This is Carly Beam with the Becker Spine
and Orthopedics podcast, and I'm thrilled to be
joined today by doctor Shalun Bira, chief of
orthopedic spine surgery at Banner University Medical Center.
Doctor Bira, thank you so much for joining
us today.
Thanks Thanks for having me. And so before
we dive into questions, I'd love if you
could just introduce yourself, share a bit more
about, your work.
Yeah. I'm a spine surgery surgeon at Banner
University Medical Center.
I've been here for about two and a
half years.
I help lead, the OrthoSpine
service line,
in the Phoenix Valley. It's a very rapidly
growing part of the country,
and, we're seeing a lot of, increase in
in, volume and then people with spinal pathology,
both for degenerative,
conditions and deformity and,
as well as trauma and tumor, kind of
the whole gamut of spine conditions we treat.
So it's been a a great, environment.
Very exciting to hear about, you know, increased
growth, increased volume. Can you talk about how
you see your role with the spine department
at Banner evolving,
and what does growth look like to you
in 2026?
Yeah. Part of it is
really sort of supply to to meet demand
quite simply. So as we grow at different
sites of service, as banner expands across the
valley and across Arizona,
really having people,
meet that demand at different points. So we
are growing as a service line. We're actively
recruiting
surgeons.
We function
with very well with neurosurgery,
colleagues. And so the neurosurgery department has certainly
grown in terms of their service line, and
so coordinating with them has been a great,
joy.
And,
so part of the growth for 2026
is going to be increasing
our capacity to do surgery at different sites
of service,
and part of it is to continue to
increase new technologies
and incorporate
new technologies
at the different sites of service.
Yeah. So, like, are you are you planning
to,
you know, absorb
practices,
build a new banner,
facilities?
What does that look like?
Mostly,
more from a personnel standpoint growing in terms
of
nonoperative
and operative spine providers.
So I think Banner has a great platform
in terms of having insights of services, whether
it's hospital, surgery centers, clinic locations,
and but really bringing,
the spine like, high quality spine providers to
those locations.
Yeah. So then you talk about, your strategy
for recruiting and then keeping,
spine surgeons and nonsurgical
spine specialists.
Mhmm. Yeah. So really growing a good collaborative
environment, a good jovial
environment,
looking for people with good camaraderie,
and people who work well in a large
institutional setting. So really just, hiring carefully and
hiring people who've had great training,
been to been to you know, we have
people on our, faculty who train at all
the best places around the country
and, who wanna be in a in a
very exciting part of the country, Phoenix and
and Scottsdale,
and the surrounding areas is is a great,
place for people to live, raise families,
and stuff like that. So has has there's
been no shortage of people who've been,
been interested in. So we've been, you know,
forming a team
that includes people with different skill sets. So
we have people who are really good at
minimally invasive type of surgery. We have different
people who are really good at intradural
surgery,
spinal cord surgery, and then we have different
people who are really traditional in deformity training
like myself.
And so, really,
just just as a football team or an
NBA basketball team is formed, you know, we
try to
recruit all stars
who are in who touch the different areas
of spine and then comprise and then come
up with a great,
overall team, which I with expertise in different
fields. And that same thing goes to the
nonoperative side as well. That's excellent. I love
the analogy you're using here of, like, an
NBA team.
And then, doctor Vierra, I wanted to ask
you, you know, specifically some questions,
related to,
spine technology, especially, with robots. You know, spine
robots, they Mhmm. Often, you know, they offer
lots of promise when it comes to precision
and consistency, but they're also,
you know, really expensive. So
how should health systems and practices
weigh these types of purchase decisions?
Yeah. I think the very first question
that either administrators and surgeon leaders have to
ask themselves is that, does these tools
solve a problem that we truly have at
the volume we have?
One of the things I learned from my
training at Cleveland Clinic was that
whenever evaluating a new technology, the first thing
to ask is that, is this solving a
problem
that that I had in my practice? You
know? And that just that scales to not
just the individual surgeon, but the institution as
well. You know? A lot of times,
the the a lot the clinical benefit,
is questionable beyond the marketing optics. You know?
You know, I've had the pleasure of going
to business school as well, and so we
learned a lot about capital allocation and,
have a, you know, whole background in finance,
prior,
you know, during during my college days and
went on. So, you know, we looking at
the return on investment
becomes very interesting when you go beyond
the
the marketing
aspect that gets, you know, highlighted in in,
you know, newspaper, magazines or platforms like Becker's.
And looking at that this what
does it change in terms of reliability? What
does it change in terms of training?
Does it build resilience in the system?
So I have a a recently started a
substack, basically, a blog on
business strategy and spine surgery.
Encourage readers to to look at it and,
recently wrote an article about robotics
and where I introduced the concept of surgical
fragility. So just as, you you know, financial
fragility is a well established topic in the
economic space,
in terms of bank fragility and and,
capital allocation in that in that world, you
know, what I have a concern of in
robotics is that is it deskilling surgeons, and
is it creating surgical fragility in, in a
sense that
having getting too used to whether it's not
or getting too used to our robots,
will that result in case cancellation if those
if that robot or if that alarm or
navigation
breaks down or is not working on that
day? You know? And so I look critically
at
systems and developing banner as an institution
to in to be antifragile, meaning,
can we function? Can we do these cases?
Can everybody in our department do these cases
with or without robots? And
and capital
decisions should be based on
being active and making the system
more antifragile or more resilient as opposed
to making decisions that lead
to fragility or dependence.
And that's a great point you bring up
about surgeons possibly becoming dependent on these technologies.
How are you approaching this and ensuring that
spine surgeons are becoming skilled
with these without falling into that trap of
fragility?
Yeah. So one of the and I I'm
not an expert on this, particular
subject. I I kinda borrow from one of
our business school professors, Kartik Hosnagar at Wharton
School,
where he,
talks about AI and how that's deskilling
different workers in the tech world.
And so I kind of adapted some of
his teachings to
propose some of these guardrails that we're working
on. You know, one is human first planning
rounds, you know, define trajectories and and bailout
options before using a robot or before using
a navigation,
you know, protecting core skills. So
freehand screw placement, you know, reasoning based on
fluoro shots, intraoperative adaptability,
that should remain as the cornerstone of how
we train residents and fellows and how we
advise our junior faculty.
You know, analog quotas and drills,
you know, routine off robot off practice. That's
one of the
the ideas that I'd adopted from professor Hosniger
about, you know,
providing
opportunities for cases that obviously do not use
a lot of stuff. And so that keeps
your
precision and keeps all of our skills up
to date,
and that ensures resilience
Mhmm. And and credentialing emphasis on baseline mastery
before robotic
usage.
And so if a robot becomes the only
path a surgeon feels comfortable taking, that's not
progress. That's just fragility.
Got it. And then, doctor Viro, I was
wondering, you know, what are three top trends
you're following in health care, whether you're looking
at it broad scale or very specific to
spine itself?
Yeah. It's interesting. You know, 2024 and 2025,
you see in the tech world outside of
our space, the AI arms race by a
lot of the big tech companies, you know,
and valuations have skyrocketed
based on on the the growing adoption of
AI. Now I think in 2026, what we
see from the tech industry is that
these we're looking at ROI now, not just
adoption.
And and so I think that is also
there. The parallel universe happening in spine.
One is capital discipline and med tech adoption.
So robotics
and AI
are in now being scrutinized in 2026 for
ROI, not just the novelty.
Hospital leaders are demanding clear and measurable value
before deploying, you know, these multimillion dollar technologies.
One of the other trends I see is
resilience and skill creation in clinical practice. You
know, as as this AI and the robotics
hype has kind of settled down,
what I was talking earlier is that we're
getting focused on preserving clinician judgment and building
anti fragility,
especially in terms of our training systems
that ensure that care continues even when tech
fails,
and as the tech continues to develop.
And then third is smart integration across of
data across care pathways. So how do we,
harness data? There's no shortage of data, but
how do we harness it to improve surgeon
judgment?
Excellent. And I was wondering if you're still
kind of hook on. I really like what
you're saying about,
AI, thinking about, you know, shift towards thinking
about
ROI. What are some of the biggest metrics
or advice that you have for
physician leaders, not just in spine, but just
in health care in general? How should they
be thinking about ROI? What are the red
flags, the green flags?
Yeah. It's in you know, one of my
articles that looks back is that there is
no real KPI or clear ROI metric.
It's really is the system being made more
resilient? So it's not just about, you know,
reduced hospital comp
infections or reduced,
complication rates in the way hospitals traditionally
view
performance, but in terms of, like, are you
building a good system, which is not easily
measurable. So I would say the real answer
is that there is no real ROI metric
or real KPI that you can use to
measure this, but it's more of like a
a you know it when you see it
in terms of are
people growing their practices well. Are are are
people doing good quality work? Are,
are people constantly doing,
cases and are able to innovate, you know,
and and expanding their surgical skill set or
their practice skill set, things like that, and
our the adoption of new technology due to
judiciously.
You know, we have multidisciplinary case rounds and
and and all the usual which which most
institutions have.
But so it's more of a sense, an
overall gestalt as opposed to any one clear
KPI.
Yeah. So it sounds like it's very qualitative
then. Yeah. Great. Well, doctor Vierra, thank you
so much again for, joining us on today's
podcast. It's great talking with you, and I
hope to connect again in the future. Thanks
so much.