Jacques Hacquebord, MD, works in some of orthopedic surgery’s most technologically ambitious territory.
He treats severe nerve and limb injuries and works in bionic reconstruction, where advanced surgery can be coupled with increasingly sophisticated prosthetic technology to restore function.
Yet when asked what could have the biggest effect on orthopedic surgery over the next decade, Dr. Hacquebord did not choose bionic reconstruction, tissue engineering or another surgical advance.
“I think the financial incentives, how systems are compensated, how physicians are compensated, are hugely important and will have a tremendous impact on how we practice medicine, more so than technology,” Dr. Hacquebord told Becker’s.
It is a notable answer from a surgeon working at the intersection of orthopedic surgery, plastic surgery and advanced prosthetics.
Dr. Hacquebord is chief of the Division of Hand Surgery at New York City-based NYU Langone and co-director of its Center for Amputation Reconstruction. He is also an associate professor in the departments of orthopedic surgery and plastic surgery at NYU Grossman School of Medicine.
From that vantage point, he sees enormous potential in where technology is headed. He also sees limits to what technology alone can solve.
The frontier is augmentation
Reconstructive surgery has traditionally followed a straightforward principle: replace damaged tissue with something as similar to it as possible.
The problem, Dr. Hacquebord said, is that the greater the tissue loss, the harder that becomes. There is only so much tissue elsewhere in the body available for reconstruction.
That is why he sees tissue engineering, synthetic replacements and bionic reconstruction as important frontiers. Severe brachial plexus injuries illustrate the challenge. Despite decades of efforts to improve nerve healing and regeneration, Dr. Hacquebord said surgeons still struggle to restore hand function after the most serious injuries.
Increasingly, he believes the answer may not be to perfectly recreate the anatomy that was lost.
“Technology is taking us more and more into the world of bionic reconstruction,” he said.
In that model, advanced surgical techniques work alongside myoelectric prosthetics.
“That might be the case for a lot of our clinical problems,” Dr. Hacquebord said. “Technology augments our natural anatomy rather than replacing it. It really is a coupling between the two.”
The idea reframes reconstruction. Instead of asking only how to recreate what was lost, surgeons can also ask how technology can work with the anatomy that remains to restore function.
Where specialization reaches its limit
As orthopedic care becomes increasingly subspecialized, Dr. Hacquebord sees another tension. For most conditions, specialization works well. But the rarest and most complex injuries can cross the boundaries between orthopedic and plastic surgery and involve bone, muscle, skin, blood vessels and nerves.
Dr. Hacquebord believes surgeons therefore need to become more specialized without losing sight of the disciplines around them.
“People need to increase their depth of knowledge, but maintain their breadth of knowledge,” he said.
Without that breadth, he said, it becomes harder to recognize where one surgeon’s expertise ends and another’s begins, and harder to have meaningful discussions across specialties.
That becomes particularly important in complex limb reconstruction. Orthopedic expertise alone may not be enough to reconstruct a severely damaged limb, Dr. Hacquebord said, but neither is plastic surgery expertise alone. Those cases require an understanding of both tissue reconstruction and the musculoskeletal anatomy, biomechanics and function of the limb.
For those uncommon cases, he sees interdisciplinary centers of excellence as particularly important. The goal is not simply to put specialists next to one another. It is to bring together clinicians with enough depth in their own fields and enough shared knowledge to solve a problem that does not fit neatly within one specialty.
The burden of proving value
The same technologies expanding what surgeons can do can also come at significant cost. For Dr. Hacquebord, that puts a responsibility on physicians to demonstrate that an innovation is doing more than adding expense.
“The onus is on us as physicians to show value,” he said. “It isn’t about cost. It isn’t about outcomes. It is about value.”
Dr. Hacquebord believes physicians have a particular responsibility in that equation because they are the ones examining patients, talking with them and measuring their progress.
“If we don’t do the research, if we don’t collect the data to show the value, then we have to leave it to payers, the government and other people to make decisions,” he said.
He does not frame those groups as adversaries. Dr. Hacquebord said he believes the different parts of the healthcare system largely share an interest in delivering value to patients. But physicians, he argues, are responsible for producing the evidence that shows where that value exists.
That standard should apply to new technology as well.
“We have to show value,” Dr. Hacquebord said, “and not just use technologies because it’s cool or because patients are asking for it.” If a new technology carries additional cost, he said, it should improve on what surgeons were doing before enough to justify that expense.
What technology can’t solve
Dr. Hacquebord’s caution about technology goes further. Better tools can expand what surgeons are capable of doing. They can also, in his view, make it easier to become overly reliant on those tools.
“Technology is wonderful, it is great,” he said. “But it can also allow physicians to be lazy, surgeons to be lazy.”
He pointed to wound care as one example. Skin substitutes and wound-closure technologies can help surgeons manage difficult wounds, but their effectiveness does not eliminate the need for surgical skill and attention.
That is why Dr. Hacquebord resists the idea that technological progress will solve the larger challenges facing medicine.
When he thinks about orthopedics a decade from now, he instead comes back to two less futuristic questions: What incentives will shape how physicians practice, and what will the relationship between physicians and patients look like?
He wants that relationship to be built on earned trust, clinical excellence and the patient’s interests. While he believes that relationship is generally strong in the U.S., he sees room to make it better.
“It could be better, and if it could be better, it should be better,” he said.
For a field moving toward engineered tissue, sophisticated prosthetics and bionic reconstruction, Dr. Hacquebord sees the more consequential challenge as decidedly human.
“At the end of the day, technology doesn’t treat patients,” he said. “People treat patients.”
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