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This is Chanel Banger with the Becker's 17 00:00:37,700 --> 00:00:40,020 Healthcare podcast, and I'm recording live at the 18 00:00:40,020 --> 00:00:43,380 21st annual Spine Orthopedic and Pain Management Driven 19 00:00:43,380 --> 00:00:43,880 ASC 20 00:00:44,454 --> 00:00:47,034 and the Future of Spine Conference in Chicago. 21 00:00:47,414 --> 00:00:50,134 And sitting down with doctor Alan Greenwald, an 22 00:00:50,134 --> 00:00:53,079 orthopedic surgeon at Astrea Health. Doctor Greenwald, thank 23 00:00:53,079 --> 00:00:54,840 you so much for joining me today. Thank 24 00:00:54,840 --> 00:00:57,000 you. It's my pleasure to be here. Perfect. 25 00:00:57,000 --> 00:00:58,440 Well, to get us started, could you please 26 00:00:58,440 --> 00:00:59,880 tell us a bit about your background and 27 00:00:59,880 --> 00:01:00,380 organization? 28 00:01:01,365 --> 00:01:04,965 Yes. I've been in orthopedic surgery for almost 29 00:01:04,965 --> 00:01:07,284 50 years now. I trained in San Francisco 30 00:01:07,284 --> 00:01:09,224 and spent a career working there, 31 00:01:09,659 --> 00:01:11,680 and I've been working in rural Washington 32 00:01:12,540 --> 00:01:13,040 since 33 00:01:14,379 --> 00:01:14,879 2005. 34 00:01:15,980 --> 00:01:18,984 I've done general orthopedics in my lifetime in 35 00:01:18,984 --> 00:01:20,364 my orthopedic career 36 00:01:20,744 --> 00:01:22,204 and fixed a lot of, 37 00:01:22,905 --> 00:01:23,405 fractures 38 00:01:23,864 --> 00:01:24,364 that 39 00:01:25,760 --> 00:01:28,659 we would call fragility fractures related to osteoporosis. 40 00:01:29,200 --> 00:01:29,700 And 41 00:01:31,759 --> 00:01:34,239 I have decided that it's important for me 42 00:01:34,239 --> 00:01:36,605 to take on the responsibility to treat those 43 00:01:36,605 --> 00:01:38,844 fractures and the cause of them in in 44 00:01:38,844 --> 00:01:40,625 addition to just fixing them. 45 00:01:41,084 --> 00:01:41,584 So 46 00:01:41,885 --> 00:01:44,045 it's like a 12 step program for orthopedic 47 00:01:44,045 --> 00:01:44,545 surgeons. 48 00:01:45,390 --> 00:01:47,709 Most of the most of my career, we've, 49 00:01:48,270 --> 00:01:50,349 been advised to tell patients to go back 50 00:01:50,349 --> 00:01:51,810 and see their family doctor 51 00:01:52,189 --> 00:01:54,495 and have a workup for osteoporosis 52 00:01:54,875 --> 00:01:57,534 and get treatment, and that rarely, rarely happens. 53 00:01:57,995 --> 00:01:58,495 So 54 00:01:58,954 --> 00:02:01,840 some years ago, the orthopedic community, 55 00:02:02,459 --> 00:02:04,959 specifically the American Orthopedic Association, 56 00:02:05,659 --> 00:02:08,159 has focused on setting up 57 00:02:08,594 --> 00:02:11,974 clinics that are designed to help capture fragility 58 00:02:12,034 --> 00:02:14,674 fracture patients and get them seen and treated 59 00:02:14,674 --> 00:02:15,174 properly. 60 00:02:15,669 --> 00:02:18,069 So that's a pivot that I'm making now 61 00:02:18,069 --> 00:02:18,889 in my career. 62 00:02:19,349 --> 00:02:19,849 I, 63 00:02:20,550 --> 00:02:21,289 plan to 64 00:02:21,590 --> 00:02:24,205 transition to doing that full time. Instead of 65 00:02:24,205 --> 00:02:27,084 doing surgery, I'm gonna try to make people's 66 00:02:27,084 --> 00:02:27,985 bones healthier. 67 00:02:28,764 --> 00:02:30,685 Exciting new ventures. Well, thank you so much 68 00:02:30,685 --> 00:02:31,664 for that introduction. 69 00:02:32,120 --> 00:02:33,180 Now moving forward, 70 00:02:33,479 --> 00:02:35,319 how have you built trust among your patients 71 00:02:35,319 --> 00:02:36,780 and community as a physician? 72 00:02:37,719 --> 00:02:38,620 Well, in medicine, 73 00:02:39,245 --> 00:02:40,064 that's actually 74 00:02:40,444 --> 00:02:43,025 not a hard thing to do. Most people 75 00:02:43,564 --> 00:02:45,985 don't have a medical education and background. 76 00:02:46,525 --> 00:02:47,825 And when they seek 77 00:02:48,330 --> 00:02:51,229 care from an a physician, especially an orthopedic 78 00:02:51,289 --> 00:02:51,789 physician, 79 00:02:52,330 --> 00:02:55,289 they go in with a preconceived notion that 80 00:02:55,289 --> 00:02:57,894 they're going to be well treated and respected 81 00:02:58,435 --> 00:03:01,155 and that they're gonna get good care. And 82 00:03:01,155 --> 00:03:02,375 so it's almost 83 00:03:04,169 --> 00:03:05,769 it it it almost doesn't need to be 84 00:03:05,769 --> 00:03:06,269 sold. 85 00:03:07,049 --> 00:03:08,989 Your job is to do a good job 86 00:03:09,049 --> 00:03:11,284 and not screw it up. And I think 87 00:03:11,284 --> 00:03:12,985 that's where people get disenfranchised 88 00:03:13,365 --> 00:03:14,745 with their health care providers 89 00:03:15,125 --> 00:03:16,824 when things don't go well, 90 00:03:17,125 --> 00:03:18,965 and then you lose the trust. But I 91 00:03:18,965 --> 00:03:19,465 think 92 00:03:20,129 --> 00:03:23,009 most people come into the arena of being 93 00:03:23,009 --> 00:03:25,009 seen and treated by an orthopedic surgeon with 94 00:03:25,009 --> 00:03:27,189 a sense of trust already preconceived. 95 00:03:27,650 --> 00:03:28,770 So it's actually 96 00:03:29,555 --> 00:03:30,775 it's it's easy. 97 00:03:31,474 --> 00:03:32,935 You just have to be professional 98 00:03:33,474 --> 00:03:34,294 and caring 99 00:03:34,754 --> 00:03:36,835 and do a good job and not lose 100 00:03:36,835 --> 00:03:37,495 the trust. 101 00:03:38,419 --> 00:03:38,919 Absolutely. 102 00:03:39,859 --> 00:03:42,340 And moving forward, how can the spine and 103 00:03:42,340 --> 00:03:45,400 orthopedic community better recognize and address osteoporosis 104 00:03:45,699 --> 00:03:48,074 in patients? So first of all, let's define 105 00:03:48,074 --> 00:03:48,574 osteoporosis. 106 00:03:48,955 --> 00:03:49,935 It's a it's 107 00:03:50,314 --> 00:03:53,194 a disease of aging bone where there's a 108 00:03:53,194 --> 00:03:56,254 a loss of bone structure and bone mass. 109 00:03:56,430 --> 00:03:58,909 So the quality of the bone deteriorates with 110 00:03:58,909 --> 00:03:59,409 age. 111 00:04:00,110 --> 00:04:01,150 It's just like, 112 00:04:03,310 --> 00:04:04,530 imagine a weightlifter 113 00:04:04,830 --> 00:04:06,824 who is like Arnold Schwarzenegger. 114 00:04:07,205 --> 00:04:07,705 He 115 00:04:08,165 --> 00:04:08,645 spent, 116 00:04:09,125 --> 00:04:11,525 many of years of his life building muscles 117 00:04:11,525 --> 00:04:12,025 and 118 00:04:12,645 --> 00:04:15,629 and establishing his great physique. But as he 119 00:04:15,629 --> 00:04:16,449 got older, 120 00:04:17,149 --> 00:04:19,310 it would be harder and harder for somebody 121 00:04:19,310 --> 00:04:21,550 like that to maintain that physique. It just 122 00:04:21,550 --> 00:04:24,689 doesn't it just doesn't happen. The body deteriorates, 123 00:04:25,365 --> 00:04:28,404 and bone in and soft tissues deteriorate. And 124 00:04:28,404 --> 00:04:30,725 we are familiar with osteoporosis, which is a 125 00:04:30,725 --> 00:04:32,105 disease of bone. We know 126 00:04:32,470 --> 00:04:34,470 we have had a grandmother that's fallen down 127 00:04:34,470 --> 00:04:36,490 and broken a hip. We we understand 128 00:04:37,030 --> 00:04:37,850 bone fragility. 129 00:04:38,470 --> 00:04:41,290 What we don't appreciate is that it starts 130 00:04:42,944 --> 00:04:45,504 in earlier ages. And by the time it 131 00:04:45,504 --> 00:04:48,625 manifests itself as a fragility fracture, it's almost 132 00:04:48,625 --> 00:04:49,844 too late to treat. 133 00:04:50,439 --> 00:04:51,100 So my 134 00:04:51,879 --> 00:04:52,379 interest, 135 00:04:52,680 --> 00:04:54,680 as I said before, is I feel like 136 00:04:54,680 --> 00:04:54,920 a, 137 00:04:55,800 --> 00:04:57,960 it's like a 12 step program. You know, 138 00:04:57,960 --> 00:05:00,375 someone who who decides that they've, 139 00:05:01,074 --> 00:05:02,774 decided that they're going to 140 00:05:04,435 --> 00:05:05,254 seek out 141 00:05:05,714 --> 00:05:06,615 help to 142 00:05:07,159 --> 00:05:09,319 fix a a problem they've had all their 143 00:05:09,319 --> 00:05:09,819 lives. 144 00:05:10,360 --> 00:05:13,259 I think orthopedic surgeons have failed to appreciate 145 00:05:13,319 --> 00:05:16,139 the need to recognize and treat osteoporosis 146 00:05:17,225 --> 00:05:19,165 early on and prevent fractures. 147 00:05:19,625 --> 00:05:20,685 So, for example, 148 00:05:21,545 --> 00:05:24,185 a woman falls down at age 55 and 149 00:05:24,185 --> 00:05:25,245 breaks her wrist. 150 00:05:26,029 --> 00:05:29,310 The wrist gets fixed, sometimes surgically, sometimes just 151 00:05:29,310 --> 00:05:32,270 a cast, but that patient rarely goes on 152 00:05:32,270 --> 00:05:33,009 to having 153 00:05:33,774 --> 00:05:35,854 treatment for the underlying disease that caused a 154 00:05:35,854 --> 00:05:38,014 fracture in the first place. And 5 to 155 00:05:38,014 --> 00:05:39,935 10 years later, they fall down and break 156 00:05:39,935 --> 00:05:42,629 a hip. 40% of patients die after a 157 00:05:42,629 --> 00:05:46,069 broken hip. If you don't start osteoporosis treatment 158 00:05:46,069 --> 00:05:48,470 after that hip fracture, within 2 years, they're 159 00:05:48,470 --> 00:05:50,389 probably gonna break the other side, and then 160 00:05:50,389 --> 00:05:53,414 they'll die. So it's a lethal disease. It's 161 00:05:53,414 --> 00:05:56,875 painless until something bad happens, a vertebral fracture, 162 00:05:57,014 --> 00:05:57,914 spine fracture, 163 00:05:59,449 --> 00:06:01,709 a wrist fracture, a humorous fracture, 164 00:06:02,410 --> 00:06:04,910 an ankle fracture, even sometimes simple 165 00:06:05,449 --> 00:06:08,329 finger and toe fractures can be attributed to 166 00:06:08,329 --> 00:06:08,829 fragility. 167 00:06:09,444 --> 00:06:12,644 And most people, even patients, don't wanna acknowledge 168 00:06:12,644 --> 00:06:14,245 that that's the cause of it. Oh, I 169 00:06:14,245 --> 00:06:16,324 fell down. It was a very big wind 170 00:06:16,324 --> 00:06:17,544 that blew me over. 171 00:06:18,324 --> 00:06:18,824 But 172 00:06:20,149 --> 00:06:22,149 the the cause is the bone is the 173 00:06:22,149 --> 00:06:24,250 underlying bone structure is compromised. 174 00:06:24,949 --> 00:06:25,449 So 175 00:06:25,990 --> 00:06:28,504 most of the time, patients fall down, break 176 00:06:28,504 --> 00:06:30,745 something, do not get treated for the actual 177 00:06:30,745 --> 00:06:33,944 cause of that disease. So I feel like 178 00:06:33,944 --> 00:06:34,685 it's important 179 00:06:35,250 --> 00:06:37,189 for orthopedic surgeons to take responsibility 180 00:06:39,170 --> 00:06:40,389 to get that patient 181 00:06:41,569 --> 00:06:43,910 treated and prevent future fractures. 182 00:06:44,314 --> 00:06:44,814 Ultimately, 183 00:06:45,355 --> 00:06:47,134 the goal would also be to 184 00:06:48,235 --> 00:06:48,735 have, 185 00:06:50,154 --> 00:06:51,134 especially women, 186 00:06:51,850 --> 00:06:53,949 treated or evaluated for osteoporosis 187 00:06:54,490 --> 00:06:56,670 well before their bone is that weak. 188 00:06:57,129 --> 00:07:00,350 Another side of this is in elective surgery. 189 00:07:01,154 --> 00:07:02,055 Orthopedic surgeons 190 00:07:02,675 --> 00:07:03,415 in general 191 00:07:03,955 --> 00:07:07,495 are concerned about risk factors for spine surgery 192 00:07:07,555 --> 00:07:08,455 and for 193 00:07:09,060 --> 00:07:12,019 joint replacements. They want good outcomes. And in 194 00:07:12,019 --> 00:07:13,779 order to do that, they'll make sure the 195 00:07:13,779 --> 00:07:14,759 patients are 196 00:07:15,060 --> 00:07:17,834 evaluated for their diabetes, for example. And if 197 00:07:17,834 --> 00:07:19,694 their diabetes is not in good control, 198 00:07:20,074 --> 00:07:21,535 the surgery would be delayed. 199 00:07:22,074 --> 00:07:24,095 If they're a smoker, if they're overweight, 200 00:07:24,779 --> 00:07:27,039 if they have bad teeth, a bad dentition, 201 00:07:27,100 --> 00:07:29,339 or high risk of infection, if they're a 202 00:07:29,339 --> 00:07:30,879 carrier for staph aureaus 203 00:07:31,500 --> 00:07:34,044 at and also more risk of developing a 204 00:07:34,044 --> 00:07:34,544 postsurgical 205 00:07:34,845 --> 00:07:38,125 infection. We screen for all these things, but 206 00:07:38,125 --> 00:07:41,264 very rarely do surgeon screen for bone health. 207 00:07:41,600 --> 00:07:42,740 And that's another 208 00:07:43,759 --> 00:07:45,860 focus that I have, which is to help 209 00:07:46,480 --> 00:07:49,699 orthopedic surgeons that deal with hard tissues like 210 00:07:50,055 --> 00:07:51,435 spine and joint replacements 211 00:07:51,974 --> 00:07:54,694 to be aware of the patient's underlying bone 212 00:07:54,694 --> 00:07:55,194 health 213 00:07:55,495 --> 00:07:58,555 and acknowledge if it's not good to 214 00:07:58,870 --> 00:08:01,509 treat it before doing surgery to have better 215 00:08:01,509 --> 00:08:02,009 outcomes. 216 00:08:02,550 --> 00:08:04,069 If you look at the data in the 217 00:08:04,069 --> 00:08:05,930 spine world, you'll see 218 00:08:06,264 --> 00:08:08,685 that there's a lot of data looking at 219 00:08:08,745 --> 00:08:11,384 poor outcomes for patients who have osteoporosis that 220 00:08:11,384 --> 00:08:12,285 are being treated, 221 00:08:12,985 --> 00:08:15,085 with surgery. They develop 222 00:08:15,550 --> 00:08:17,550 fractures adjacent to the, 223 00:08:18,029 --> 00:08:20,689 instrumented level. They have hardware failure. 224 00:08:21,709 --> 00:08:23,970 Patients have subsidence of their 225 00:08:24,495 --> 00:08:27,714 implants, their cages and screws, screws break out, 226 00:08:28,415 --> 00:08:29,634 rods come apart. 227 00:08:30,014 --> 00:08:31,899 There's a higher infection rate. So when you 228 00:08:31,899 --> 00:08:34,879 don't acknowledge that patient's underlying bone health 229 00:08:35,580 --> 00:08:37,340 and you miss the boat, you have a 230 00:08:37,340 --> 00:08:40,320 higher risk of infection and failure and fracture. 231 00:08:40,545 --> 00:08:42,625 Same thing with with joint placements. If you're 232 00:08:42,625 --> 00:08:43,125 not 233 00:08:43,585 --> 00:08:47,504 cognizant of that patient's underlying bone health, you 234 00:08:47,504 --> 00:08:50,129 could use the wrong implant. You could, 235 00:08:50,850 --> 00:08:51,669 make a mistake 236 00:08:52,049 --> 00:08:53,970 and end up with a a patient that's 237 00:08:53,970 --> 00:08:55,730 unhappy and has a bad result from the 238 00:08:55,730 --> 00:08:56,230 surgery. 239 00:08:56,529 --> 00:08:59,524 So I'm trying to get physicians to focus 240 00:08:59,904 --> 00:09:00,404 on 241 00:09:01,024 --> 00:09:03,745 looking at least looking and assessing a patient's 242 00:09:03,745 --> 00:09:05,845 bone health as a risk factor 243 00:09:06,389 --> 00:09:08,730 just like they would smoking and diabetes 244 00:09:09,149 --> 00:09:09,649 and, 245 00:09:10,470 --> 00:09:10,970 dental 246 00:09:11,509 --> 00:09:13,830 infections and so on. So that's that's another 247 00:09:13,830 --> 00:09:16,090 focus of mine. Absolutely. And 248 00:09:16,534 --> 00:09:17,834 what age would you recommend 249 00:09:18,214 --> 00:09:20,534 patients get screened for bone health so they 250 00:09:20,534 --> 00:09:21,034 don't 251 00:09:21,654 --> 00:09:22,714 That's a great question. 252 00:09:24,500 --> 00:09:26,200 The short answer is 253 00:09:26,899 --> 00:09:28,200 women over 65, 254 00:09:29,539 --> 00:09:30,839 men over 70, 255 00:09:32,535 --> 00:09:35,415 anyone who's had a recent fragility fracture should 256 00:09:35,415 --> 00:09:37,355 be considered high risk. So 257 00:09:37,735 --> 00:09:40,134 if you're seeing a patient who needs a 258 00:09:40,134 --> 00:09:42,549 spine surgery, maybe a 2 or 3 level 259 00:09:42,549 --> 00:09:43,370 spine fusion, 260 00:09:43,750 --> 00:09:45,690 and they recently broke their wrist, 261 00:09:46,309 --> 00:09:47,769 that patient has a risk 262 00:09:48,149 --> 00:09:48,524 of 263 00:09:49,004 --> 00:09:51,165 of of failure or problems with the spine 264 00:09:51,165 --> 00:09:51,665 surgery. 265 00:09:52,125 --> 00:09:54,445 And then there's another calculation, which is really 266 00:09:54,445 --> 00:09:56,300 easy to do. If if, 267 00:09:56,860 --> 00:10:00,700 you go online and you Google fracs, f 268 00:10:00,700 --> 00:10:03,840 r a x, you'll find a, calculator, 269 00:10:04,540 --> 00:10:05,440 and you can 270 00:10:05,855 --> 00:10:06,834 insert the patient's 271 00:10:07,615 --> 00:10:09,714 date of birth, their height, their weight, 272 00:10:10,095 --> 00:10:13,475 and some risk factors such as steroid use, 273 00:10:13,774 --> 00:10:14,274 diabetes, 274 00:10:15,170 --> 00:10:17,410 a family history of a hip fracture, and 275 00:10:17,410 --> 00:10:18,790 so on. And if you 276 00:10:19,490 --> 00:10:21,730 put in those points even without a bone 277 00:10:21,730 --> 00:10:22,790 density score, 278 00:10:23,144 --> 00:10:25,384 it'll give you a readout that'll tell you 279 00:10:25,384 --> 00:10:27,865 the the percentage of risk of fracture, a 280 00:10:27,865 --> 00:10:30,125 major osteoporotic fracture for that patient, 281 00:10:30,750 --> 00:10:32,449 and a risk of hip fracture. 282 00:10:32,750 --> 00:10:34,589 And if there are risk of hip fractures 283 00:10:34,589 --> 00:10:37,169 over 3 and their risk of 284 00:10:38,054 --> 00:10:40,394 major osteoporotic fractures over 8.5, 285 00:10:41,414 --> 00:10:44,294 that patient has a high risk of failure 286 00:10:44,294 --> 00:10:46,695 with surgery. And you need to, again, be 287 00:10:46,695 --> 00:10:49,160 really careful as to whether you would pre 288 00:10:49,160 --> 00:10:49,980 treat them 289 00:10:50,360 --> 00:10:51,879 or whether you would, 290 00:10:52,279 --> 00:10:55,259 defer their surgery completely if they're really, really 291 00:10:55,764 --> 00:10:58,245 suffering from weak bones. So a spine surgeon 292 00:10:58,245 --> 00:10:59,065 should really 293 00:10:59,445 --> 00:11:01,205 look at those four things. They're very simple. 294 00:11:01,205 --> 00:11:03,509 It doesn't take much to to figure those 295 00:11:03,590 --> 00:11:05,509 those four questions out. And once you figure 296 00:11:05,509 --> 00:11:07,990 those four questions, you'll know whether you should 297 00:11:07,990 --> 00:11:09,669 get a DEXA scan or whether you should 298 00:11:09,669 --> 00:11:12,309 delay surgery. And it doesn't take a long 299 00:11:12,309 --> 00:11:12,809 time 300 00:11:13,284 --> 00:11:15,684 to strengthen somebody's bones with the medicines that 301 00:11:15,684 --> 00:11:18,404 we have now. It's it's quite possible to 302 00:11:18,404 --> 00:11:20,024 get the bone strength improved 303 00:11:20,325 --> 00:11:22,024 even after 3 or 4 months, 304 00:11:22,325 --> 00:11:24,089 and many of these patients 305 00:11:24,470 --> 00:11:26,949 know they're gonna need spine or joint replacement 306 00:11:26,949 --> 00:11:30,149 surgery months, if not years in advance, so 307 00:11:30,149 --> 00:11:31,610 it doesn't really delay 308 00:11:32,245 --> 00:11:34,565 the process of getting somebody to the operating 309 00:11:34,565 --> 00:11:36,325 room. We have a saying that if you 310 00:11:36,325 --> 00:11:38,485 don't think of the diagnosis, you'll never make 311 00:11:38,485 --> 00:11:40,504 it. And it's the same thing with osteoporosis. 312 00:11:40,725 --> 00:11:42,309 If you don't think of bone health, you 313 00:11:42,309 --> 00:11:43,370 don't think of osteoporosis, 314 00:11:44,309 --> 00:11:46,789 you'll miss it. You'll you'll you'll just miss 315 00:11:46,789 --> 00:11:47,289 it. 316 00:11:47,830 --> 00:11:49,350 Got it. Thank you so much for walking 317 00:11:49,350 --> 00:11:51,924 us through that. Now kind of shifting gears 318 00:11:51,924 --> 00:11:54,324 a bit, what does the outlook look for 319 00:11:54,324 --> 00:11:56,485 employed physicians like yourself? I know that you 320 00:11:56,485 --> 00:11:58,879 mentioned a pivot room. Was a sidebar. 321 00:11:59,419 --> 00:12:01,659 I was a self employed physician for 35 322 00:12:01,659 --> 00:12:02,159 years, 323 00:12:02,940 --> 00:12:03,440 and 324 00:12:04,355 --> 00:12:06,934 there were many months where I couldn't sustain 325 00:12:07,154 --> 00:12:09,554 the cost of doing business with the income 326 00:12:09,554 --> 00:12:11,860 I was making. I couldn't pay. I had 327 00:12:11,860 --> 00:12:14,279 to pay my salaries and employee benefits. 328 00:12:14,659 --> 00:12:16,019 I had to pay rent. I had to 329 00:12:16,019 --> 00:12:16,759 pay malpractice. 330 00:12:17,059 --> 00:12:19,079 I had to place certain cash supplies, 331 00:12:19,475 --> 00:12:20,774 and I had to pay utilities, 332 00:12:21,315 --> 00:12:23,154 and I wouldn't pay myself. There would be 333 00:12:23,154 --> 00:12:24,915 many, many months where I wouldn't pay myself, 334 00:12:24,915 --> 00:12:26,274 and then I might have a good month 335 00:12:26,274 --> 00:12:27,715 or 2, and then I would kinda make 336 00:12:27,715 --> 00:12:28,615 up for it. 337 00:12:29,460 --> 00:12:31,160 I got tired of that 338 00:12:31,779 --> 00:12:32,840 revenue stress, 339 00:12:33,379 --> 00:12:35,299 and so I took a job as an 340 00:12:35,299 --> 00:12:36,279 employed physician, 341 00:12:37,465 --> 00:12:40,184 oh, almost 20 years ago now, and I 342 00:12:40,184 --> 00:12:42,504 haven't looked back. And I think that that's 343 00:12:42,504 --> 00:12:44,904 been the trend. When I started in practice 344 00:12:44,904 --> 00:12:46,045 back in the eighties, 345 00:12:46,889 --> 00:12:49,950 there were more self employed physicians by far 346 00:12:50,330 --> 00:12:52,990 than employed physicians. I would say it was 347 00:12:53,129 --> 00:12:54,110 80 to 85% 348 00:12:54,490 --> 00:12:55,870 in self employed 349 00:12:56,295 --> 00:12:57,195 and maybe 15% 350 00:12:57,735 --> 00:12:58,555 employed physicians. 351 00:12:59,335 --> 00:12:59,835 That 352 00:13:00,375 --> 00:13:03,175 ratio is completely reversed now. I would say 353 00:13:03,175 --> 00:13:04,154 that 80% 354 00:13:04,535 --> 00:13:05,274 of physicians, 355 00:13:06,019 --> 00:13:08,420 orthopedic surgeons I can speak to orthopedic surgeons 356 00:13:08,420 --> 00:13:10,980 because that's my specialty in this country are 357 00:13:10,980 --> 00:13:13,480 employed now, and maybe 15% 358 00:13:14,019 --> 00:13:15,160 are self employed. 359 00:13:15,865 --> 00:13:16,365 That 360 00:13:17,225 --> 00:13:18,684 trend is gonna extend 361 00:13:19,144 --> 00:13:20,285 the reimbursement 362 00:13:22,745 --> 00:13:24,125 model that we have, 363 00:13:24,470 --> 00:13:25,289 which is based 364 00:13:26,629 --> 00:13:27,769 on fee for service, 365 00:13:28,950 --> 00:13:30,730 in many ways is perverse. 366 00:13:31,669 --> 00:13:35,324 It it makes doctors sometimes do work that 367 00:13:35,944 --> 00:13:38,904 they shouldn't do surgically just because they need 368 00:13:38,904 --> 00:13:39,564 the revenue. 369 00:13:40,220 --> 00:13:43,500 Those stresses are completely alleviated by being employed 370 00:13:43,500 --> 00:13:44,000 physician. 371 00:13:44,779 --> 00:13:47,360 And there are some definite downsides of employment 372 00:13:47,500 --> 00:13:50,154 because when a a physician's employed, 373 00:13:51,014 --> 00:13:53,915 they don't understand that there's still the same 374 00:13:54,455 --> 00:13:55,675 same risk or vulnerability 375 00:13:56,259 --> 00:13:58,179 as an employed physician in terms of their 376 00:13:58,179 --> 00:13:59,399 ability to do business. 377 00:13:59,779 --> 00:14:01,399 Somebody has to pay the bills. 378 00:14:01,860 --> 00:14:04,339 So the employer, which is a health care 379 00:14:04,339 --> 00:14:04,839 plan, 380 00:14:05,139 --> 00:14:05,639 hospital, 381 00:14:06,274 --> 00:14:07,014 insurance company, 382 00:14:07,875 --> 00:14:08,375 Walmart, 383 00:14:08,915 --> 00:14:10,215 Walgreens, whoever, 384 00:14:11,154 --> 00:14:13,335 they still have to pay the bills. So 385 00:14:13,394 --> 00:14:15,654 they have to generate some revenue somehow, 386 00:14:16,309 --> 00:14:18,809 and they're still at the, risk 387 00:14:20,149 --> 00:14:23,350 of reimbursement issues that employed physicians have to 388 00:14:23,350 --> 00:14:25,610 deal with. So it's not 389 00:14:26,134 --> 00:14:29,254 it's not a complete solution, but it it's 390 00:14:29,254 --> 00:14:31,274 led to trends in health care, 391 00:14:31,815 --> 00:14:34,455 which I find difficult. I've always been involved 392 00:14:34,455 --> 00:14:34,955 in 393 00:14:36,009 --> 00:14:36,909 medical leadership, 394 00:14:37,289 --> 00:14:40,490 and I've been president of medical societies and 395 00:14:40,490 --> 00:14:42,110 state orthopedic associations. 396 00:14:43,105 --> 00:14:45,424 And what I found is that over time, 397 00:14:45,424 --> 00:14:47,684 there's been less and less interested 398 00:14:48,065 --> 00:14:51,059 in these organizations, which do good work, especially 399 00:14:51,059 --> 00:14:53,699 in the advocacy realm, like the, you know, 400 00:14:54,179 --> 00:14:56,919 legislative advocacy to help improve 401 00:14:57,539 --> 00:15:00,274 patient benefits, insurance benefits, and 402 00:15:00,735 --> 00:15:04,014 and reimbursement models and so on. And physicians 403 00:15:04,014 --> 00:15:06,894 that are employed generally don't see the value 404 00:15:06,894 --> 00:15:09,379 in that, and younger physicians just don't seem 405 00:15:09,379 --> 00:15:10,279 to be involved 406 00:15:10,659 --> 00:15:11,559 in advocacy 407 00:15:11,940 --> 00:15:15,865 and medical organizations and leadership. That's a downside 408 00:15:16,085 --> 00:15:18,345 of the employment model. It just 409 00:15:18,965 --> 00:15:21,125 takes that out of people's thinking just like 410 00:15:21,125 --> 00:15:24,404 osteoporosis isn't something that most orthopedic surgeons think 411 00:15:24,404 --> 00:15:27,029 about. So, I think the trend is that 412 00:15:27,029 --> 00:15:29,610 it's going to be more prevalent with time. 413 00:15:30,070 --> 00:15:32,870 I can't say that all orthopedic surgeons are 414 00:15:32,870 --> 00:15:33,769 gonna be 415 00:15:34,095 --> 00:15:34,995 employed. They're 416 00:15:35,375 --> 00:15:37,855 going to be entrepreneurial orthopedic surgeons that are 417 00:15:37,855 --> 00:15:40,254 gonna wanna do it on their own, but 418 00:15:40,254 --> 00:15:42,514 they're gonna find novel ways to do it. 419 00:15:43,170 --> 00:15:45,649 For example, by opting out of insurance or 420 00:15:45,649 --> 00:15:46,149 letting 421 00:15:46,529 --> 00:15:49,090 or having a concierge practice where they're gonna 422 00:15:49,090 --> 00:15:51,190 have patients pay cash and 423 00:15:51,615 --> 00:15:53,794 seek reimbursement through their insurance companies. 424 00:15:54,495 --> 00:15:56,575 I mean, the the trend over the over 425 00:15:56,575 --> 00:15:58,195 the years has been for, 426 00:15:59,129 --> 00:15:59,629 insurances 427 00:16:00,330 --> 00:16:02,590 to narrow the network such that, 428 00:16:03,370 --> 00:16:05,629 they control reimbursed and contracting 429 00:16:06,009 --> 00:16:06,750 with physicians. 430 00:16:07,129 --> 00:16:07,629 Physicians 431 00:16:08,335 --> 00:16:11,235 don't have the expertise and time to contract 432 00:16:11,295 --> 00:16:12,754 with all the insurance carriers. 433 00:16:13,615 --> 00:16:15,934 And so I think that the future of 434 00:16:15,934 --> 00:16:17,879 the self employed physician 435 00:16:18,340 --> 00:16:21,220 is going to be one of a cash 436 00:16:21,220 --> 00:16:22,360 basis reimbursement. 437 00:16:23,220 --> 00:16:25,480 They'll they'll probably opt out of Medicare. 438 00:16:25,884 --> 00:16:27,264 They'll opt out of insurance, 439 00:16:27,804 --> 00:16:29,965 insurance plans and put the onus on the 440 00:16:29,965 --> 00:16:32,044 patients to pay for it. I think that's 441 00:16:32,044 --> 00:16:33,264 the way it's gonna be. 442 00:16:33,879 --> 00:16:34,379 Absolutely. 443 00:16:35,399 --> 00:16:37,100 And switching gears once more, 444 00:16:37,639 --> 00:16:39,960 are there any spine and orthopedic innovations that 445 00:16:39,960 --> 00:16:41,340 are exciting you at the moment? 446 00:16:42,115 --> 00:16:42,615 Sure. 447 00:16:43,235 --> 00:16:44,774 Well, I mean, I look at, 448 00:16:45,235 --> 00:16:47,254 legislative issues in orthopedics 449 00:16:47,634 --> 00:16:49,254 in terms of, you know, reimbursement, 450 00:16:49,634 --> 00:16:50,774 especially in Medicare. 451 00:16:51,429 --> 00:16:53,370 But, in terms of innovation, 452 00:16:54,149 --> 00:16:55,690 I'm really excited about 453 00:16:56,070 --> 00:16:58,309 the biologics that are being used now in 454 00:16:58,309 --> 00:17:00,250 orthopedic surgery, especially 455 00:17:01,115 --> 00:17:03,914 those that have impact on on, 456 00:17:04,714 --> 00:17:07,615 bone strengthening, bone regeneration, and bone health. 457 00:17:07,914 --> 00:17:09,694 So, for example, in the osteoporosis 458 00:17:10,529 --> 00:17:11,029 treatment 459 00:17:11,490 --> 00:17:12,450 world, we have, 460 00:17:13,170 --> 00:17:15,670 a new class of drugs called anabolics, 461 00:17:15,970 --> 00:17:16,470 osteoanabolics. 462 00:17:17,490 --> 00:17:20,150 And they perform by 463 00:17:20,674 --> 00:17:22,615 stimulating bone forming cells 464 00:17:23,075 --> 00:17:25,494 to be more active and strengthen the bone. 465 00:17:26,195 --> 00:17:28,195 Okay. One of them in particular is a 466 00:17:28,195 --> 00:17:31,490 monoclonal antibody, and it's directed against a particular 467 00:17:31,630 --> 00:17:33,009 protein which blocks 468 00:17:33,789 --> 00:17:35,089 the, osteoclast, 469 00:17:35,390 --> 00:17:36,930 which is the cells that 470 00:17:37,265 --> 00:17:39,025 eat away at the bone to remodel it. 471 00:17:39,025 --> 00:17:41,585 The osteoblasts come in afterwards to build the 472 00:17:41,585 --> 00:17:42,085 bone. 473 00:17:42,865 --> 00:17:44,805 But if you can biologically 474 00:17:45,265 --> 00:17:45,765 modulate 475 00:17:46,299 --> 00:17:47,519 that kind of process 476 00:17:47,980 --> 00:17:48,480 through, 477 00:17:49,660 --> 00:17:52,240 for example, monoclonal antibody, you can 478 00:17:52,700 --> 00:17:53,200 revolutionize, 479 00:17:54,974 --> 00:17:57,474 the treatment of of, weak bones. 480 00:17:57,934 --> 00:18:00,015 So for example, another example of that is 481 00:18:00,015 --> 00:18:01,315 in the world of rheumatology, 482 00:18:01,909 --> 00:18:04,409 there is a class of drugs called DMARDs, 483 00:18:05,029 --> 00:18:06,730 disease modifying agents, 484 00:18:07,190 --> 00:18:09,509 that the rheumatologists have been using for the 485 00:18:09,509 --> 00:18:10,649 last 20 years. 486 00:18:11,195 --> 00:18:11,695 And 487 00:18:12,234 --> 00:18:14,494 these drugs are so effective in preventing 488 00:18:14,795 --> 00:18:15,295 the, 489 00:18:16,474 --> 00:18:20,119 deformities and arthritis that rheumatoid arthritis causes that 490 00:18:20,279 --> 00:18:22,359 orthopedic surgeons don't even know how to treat 491 00:18:22,359 --> 00:18:24,839 these conditions anymore. When I was a resident, 492 00:18:24,839 --> 00:18:28,220 we used to see horrible rheumatoid arthritis joints 493 00:18:28,555 --> 00:18:31,035 that would need a joint replacement or hand 494 00:18:31,035 --> 00:18:31,535 surgery. 495 00:18:31,994 --> 00:18:35,115 And these conditions no longer exist just because 496 00:18:35,115 --> 00:18:36,654 of the the osteobiologics 497 00:18:37,035 --> 00:18:39,579 that have come out. So, anyway, I'm I'm 498 00:18:39,579 --> 00:18:40,720 I'm excited about 499 00:18:41,180 --> 00:18:41,680 future, 500 00:18:42,299 --> 00:18:42,799 osteobiologic 501 00:18:43,420 --> 00:18:45,119 mod drug modifiers, 502 00:18:45,420 --> 00:18:47,119 you know, to modify the biology. 503 00:18:47,724 --> 00:18:48,545 That is exciting. 504 00:18:48,924 --> 00:18:50,684 Well, doctor Greenwald, I wanna thank you for 505 00:18:50,684 --> 00:18:52,285 your time today. But before I let you 506 00:18:52,285 --> 00:18:54,365 go, is there anything else that listeners should 507 00:18:54,365 --> 00:18:57,759 know? Sure. I just wanna put in a, 508 00:18:58,339 --> 00:18:59,240 kind of a gratuitous 509 00:18:59,539 --> 00:19:02,339 plug for the, own the bone program, which 510 00:19:02,339 --> 00:19:02,839 is, 511 00:19:03,525 --> 00:19:06,424 a subsidiary of the American Orthopedic Association, 512 00:19:07,605 --> 00:19:08,505 that is 513 00:19:09,845 --> 00:19:12,164 very interested in setting up programs around the 514 00:19:12,164 --> 00:19:13,869 country to help doctors 515 00:19:14,650 --> 00:19:17,769 treat patients who have these bone diseases, weak 516 00:19:17,769 --> 00:19:18,509 bone diseases. 517 00:19:18,890 --> 00:19:20,509 So I'm excited to 518 00:19:21,164 --> 00:19:22,625 be involved with that organization 519 00:19:23,164 --> 00:19:25,644 and looking forward to starting my own clinic 520 00:19:25,644 --> 00:19:26,465 in Montana 521 00:19:26,845 --> 00:19:28,065 in this in the fall. 522 00:19:28,559 --> 00:19:30,500 And I'm excited to be starting 523 00:19:31,200 --> 00:19:32,259 a new career 524 00:19:32,960 --> 00:19:33,460 that 525 00:19:34,000 --> 00:19:34,500 is 526 00:19:34,799 --> 00:19:36,900 opening up a bone health clinic 527 00:19:37,275 --> 00:19:39,295 at the Great Falls Clinic in Montana 528 00:19:39,994 --> 00:19:42,474 using the own the bone model, which is 529 00:19:42,474 --> 00:19:45,054 the AOA that I was speaking about before. 530 00:19:45,859 --> 00:19:47,779 Got it. Well, doctor Greenwald, I wanna thank 531 00:19:47,779 --> 00:19:49,380 you once again for your time today and 532 00:19:49,380 --> 00:19:50,740 for joining me on the Becker Self Care 533 00:19:50,740 --> 00:19:53,480 podcast. Thank you. You're very welcome. Thank you.