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This is Laura Dirda with the Becker Spine
and Orthopedic podcast.
I'm thrilled today to be joined by doctor
Arthur Jenkins the 3rd, board certified neurosurgeon
and an expert in complex and minimally invasive
spine and neurological surgery. Doctor Jenkins, it's a
pleasure to have you on the podcast today.
Thank you very much, Lloyd. It's a pleasure
to be here. Always happy to,
to join any interested colleagues in discussing the
the present and future of spine surgery.
Oh, excellent. I think this will be a
really fun conversation. I know we've got a
lot of ground to cover and certainly,
fascinating time to be in spine, and so
I'm excited to hear more about your perspective.
But before we dig into my questions here,
I was wondering, could you tell us a
little bit more about yourself and your background?
Sure. So I am a,
board certified fellowship trained spinal neurosurgeon.
I did my fellowship training at the Brigham
in at in Boston.
I did my residency at Mount Sinai. I
went back as after fellowship and was full
time faculty for 17 years
doing research on everything from minimally invasive techniques
to spinal cord injury,
and including brain computer interface type research on
spinal cord
functional regeneration.
And
it was a great experience for me. But
after,
oh, 17 years or so, it seemed like
it was time for me to go in
my own path. So I went into private
practice,
and really just have enjoyed
the challenges
as well as the the, the joys of
being a my own boss,
for the last six and a half years.
And so it's, it's been an interesting time.
It's an old curse, although nobody can agree
upon how old this curse is that may
you live in interesting times.
And these are certainly
interesting times.
Indeed. It's just fascinating,
to think about it and, you know, really,
really, truly, I I feel like over the
last couple years, the number of times I've
heard unprecedented,
connected to something happening in the health care
space is, you know, just really,
kind of serves as a great litmus test
of how much,
how many revolutionary things are happening right now.
So
given the, you know, the times we live
in as well as,
your role, obviously,
experience at a health system and really a
a big,
institution and now being a private practice. What
are some of the big trends and headwinds
that you're following?
What is really top of mind for you
right now?
Well, I I think the biggest
trend and and headwind
is the massive
consolidation
of physicians and specifically
spine surgeons
as employed
physicians
in in the as a market,
broad market thing.
It is,
more spine surgeons than ever have and a
larger percentage of the active spine surgeons are
currently working either for
a a large hospital chain, a large hospital
in the in an in a particular market,
a private equity owned
group of surgeons or doctors,
and ultimately,
more than ever are not their own boss
or are not
even within a small group able to call
their own shots. So these
are typically
driven
on an incentive basis, assuming they even have
an incentive basis.
Their incentive basis is usually purely upon the
volume of cases they do
knowing that
the system has been set up that the
boss, whether it's the hospital, the hospital chain
or the private equity group, makes the most
money off of the clinician
doing the most volume.
And the only way spine surgeons can do
a large volume
is by seeing many patients quickly
in their office hours
and operating
regularly on the same case over and over
so they can be done quickly and efficiently,
frequently in a surgery center that the physician
may have an ownership stake in or the
practice may have an ownership stake in.
This has created,
a number of
potentially
misaligned
incentivizations
where the surgeon wants to get through as
many patients as possible. The only way to
do that is to do so quickly
or refer the patient to somebody else or
more likely than not because they don't want
to admit that this isn't either in their
wheelhouse
or that they just don't wanna deal with
the complexity of the situation.
Many of these patients are being told, well,
there's nothing that can be done
for you. So go to pain management. Go
to see a psychologist. Go see somebody other
than a surgeon
to manage these complex patients.
Now as you can imagine with interesting times,
that as we are our body of knowledge
is growing
and then the complexity
of some of the patients we're dealing with,
there are more and more patients who are
basically being shunted out of
the high volume clinics
and being
essentially medically gaslit by their patient by their
by their practitioners.
The other side the other big headwind we're
facing,
and this is also driving many of those
same,
high volume,
issues, is the insurance companies
are cutting back more and more on what
they pay the physicians.
So the hospitals are subsidizing
through what's called an RVU based model or
resource value unit based model.
They're back subsidizing those surgeons since they're not
making as much on the on the insurance
company payment for their services,
But the hospital is making so much more
on the inpatient stay that they can afford
to subsidize the physicians
to the standard of care that they
rightfully so believe that they're entitled to.
And so the insurance companies at a time
when they are reporting record profits,
for their themselves and for their their shareholders
and payments to their their board members
are paying out
less and less to the physicians and especially
physicians like me in private practice.
Now this is
part of the headwind because
if there are fewer doctors in private practice,
those same physicians
are going to be less inclined to say
to their boss, well, I could go into
private practice.
Therefore, I don't accept this lowball offer of
salary.
And so the fewer the fewer opportunities in
private practice,
the less that those doctors can push back.
And so their salaries are actually, on an
inflation basis, starting to drop.
So it's getting harder and harder for a
spine surgeon to
do well and get ahead
in an environment where the insurance companies are
paying less. And the hospitals know they have
a greater market share, essentially becoming what's known
as a monopsony
or a monopoly of employment.
And the doctors really are the ones stuck
in the middle.
So I think those are the 2 biggest
headwinds.
1 is the
the marginalization
of the more complex patients
and the second is the marginalization of the
spine surgeons
as being a cog in a wheel that's
controlled by somebody other than
other spine surgeons or themselves.
That's really fascinating to hear. And, certainly, you
know, I I can see where all of
those trends tie together
in looking at, you know, how health care
has evolved and really the the pressures, like
you mentioned, from
the insurance company in in the hospital and
and, just from, you know, the surgeon's perspective,
trying to figure out how to navigate
all these areas and spaces,
it just really, you know, is a challenge.
So for you, it seems like you've gone
in the opposite direction instead of joining in
with the hospital or
consolidating,
you know, striking out and doing your own
private practice for the last few years.
You know, do you see,
that being a space that'll be possible in
the future? Do you see, you know, kind
of this bubble bursting at some point? Or
what's in store, do you think, for spine
surgeons in the next 6 to 10 years
down the line?
Well, I think that the biggest opportunity for
growth here
is to capitalize
on what you do and how well you
do it.
It's actually many of the hospitals make it
hard for the physicians to find out how
well they're doing.
After all, if the bosses has an negative
incentive about paying your bonus by finding things
you're doing poorly,
those are the metrics you're likely to get
from them. But many of the physicians that
I speak to can't get
the data from their own hospital or the
even their own department
about how much they contribute to the hospital's
bottom line, what's known as the adjusted contribution
to margin.
When physicians know how much they bring to
the table, they tend to have more
marketing power and more negotiation power within their
own institution as well as, you know, being
able to market themselves
as a potential transfer to another place of
business.
But I think also even within their own
practice, they can
by tracking their own data more
and their patient outcomes more and even looking
at long term outcomes more, they can show
that what they're doing provides value
and then that's an opportunity both to let
the world know how well you're doing what
you do,
but also let your employer know how well
you're doing and that if you're doing better
than your than your peers,
then that's an opportunity for you to negotiate
a better deal for yourself, as well as,
you know, potentially, if we could get together
as a group of physicians and get the
insurance companies
to reimburse
physicians
better for better care,
which right now, there is no
bonus
for a physician who provides great care versus
good care or even good care versus mediocre
care. I mean, as long as you're above
the level of malpractice
care, you get paid the same by the
most for the most part by all of
the insurance carriers and even the government.
So that what we really need to do
and is to at least leverage
your ability to provide
good to great care,
incentivize people to provide better care, and then
the marketing on that will follow itself and
be the path you know, people will be
the path to your door.
That makes a lot of sense, and, you
know, it's just a fascinating way to think
about it, you know, a 100%
in in you're right,
in looking at you know? Again, as long
as you're above malpractice, you get paid at
the same rate, which,
doesn't make a lot of sense or doesn't
translate to most other industries. And so having
that incentive
to really be great, produce those outcomes, and
do what you need to do,
could really be beneficial.
From your perspective,
I I guess, are there any other ways
that you see spine and orthopedics evolving over
the next 2 to 3 years or so?
What do you see as realistically being ways
that, you expect the industry to change, both
either from the business side or the clinical
side? I know you do a lot of
innovation,
within
complex surgery as well as minimally invasive procedures.
I I think that that is certainly one
way that it's been evolving and will continue
to evolve.
There the The use of AI is probably,
you know, the widespread use of AI is
probably
a 3 to 10 year horizon
and there are a number of ways that
that can help practitioners
to
improve their process, but not necessarily completely eliminate
certain steps.
For example, I personally,
use,
an AI digital scribe,
and I have used a couple of different
one over the years.
The,
shout out playback health is is currently my
AI digital scribe, but even that is not
perfect. I still have a human scribe who
helps to take what the digital scribe has
done
to, and put it into my final note
format
because there are things that a digital scribe
from a particular office visit doesn't have access
to that my human scribe does. For example,
going back and looking at prior visits for
comparisons.
You know, if I'm checking grip strength on
a patient
who's had surgery that impacts on their hand
strength,
I may be tracking that over time and
my and we can add that data in.
It's harder to do
from a just a a current the current
generation of AI scribes.
But the next generation may actually allow you
to dig into those outcome measures we talked
about earlier
and track the patient's progress through their recovery,
and be able to put that data
right front and center in the note.
I think it's also
the one of the ways that I'm hoping
the industry goes is away from the
hospital
generated
7 page progress note that dumps 6 and
a half pages of old data into the
note to document
a higher complexity of the evaluation
more than actually improve the
insight of the note itself,
but then they turn around and they bill
more back to the insurance carrier for that
level of service
that was provided. But that creates
a mess of a note,
literally 7 pages sometimes I have to wade
through to find the 2 or 3 sentences
that actually mean something for how the patient
was doing that particular day. Having MRI reports
from 3 days ago
in the note as
transcribed verbatim
and then having to find where on that
note
the physician's actual impression was, it's just tedious.
And so I'm hoping that many people do
what I do, which is put on the
very first line
the impression,
what they're there for with impression
and have that be first and then any
ancillary data that supports that conclusion
be down afterwards.
Let's just communicate better, guys.
Absolutely. Wouldn't that be, you know, the the
goal in so many different connections or relationships
is just having that communication aspect,
easier, more streamlined, and and a a better
understanding overall?
Absolutely. Well, you know, I I've appreciated a
lot of your perspective here, and I I
know we're running out of time. But before
we go, I was wondering where do you
see some of the best opportunities for continued
to grow growth and development in the field
as well as in your practice?
Well, I certainly think that from from my
perspective, I've been,
just learning more about the different areas that
I just didn't understand. I mean, I've learned
more in the last 5 years about
autonomic
dysfunction and the spine and peripheral nervous system's
impact upon patients who are
hypermobile
or had an injury that has made their
body
kink and pinch
the autonomic nerves and cause severe problems
that we can treat if we understand the
biomechanics
and then the neurobiology
of this. And it's just not taught widely
in neurosurgical
training, so I had to learn all of
this on my own. But as I learn
it and I realize there are a whole
population of patients out there who are un-
or under treated
for these conditions, and that's an opportunity to
figure out how can you meet the needs
of the patients who are coming in to
see you better.
And so I've learned to work with vascular
surgeons and I've actually added
surgical treatments for thoracic outlet syndrome to my
clinical practice,
once again, something I was not taught during
residency, but after working with others
and and coming up with a better way
of doing it, it's really, it's been very
gratifying.
And then other areas are are clearly,
you know, finding
better ways to provide care to people
through minimally invasive approaches that maybe they were,
like for cancer patients, maybe they weren't healthy
enough for the big old school classic operation,
but a minimally invasive procedure that may have
minimal downtime and recovery
but give them better quality of life and
potentially even longer life,
that's an opportunity to treat people, once again,
who may have been told there's nothing more
we can do for you,
when that's actually not true. So
finding new, better ways to treat the people
who haven't been treated, that's an opportunity for
growth.
And then just finding better ways of doing
the things we're currently doing
and maybe even finding ways to deliver stem
cells,
not just percutaneously
with needles, but in a more targeted fashion
through surgery,
into target areas.
As the biology and and technology of stem
cells evolves, we may find even better ways
to use them.
That's really encouraging to hear. Doctor Jenkin, thank
you so much for joining us on the
podcast today. This has been a fascinating discussion,
and I look forward to connecting with you
again soon.
Great. Well, thank you very much for, for
the opportunity. Have a great day, and,
say hello to all your your, listeners out
there.