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Christopher M. Bono, MD.

AAOS Now

Published 6/1/2016
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Eeric Truumees, MD

A Spine Surgeon's Perspective

Recently, I interviewed the 2015–2016 president of the North American Spine Society (NASS), Dr. Bono is associate professor of orthopaedic surgery at Harvard Medical School and chief of orthopaedic spine surgery at the Brigham and Women's Hospital in Boston.

As a spine surgeon myself, I was curious about his perspective on several issues facing orthopaedics. We began by discussing his background.

Dr. Bono: I was raised in Brooklyn and Staten Island. My mother was a first-generation immigrant. She came over from Sicily in the 1950s.

Education was very important to my family. It was my parents' dream that I become a doctor, and I am the only doctor in the family. My career has gone beyond anything I could have expected or anything they could have imagined.

Dr. Truumees: Given the changes in the healthcare climate, would you recommend your children go into medicine?

Dr. Bono: I wouldn't dissuade them. I was admitted into a 7-year combined undergraduate-medical program at Brooklyn College and the State University of New York (SUNY) Downstate Medical Center. Even then, we were hearing about all of the changes coming. Our professors were saying that medicine is going to change and reimbursements will fall.

From 1988—when I was accepted into medical school—to 2002—when I went into practice—there was a huge difference. Since then, there have been even more huge changes.

But would it have changed my decision to go into medicine or orthopaedic surgery? No, because I love what I do every day. Would it influence my decisions about going into private practice versus academics? Probably not. But I wouldn't push my kids into medicine. If they were interested in medicine, I would warn them that what they see today is not what they are going to see when they finally get into practice. It's going to be completely different. So, you have to love actually taking care of patients more than anything else.

Dr. Truumees: Can you tell our readers who are not spine specialists how NASS fits into the group of other spine organizations?

Dr. Bono: NASS is the largest of the spine societies, and it is multidisciplinary. NASS has members from all of the specialties that take care of the spine. Most of the other spine societies are predominantly surgical. Others, like the International Society for Study of the Lumbar Spine (ISSLS), have a strong research focus. NASS is the one spine organization that fulfills multiple roles—including research, advocacy, and health policy. To my knowledge, no other spine organization in the world provides that breadth of scope.

Dr. Truumees: What do you see as the greatest challenge to orthopaedic surgeons over the next few years? What are your goals for your presidency?

Dr. Bono: The greatest challenge continues to be navigating the insurance system. I spent a good bit of the last 2 years developing a Coverage Committee under our Health Policy Council. That committee develops credible and reasonable coverage recommendations for spine care by proactively reviewing and incorporating existing NASS policy comments and evidence-based medicine guidelines to educate physicians and payers on fair coverage decisions.

But I realize that work may have an expiration date. Under bundled payment systems or accountable care organizations, no one is going to care what the coverage recommendations are because providers will receive a lump sum of money for the care of a particular disorder, regardless of the type of treatment.

During my presidential year, I'd like to get NASS up and running in developing care pathways. Many centers, like the Geisinger Health System, have already developed care pathways, but others are just starting to draw up their own. Some are even paying for third-party care pathways. If NASS could offer multidisciplinary, evidence-based care pathways, they would be a powerful tool for NASS members.

Dr. Truumees: Preauthorization is becoming more of an issue in the world of total joint arthroplasty, although it has long been required for spine surgery. Do you have any pearls or words of wisdom to share with our total joint colleagues?

Dr. Bono: We all face challenges, although spine is more complex due to the different variables, and spine care is also variable. Patients with similar diagnoses and profiles could be treated 50 different ways, with a wide range of costs.

Spine surgeons can learn from total joint specialists about streamlining care. One of my colleagues at Brigham and Women's Hospital, John Wright, MD, was working with [Harvard Business School professor and healthcare economist] Michael Porter on a detailed analysis of the costs involved in performing a knee replacement. Even though the surgery is simpler than spine surgery, it was still enormously complex. But the technology available today, such as electronic medical records, will help this process.

Dr. Truumees: Another controversy surrounds volume of care. In 2016, should general orthopaedic surgeons be doing spine surgery? Should there be limits on the types of procedures performed by low-volume, spine-trained physicians? Should general orthopaedic surgeons be credentialed to do spine surgery?

Dr. Bono: I've faced this question with residents who want to do more than just spine surgery. They want to know whether they need a fellowship or should do two fellowships.

A surgeon who has had a high volume of spine training in residency—and some orthopaedic centers in the United States have this—can probably do simple spine cases in practice [without a fellowship]. But that probably should not be universal. I'd like to see that reserved for underserved areas. In those areas, it's fantastic if a full-service orthopaedic surgeon can offer a good laminectomy and decompression, a one-level lumbar fusion, and straightforward cervical procedures. But that individual is probably not going to be doing complex deformity and revision spine surgery.

Dr. Truumees: Do you think spine surgery will ever exist on its own—outside of orthopaedics and neurology—as a specialty?

Dr. Bono: I think there are tremendous political challenges to that. In the current situation, you could put full-time orthopaedic spine surgeons and neurosurgeons side by side, and you would not be able to distinguish one from the other. In my institution, orthopaedists and neurosurgeons share spine call and patient care. It would be an easy transition in terms of the practicality of delivering care.

But, the politics—in terms of taking spine away from neurosurgery and away from orthopaedic surgery—would be the biggest challenge.

I think all spine surgeons would welcome the balance of training because orthopaedic surgeons focused on spine could benefit from parts of the neurosurgical training and vice versa. A dedicated spinal surgery training program may be 10 to 15 years down the road. But, we'd have to demonstrate that it provides superior training and better spine surgeons.

Dr. Truumees: A hot topic for other orthopaedic specialists is scope of practice. Orthopaedic spine surgeons have been sharing spine care with neurosurgeons for a long time.

Dr. Bono: Scope of practice is a local issue. It comes down to hospital privileges and credentialing to do specific procedures.

Recently, my hospital tackled the minimally invasive lumbar decompression (MILD) procedure, which is a percutaneous resection of the ligamentum flavum. I sat at the table and my anesthesia pain colleagues wanted to know why I resisted their billing this as a laminectomy. As procedures evolve, those lines might be blurred. I appreciated that we were able come to an arrangement at the hospital level rather than at the society level. Local environments may be very different.

Dr. Truumees: Do you perform laser spine surgery? If not, what do you tell patients when they ask for it?

Dr. Bono: I do not perform laser surgery. I tell patients that use of a laser to remove or alter tissue is a component of a procedure—not a procedure in itself. The operative reports from those who call themselves laser spine surgeons show that these are minimally invasive procedures in which use of the laser is one small part.

Dr. Truumees: Overall, how would you like your presidential year to be remembered in future years?

Dr. Bono: As I sought to accomplish from day one, I would most like my year to be remembered for the period in which NASS became a unifying body among practicing spine surgeons and practitioners worldwide, related professional medical organizations, industry partners, and governmental and private insurance stakeholders.

If this year were remembered as the culmination of these efforts with benefits to still be realized, I'd feel that I accomplished something worthwhile.

For more information about NASS, visit www.spine.org

Eeric Truumees, MD, is editor-in-chief of AAOS Now. He can be reached at etruumees@gmail.com