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cast. This is Chanel Banger with the Becker's
Healthcare podcast, and I'm recording live at the
21st annual Spine Orthopedic and Pain Management Driven
ASC
and the Future of Spine Conference in Chicago.
And sitting down with doctor Alan Greenwald, an
orthopedic surgeon at Astrea Health. Doctor Greenwald, thank
you so much for joining me today. Thank
you. It's my pleasure to be here. Perfect.
Well, to get us started, could you please
tell us a bit about your background and
organization?
Yes. I've been in orthopedic surgery for almost
50 years now. I trained in San Francisco
and spent a career working there,
and I've been working in rural Washington
since
2005.
I've done general orthopedics in my lifetime in
my orthopedic career
and fixed a lot of,
fractures
that
we would call fragility fractures related to osteoporosis.
And
I have decided that it's important for me
to take on the responsibility to treat those
fractures and the cause of them in in
addition to just fixing them.
So
it's like a 12 step program for orthopedic
surgeons.
Most of the most of my career, we've,
been advised to tell patients to go back
and see their family doctor
and have a workup for osteoporosis
and get treatment, and that rarely, rarely happens.
So
some years ago, the orthopedic community,
specifically the American Orthopedic Association,
has focused on setting up
clinics that are designed to help capture fragility
fracture patients and get them seen and treated
properly.
So that's a pivot that I'm making now
in my career.
I,
plan to
transition to doing that full time. Instead of
doing surgery, I'm gonna try to make people's
bones healthier.
Exciting new ventures. Well, thank you so much
for that introduction.
Now moving forward,
how have you built trust among your patients
and community as a physician?
Well, in medicine,
that's actually
not a hard thing to do. Most people
don't have a medical education and background.
And when they seek
care from an a physician, especially an orthopedic
physician,
they go in with a preconceived notion that
they're going to be well treated and respected
and that they're gonna get good care. And
so it's almost
it it it almost doesn't need to be
sold.
Your job is to do a good job
and not screw it up. And I think
that's where people get disenfranchised
with their health care providers
when things don't go well,
and then you lose the trust. But I
think
most people come into the arena of being
seen and treated by an orthopedic surgeon with
a sense of trust already preconceived.
So it's actually
it's it's easy.
You just have to be professional
and caring
and do a good job and not lose
the trust.
Absolutely.
And moving forward, how can the spine and
orthopedic community better recognize and address osteoporosis
in patients? So first of all, let's define
osteoporosis.
It's a it's
a disease of aging bone where there's a
a loss of bone structure and bone mass.
So the quality of the bone deteriorates with
age.
It's just like,
imagine a weightlifter
who is like Arnold Schwarzenegger.
He
spent,
many of years of his life building muscles
and
and establishing his great physique. But as he
got older,
it would be harder and harder for somebody
like that to maintain that physique. It just
doesn't it just doesn't happen. The body deteriorates,
and bone in and soft tissues deteriorate. And
we are familiar with osteoporosis, which is a
disease of bone. We know
we have had a grandmother that's fallen down
and broken a hip. We we understand
bone fragility.
What we don't appreciate is that it starts
in earlier ages. And by the time it
manifests itself as a fragility fracture, it's almost
too late to treat.
So my
interest,
as I said before, is I feel like
a,
it's like a 12 step program. You know,
someone who who decides that they've,
decided that they're going to
seek out
help to
fix a a problem they've had all their
lives.
I think orthopedic surgeons have failed to appreciate
the need to recognize and treat osteoporosis
early on and prevent fractures.
So, for example,
a woman falls down at age 55 and
breaks her wrist.
The wrist gets fixed, sometimes surgically, sometimes just
a cast, but that patient rarely goes on
to having
treatment for the underlying disease that caused a
fracture in the first place. And 5 to
10 years later, they fall down and break
a hip. 40% of patients die after a
broken hip. If you don't start osteoporosis treatment
after that hip fracture, within 2 years, they're
probably gonna break the other side, and then
they'll die. So it's a lethal disease. It's
painless until something bad happens, a vertebral fracture,
spine fracture,
a wrist fracture, a humorous fracture,
an ankle fracture, even sometimes simple
finger and toe fractures can be attributed to
fragility.
And most people, even patients, don't wanna acknowledge
that that's the cause of it. Oh, I
fell down. It was a very big wind
that blew me over.
But
the the cause is the bone is the
underlying bone structure is compromised.
So
most of the time, patients fall down, break
something, do not get treated for the actual
cause of that disease. So I feel like
it's important
for orthopedic surgeons to take responsibility
to get that patient
treated and prevent future fractures.
Ultimately,
the goal would also be to
have,
especially women,
treated or evaluated for osteoporosis
well before their bone is that weak.
Another side of this is in elective surgery.
Orthopedic surgeons
in general
are concerned about risk factors for spine surgery
and for
joint replacements. They want good outcomes. And in
order to do that, they'll make sure the
patients are
evaluated for their diabetes, for example. And if
their diabetes is not in good control,
the surgery would be delayed.
If they're a smoker, if they're overweight,
if they have bad teeth, a bad dentition,
or high risk of infection, if they're a
carrier for staph aureaus
at and also more risk of developing a
postsurgical
infection. We screen for all these things, but
very rarely do surgeon screen for bone health.
And that's another
focus that I have, which is to help
orthopedic surgeons that deal with hard tissues like
spine and joint replacements
to be aware of the patient's underlying bone
health
and acknowledge if it's not good to
treat it before doing surgery to have better
outcomes.
If you look at the data in the
spine world, you'll see
that there's a lot of data looking at
poor outcomes for patients who have osteoporosis that
are being treated,
with surgery. They develop
fractures adjacent to the,
instrumented level. They have hardware failure.
Patients have subsidence of their
implants, their cages and screws, screws break out,
rods come apart.
There's a higher infection rate. So when you
don't acknowledge that patient's underlying bone health
and you miss the boat, you have a
higher risk of infection and failure and fracture.
Same thing with with joint placements. If you're
not
cognizant of that patient's underlying bone health, you
could use the wrong implant. You could,
make a mistake
and end up with a a patient that's
unhappy and has a bad result from the
surgery.
So I'm trying to get physicians to focus
on
looking at least looking and assessing a patient's
bone health as a risk factor
just like they would smoking and diabetes
and,
dental
infections and so on. So that's that's another
focus of mine. Absolutely. And
what age would you recommend
patients get screened for bone health so they
don't
That's a great question.
The short answer is
women over 65,
men over 70,
anyone who's had a recent fragility fracture should
be considered high risk. So
if you're seeing a patient who needs a
spine surgery, maybe a 2 or 3 level
spine fusion,
and they recently broke their wrist,
that patient has a risk
of
of of failure or problems with the spine
surgery.
And then there's another calculation, which is really
easy to do. If if,
you go online and you Google fracs, f
r a x, you'll find a, calculator,
and you can
insert the patient's
date of birth, their height, their weight,
and some risk factors such as steroid use,
diabetes,
a family history of a hip fracture, and
so on. And if you
put in those points even without a bone
density score,
it'll give you a readout that'll tell you
the the percentage of risk of fracture, a
major osteoporotic fracture for that patient,
and a risk of hip fracture.
And if there are risk of hip fractures
over 3 and their risk of
major osteoporotic fractures over 8.5,
that patient has a high risk of failure
with surgery. And you need to, again, be
really careful as to whether you would pre
treat them
or whether you would,
defer their surgery completely if they're really, really
suffering from weak bones. So a spine surgeon
should really
look at those four things. They're very simple.
It doesn't take much to to figure those
those four questions out. And once you figure
those four questions, you'll know whether you should
get a DEXA scan or whether you should
delay surgery. And it doesn't take a long
time
to strengthen somebody's bones with the medicines that
we have now. It's it's quite possible to
get the bone strength improved
even after 3 or 4 months,
and many of these patients
know they're gonna need spine or joint replacement
surgery months, if not years in advance, so
it doesn't really delay
the process of getting somebody to the operating
room. We have a saying that if you
don't think of the diagnosis, you'll never make
it. And it's the same thing with osteoporosis.
If you don't think of bone health, you
don't think of osteoporosis,
you'll miss it. You'll you'll you'll just miss
it.
Got it. Thank you so much for walking
us through that. Now kind of shifting gears
a bit, what does the outlook look for
employed physicians like yourself? I know that you
mentioned a pivot room. Was a sidebar.
I was a self employed physician for 35
years,
and
there were many months where I couldn't sustain
the cost of doing business with the income
I was making. I couldn't pay. I had
to pay my salaries and employee benefits.
I had to pay rent. I had to
pay malpractice.
I had to place certain cash supplies,
and I had to pay utilities,
and I wouldn't pay myself. There would be
many, many months where I wouldn't pay myself,
and then I might have a good month
or 2, and then I would kinda make
up for it.
I got tired of that
revenue stress,
and so I took a job as an
employed physician,
oh, almost 20 years ago now, and I
haven't looked back. And I think that that's
been the trend. When I started in practice
back in the eighties,
there were more self employed physicians by far
than employed physicians. I would say it was
80 to 85%
in self employed
and maybe 15%
employed physicians.
That
ratio is completely reversed now. I would say
that 80%
of physicians,
orthopedic surgeons I can speak to orthopedic surgeons
because that's my specialty in this country are
employed now, and maybe 15%
are self employed.
That
trend is gonna extend
the reimbursement
model that we have,
which is based
on fee for service,
in many ways is perverse.
It it makes doctors sometimes do work that
they shouldn't do surgically just because they need
the revenue.
Those stresses are completely alleviated by being employed
physician.
And there are some definite downsides of employment
because when a a physician's employed,
they don't understand that there's still the same
same risk or vulnerability
as an employed physician in terms of their
ability to do business.
Somebody has to pay the bills.
So the employer, which is a health care
plan, hospital,
insurance company,
Walmart,
Walgreens, whoever,
they still have to pay the bills. So
they have to generate some revenue somehow,
and they're still at the, risk
of reimbursement issues that employed physicians have to
deal with. So it's not
it's not a complete solution, but it it's
led to trends in health care,
which I find difficult. I've always been involved
in
medical leadership,
and I've been president of medical societies and
state orthopedic associations.
And what I found is that over time,
there's been less and less interested
in these organizations, which do good work, especially
in the advocacy realm, like the, you know,
legislative advocacy to help improve
patient benefits, insurance benefits, and
and reimbursement models and so on. And physicians
that are employed generally don't see the value
in that, and younger physicians just don't seem
to be involved
in advocacy
and medical organizations and leadership. That's a downside
of the employment model. It just
takes that out of people's thinking just like
osteoporosis isn't something that most orthopedic surgeons think
about. So, I think the trend is that
it's going to be more prevalent with time.
I can't say that all orthopedic surgeons are
gonna be
employed. They're
going to be entrepreneurial orthopedic surgeons that are
gonna wanna do it on their own, but
they're gonna find novel ways to do it.
For example, by opting out of insurance or
letting
or having a concierge practice where they're gonna
have patients pay cash and
seek reimbursement through their insurance companies.
I mean, the the trend over the over
the years has been for,
insurances
to narrow the network such that,
they control reimbursed and contracting
with physicians.
Physicians
don't have the expertise and time to contract
with all the insurance carriers.
And so I think that the future of
the self employed physician
is going to be one of a cash
basis reimbursement.
They'll they'll probably opt out of Medicare.
They'll opt out of insurance,
insurance plans and put the onus on the
patients to pay for it. I think that's
the way it's gonna be.
Absolutely.
And switching gears once more,
are there any spine and orthopedic innovations that
are exciting you at the moment?
Sure.
Well, I mean, I look at,
legislative issues in orthopedics
in terms of, you know, reimbursement,
especially in Medicare.
But, in terms of innovation,
I'm really excited about
the biologics that are being used now in
orthopedic surgery, especially
those that have impact on on,
bone strengthening, bone regeneration, and bone health.
So, for example, in the osteoporosis
treatment
world, we have,
a new class of drugs called anabolics,
osteoanabolics.
And they perform by
stimulating bone forming cells
to be more active and strengthen the bone.
Okay. One of them in particular is a
monoclonal antibody, and it's directed against a particular
protein which blocks
the, osteoclast,
which is the cells that
eat away at the bone to remodel it.
The osteoblasts come in afterwards to build the
bone.
But if you can biologically
modulate
that kind of process
through,
for example, monoclonal antibody, you can
revolutionize,
the treatment of of, weak bones.
So for example, another example of that is
in the world of rheumatology,
there is a class of drugs called DMARDs,
disease modifying agents,
that the rheumatologists have been using for the
last 20 years.
And
these drugs are so effective in preventing
the,
deformities and arthritis that rheumatoid arthritis causes that
orthopedic surgeons don't even know how to treat
these conditions anymore. When I was a resident,
we used to see horrible rheumatoid arthritis joints
that would need a joint replacement or hand
surgery.
And these conditions no longer exist just because
of the the osteobiologics
that have come out. So, anyway, I'm I'm
I'm excited about
future,
osteobiologic
mod drug modifiers,
you know, to modify the biology.
That is exciting.
Well, doctor Greenwald, I wanna thank you for
your time today. But before I let you
go, is there anything else that listeners should
know? Sure. I just wanna put in a,
kind of a gratuitous
plug for the, own the bone program, which
is,
a subsidiary of the American Orthopedic Association,
that is
very interested in setting up programs around the
country to help doctors
treat patients who have these bone diseases, weak
bone diseases.
So I'm excited to
be involved with that organization
and looking forward to starting my own clinic
in Montana
in this in the fall.
And I'm excited to be starting
a new career
that
is
opening up a bone health clinic
at the Great Falls Clinic in Montana
using the own the bone model, which is
the AOA that I was speaking about before.
Got it. Well, doctor Greenwald, I wanna thank
you once again for your time today and
for joining me on the Becker Self Care
podcast. Thank you. You're very welcome. Thank you.