with a comprehensive and conservative program, as opposed to surgical intervention. 

Ali Mesiwala, MD. DISC Sports & Spine Center (Newport Beach, Calif.): My focus in terms of surgeon and physician advocacy has generally involved establishing coverage policies for a variety of procedures and expanding coverage for patients regarding new technology. Whether it is supplying data to change an insurance company's perspective or participating in studies to establish new CPT codes, my primary focus has been on clinical endeavors. I make financial contributions to the various political action committees that our societies are involved with, but I'm not involved directly on the ground.

Emeka Nwodim, MD. The Centers for Advanced Orthopaedics (Bethesda, Md.): I have been involved with the corporate compliance committee here at the Centers for Advanced Orthopaedics as the physician liaison and a new member of our corporate human resources committee. Both committees aim to establish practices and policies for patient and staff advocacy.

I hope and encourage all spine surgeons to prioritize and improve their patient communication skills. We surgeons must all do a better job communicating with patients in language that they understand. I believe and have experienced superior patient outcomes when patients understand their condition and treatment.

Edward Perry, MD. Swift Institute (Reno, Nev.): As the chief of neurosurgery at our region's largest hospital and trauma center, I have many opportunities to advocate for fellow surgeons and patients. We have advanced value initiatives to improve spinal surgery costs, reduce the length of stay with minimally invasive surgical techniques, and improve patient awareness and education through myriad pathways. We have a robust quality control reporting system to ensure patient care stays on the cutting edge of technique and compassion. I do wish spine surgeons would become more involved in helping to form collegial but rigid guidelines in the community to support pain management and pain anesthesia practitioners in making good choices about new implant technologies to help patients avoid getting inappropriate or questionable procedures. I believe this needs to be led by the physicians with the ultimate responsibility to care for those complications — well-trained spine surgeons. 

Vijay Yanamadala, MD. Hartford (Conn.) HealthCare: Our first and foremost priority as surgeons is the welfare of our patients. Advocating for our patients is always front and center of what we do. Advocating for our patients means ensuring that they get the right care, whether it is surgery or some other type of treatment. It is also ensuring that they get fair and equitable care every step of the way, in our clinics, in the hospitals and at home. 

As surgeons, we also have a responsibility to each other. How do we continue to advocate for fair pay, malpractice reform in a system that is truly broken, and a voice at the table when it comes to healthcare reform? As we advocate for our patients, we must also advocate for ourselves in a united manner, which will make our field sustainable for everyone.

Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): Many times, during my career, has the opportunity for judiciousness replaced impulse for unnecessary and emotionally laden encounters. Basis of civic position rarely wavered, yet I find myself questioning and enervating over simple governmental responsibilities that have been clearly shunned of recent: the fitness and safety of healthcare delivery and the patients meant to be served. 

Separating medicine and politics is as likely as church and state, considering the constitutional provenance on religious freedom, advocating for the populace's well-being and safety should be top of somebody's list. Healthcare delivery to our citizenry has become a cultural annoyance  and any discussion about its past or current state is deemed awkward and soon forgotten. 

What was recently divulged this past weekend as to the origins of the most impactful public health crisis in modern history and its not from over-reverberation should be addressed if not clarified. The entirety of healthcare delivery and its economic fitness has been negatively affected, especially now with most either avoiding care or postponing medical vigilance because of a new system encountered. Advocacy by all physicians for the patients we serve, and the workers we rely upon, should resound more loudly than in the past. Answers and solutions.

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