Cleveland Clinic has one of the most revered spinal health programs in the country because they have successfully combined orthopedic spine surgeons and neurosurgeons with other spine specialists to collaborate on patient care and research. Edward Benzel, MD, chairman of the Department of Neurosurgery, Medial Co-director of the Cleveland Clinic Spine Research Laboratory and former Director of the Center for Spine Health, and Adam Bartsch, PhD, director of the Spine Research Laboratory, discuss the program and trends for spine and neurosurgery collaboration in the future.
Q: Traditionally, where has the conflict between orthopedic spine surgeons and neurosurgeons stemmed from?
Dr. Edward Benzel: Thirty years ago, when I started practice, there was a huge conflict between orthopedic spine surgeons and neurosurgeons. It was rampant and omnipresent. Neurosurgeons had previously tended to perform decompression operations and orthopedic surgeons had focused on both spine decompression and spinal instrumentation. Then, approximately 30 years ago, neurosurgeons began performing spine instrumentation procedures — and then the battles began.
Over the years, the battles diminished in magnitude and frequency, such that today they are few and far between. Orthopedic Spine Surgeons and Neurosurgeons, as it became clear to both sides, had a common ground. Where there had been battles and conflicts, there gradually developed a sense of fellowship. This was present for years at the Cleveland Clinic, and began coalescing into a formative structure in the late 1990s. This was predominantly influenced by a strong sense of collegiality and cooperativeness that had been present for years.
Q: What makes the program at Cleveland Clinic so unique?
EB: When I joined Cleveland Clinic in 1999, we had an Orthopedic spine service and a Neurosurgery spine service. A combined Orthopedic and Neurosurgery spine surgery fellowship program was established. This program has grown substantially over the last decade; to six surgical fellows trained annually — usually half from an Orthopedic Surgery and half from a Neurosurgery training background. In spite of the fellowship, the parent departments (Orthopedic Surgery and Neurosurgery) initially maintained their territorial presence regarding finances and operational issues.
Over a five year period, beginning in the early to mid 2000s, we were able to create one department that 'sat' between the Orthopedic Surgery and Neurosurgery. This was, at the time, called the Cleveland Clinic Spine Institute (CCSI) and the CCSI shared revenue between the orthopedic and neurosurgeons on a 50/50 basis. The CCSI established a separate research laboratory, employed a separate administrator and kept a separate 'pocketbook.' All of this, particularly the latter, helped to unite as 'one.' The Orthopedic Surgeons and Neurosurgeons worked side by side as partners and colleagues, while caring for patients, teaching performing research and innovating. This has subsequently evolved into a Center in the Cleveland Clinic Neurological Institute — the Center for Spine Health (CSH). The name has changed, as has its leadership. The current Center Director, Gordon Bell, ND, has held the post since the late 2000s. The mission and course, however, have not changed since the inception of the original CCSI.
We (Orthopedic Surgeons and Neurosurgeons) at the Cleveland Clinic distinctly differ from most other academic groups because we are truly partners in each and every aspect of care, research, education and innovation. Most other academic institutions cannot get over the financial barrier — that barrier associated with being united financially as true partners.
Q: What were the keys to ensuring that the Cleveland Clinic program succeeded where others have failed?
EB: The key to our success gets back to what I mentioned earlier — great partnerships. The administrative key is having the same pocketbook. We aren't in competition with each other because of our fundamental training (Orthopedic Surgeon vs. Neurosurgeon). In fact, it matters not whether a case is done by an Orthopedic Surgeon or Neurosurgeon. What matters is simply the provision of quality care. That's the bottom line.
I've seen time and time again, collaborations in other institutions, where there is initial success, with subsequent failure because of a true lack of collaboration. It's hard to have the same research lab and manage finances when you are working with two different departmental infrastructures. Financial competition between departments prevails as a dividing force that has been often shown to be ultimately insurmountable.
I liken the difference between these two models to a basketball team playing for a collegiate championship versus a weekend pick-up game. The collegiate players are committed to the same team; they have the same coach and trainer, and they work out in the same facility, etc. They practice as a team and work together well. In a Saturday morning pickup game, if things don't go a player's way, he can simply leave early or decide not to show up the next week. Again, the key to success of such teams, both medical and basketball, is a unifying factor that bonds the 'players' together so that they function as a single unit.
In our center, the CSH, if someone is disgruntled, we all work it out — like a family.
Q: In addition to the clinical work, the Orthopedic Spine Surgeons and Neurosurgeons also partner in the research laboratory. How does this collaboration work for the researchers?
Adam Bartsch: From the research perspective, a surgeon is a surgeon. We are doing studies where some of the Orthopedic surgeons are more involved because they have more of an orthopedics interest — such as a bone fracture or motion between two vertebral bodies. We have some projects where Neurosurgeons are more interested — such as concussion work or spinal cord injuries. From my perspective, I don't know, nor do I care, which surgeons are which — because all of the projects I do have Orthopedic and Neurosurgical components.
We also have the benefit of multidimensional groups of surgeons. Generally speaking, Orthopedic Spine Surgeons have interaction with the Sports Health providers and the Neurosurgeons work more with Neurologists and Radiologists. We really want to do almost any project related to the head, neck or spine — and we have a team that is poised to 'pull it off' every time.
Collaboration between the surgeons makes the researcher's life easy — real easy.
Q: Are there any benefits of this collaboration you wouldn't have otherwise predicted?
EB: When you have Orthopedic Surgeons and Neurosurgeons working together, they both bring unique skill sets and backgrounds to the middle. It has been suggested that a separate residency training program for spine surgery be created. However, what is unique about our training program is that both specialties have a chance to work with surgeons from the other specialty — hand in hand. I look at it as two overlapping circles like a Venn diagram, because in the middle, 90 percent of what we do is the same.
I think it would be a real shame to eliminate the collaboration between Orthopedic Surgery and Neurosurgery. Our model allows us to provide better care and do better research because of our financial and collegial relationship.
AB: From the research side, the structure of collaboration is great for fundraising and fund seeking because of the broader net we can cast. There are many projects that are a blend of Orthopedic and Neurosurgical concepts. In spine, if we are looking for funding, we can tap into both Orthopedic and Neurosurgical sources. Other specialties don't have that opportunity.
Q: How can other hospitals around the country build a foundation for collaboration between spine specialists?
EB: They should begin with a common clinic space so that, on any given day, a surgeon could send cases to your colleague in another specialty, or walk around the corner to a medical spine specialist if the patient doesn't need surgery. In addition, the fact that the physicians are on salary helps. Financial competition becomes less divisive in a salary-based physician reimbursement model.
In addition, we have conferences where we discuss cases and solicit opinions from colleagues. Such a team approach goes far beyond the traditional relationships between colleagues. Meetings happen in the hallway, in the clinic, in the operating room, in the conference room, by telephone, and by email. We are constantly communicating with each other. Communication is a very good thing.
Q: Do you think more hospitals around the country will adopt a similar collaborative model?
EB: I believe that such a model will become more common in the future. As physicians learn to deal with the political and economic barriers they face in individual practices or in their institutions, they will gravitate toward a more collaborative care model. It will never work if the physicians are selfish. Just like with a basketball team, every player has to give a little. Once the 'players' do just that and understand the benefits of such a program, it would seem (at least to me) that the Cleveland Clinic model will become much more common and, in fact, common place.
More Articles on Spine Surgery:
10 Trends in Reimbursement for Spinal Surgery
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Q: Traditionally, where has the conflict between orthopedic spine surgeons and neurosurgeons stemmed from?
Dr. Edward Benzel: Thirty years ago, when I started practice, there was a huge conflict between orthopedic spine surgeons and neurosurgeons. It was rampant and omnipresent. Neurosurgeons had previously tended to perform decompression operations and orthopedic surgeons had focused on both spine decompression and spinal instrumentation. Then, approximately 30 years ago, neurosurgeons began performing spine instrumentation procedures — and then the battles began.Over the years, the battles diminished in magnitude and frequency, such that today they are few and far between. Orthopedic Spine Surgeons and Neurosurgeons, as it became clear to both sides, had a common ground. Where there had been battles and conflicts, there gradually developed a sense of fellowship. This was present for years at the Cleveland Clinic, and began coalescing into a formative structure in the late 1990s. This was predominantly influenced by a strong sense of collegiality and cooperativeness that had been present for years.
Q: What makes the program at Cleveland Clinic so unique?
EB: When I joined Cleveland Clinic in 1999, we had an Orthopedic spine service and a Neurosurgery spine service. A combined Orthopedic and Neurosurgery spine surgery fellowship program was established. This program has grown substantially over the last decade; to six surgical fellows trained annually — usually half from an Orthopedic Surgery and half from a Neurosurgery training background. In spite of the fellowship, the parent departments (Orthopedic Surgery and Neurosurgery) initially maintained their territorial presence regarding finances and operational issues.
Over a five year period, beginning in the early to mid 2000s, we were able to create one department that 'sat' between the Orthopedic Surgery and Neurosurgery. This was, at the time, called the Cleveland Clinic Spine Institute (CCSI) and the CCSI shared revenue between the orthopedic and neurosurgeons on a 50/50 basis. The CCSI established a separate research laboratory, employed a separate administrator and kept a separate 'pocketbook.' All of this, particularly the latter, helped to unite as 'one.' The Orthopedic Surgeons and Neurosurgeons worked side by side as partners and colleagues, while caring for patients, teaching performing research and innovating. This has subsequently evolved into a Center in the Cleveland Clinic Neurological Institute — the Center for Spine Health (CSH). The name has changed, as has its leadership. The current Center Director, Gordon Bell, ND, has held the post since the late 2000s. The mission and course, however, have not changed since the inception of the original CCSI.
We (Orthopedic Surgeons and Neurosurgeons) at the Cleveland Clinic distinctly differ from most other academic groups because we are truly partners in each and every aspect of care, research, education and innovation. Most other academic institutions cannot get over the financial barrier — that barrier associated with being united financially as true partners.
Q: What were the keys to ensuring that the Cleveland Clinic program succeeded where others have failed?
EB: The key to our success gets back to what I mentioned earlier — great partnerships. The administrative key is having the same pocketbook. We aren't in competition with each other because of our fundamental training (Orthopedic Surgeon vs. Neurosurgeon). In fact, it matters not whether a case is done by an Orthopedic Surgeon or Neurosurgeon. What matters is simply the provision of quality care. That's the bottom line.
I've seen time and time again, collaborations in other institutions, where there is initial success, with subsequent failure because of a true lack of collaboration. It's hard to have the same research lab and manage finances when you are working with two different departmental infrastructures. Financial competition between departments prevails as a dividing force that has been often shown to be ultimately insurmountable.
I liken the difference between these two models to a basketball team playing for a collegiate championship versus a weekend pick-up game. The collegiate players are committed to the same team; they have the same coach and trainer, and they work out in the same facility, etc. They practice as a team and work together well. In a Saturday morning pickup game, if things don't go a player's way, he can simply leave early or decide not to show up the next week. Again, the key to success of such teams, both medical and basketball, is a unifying factor that bonds the 'players' together so that they function as a single unit.
In our center, the CSH, if someone is disgruntled, we all work it out — like a family.
Q: In addition to the clinical work, the Orthopedic Spine Surgeons and Neurosurgeons also partner in the research laboratory. How does this collaboration work for the researchers?
Adam Bartsch: From the research perspective, a surgeon is a surgeon. We are doing studies where some of the Orthopedic surgeons are more involved because they have more of an orthopedics interest — such as a bone fracture or motion between two vertebral bodies. We have some projects where Neurosurgeons are more interested — such as concussion work or spinal cord injuries. From my perspective, I don't know, nor do I care, which surgeons are which — because all of the projects I do have Orthopedic and Neurosurgical components.We also have the benefit of multidimensional groups of surgeons. Generally speaking, Orthopedic Spine Surgeons have interaction with the Sports Health providers and the Neurosurgeons work more with Neurologists and Radiologists. We really want to do almost any project related to the head, neck or spine — and we have a team that is poised to 'pull it off' every time.
Collaboration between the surgeons makes the researcher's life easy — real easy.
Q: Are there any benefits of this collaboration you wouldn't have otherwise predicted?
EB: When you have Orthopedic Surgeons and Neurosurgeons working together, they both bring unique skill sets and backgrounds to the middle. It has been suggested that a separate residency training program for spine surgery be created. However, what is unique about our training program is that both specialties have a chance to work with surgeons from the other specialty — hand in hand. I look at it as two overlapping circles like a Venn diagram, because in the middle, 90 percent of what we do is the same.
I think it would be a real shame to eliminate the collaboration between Orthopedic Surgery and Neurosurgery. Our model allows us to provide better care and do better research because of our financial and collegial relationship.
AB: From the research side, the structure of collaboration is great for fundraising and fund seeking because of the broader net we can cast. There are many projects that are a blend of Orthopedic and Neurosurgical concepts. In spine, if we are looking for funding, we can tap into both Orthopedic and Neurosurgical sources. Other specialties don't have that opportunity.
Q: How can other hospitals around the country build a foundation for collaboration between spine specialists?
EB: They should begin with a common clinic space so that, on any given day, a surgeon could send cases to your colleague in another specialty, or walk around the corner to a medical spine specialist if the patient doesn't need surgery. In addition, the fact that the physicians are on salary helps. Financial competition becomes less divisive in a salary-based physician reimbursement model.
In addition, we have conferences where we discuss cases and solicit opinions from colleagues. Such a team approach goes far beyond the traditional relationships between colleagues. Meetings happen in the hallway, in the clinic, in the operating room, in the conference room, by telephone, and by email. We are constantly communicating with each other. Communication is a very good thing.
Q: Do you think more hospitals around the country will adopt a similar collaborative model?
EB: I believe that such a model will become more common in the future. As physicians learn to deal with the political and economic barriers they face in individual practices or in their institutions, they will gravitate toward a more collaborative care model. It will never work if the physicians are selfish. Just like with a basketball team, every player has to give a little. Once the 'players' do just that and understand the benefits of such a program, it would seem (at least to me) that the Cleveland Clinic model will become much more common and, in fact, common place.
More Articles on Spine Surgery:
10 Trends in Reimbursement for Spinal Surgery
5 Expectations for the Minimally Invasive Spine Market
15 Spine Surgeons & Specialists Pioneering Surgical Technique