The key skills every spine surgeon needs beyond clinical care


Seven spine surgeons discuss the most important non-clinical skill-sets.

Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. We invite all spine surgeon and specialist responses.

Next week's question: What is your professional five-year plan?

Please send responses to Anuja Vaidya at by Wednesday, May 22, 5 p.m. CST.

Question: What are the key non-clinical skills every spine surgeon needs to have?

Mark M. Mikhael, MD. Spine Surgeon at NorthShore Orthopaedic & Spine Institute and Illinois Bone & Joint Institute (Chicago & Glenview, Ill.): Basic social skills are key for every spine surgeon to have. Physicians need to maintain eye contact, show empathy and listen well to their patients. We all need to find that happy medium between giving patients the time to speak without interrupting and asking the right questions to fully understand patient concerns and explain to them the necessary next steps.

Alok Sharan, MD. Co-Director of Westmed Spine Center (Purchase, N.Y.): I would recommend that every spine surgeon understand the basics of management operations, data analysis on [Microsoft] Excel and gain an understanding of basic leadership skills.

As we continue to move toward value-based care it will be critical for spine surgeons to lead in their local community on redesigning care. To do so would require an understanding of how to look at basic processes/operations and understand how to optimize the processes.

It is hard to improve a process unless you have data. I think every surgeon should be familiar with Excel and how to use Pivot tables, [an Excel feature,] as this is a useful way to analyze data.

Finally, spine surgeons should continue to be leaders in their local communities. A basic understanding of leadership skills would be helpful.

Brian R. Gantwerker, MD. Founder of the Craniospinal Center of Los Angeles: The stand-out skills are the same we learned when we were in grade school. First is empathy. If you cannot find common ground with your patient, your connections will never be as strong, and your investment in their outcome will never be as strong as it could be. Second is patience. Let the patient finish a sentence. Rushing through an appointment, even if you and or the patient are late, will almost certainly result in miscommunication and in some disastrous situations or errors.

Next is something I refer to as wonderment. Don't ever stop being amazed at the body's healing potential and ability to repair itself. Put yourself also in the patient's shoes and feel their gratitude when they thank you for what you have done. It still amazes me when a foot drop disappears, or a patient can swim laps again without pain. Last is faith. I think no matter how you worship, or even if you worship, you must have faith in the human being in front of you and the one in the mirror.

Srdjan Mirkovic, MD. Spine Surgeon at NorthShore Orthopaedic & Spine Institute (Chicago & Glenview, Ill.): Two key non-clinical skills spine surgeons need are being a good communicator and being affable. Patients usually come to clinic with a litany of information. As a spine surgeon, you need the ability to process the information quickly and categorize it, directing the conversation in a targeted way.

You want to be a good listener but also be efficient with the time you have with your patients. You need to be tenacious in your approach to understand the most pressing issue and address it. Patients also appreciate when surgeons apologize for running late and when they take the time to hear them out. Adding humor and being light-hearted in your interactions helps, especially when the conversation gets serious or stressful. In the end, patients want to feel like you truly care about them and empathize with their situation.

Issada Thongtrangan, MD. Orthopedic Spine and Neurosurgeon at Minimally Invasive Spine (Phoenix): For me practicing humility, being a team player, treating everyone with respect and knowing my limits are keys in my practice.

Exercising humility can foster important relationships with patients and colleagues that go a long way to building a strong practice. Your staff and patients can be your biggest advocates or your worst PR disasters especially in this current social media world.

The other non-clinical aspect that is very important for me is to learn and understand the business side of medicine. Physicians are well-trained in medical practice but often lack the knowledge and experience to fully grasp the undertaking of going into the business of medicine. It is an ongoing learning for me to self-educate myself on this subject as the landscape of business in medicine has been constantly changing.

Richard Lin, DO. Director of Orthopedic Spine Surgery at Foothill Regional Medical Center, (Tustin, Calif.): I think the first non-clinical skill every spine surgeon needs to master is the business and politics of medicine. This requires a thorough understanding of physician versus hospital reimbursements and how it can be impacted by insurance payers/contracts, type of procedure performed, use of instrumentation (type of instrumentation), operating room time utilization and length of stay. It is imperative the surgeon understands how to be cost effective when performing a surgical case by being conservative and minimizing the extensiveness of the procedure and, therefore, minimizing blood loss, levels addressed, and degree of instrumentation used. This will usually translate to better overall surgical outcome, decreased length of stay and lower readmission rate, and by doing so, will increase overall profit margin for the hospital.

Ultimately this will likely translate to better reputation within the surgeon's community and lead to additional surgical referrals with potential better payers. This will provide a strong foundation to grow your practice with support from hospital administration and the general medical staff/referring bodies.

In addition, understanding the different types of payers is also critical to building a practice as it can increase your efficiency depending on the current state of your practice. This includes an understanding of HMO/PPO plans, workmen's compensation and even personal injury. Each type of payer includes their own set of advantages and disadvantages, and the overall mix of the practice should be tailored individually.

Lastly, marketing is absolutely critical and although nothing beats word-of-mouth and good surgical outcomes; the presentation is critical. A good web designer is a valuable asset and obtaining video and written patient testimonials can be very helpful as they can help the surgeon build a strong and positive online presence. In conclusion, having a good understanding of surgical principles with advanced technical skills is no longer sufficient to be successful, especially in a saturated market. It is imperative to take a comprehensive approach to building a practice and to be able to recognize and properly utilize the instruments available to set yourself apart from the general market.

Josh Schwind, MD. Orthopedic Spine Surgeon at Hoag Orthopedic Institute (Orange, Calif.): Non-clinical skills can be described as a collective term used to describe skills and behaviors encompassing four domains: cognitive, interpersonal, performance optimization and professionalism. More specifically, there are seven strictly non-clinical or non-technical skills that seem to be critical to develop to be a successful spine surgeon: situational awareness, decision-making, communication and teamwork, leadership, task management, fatigue/stress management and professionalism.

First, the cognitive domain.

1. Situational awareness. The operating room is a prime example of a complex, continually evolving situation. The human brain has a limited capacity to process all of the information available to them, especially in the setting of a crisis happening during the surgery, so surgeons must be specifically adept at handling and utilizing that information wisely.

2. Decision making. With thousands of articles being published each year, that poses a considerable challenge for the surgeon to remain up-to-date. However, outcomes are optimized when the right procedure is performed on the right patient, for the right reason. To know and understand those three components, however, takes diligence and adherence to the principle of being a 'lifelong learner.' This also allows the surgeon to discuss with and counsel patients as to the real risk-benefit ratio of any given treatment.

Second, the interpersonal domain.

1. Communication and teamwork skills. Communication has been shown, time and again, to be a major factor in malpractice claims, near-misses, and delays in diagnosis or treatment. Also, improved outcomes for high-volume ORs can be directly tied to the experience and efficiency gained through the repetition of cases and tasks performed by a team of professionals from a variety of disciplines who work and communicate effectively, together.

2. Leadership and management skills. Doctors have historically held a privileged position in society. As respected members of the community in which they serve, they frequently become leaders and advocates at the individual, community and national levels. They are looked to for direction and guidance in the hospitals where they work, and in the healthcare profession at large.

Third, the performance optimization domain.

1. Task management. Every day the surgeon must deal with numerous projects and tasks, all with different deadlines. Keeping track of the innumerable responsibilities can be tedious, but fulfilling duties, chiefly to the patient, in a timely manner is key and critical to a successful practice.

2. Managing fatigue and stress. A variety of maladaptations befall the physician who is not well-versed in managing fatigue and stress. The personal risk to the physician includes issues such as: depression, anxiety, sleep disturbance, substance misuse, marital dysfunction and suicide. Moreover, poor decision making, damaged working relationships and medical errors are the professional components of burnout, a widely recognized risk within the surgical profession.

Finally, the professionalism domain. It is a privilege to be a surgeon, and to be entrusted by our fellow man with inspiring hope, giving counsel and alleviating suffering. Practicing with integrity and adherence to the ultimate goal of compassionate care with respect for patient autonomy is crucial. This will improve the care of our patients and elevate the profession.


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