The Surgeon's Record | Welcome + what it really means to be a surgeon 🪚
Edition #1
Wheels In
Intro + Opening Thoughts
Welcome to “The Surgeon’s Record,” presented by Commons Clinic. I am beyond excited to spearhead this effort as Editor-in-Chief. This post is a soft launch for a newsletter we intend to make required weekly reading for anyone interested in healthcare innovation, healthcare technology, and novel care delivery models.
In the coming weeks, we’ll incorporate guest authors, cross posts, webinars, interviews, and other avenues to drive meaningful discourse and thoughtful discussion. This is another step in the long but necessary journey towards a sustainable healthcare future that emphasizes quality, value, experience, and the clinician-patient relationship.
In the inaugural edition of “The Surgeon’s Record,” I’ll be highlighting my own experience as a surgeon and sharing some thoughts about the coming evolution of my profession.
[What’s the difference between God and a surgeon? God knows he’s not a surgeon. Classic. No wait—don’t unsubscribe yet! Next week, I’m sharing my thoughts on value-based tithing!]
Dem Dry Bones
From the EIC’s Desk
What does it mean to be a surgeon? Newsweek published an article this week declaring surgeons among the most trusted health care operators. It’s a nice win for our profession at a time when there seems to be a lot of negative sentiment toward surgeons in the healthcare innovation ecosphere.
I feel this acutely as an orthopedic surgeon. There’s an entire subset of health-tech operators whose primary focus is to keep patients away from people like me. You can’t invoke virtual musculoskeletal system (MSK) or value-based specialty care without adding “unnecessary procedures.”
Based on the discourse, you’d nearly expect surgeons to be standing at the hospital entrance, ready to shake patients down for every last penny in their pockets. It’s enough to make a sawbones question if any of the procedures he’s doing are indicated. So it’s nice to see Newsweek offer surgeons some much-appreciated praise.
The operating room is, in many ways, a sanctuary. For the duration of the procedure, the focus is on the patient and the upcoming job. In the best operating rooms, distractions are minimized and near perfect synchronization is achieved. Going under anesthesia is the ultimate abdication of control and expression of trust from a patient to their surgeon. As Commons Clinic’s Amandeep Bhalla, MD says, being imbued with this level of trust is a “fantastic gift,” one that comes with a certain level of expectation.
“When a patient is under anesthesia, the only thing in the world that everybody in the room is focused on is the patient” — Amandeep Bhalla, MD
We now live in a society where skepticism and distrust of institutions are the norm. According to the Newsweek article, only 56% of Americans rate medical doctors “high” or “very high” in terms of honesty and ethical standards (down from 65% in 2019).
Trust is a critical component of delivering high-value care. In today’s healthcare environment of declining reimbursement, increasing administrative burden, and electronic health record (EHR) inefficiencies, time is compressed and the doctor-patient relationship suffers.
Trust is developed through engagement. Patients want to express their concerns and feel heard, but they only get about 11 seconds to do so. Overcoming this loss of trust will not be easy, but doing so is critically important to realizing the promise of value-based care. Our challenge is to reverse the processes that have degraded the doctor-patient relationship. Surgeons may be best positioned to lead this charge due to the nature of the care they deliver.
To restore trust, we need to strip away the barriers and the mechanisms that created them. That’s advanced care delivery. To steal a quote from noted X health-tech instigator Stuart Blitz, “Who’s building this?”
“[S]urgery demands that doctors cross [the] divide and understand their patients from the inside out.” — Alexis Kayser, Newsweek
What it means to be a surgeon is changing. When I started my career, joint replacement patients spent days in the hospital, languished in bed, got blood transfusions, desperately jabbed PCA buttons for a tiny dose of pain medication, and were strapped to knee machines that involuntarily bent and straightened their freshly replaced knees. Most were sent to rehab centers or skilled nursing facilities. We rarely considered the costs or consequences of the care we delivered. Healthcare resources seemed endless and dogma was the only required evidence. But 15 years have brought sea changes to the way we practice.
Patients walk within hours of surgery, and many now leave the same day. With advanced anesthetic and surgical techniques, blood transfusion rates are near zero and opioid-sparing surgery is a reality. A discharge home is not just preferred—it’s proven to be safe and less likely to lead to a readmission or complication following joint replacement.
We’re no longer oblivious to the impact of the decisions we make. Where before our healthcare economic ignorance was bliss, we now embrace optimization, gainsharing, co-management, and reference-based pricing. The value creation generated by these advances cannot be underestimated.
Value capture has proven more elusive. We have become victims of our own success as “ratchet” mechanisms create a race to the healthcare bottom. It’s increasingly difficult to maintain autonomy and independence while finding a sense of fulfillment. In high pressure, high-stakes surgical fields, this struggle is accentuated. Expectations of stoicism and perfectionism produce the facade of surgeon as God. Humbling episodes lurk. Humility, if not innate, will be imparted. These aspects of being a surgeon are immutable.
Of course, the purpose of “The Surgeon’s Record” isn’t to catalog problems—it’s to highlight solutions. What it means to be a surgeon is changing, and our goal is to embrace, lead, and shape that change. We intend to drive difficult conversations and meaningful discourse. By surfacing innovative approaches and amplifying insightful voices, we aim to build a robust community of the best and brightest healthcare thinkers and doers. As surgeons, we can and should be catalysts for innovation and agents of change. Our motto must transform from “a chance to cut is a chance to cure” to “a chance to heal is a chance to provide value.” It’s an exciting time to be leading the discussion around value-based specialty care and translating real world clinical experience into next generation healthcare delivery. First step: Taken.
- Ben
Small Incisions
Quick Takes on Timely Topics
CMS Releases 2023-2032 National Health Expenditure Projections
My take: Yep, costs are going up and continuing to outpace GDP. Health spending will rise from 17.3% of GDP in 2022 to 19.7% in 2032. Some good-ish news: Medicare enrollment will slow somewhat as the last of the Baby Boomer generation turns 65 in 2029.
Increase $$ for Physicians, Institute Site-Neutral Payment, MedPAC Report Suggests (MedPage Today)
My take: Doctors dropping Medicare has been discussed for years now, but it hasn’t happened in large numbers yet. We may be approaching the point where those threats become reality. I have pretty mixed feelings about the idea of no longer seeing Medicare patients. On the one hand, it’s rapidly becoming our only leverage point. On the other hand, it feels like a violation of our oath and mandate as physicians.
A Social ACO For Medicaid Managed Care (Health Affairs)
My take: One of the biggest lessons from MSK VBC programs has been the importance of HRSNs when it comes to achieving good outcomes and reducing costs. Advanced primary care models like Oak Street Health and Iora Health have long understood this. As specialists, we’re getting better, but we’re still not great at it. A successful shift to condition-specific specialty care will rely on some form of social ACO or elements thereof.
Vinod Khosla: A Case Study of Unreasonable Tenacity (and Frozen Pizza)
My take: Four lessons in tenacity when innovating taken from Mario Gabriele’s email exchange with Vinod Khosla. Briefly: you’re closer than you think, associate with the best (not necessarily the most qualified) people, expect resistance, and don’t neglect selling. These are especially difficult lessons in risk-averse, traditionalistic, credentials-obsessed healthcare. Risk taking should challenge “the way we’ve always done things,” not take risks with patient care. In today’s environment, care delivery innovation is every bit as important as new treatments, techniques, and medications. Talent wins. Find great people, not great CVs.
America's Best Spine Surgeons 2024 (Newsweek)
My take: Congrats to four Commons Clinic spine surgeons—Drs. Sanjay Khurana, Hyun Bae, Amandeep Bhalla, and Leonel Hunt—for making the list. Nothing like collaborating with an organization that immediately grants you excellence by association!
The Light Box
Healthcare Visuals
From the Gallery
Amplifying Community Voices
One of our main goals here is to drive discourse and discussion. In the future, this section will feature thoughts, comments, and questions from the community we aim to build. For now, feel free to reach out or comment on this article. You may (with permission, of course) end up featured in next week’s edition!
Wheels Out
Signing Off and Looking Ahead
Thanks for reading this inaugural edition of “The Surgeon’s Record.” As we’re building a community, we’d love to hear from you. If what’s written here resonates with you, feel free to share, comment, and connect. In the coming weeks, we’ll be expanding our content, collaborating with other thought leaders, and continuing the conversation.
On a personal note: This week, I’m recording an episode of the Current Concepts in Joint Replacement’s podcast, The Learning SHAK, with one of my mentors, Richard Iorio, MD. Rich has forgotten more about VBC Ortho than I’ll ever know, and I consider him not only a mentor, but a friend. Can’t wait to share our conversation—it should be a good one. The session will be moderated by another MSK pioneer and role model of mine, Keith Berend, MD.
At the end of the week, I’m traveling to North Carolina to speak at the Collaborative Summit on Health Equity and Value-Based Care, presented by Duke Orthopedics. My talk is title “Next Generation VBC: The Evolving Role of Technology and Artificial Intelligence.” I’ll be sure to include it in a future edition of “The Record.”
Until next time,
Ben Schwartz, MD, MBA
Editor-in Chief / Senior Clinical Fellow
Great discussion Ben, thank you.
Would love to gain a perspective on the implications of how the condition specific comprehensive care model might fit N of the border?
From another perspective, 'who best in charge', Ortho Surg Team incorporating PT and PC providers, or a mix the other way, based in PC? Perhaps room for both?
Nice intro with many valid points but:
1) Much of the drive to cost containment, such as minimizing SNF use, moving to ASCs, were pushed by CMS value based care models where Surgeon's saw the benefit to gaining more revenue on the upside, not because of Surgeon's drive to maintain cost control. If it were the latter, it would have happened much earlier.
2) The Newsweek article seems like a bit of a promo piece for their America's Best Surgeons material.