CODE speaking with Dr. Mark Weidenbaum, MD at the 4th Interdisciplinary Conference on Orthopedic Value Based Care 2020

Session Topics:

  • Preoptimization in Spine Surgery – The Orthopedic Approach
  • An Innovative Approach to Clinical Pathways in Spine Surgery

Interviewee: 
Dr. Mark Weidenbaum, MD
Vice-Chair & Professor of Orthopedic Surgery
New York-Presbyterian Hospital
Columbia University College of Physicians and Surgeons

Breanna Cunningham:
Hi, there. This is Bre Cunningham with CODE Technology. I am here with Dr. Mark Weidenbaum. He is the Vice-Chair and the Professor of Orthopedic Surgery at New York-Presbyterian Hospital. They just went live this month with Epic, so God bless you for being here. And we are here at the OVBC Conference, 2020 is the fourth year that this conference has been going on but your first time here.

Dr. Mark Weidenbaum:
That’s right.

Breanna Cunningham:
So let’s start with this, how are you here?

Dr. Mark Weidenbaum:
I’m here because I spoke to Zeev about this conference because I thought it was a very interesting venue. And the topics that I have in mind seem like they could have a place here, and he was very receptive to that idea and invited me.

Breanna Cunningham:
And you have two talks tomorrow?

Dr. Mark Weidenbaum:
Yes.

Breanna Cunningham:
What are the titles of those talks?

Dr. Mark Weidenbaum:
So one of the talks is really talking about the process that we use to evaluate people before they have surgery. And the other talk is about the process that we go through in terms of what we call a clinical pathway, which is how we think about the process of indicating somebody for surgery, what we do to prepare them, how we think about it during the surgery and afterwards. And then some comments also about culture and safety.

Breanna Cunningham:
Interesting. For your first talk, that prehab concept or really activation and determining whether a patient is a candidate for surgery, should have surgery, is such an important topic and has come up throughout this conference. Can you talk to me about what you are doing at your campus to ensure that the right people, the right candidates, are being converted to a surgical candidate?

Dr. Mark Weidenbaum:
So our conference really, we have what’s called a POC, the preoperative optimization conference. And the idea of this is, for you, if you have a difficult surgery, it’s not so much as the surgery indicated, it’s usually a surgery that you think should be done. But either the person has a lot of medical problems, they have diabetes, they have high blood pressure, they have heart disease, they may have depression, they may have had a blood clot, they may have something in their history that makes them a little bit more complicated. And the other question is, should I do this particular surgery or should I do a modification of that, do something slightly different. 

And so, we try to get people together, obviously, the surgeons are there, but we really want the anesthesiologists, the medical people, the ICU people, the physical therapists, the PA’s, the nurses, and the people that are going to be actually taking care of that person on the floor. Because we all know that spine surgery is sometimes complex, and it isn’t always guaranteed and that there can be problems afterwards. And if we can minimize the likelihood of a problem happening afterward by really being well prepared beforehand, that would be the best thing.

And so, the purpose of the conference and to get everybody in the same room and, in particular, the surgeon. If the surgeon is planning to do an operation, they have to be physically in the room or at least remotely connected so that their case can be discussed, if it’s at a particular level. And the way that this happens is after surgery, say you schedule a surgery, we have a dedicated person who goes through the chart, and we have developed a sort of homegrown, in house process for grading that, or evaluating that, and it’s called green, yellow, red. If somebody’s green, it means that they’re basically healthy, the surgery is not a problem and there’s not…

Breanna Cunningham:
No conference needed.

Dr. Mark Weidenbaum:
No conference needed, exactly. If they’re yellow, it means that there are issues, but they’re what we would call modifiable issues.  Maybe they have diabetes and maybe their diabetes isn’t that well-controlled or maybe they have to have something done for their heart. That’s something that can be fixed so to speak, and tuned up prior to surgery. That would be a yellow type of case. In a red case would be one where there’s something that’s not likely to change. For example, if someone is very elderly or if someone has a very, very serious medical problem, but for whatever reason, the surgery still seems to be indicated. Obviously, there’s high risk with that, so should that case be done? And we want the patient to have the advantage of having many eyes on that.

And so, what we do is the screener identifies the yellow and red cases, notifies the appropriate surgeons in advance, and then we meet once a month to go over these difficult cases. And the meeting is usually held about a month before the surgery is planned for, so if any comes up in the meeting there’s time to fix it before the surgery. And then we go through a very, shall we say, energetic discussion with various parties back and forth, and try to get everything as best as we possibly can and come away from that either with, “Oh, gee, you didn’t do this, or you should’ve done that in terms of preparing the patient,” or, “Gee, you did a great job. They’re really ready to go.”

And yeah, it’s a tough case, but there’s nothing else to do. And the problem with not doing these tough cases is they only get tougher. If somebody is older, they’re just going to be that much older. If they have medical problems or what we call comorbidity, those comorbidities don’t usually go away with time.

Breanna Cunningham:
How long have you been doing this?

Dr. Mark Weidenbaum:
We started a year ago.

Breanna Cunningham:
And what’s the early feedback from it? And also, the whole green, yellow, red, I love that because it’s simple. But have you had to refine or massage that over the course of the year?

Dr. Mark Weidenbaum:
It’s a great question. Yes. And so, we realize that our way of measuring isn’t really quite there yet. We’ve noticed that in some cases we’ve underestimated somebody and overestimated somebody else. So we’re trying to refine that, so before we actually try to publish it or do anything or have other people try to do it, we want to try to get it as good as we can so to speak.

The way that the metrics that you use to decide whether or not it’s working, there’s something to be discussed about that. Because do you look at returning to the operating room? Do you look at returning to the hospital, to the ER, etc? Do you look at the amount of pain the person has? What’s their functional capacity? And there’s some discussion about what metrics to use with that. But at least we’re looking now and, most importantly, of all the things that really is happening now is that you have people understanding each other.

Previously, you were siloed, you kind of know your part. The surgeons weren’t interested in the medical part. The medical doctors often were not familiar with what the surgeries were going to be. Some of the anesthesiologists were very familiar with the surgeries, others were not, nurses, therapists, et cetera. So now, everybody’s in the room seeing, hearing, discussing. We solicit opinions and this and that. And so, it’s a dynamic process. It won’t be the same next year. Hopefully, it’ll be better. But it’s challenging.

A, it’s tough to find a time when everybody can meet. So we have our meeting at 6:00 in the morning, which is not difficult for us surgeons, but it’s very difficult for people that are not used to getting up that early. An issue to is that it’s time-consuming to do this, which means that you’re pulling people… Obviously, everybody should want to do this, but the reality is everybody’s really quite busy. So you really need the resources to be able to do it properly.

Breanna Cunningham:
You’re right, it’s a big commitment. So after a year, are people still excited and ready to continue going with it, continue having it evolve and get better, participating?

Dr. Mark Weidenbaum:
Everybody comes, everybody now knows and they feed us cases. We have a certain set of, like I said, the yellow and red cases. And we now have people that say, “Hey, can we bring this case up? Can we bring that case up?” Because they know it’s a forum. We have a regular conference once a week for spine surgery cases, but there are so many cases to go through you don’t have enough time to really delve into the detail and complexity of any given case. And so, with everybody’s schedules, there’s no time to do it. So people look forward now to this. It’s a really high quality, a high-value time where we can get done what there’s been no other way to do in the past.

Breanna Cunningham:
Nice. So I want to talk a little bit about how you got this process started, because Dr. Bruce Cohen from OrthoCarolina, yesterday in his talk, on a panel discussion, had a really fun comment. He said that “Healthcare practitioners are like Norm from Cheers, and they want to walk in, they want to sit at the same stool, they want to have the same beer from the same person.” Right? And I think that is really true, especially when you get in your groove. So when you first started this, how did you drive adoption of a multidisciplinary team, particularly the providers that are involved that’s shaking up with their norm is?

Dr. Mark Weidenbaum:
Well, the way…

Breanna Cunningham:
Norm is? Did you get that?

Dr. Mark Weidenbaum:
Kind of slow, sorry about that. It’s been a little while since I’ve seen Cheers though.

Breanna Cunningham:
I know, I don’t think I ever have.

Dr. Mark Weidenbaum:
We began this process actually at the behest of our malpractice carrier. The company that insures our university and several others asked us to do this, and not only us, but each of the other universities that they insure. “Hey, folks, can we get a team together to look into how can we look at spine surgery?” And they supported us to do it, and they encouraged us to do it, and they continue to support us doing it. And it always takes something to initiate and to get it going, but I think at this point everyone’s used to it. I think that they, other than having to get up early, they look forward to it.

Breanna Cunningham:
I love that. And I will say that that’s going to be a perfect subject for this conference and the audience that’s here. Having those practical things to take home to their groups of what have people been able to do to get that inertia. Getting that inertia sometimes is the hardest part, right?

Dr. Mark Weidenbaum:
Sure. Yes.

Breanna Cunningham:
What are you most excited about for tomorrow’s sessions? Outside of your talks, of course, which everyone should attend.

Dr. Mark Weidenbaum:
No, it’s a great meeting. I mean, it’s wonderful. There’s a tremendous diversity of topics and, again, it’s nice to have people from different walks of the interface and understand each other a little bit better. Because, as you know, the more modes there are for communication, the more we get locked into our silo. And you’ve got to constantly break that, and look in the next room, and talk to other people, and understand things differently. Because we all know it’s going to be whatever we’re doing now it’s going to be different shortly.

Breanna Cunningham:
Absolutely. Well, I couldn’t agree more. It’s a great conference. Looking forward to hearing your talks tomorrow, and also looking forward to seeing you back next year for 2021. Welcome to your first conference here with Dr. Kain.

Dr. Mark Weidenbaum:
Thank you very much, thanks for the invitation.

Breanna Cunningham:
Nice to meet you. Thank you.

Dr. Mark Weidenbaum:
Nice to meet you too.

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