More than eight in 10 of us have had or will have back pain, but far fewer will have surgery for it. Those who do have surgery enter a realm of innovation like few other areas of medicine. That’s what drew Dr. Isaac Moss into the specialty, yet he says there’s still so much we don’t know. Dr. Moss, renowned spine surgeon and the chair of UConn Health’s Department of Orthopaedic Surgery, joins Dr. Anthony Alessi to discuss the advances in spine surgery, its promising future, and the importance of academic medicine, and offers his first-hand perspective on the health care systems in the U.S. and Canada.
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Transcript
Dr. Alessi: Welcome to the Healthy Rounds Podcast, where we provide you with up to date and timely information that’s brought to you by national and international leaders in their fields. This podcast is brought to you by UConn Health, with support from the Department of Orthopedic Surgery, in addition to a grant from Coverys.
This podcast is not designed to direct your own personal medical care, and that should only be done by your physician. I’m your host, Dr. Anthony Alessi, and it’s great to have as my guest today, Dr. Isaac Moss. Dr. Moss is professor and chairman of the Department of Orthopedic Surgery here at the University of Connecticut.
He is also a fellowship trained spine surgeon. Welcome to the show, Isaac.
Dr. Moss: Thank you, Tony. Great to be here.
Dr. Alessi: First of all, let me thank you for your support of this podcast, which we’re looking forward to really furthering medical information coming from our institution. To begin, I want to go back a little bit, back to 2019.
Here you are at the University of Connecticut. You’re a very successful, well-known spine surgeon. You have grant support and suddenly you are thrust into the limelight of being chairman of one of the largest departments at the University of Connecticut, certainly one of the busiest. Walk me through that.
I mean, did you want to become a chairman because you were fairly young at the time? And when I think of chairs, I mean, they’re usually older folks.
Dr. Moss: So, I appreciate first of all that shout out and calling me young. I’ll let my kids know. But yeah, I think I was a little, I was typically a little bit younger than the average person who takes this kind of job on, but, you know, sometimes kind of opportunities come your way and they’re hard to say no to. And this particular opportunity, you know, we’re lucky. We have a tremendous, tremendous orthopedic department, all specialties, great people, great education, great research. And at the time there was a transition at the health center and the leadership came to me and said, “Hey, you know, we need some leadership in the department at this time, we think you’re well suited to do it.” And that was flattering, first of all, and somewhat hard to say no to, especially if you ask my mom.
But, you know, so I took a step back and said, okay, is this something, well, you go from a sort of your own practice to leadership, you have to change your focus from what’s good for you and what’s good for your patients is obviously your main focus, to what can you do for everybody else? And, you have to be at a certain point in life where you can do that, first of all, and a certain attitude to do it. And, so actually the first thing I did was I sat down with a group of orthopedic surgeons. I said, “Hey guys, is this something you want me to do?”
Right? Because one of the great things we have in a department is we have a tremendous team, right? So even though we’re individual surgeons, we all have our subspecialties, we really work as a team together. And I think that’s one of the strengths of our department because we get that whether it comes to patient care, right, so in fact, yourself, Dr. Alessi, you’re part of our department. And so how often do I send you a patient saying, I’m not sure what to do with this person. They have some particular neurologic problem. Can you help me define it so that I can give them the right care?
That also happens sometimes somebody comes in, we think is a neck problem, maybe it’s a shoulder problem. I have great colleagues that can do that too, so that is a tremendous asset to our department. And so, which is one of the reasons I said, “Hey team, if we can do this together and we can make ourselves better, I’ll take this on as a responsibility.” And it was, you know, a tremendous privilege to be able to do it. Certainly, I’m not sure that it made my life any easier, but it’s been an education and a privilege to do so for the past six or seven years.
Dr. Alessi: You know, and I think that’s a rarity. Having lived through that, those events with you, I mean, to have the unanimous support of your department, makes a big difference when becoming chair.
But let’s talk about now. I mean, so now you’re chair of the department the last six years. What’s the biggest challenge? I mean, there are a lot of challenges. I mean, you have to coordinate clinical care, right? We have research to deal with, funding, teaching. What’s the biggest headache?
Dr. Moss: That’s a tough question.
I’ll start off with saying what’s the, you know what’s interesting is, and one of the nicest things about this job is I certainly don’t need to motivate my employees, right? So, like, orthopedic surgeons are intrinsically motivated to work hard. And so in a way, while it’s a blessing certainly, but you know, we also work in a large institution and there’s a lot of moving parts to this institution.
So really what I lose sleep over is how do I set things up or how can I work with the rest of the institution to almost allow our surgeons to be as productive as they want to be, right? And not only surgeons, we have, as you know, surgeons, neurologists, non-operative doctors, physiatrists and all these, there’s all these providers who want to provide care for their patients and sometimes their pace may exceed the pace of the rest institution for certain cases.
And that’s again, it’s not to the fault of the institution. It is a big place and there’s a lot of priorities, so how do I make sure that our providers can almost work to their capacity. And again, everybody wins that way. We’re getting them, the institution’s getting the most out of their providers.
Our patients are getting the most of their providers and the department. That’s one challenge. But we also have to balance clinical care is one of our pillars. But there’s three pillars in an academic environment. There’s patient care, there’s research, there’s education. And trying to balance all those things, especially in an environment where one of them is financially is driving, some are less so.
But again, we don’t want to lose our mission, which is again, to make sure we’re educating the rest of the next generation of orthopedic surgeons to develop the new knowledge through research that’s making everybody’s care better and at the same time treating our patients in Connecticut and making sure they have excellent orthopedic care.
Dr. Alessi: So, I think you may have answered the next question, but what do you think are the goals for the department now that you look at the future of orthopedic care? I mean, you must go to meetings, you must meet with other chairs, and what are the trends towards departments? Are most people facing the same challenges? Is funding an issue?
Dr. Moss: Sure. Yeah, I mean, actually one of the, it is nice to go to some of these meetings sometimes because you realize that regardless of an institution, we all have the same problems to a certain extent, and they may be highlighted more in one than the other, and there may be particular nuances, but really if you look at it in general as orthopedics, we’re very lucky because we can generate significant revenue, but we also need to get that reinvested in our business, right? Which means to provide care, which is whether that’s expansion, whether that’s new technology and equipment which we’ll talk about later, whether that’s just ensuring that, again, we have the infrastructure to provide the care we want. The second part though, is how do we balance that with some of the non-revenue generating activities, right?
Like research, which can, but not always, or like education, which again, without that why we’re really here. I mean, our doctors are here because A, they love to provide care, but B, they want to be teaching. That’s exciting. That actually just makes our job interesting, and in fact, I think it actually improves the quality of care because we have a young doctor asking us, “Hey, why are you doing that today?”
Right? I’m not just sitting there doing whatever I want. I’ve got to justify my decisions to a very smart orthopedic resident or spine surgery fellow every day, which actually makes me a better doctor I think, and makes me give better care to our patients.
Dr. Alessi: Absolutely. I agree wholeheartedly. You came here from Canada and trained in Chicago at Rush in spine.
How does your experience here compare to medical care in Canada? And I use it as a general term, you know, delivery of care, quality of care, access to care, how do we compare? Because people are always saying, “well, the Canadian system, everything’s paid for”, and things like that. Give us some insight since you’ve worked on both sides of the water.
Dr. Moss: Yeah, so it’s interesting. I think first the easy part is I think quality of care is the same once you get down to, once you get the healthcare that you’re getting in Canada, and again, being part of that system, having relatives and colleagues that work in the Canadian healthcare system, once you are there, once you get to the doctor, you’re getting very high quality care.
I think the issue that the system has is access, right? And if I compare to here, we almost have too much access, right? So I grew up and I went to medical school in Montreal, which is the city of, I don’t know, four and a half million people or something like that, at this point. I think there are more spine surgeons in Hartford, for instance, than there are in Montreal.
Dr. Alessi: Really? Wow
Dr. Moss: Right, which is probably a quarter of the population. And again, so, the issue we have here is it’s, in certain respects, access is almost too easy, right? You have an itch in your nose, you’re going to go see an ENT surgeon. That’s not necessary, right? Probably you should wait it out or go to your doctor, right? Or for instance, I remember when I started my training when I was in Chicago and somebody came to our spine surgeon’s office with like two days of back pain. Now, back pain is ubiquitous. 85% of people have it and most of it goes away.
So you know the idea that you’re in a spine surgeon’s office within a couple of days. To me, this was in Canada that would never happen. By the time you get to the surgeon, you need the surgeon. Whereas here, because of access, because of market forces, it is just different, right. And so to me, I think some of the, now granted there’s extremes to all of this, and there are people that are probably waiting too long for their care in the Canadian healthcare system.
And that’s been the subject of some debates, that’s been the subject of some healthcare changes that are happening up there. But the flip side is, it is a bit of a barrier and probably does in a way regulate some of the care, which may not be entirely necessary that happens in this country.
Dr. Alessi: It’s interesting, but I guess it leads into my next question. Do we operate too much here in America? When you look at the literature, right? I remember the early Swedish studies done at the Volvo plant, and they were really seminal articles about how, you know, conservative management really help these people stay on the line.
And that must be, what, 30 years ago or more. Do we operate too much?
Dr. Moss: As a surgeon, I would say I think to a certain extent we do, right? And I think there’s a lot of things, though. I don’t know that it’s necessarily driven by physicians, driven by patients, driven by marketing. But again, when you have access to something and people are, I mean, again, people are in pain, right?
And part of it is you can see as a patient, and you’ve seen these patients yourself as a neurologist, you know, if you have a really bad sciatica and I’m telling you, "Hey man. Most likely you waited out six weeks, this will go away.” Not everybody wants that.
Dr. Alessi: No.
Dr. Moss: Right. And I’m a very conservative surgeon in general, and I will really sit there and in fact, it’ll take me more time to talk a patient out of surgery than I would just say, “Hey, have your discectomy. It's a quick operation,” but I know that if it was me or if it was my family member, which is how I always try to treat my patients, I would say, wait. In fact, I had a hernia disc in my neck a couple years ago. I waited. It was a miserable three months. But it went away. I never ended up with surgery. So for the not wrong reasons, right?
Patients are there, they have issues that we can help. But this idea, and then part of it is we just live in a quick fix society. Everybody wants everything now. And if I say, wait six weeks, you’ll get better versus have surgery next week and you’ll get better next week, a lot of people would sign up for that.
Right or wrong, it may not be necessary.
Dr. Alessi: Good point. Let’s talk about some of the advances. I mean, spine surgery is one of the fields that we look at where we’ve seen so many advances in how things are done. I mean, the operating room looks nothing like when I was a medical student and when I was in training and certainly over the last 30 years.
Dr. Moss: That was candlelight then, right?
Dr. Alessi: It was candlelight. And, you know, you just had to wash your hands. No gloves. But just looking at that, what are some of the biggest advances you’ve seen since you’ve been practicing spine surgery?
Dr. Moss: It’s funny you should ask that because that is actually the reason, one of the reasons I went into spine, so I remember my first rotation of residency, two amazing things happened.
So number one, I showed up and turned out the attending was actually my hockey coach when I was six years old. So Stephen Lewis, who’s a tremendous spine surgeon in Toronto, taught me how to skate as well. Which again is funny from a very stereotypical Canadian story I think. But, so I showed up, I said Coach Steve, and he was doing these amazing things and, him and this other guy, Raj Rampersaud, who this was 2003, so it was the beginning of some of this navigation technology, minimally invasive surgery.
And I walked into this OR, things I had never seen before in my life as a medical student. And I said, wow, there is opportunity in this field to innovate. And that was actually one of the things that really drove me towards spine surgery, I ended up learning from them. I took two years in the middle of residency, I did a master’s of bioengineering looking at how to regenerate, some of the, because there was just such a need, right?
We didn’t know what we were doing to a certain extent. We could do certain things, but really when you look at the larger picture, there was so much we didn’t know about spine surgery. And to me that was the most exciting thing and which is honestly what pushed me to choose that as a specialty.
There are things in my practice I do now I never even heard of in residency, which is pretty cool, right? I mean, that’s over 15 years ago. But it’s procedures that I do routinely that did not exist. There’s technology that I use routinely that did not exist. And when I think of what’s coming next, I mean, it’s a super exciting field, right?
And there’s so much we don’t know. So, I’ll hit on two things. So, number one is diagnostics. So, if you think about it, and again, you see this in your practice. We have no idea how to diagnose a painful disc in your spine, as crazy as that is, right? So again, back pain is ubiquitous. Everybody has it to a certain extent. But the problem is if you take an MRI, if you do an MRI of everybody, whatever decade you’re in, more or less, that’s the chance you’ll have an abnormal MRI. So if you’re 50 years old, there’s a 50% chance you’ll have an abnormal MRI regardless of symptoms.
So, I see patients with terrible MRIs and basically no pain, patients with beautiful MRIs and tons of pain. So, there’s something we’re missing, right? And there are studies, there are things being done on this front. So, there’s different MRI sequences that people have been experimenting on. There’s a group in San Francisco that’s been doing this and trying to commercialize how to say what is painful.
We’re looking at some different kinds of nuclear medicine studies, but again, that whole world, we can’t even diagnose. Imagine this, we have this whole treatment. We can treat, we can do all these things, but we don’t even say, “Hey, this is the disc that hurts.” So, I think that’s a huge opportunity for the future and we’re going to see a lot of investment, I would say, in making that, because if we could narrow that down, the reason spine surgery gets a bad wrap is a diagnosis problem. It’s not a surgery problem, right? The surgery generally works, but are you doing it on the right person at the right place? So that’s one side of things.
The other side is what we call enabling technology. So, enabling technology allows us to do surgery that we were doing before, but in an easier way. So, this robotics was one thing. So, we were actually one of the first in New England to have robotic-assisted spine surgery where that helps us, almost guides us. And it used, it’s actually an Israeli company that used missile-tracking technology to allow us to then track and put screws in the spine.
And, very, very cool technology. So we had that for a while, and now over the past several years, been using Augmented Reality. And so what this is, it’s actually x-ray vision, more or less. It’s like a really awesome thing. So it will project the spine through your body. So now through tiny incisions, I can see exactly where I am, do exactly what I was doing in open surgery, but without the morbidity of that kind of a procedure.
Dr. Alessi: So, it sounds like these enabling technologies are things we’re going to be seeing. So, when you’re sitting back here 10, 20 years from now, do you think these enabling technologies are going to be the thing that we’re talking about?
Dr. Moss: Hopefully we’re not talking about them ’cause they’ll be so commonplace, right? It’s like we don’t talk about FaceTime anymore. I mean, we think about the iPhone in our pockets, right? Like when that came out in 2000 and whatever, nine, that blew our minds, right? We had Blackberries and all of a sudden we’re like, you know? So I don’t think we’ll be, we probably won’t be talking about it. I think it would be cool ’cause we probably won’t be talking about it, but what would be awesome would be, and again, not necessarily good for our business here, but this should commoditize surgery. It should make no difference if Tony Alessi is having a spine surgery at the University of Connecticut or in the middle of a cornfield somewhere, right?
So as long as you have a spine surgeon, this technology should level the playing field and allow us to that everyone’s care, to deliver the same care no matter where you are. And I think then society will be better on a whole.
Dr. Alessi: Boy, you’ve certainly given all of us something to really think about. Isaac, thank you for your time today.
It’s been great to have you. And, thank you for all you do for our patients here at the University of Connecticut.
Dr. Moss: Thank you, Tony. Pleasure.
Dr. Alessi: Many thanks to our guest today, Dr. Isaac Moss, who is professor and chairman of the Department of Orthopedic Surgery here at the University of Connecticut. If you have any questions or ideas for future programming, you could reach out to healthyrounds@uchc.edu.
Jennifer Walker is our executive producer here.
Chris DeFrancesco is our studio producer for the Healthy Rounds podcast.
Until next time, this is Dr. Anthony Alessi. Please stay healthy.
