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This is Laura Dirdo with the Becker's Healthcare
podcast. I'm thrilled today to be joined by
doctor Cho Kim, who's a spine surgeon with
ExCeL Spine Center and UCSD
Medical Center East Campus. Doctor Kim, it's a
pleasure to have you on the podcast today.
Thank you very much for having me.
Now I'm looking forward to our conversation because
I know you're really on the cutting edge
of a lot of the things that are
happening in spine surgery, really more minimally invasive
procedures, and some really cool,
innovative things that you're working on. But before
we dive into that discussion, could you tell
us a little bit more about yourself and
your background?
Absolutely.
Let's see. I'm in private practice in, sunny
San Diego, California.
I specialize in minimally invasive surgery and endoscopic
spine surgery in treating patients with,
degenerative conditions of the neck and back. I
went to medical school at Harvard,
did my orthopedic surgery internship and residency at
the universe University of California San Diego. Then
I did a fellowship in spine surgery at
the Mayo Clinic in Rochester,
and then I came right back. I was
on faculty
at UCSD.
And during that time, I was the, fellowship
director, the research director, and I started the
Society For Minimally Invasive Spine Surgery, which I
think is coming up on its 20 year
anniversary.
And then after about 8 years, I left
and
started private practice where I am now.
And I try to take care of,
like, high demand, high activity patients
who are looking for, like, minimum invasive options.
And I kind of really focus on a
few surgeries. My favorite surgeries are endoscopic discectomies
and decompressions,
minimum invasive fusions for spondees,
and cervical dis replacements for,
cervical radiculopathy or stenosis or neck pain.
I used to do everything, like deformity, but
it more recently, I've really focused on trying
to do a few surgeries really, really well
and try to optimize it. And, at this
stage in my career, that's been a really
good idea because I've been at it for
about 22 years now.
Oh, that's amazing to hear. You know? And
and certainly,
great to hear about all the different things
that you've done throughout your career. And congratulations
on 20 years with the Society For Minimally
Invasive Spine Surgery. That's a huge accomplishment, and
I know, you know, such an important way
to connect spine surgeons and those in the
spine field,
to to make sure that patients have access
to care. Now
from your vantage point, what are some of
the biggest issues you're following in health care
right now, especially as a private practice spine
surgeon and and somebody who is interested in
in the cutting edge technologies? What's really top
of mind for you?
I think the overwhelming
thing that really is
worrisome,
and I think it's an issue is
what I call insurance directed care.
So over the last 22 years, it's just
obvious how
every year there's more and more impact of
medical decision making based on what insurance companies
tell us to do. So,
I find
myself and my a lot of my colleagues
make
medical decisions and decisions on what type of
surgery and what type of care to provide
based on what is allowed by insurance companies.
So
I would like it
that we're more
physician directed care because that seems more normal,
but
it has been a relentless kind of progression
toward more and more impact of insurance companies.
So if there's one thing that I'm really
worried about is is
how little say we have in medical care
as it comes to policy making and how
difficult it is for us to impact that
kind of field
in part because,
you know, our pair our payers and insurance
companies,
they make it very difficult for us to
interact with them. Like, I wouldn't even know
how to reach them and explain something to
them. And and when I do do these
things, what we call peer to peers,
I've noticed that there's nothing I can say
or do to change their mind. Whereas 10,
15 years ago, they would ask me, and
they would legitimately care about my opinion. And
let's face it. Patients are unique and different,
and everyone's different. So that's why we have
these doctor to doctor interactions. But,
most of the interactions that I have with
another
physician that represents the insurance company is more
about than just telling me what the policy
is and very little about,
you know, my kind of take on the
situation,
why I wanna do this. And and it's
very difficult to convince them that what I
wanna do for the patient is right.
But here's the thing. Eventually, they will
they will
relent
because, you know, I'm not I'm just trying
to do what's best for the patient, and
they just make us work very, very hard
to get that point across. And at some
point, I can just picture a lot of
people just just give up. So
we need to figure out a way where
we can be more
impactful in that whole process because it should
be a team approach. It should not be
so adversarial.
And I can just tell you that's the
one thing that I feel very
unempowered to address. I wouldn't even begin to
know how to tackle that problem.
That's such a great point. And, you know,
something that we have certainly watched over the
years here at Becker's is that
relationship
between those peer to peer conversations with the,
physicians on the from the insurance companies. And,
you know, hearing that, it's become more challenging
to
have those conversations in a longer process,
than to eventually get those procedures approved. I
can imagine it's hard to work,
through that on the process side and the
operation side of the practice, but more so
even just for the patient trying to access
care.
It seems like it'll be such a big
challenge.
When you think about, you know, moving forward,
I know you mentioned it's hard to know
exactly even the first, move to make in
how to resolve that problem. But,
you know,
is there anything that you're trying to do,
in order
to figure out how to,
you know, continue to move forward and make
sure your patients have access to care in
the best way possible despite some of these
challenges?
Well, unfortunately,
the strategy that I've taken is just hire
more people to spend more time
badgering the insurance companies because they will relent
if you
badger them enough because they figured, okay. He's
serious. He's not just joking around.
So, I have a massive team,
and then processes that try to do the
best we can. But I think the first
thing is is that we need to increase
awareness of this problem among everybody.
Because if it's just the physicians, I don't
think we'll have much say because
I don't find that policymakers really care what
we think as an individual.
Almost, like, as a as a group.
But they do care about everybody else, especially
the patients who
are their clients, who pay the premiums.
And I'll just give you an everyday example
of how how big of a deal this
is.
Just the nature of my practice. I take
care of a lot of high demand individuals,
including physicians.
And
the way they get their care is entirely
different than a whole another group of patients,
like, when I was,
early in my practice and took care of
everybody that's insured and a lot of HMO
patients,
and, like, managed care models.
So if you blew out a disc today
or a week ago,
if you're the typical
patient,
the this is the way the insurance companies
want you to get your care. You go
to your primary care doctor. You tell them
I blew out a disc. I'm in severe
pain. I can't get out of bed.
I think something's really wrong. Can we get
an MRI to find out what's going on?
The answer would be no because the insurance
companies won't authorize an MRI until you do
6 weeks of PT.
So there's a large group of patients that
go through PT in the right. They get
better, and you don't need an MRI.
But there's a significant group of patients that
the whole that at the end of PT,
they're not better, and then they get the
MRI. And then there's a group of patients
that even though they get better, the whole
time they're worried that they're doing something wrong
and they're harming something, so they don't really
participate in physical therapy meaningfully.
And
I guess 20 years ago when MRIs cost
2, $3,000,
that kind of made sense.
But MRIs are, like, 2 or $300 now.
And it doesn't make sense
to not have a diagnosis before you start
any kind of treatment. We don't do that
anywhere else.
It's it's so now that it's only 2300,
you'd think it like that wouldn't
change, but it doesn't.
Because
change is slow for 1. And 2,
no one says that this is a problem.
Now
here's the other group of patients.
If you're a physician or somebody that knows
a physician or has a family member that's
a physician,
if you had a blown out disc in
your bed bound a week ago, you're gonna
get an MRI this week sometime, and you're
gonna probably
hear from a spine surgeon sometime this week.
This is what happens the vast majority of
time if you're a physician or have a
family member that's a physician where you just
pick up the phone and make some phone
calls.
And I find a lot of my patients
just pay cash to get the MRI because
that's what I would do.
I wouldn't wanna start PT
without knowing what my diagnosis is.
I mean, just mentally, and it's makes more
sense. So that's just one small example of
the difference between,
what should be happening. I mean, that may
be an extreme case and what is happening.
And
I think the first step is awareness, and
then the second step would be find people
that care about this, that like interacting with
insurance companies and
let them know that some things need to
change. And just I bet you if we
just ask the insurance
executives
by the way, I take care of a
lot of, like, doc I took care of
several doctors that are peer review doctors that
get on the phone and tell you you
can't do your surgery. Guess what they do?
They that they do exactly what I just
said. They get an MRI within that week.
They they hear from somebody,
like a spine surgeon, right away about what
the diagnosis is. And if it's a big
blown out disc, they'd get seen. If it's
nothing, then they go to PT and stuff
like that. But,
we just need to ask them, what would
you do for yourself? Because that's what you
should do for your clients.
That simple question, I think, will take us
most of the way there.
That's, you know, fascinating to hear. And, certainly,
I can imagine, especially as I've been hearing,
you know, for a while now that consumerism
is becoming a huge part of the health
care ecosystem. And those, like you said, who,
you know, don't wanna wait for care, it
seems like such a reasonable price, a couple
$100,
versus going through 6 weeks of physical therapy.
If you think you have a a problem,
makes a lot of sense. And, yeah, it
just it'll be fascinating to see how the
next couple years, you know, with the focus
and and really looking into,
the types of issues on quality as well
as costs, if that will make a difference.
Now I'm wondering too, what are you most
excited about right now, and and what makes
you nervous?
Probably 2 things.
And and these are both exciting and,
nerve wracking. The first is, like, social media.
And I've really embraced social media because
I'm all about awareness. And things have changed
drastically compared to 10 years ago and before
COVID. Because social media is so
prevalent now and such
a
common way for
everyone to get information that I can just
make a post and thousands of people might
see it. I I have a video that
has over a 100,000,000 views.
10 years ago, there'd be no way I
can get any kind of message across to
that many people.
So,
you know, social media has all its problems,
but one huge advantage is that
it allows
information transfer to be
much more easy
and much more grassroots.
And I bet you
it's gonna be the swell of,
you know,
knowledge on social media, awareness through social media
that's all these issues that will kind of
stimulate
change much more rapidly.
But at the same time, you have to
be careful because it's an opportunity to put
out there a lot of misinformation too. Now
looking at it from my perspective, I'd rather
have,
you know, an open spigot on both ends,
good information and misinformation than to try to
control information
and decide which is good and which is
bad.
I mean, those are the two options, and,
I don't know how to
how to police that.
That's hopefully something that somebody's thinking about. But,
overall, net net, I would say that if
I was a patient and a consumer,
social media is unbelievably helpful
in trying to learn about what's going on
and trying to figure out what I should
do next and who I should believe and
who I should go see and,
and questioning, you know, information from just one
source because there's multiple sources. And after a
while, you can kinda get a sense of
what's believable or not. That's that's my optimistic
view of information transfer.
But if, if an evil entity decided to
overwhelm
the Internet with misinformation by the way, that
happens a lot. Like, our food industry is
like that.
That would be bad. The other thing I'm
really excited about and also petrified about is
AI. And
I don't like the using the word AI.
I just like using it's it's like
you want, like, better and better apps
and programs
that do stuff that you don't need to
do and remember things. And there's so many
things that we do in medicine that involves
these huge checklists,
and it's shocking how resistant humans are
in going through a checklist of, like, 50
items. The airline industry does it meticulously. That's
why they're probably one of the safest
industries on the planet. I mean, they they
have very little,
relatively speaking, like industrial injuries, like crashes and
things like that because they are
they're like into Sigma 6 and checklist manifesto
and things like that.
In the field of medicine, we really kind
of resist that for some reason.
So with AI, we're gonna be in a
situation where we can focus people's energies on,
like, high level things. Not like making sure
that, you know, there's enough Band Aids in
the in the Pyxis, and we're not we're
not in the middle of surgery forgetting to
do this.
Like, everything is just
totally laid out, consistent.
And just like all the kind of apps
and programs and
and things that we use, like
like, you know, NASA? They have programs to
plot out all the different trajectories of their
space flights because it's kinda complicated. It's not
like just a straight line. They use all
kinds of, you know, gravity
things that
swing things around planets and just bizarre things,
and you can do it in so many
different permutations at different times to find when's
the best time to launch this rocket. If
you didn't have programs to do that, you
would it would be impossible to find easily
all these different parameters.
And the same thing should happen in medicine.
We should be empowered
to be better at what we do,
and that includes, like, an AI program that
will help me decide what the best
treatment for this diagnosis is. It may help
me decide
what that diagnosis might be if it's a
little confusing because we can always use information.
You as a human
make the final decision. You may have a
few options
to choose from, but you don't have to
rack your brain and your cognitive energy to
do all the basic things to get to
that point. You can save all that energy
for very high level things that involve human
things. Like, you know, we don't make decisions
purely on logic. We're not Vulcans on Star
Trek. You know, Vulcans are never the hero.
It's always that really emotional
Kirk. Kirk is like the he's, like, not
rational.
He's passionate,
and and that's what, in the end, we
gravitate towards. So I don't think AI will
ever replace humans
at the end,
but they will replace a lot of things
that humans aren't very good at
and really
don't enjoy doing. And so
I think for somebody like me that's always
looking to be better and better and better
and better and trying to, like, eliminate, like,
little things that slow me down,
AI would be great because I'm a huge
checklist guy.
But at the same time, I can just
see if we swing too far that we
start living in a world that is completely
devoid of emotions,
feelings,
of things that are very human.
And we may end up making
poor decisions because we don't take that into
account. I can't picture an AI program being
able to address that issue. It'd be sort
of like AI can generate art,
but
whether that art is beautiful or not, in
the end, is in the eye of the
beholder.
Right? The final decision on if you're gonna
pay some money for that piece of art
and how much if that's a human decision.
And we'll always have that.
And those two things are, like, social media
with AI. Those are all high technology things
that,
its evolution
is not like little by little. It is,
like,
exponential.
So in 10 years,
I think my work environment will be very
different. I will have a lot less people
doing mundane tasks.
All those things will be done by, like,
scheduling,
authorizations.
I mean, even dictating a note. Like, there
are pro AI programs that will generate a
clinic note based on your conversation with the
patient. It will just record your normal conversation.
And you have to right now, you have
to do a few things to kind of
prompt it to know that you're looking at
an MRI.
But you can you don't have to go
in order. You can just see the patient,
record the whole thing. It will know who
you are, who the patient is, who patient's
partner is.
It will know that you don't have to
put in things about the dog walk yesterday
and how the dog pooped on your lawn
and a lot of extraneous thing. It's shocking
how already it's so much better. So we
don't need, like, scribes. We don't need transcriptions.
We don't need me to sit down and,
like, type while we're talking to the patient.
I can devote my entire
cognitive energy and attention to the patient and
the patient's needs. And that's gonna be great.
But I'm fearful that
I'll end up being by myself in an
office with no one to talk to, and,
you know, I'm an extrovert as you can
tell.
And
that sounds really lonely.
So,
like everything, it's a good and a bad,
but this is a those 2 things are
freight trains coming. There's just no way we
can avoid it.
And I think the best thing to do
is that we embrace it,
identify all the positives, and take advantage of
it, and try to
limit,
mitigate,
control if possible
as many negative aspects of it as possible.
And it will be no different. Like, I
guess when TV came out, people said, like,
when it gen create a generation of, like,
brain dead people because they'll never read. That
never happened. Same thing with,
calculators. Like, you're not gonna be able to
do math. It's like, who cares, like, if
I can't add up all that stuff? It's
not, like, important to me. No one's gonna
test me on it anymore. And it's just
that in a whole another level. So,
net net, I love technology. I love doing
things better and better and better. And,
overall, I'm extremely excited about the future.
That's fascinating. And, you know, certainly, all those
different things that you've mentioned, whether it's looking
at AI or social media or other ways
that technology is really transforming health care in
so many industries right now. It is exciting
to think about the future and what the
possibilities are. We'll also, you know, trying to
be mindful of limiting or mitigating some of
the challenges. And, certainly,
you know, we always love having you here
at Becker's, doctor Kim. So, you know, never
have to be in a
room by yourself with us. That's for sure.
Before we wrap up here, I'm wondering, you
know, looking into the future, whether it's some
of the,
payment challenges or some of the other challenges
on the operational side of health care and
then to some of the exciting possibilities and
opportunities,
what do you think is going to be
important for spine surgeons and leaders in spine
in general to do in order to be
successful in the next 2 to 3 years
or so?
Well, there's kind of, I think, 2 layers
of that.
There's the layer of how can spine surgeons
be successful on a day to day basis
with their practice.
And then
what spine surgeons need to do to
deal with this whole issue of what I
call, like, you know, insurance directed health care
and hospital
administrator
directed health care. Because I'm sure you all
know, but I'm not sure that everyone else
is aware. If you plot the growth of
physicians at a hospital on a curve, it's
kind of like this flat linear line that's
just gradually increasing. If you plot the number
of administrators in a hospital, it is like
it's, you know, log myth logarithmic curve. So
maybe 20 10, 20 years ago, it was
like 1 to 1, maybe 2 to 1.
Now it's like 20 to 1 or 30
to 1.
Administrators
to physicians.
So,
you know,
the kind of, like, the momentum is toward
more
people that
are not directly involved in patient care, making
lots of really important medical decision making policy
policies.
And I
came to realize how important this is with
the recent acquisition of my little hospital called
Alvarado by UCSD Medical Center. So I've been
at UCSD for a long time. I did
my undergrad there. I did my internship and
residency there. I
was on staff as faculty,
assistant and associate professor there for 8 years.
And when I had a big surgery, guess
what? I had it at UCSD.
So I know that entity very well. And
10, 20 years ago,
it was like a
state university.
That's why I left.
But something happened in the last 10 years,
and the leadership of UCSD really represents kind
of, like, what I think
what the future
you know, like, health care leaders should look
like,
to really
address some of the problems that we deal
with. So, you know, as you can imagine,
I'm talking about the whole policy thing. So
UCSD,
all the big gun leaders
still see patients.
Now
from a salary perspective,
it is hard to, like, replace
the income that you might have with seeing
a patient because that's what you've been trained
for. You're not trying to be, like, an
administrator. So, usually, when you do administrative work,
it's almost like you're volunteering your time. So
you never get anybody that's really high level,
dedicated, and has enough time and cognitive energy
to devote toward important administrative functions. But
if you set up a system where
the leaders
can see patients, but they have protected time
to be like the vice chancellor
without having to sacrifice too much.
Now you've got,
you know, a group of physician leaders that
still are reminded
what it's like being in the trenches. Because
in the end,
no matter what you do, it's all about
the patient in front of you. I mean,
if that's not important to you, you should
have probably not gone into medicine.
When you have a patient in front of
you, that's like that's begging you for help.
You feel very important.
Making decisions about policy? Yeah. But when a
patient's looking to you for help, that is
the most important thing you gotta be doing
at that time. So if you have trouble
with things like that and you run into,
like, these little obstacles
and you are in a situation of lead
in a position of leadership that can make
change,
I think when I go to tell them
what I'm trouble having trouble with, they're more
likely to understand.
And I'll give you an example. I just
did a peer to peer with insurance
physician.
And one of the first things that physician
said is,
I looked it up on UpToDate,
and I didn't see
I I couldn't get enough information to make
a decision.
So I said, great. I've got tons of
information because up to date is trying and
it's great, but it's not usually up to
date. And let's face it.
Every patient's different. So I went on this
long diatribe about why this patient needed the
surgery.
And that physician listened, listened, listened, and you
could tell he couldn't care what I said.
He goes,
well,
I can't
change this. This is actually not a peer
to peer. I'm just here to tell you
why
it's denied.
I can't actually override this.
And
I was shocked.
I mean, I'm on the phone. I did
some research. I pulled articles.
I talked to him about it, and I
gave him a very coherent,
convincing argument,
but he does not care because
he's an insurance guy.
He probably doesn't seem to have any patients
because he's not busy enough to, like,
fill up his time. Otherwise, why would you
wanna do that? Why would you wanna deny
care to other surgeons
unless you need to fill up your
kind of book of business? And he wasn't
even a spine surgeon.
So,
I think the change needs to happen at
the top. We need to figure out a
way to
have the, you know, talented people, not the
people that are not succeeding in clinical practice
that go because usually the people that aren't
succeeding clinical practice
tend to go into these types of fields.
If you're a busy,
successful physician, why would you wanna do insurance
work? You're too busy seeing patients.
Those are the types of people that you
want in the leadership position because they've demonstrated
success in clinical care.
They,
are aware of all the challenges that we
face, taking care of patients, and it's already
challenging enough just medically taking care of patients
as a spine surgeon.
I try to do the perfect surgery on
every patient.
There's no way I have perfect results. It's
like Formula 1. You're gonna crash
a lot. And then now you got me
trying to think about something else on top
of that. It's completely unrelated to this particular
patient.
There's just no way. It's like trying to
play 2 professional sports well. There's only a
few people that can do that. Maybe Bo
Jackson.
Maybe one. Bo Jackson.
Even
Michael Jordan, the most talented athlete on the
planet,
didn't do well enough to to make it
in the major leagues. Yet in basketball, he's
just a standout.
So,
we need to figure out a way, like
UCSD did, to take talented clinicians
and
embrace their desire to make change because they're
leaders,
and make it so that they're able to
do that without too much sacrifice. I suspect
they're sacrificing anyway, but if you make them
sacrifice too much, they won't do it.
People that are talented and capable and successful
won't
won't do it. It's it's
it's not the most pleasant job being an
administrator as a physician.
So if there's one thing I would do
is I would tell every hospital system and
every university that they need to fill their
ranks, not with a bunch of administrators, but
with
physician leaders
that take care of patients
and then
find a way to protect their time so
that they can devote to leadership activity without
sacrificing too much.
That's
amazing to hear, you know, and certainly great
to know what you've done in UCSD and
how they've been able to,
tap on not only clinical leaders who have
been very successful clinically, but then support them
on the administrative and leadership side as well.
Doctor Kim, thank you so much for joining
us on the podcast today. This has been
such a fascinating conversation, and I look forward
to connecting with you again soon.
Thank you very much.
It was great being here.