51 Spine Surgeons on Top Leadership Strategies

Todd Albert, MD, President, Rothman Institute, Philadelphia: The key to being a leader in today's healthcare environment requires a unique understanding of the situation, the need for collection and reporting of outcomes, and the interface between practice partners, hospital partners and patients.

Howard An, MD, Director of the Division of Spine Surgery, Rush University Medical Center, Chicago: I believe that a key to being a spine leader is the ability to work with others effectively. In taking care of patients, surgical techniques are important but all the cares that the patients receive prior and after surgery by nurses, physical therapy, residents and fellows are also important for the ultimate patient outcome.

In academics, it is important to interact with PhD colleagues for basic science research, and to effectively collaborate and delegate responsibilities to residents and fellows for clinical studies. Above all, setting a good ethical example and role model for young residents, fellows and faculty is the most important aspect of being a spine leader.

Neel Anand, MD, Director of Spine Trauma, Cedars-Sinai Spine Center, Los Angeles: To be recognized for the work that you do, most spine leaders must have contributed something to the field in some form — a technique or analysis of patients or considerable experience with a procedure. Those things would lead you to be recognized among your peers.

The key to being a leader is just being honest and reporting the results. You should also have good follow-up and reporting of both short-term and long-term results, including technique used and patients treated, and be forthright in what issues comes up. Spine leaders should be articulate about their research through speaking about it and publishing papers and reports.

Lastly, a key would be teaching — the ability to impart that knowledge to others, including peers, students, residents and fellows and train them in those techniques appropriately.

Gunnar Andersson, MD, Chairman Emeritus, Department of Orthopedic Surgery, Rush University Medical Center, Chicago: There's probably not a single number one key to being a spine leader, but in general I think it is important to lead by example. There is an old saying that "you're evaluated by what you do not by what you say you're going to do."

The specialty of spine surgery and indeed of spine care in general is under pressure. Procedure denials are common, new technology is not being reimbursed and it's increasingly difficult and costly to get FDA approval for new technologies. Only by working together within the spine community and listening to our patients can we successfully address those concerns. It is up to us to rise to the task.

Hyun Bae, MD, Medical Director, Cedars-Sinai, Los Angeles: Keep asking questions. As a leader you automatically assume the position of teacher, and it really is your responsibility to do so. But taking on the student role puts you in a great position to ask new questions, the hard ones, and cross-examine what we think are the easy ones, all the while using your experience and expertise to not get lost in the weeds. In doing this we keep improving the field and art of what we do.

Scott Blumenthal, MD, Co-Director, Texas Back Institute, Plano, Texas: The one key to being a leader in spine surgery is the willingness to take some risk. What I mean is not being reckless with patient care but willing to investigate a technique or technology that may or may not ultimately be the treatment standard. The goal would be to advance the field of spine surgery.

An example of this was when I agreed to be perform the first artificial disc replacement study in the U.S. and be the principal investigator for the FDA study. I believe the next frontier will be disc regeneration, possibly with the use of stem cells. This is by no means a foregone conclusion but it certainly seems like the logical progression for disc disease treatment.

Christopher Bono, MD, Chief of Orthopedic Spine Service, Brigham and Women's Hospital, Boston: The number one key to being a spine leader for me is the ability to listen. This sounds ridiculously simple, but in fact is sometimes hard to do. Leading in the board room means listening to all of the board members' concerns, comments and ideas. They are a smart group (a lot smarter than me in fact). The way I see my job is to recognize common themes in what the board members are saying, determining why there may be disagreement on a particular topic, clarify the nature of the disagreements, and then move forward with a resolution that satisfies all (or most parties).

In order to listen properly, a leader has to place any agenda of his or her own to the side. While it's important to have vision, barreling forward with one's own agenda with disregard to the rest of the group's concerns is a sure fire way to engender dissent and dissatisfaction. Beyond the board room, a spine leader needs to listen to the general spine and lay community. It's important to know what are they thinking and what their concerns are. These need to be balanced with a society's initiatives. Again, it is key to not lead in isolation.

Robert Bray Jr., MD, Founder & CEO, DISC Sports & Spine Center, Marina Del Rey, Calif.: We need to assure that all choices for treatment are quality outcome-driven, and that data is collected for outcome analysis. This key point drives the best treatment plan for patients, a progression to cost-effective medicine, and sets the standard for what procedures we teach to future fellows.

Frank Cammisa, MD, Chief of Spine Service, Hospital for Special Surgery, New York City: Advocating for new ideas, technologies and directions, whether in education, research, or clinical care, is a key attribute of leadership. The second and equally important attribute is the ability to persuade others to embrace those ideas and work collaboratively towards them. When I consider those dual challenges, the words of legendary football player Vince Lombardi always come to mind: "Individual commitment to a group effort — that is what makes a team work, a company work, a society work a civilization work."

As leaders we must demonstrate that individual commitment to our ideas and goals, but also be willing to put our shoulder to the wheel along with our colleagues. We must lead from the front. In spine surgery that translates into mentorship and positive collaboration, so technological advances can move from concept to clinical adoption. Clinical care leadership is not judged on proficiency alone, but also demonstration of strong moral character and integrity so patients believe you have their best interests in mind when choosing the surgical pathway based on their individual indications.

Brian Cuddy, MD, Charleston Neurosurgical Associates, S.C.: The key to leadership in the spine field is similar to that in other areas — relationships. Whether those relationships are with patients, hospital administrators, other physicians or community leaders, the ability to forge strong relationships is essential. To be seen as a caring surgeon, an engaged physician partner, a supportive colleague or an active citizen allows one to have perhaps the strongest asset on one's side — goodwill and the ability to influence.

Leadership in the spine field, especially in today's environment, is so important. One cannot simply see themselves in the vacuum of their own practice or sphere of influence. With so many outside forces affecting everything that surgeons do, a strong understanding of and a willingness to engage in the process of healthcare changes and care redesign is essential. By making myself a part of the process, I feel that I can make the strongest impact not only for myself but for the next generation of surgeons that will follow.

Bradford Currier, MD, Mayo Clinic, Rochester, Minn.: Communication. We can accomplish much more together than we can alone, and communicating effectively is the key to strong teamwork. Good communication is a two-way process that starts with listening and keeping an open mind. It involves many facets that are each keys to effective leadership in their own right, like integrity, mutual respect and empowering others. Finally, communication must be clear, delivered with a positive attitude and consistent with the organization's vision.

John Finkenberg, MD, Chair of the NASS Advocacy Council: I believe the spine leaders in the future will need to be intimately involved with understanding the governmental changes taking place in our healthcare system and then be excellent communicators with patients and colleagues to help them navigate through the major changes. Good leaders are great listeners, but the exceptional ones will assimilate the information and then take action that is both balanced and comprehensive. Physicians need to remember that our patients will eventually drive the direction of our healthcare system and fortunately they believe that doctors, not Congressmen, are the most capable of steering the course.

Steven Garfin, MD, Chief of Spine Surgery, UC San Diego School of Medicine: A key to leadership is getting actively involved with a new idea, surgical treatment/device, and/or organization that helps the greater good. This can be achieved through presentations (basic science, translational or clinical) that add new information to the literature (not just more of the same) that helps alter and improve care for patients; or doing behind the scenes, as well as up front, work in organizations/societies that help promote rational patient care and ideas, as opposed to a narrow ideology that benefits a few or self promotes some.

There is, however, a cost to this which involves individual time, energy, effort, frustration, taking a chance and promoting the successes of the work/work group, at the expense of not necessarily being in the lime light, or financially being rewarded, for one's own efforts. This to me is the reward, and in the long term moves the individual up in respect and in leadership roles to continue doing more of the same for others.

Michael A. Gleiber, MD, Founder, Michael A. Gleiber, MD, PA, Jupiter and Boca Raton, Fla.: The key to being a leader, in my opinion, is to strive to develop a reputation as an educator at the local level, within the community you serve. Constantly striving to provide care with excellent results as well as demystifying many of "the snake oil" type claims about spine surgery is paramount. Always operating, literally and figuratively, in the best interest of your patients will provide you with a reputation as a well-respected surgeon within the community and amongst your peers.

Jeffrey Goldstein, MD, Director of Spine Service, NYU Langone Medical Center's Hospital for Joint Diseases: In the spine field, we are privileged to have many bright, accomplished leaders, educators and innovators. I believe one of the keys to effective leadership is to appreciate this and have a sense of humility and attempt to be "a leader amongst leaders" and not "a leader of leaders." Effective, self-confident leaders promote and recognize those around them and understand that a rising tide floats all boats. By fostering the success of the team the entire team improves. The leader provides the vision and goals and sets the example.

Building a consensus recognizes that each member of the team contributes an expertise. A good leader who has built a strong team is confident enough in himself to appreciate that when his team shines it reflects positively on him/her.

Richard Guyer, MD, Chairman, Texas Back Institute Research Foundation: I have had the privilege of being chairman of the Texas Back Institute Research Foundation, president of Texas Back Institute and president of NASS, and each of them has presented a variety of challenges. Although there are many different levels of leadership the principles remain the same. First and foremost, one must lead by example. I never ask anyone to do anything I would not do myself. One must be passionate about the job at hand but never be so rigid to be blind to other opinions.

Great leaders surround themselves with the brightest and best people empowering them to develop their expertise for the common goal of the organization. One must also be clear in his vision and decisions and be flexible and nimble to make adjustments depending on the environment. Particularly in these challenging medical economic times one must be creative in finding opportunity even in the face of adversity. Not all the decisions one makes will be popular with everyone, but as long as they are consistent with the vision of the organization one must have the conviction to see them through.

Raqeeb Haque, MD, Cleveland Clinic: I think the number one key to being a spine leader is being able to work and learn from everyone, whether it be from your peers, your students or other people you work with. Being amenable to learn new things is an important skill to have, and never stop asking questions. As we have seen, concepts we often take for granted can be turned upside down relatively quickly, so taking the initiative to question how and why things are done can lead to innovation from those with the prepared mind. Enjoy learning because that is what we do everyday in spine surgery;

Andrew Hecht, MD, Co-Director of Spine Surgery, Icahn School of Medicine at Mount Sinai, New York: My strategic approach to leadership has been to help provide vision and direction for the growth and success of our spine center and service. It's important to involve all the different members of your center and service including other surgeons, physiatrists, pain specialists, physical therapy and administrators, as well as the clinical and basic science research team.

As a leader, you need to understand the expectations and concerns of your team as well as anticipate the changes in both your clinical area of expertise as well as the changing healthcare environment in which you practice in order to get the support and buy-in of your entire service. As our health systems continue to consolidate and centers become more complex networks of providers at multiple clinical sites and hospitals, it's important to identify key experienced faculty in the various subspecialties at different sites to help provide a unified vision/strategy that can be implemented across the board.

I read an article recently where the CEO of Honeywell said, "Your job as a leader is to be right at the end of the meeting, not at the beginning."

Stephen Hochschuler, MD, Co-Founder, Texas Back Institute, Plano: I believe leadership can be learned and must involve vision, empathy, the ability to execute and take responsibility while being transparent and ultimately accountable. One needs to set goals, milestones and timelines. An example of total lack thereof is all of Washington.

Christopher Kauffman, MD, Premier Orthopaedics, Nashville, Tenn.: The strategic approach and greatest challenge for all the leaders in spine care is to advocate through current evidenced-based medicine and ongoing outcomes measures to make sure our patients have access to treatment both non-operative and operative that we know adds value for our patients. Despite evidenced-based medicine supporting current treatments, both governmental and private payers continue to restrict appropriate spine care.

All spine care providers must continue to advocate individually and through their societies with payers to make sure patients have continued access to appropriate care and procedures. Surgeons, physicians and allied health professionals alleviate significant suffering, yet we are often not good at documenting our patient's successes.

Choll Kim, MD, Director of the Minimally Invasive Spine Center at Alvarado Hospital, San Diego: One of the most important leadership strategies for me has been to create a vehicle by which I can interact with my surgeon colleagues in a meaningful and productive way. I discovered this during my work as one of the founding member of the Society for Minimally Invasive Spine Surgery. Through this organization, I was able to connect with a variety of surgeons from diverse backgrounds throughout the country.

This robust interaction gave me great insight into the common issues we face in spine care. Without such a venue for interaction, I would likely have a limited perspective on our field and consequently limit my ability to participate in meaningful leadership activities. This insight has led me to begin a new organization that will "identify, support and promote" spine centers of excellence, MIS-COE.org. Using a prospective registry system to collect outcomes data in an "invisible" way, I hope to help my minimally invasive colleagues who struggle with the ever-increasingly important non-patient aspect of a successful spine practice.

Richard Kube, MD, Founder, Prairie Spine & Pain Institute, Peoria, Ill.: I believe leadership in spine surgery is much like any other type of leadership. When I set out to accomplish goals, I do not do it with the mindset that I am trying to be a leader. I believe that attitude is a bit more self-serving, and people can sense that vibe as a turnoff. Instead, I believe you get further by setting an example for others to follow. The best leaders always appear to have a charisma that at times seems unexplainable. Somewhere deep within that mystery is typically a desire to emulate or become more like that person. You are being drawn to follow a path that individual has lain before you, and you are being a leader without even realizing it. I never ask anyone to do something I am not afraid to do myself.

I also engage those around me in a way that helps them feel accountable for our success as well as our failures. In that manner, I can create evangelists within our company who appear bathed within our brand. They understand our goals and objectives and are driven from within to follow the vision.

Lawrence Lenke, MD, Chief of Orthopedic Spine Surgery, Washington University School of Medicine, St. Louis: My strategic approach to leadership as applied to my staff is to empower them to perform their duties at the highest level possible with rewards for optimal achievement. For my trainees, I try to lead by example, treating each patient as if they were a relative or friend and emphasizing precise and technical excellence in surgery. For colleagues, I aim to lead with confidence, but with a humility that respects the challenge that spinal reconstructive surgery provides on a daily basis. My personal quote when discussing complex spinal surgery is, "It is better to be lucky than good, but it is best to be both lucky and good," with the second "good" a reference to one's training, preparation and performance.

Isador Lieberman, MD, Director of the Scoliosis and Spine Tumor Center, Texas Back Institute, Plano: Leadership in the clinical arts: surround yourself with the most enthusiastic and compassionate team; involve the team directly in patient care and decision making; articulate each team member's expectations and responsibilities and reinforce those ideals on a regular basis; empower the team to implement any effort to optimize patient care; and instill a sense of responsibility and accountability on behalf of the patient in each team member.

Morgan Lorio, MD, Neuro-Spine Solutions, PC, Bristol, Tenn.: The future of spine depends first on econometric value. Economic benefit evidence will drive carriers (who hold the purse strings) to direct the future of leadership in spine. Spine societies must accommodate the paradigm shift in spine with absolute transparency with their constituent members in the trenches. Surgeons must be apprised as to what criteria are required for approval to achieve prompt, efficient point of service, the business of spine.

A level playing ground strategically mapped out by spine leaders within International Society for the Advancement of Spine Surgery and other societies must carry out a five-year, 10-year plan now if we are to continue to deliver spine care. Meanwhile, a currently fragmented think tank must come together within the American Medical Association, spine societies, industry, Medicare, private insurance carriers and hospitals led by responsible spine surgeon leadership and powered with the voice of patient advocacy.

Robert Masson, MD, Founder, NeuroSpine Institute, Orlando: We believe in a proactive, service-oriented approach to our entire spine health delivery. Through my teaching program we try to inspire a leadership strategy for control of all aspects of spine health delivery, conservative and surgical, and emphasize a mutually beneficial team approach to the operating room environment, demanding excellence and accountability from every member of our team, hospital and outpatient.

Pierce Nunley, MD, Director, Spine Institute of Louisiana, Shreveport: No matter what discipline — government, business, medicine, etc. — leaders are directing a team of individuals with a common goal. Effective communication, trust, mutual respect and balanced delegation are vital to this process. In the area of spine surgery, our goal is simple: to provide our patients with the best possible care. Everything else comes second. The field of spine surgery is constantly evolving. In this evolution, it is important for all of us to use evidence-based medicine.

At the Spine Institute of Louisiana, we have a research institute and conduct formal research to add to this growing body of evidence-based information and help lead the evolution. In addition, leadership requires vision, the ability to think forward. This thinking outside the box balanced with evidence-based knowledge helps direct our next leap forward while maintaining the art of medicine in a responsible way.

Mick Perez-Cruet, MD, Chief of Minimally Invasive Spine Surgery, Beaumont Hospitals, Southfield, Mich.: In my opinion spine surgery leaders need to take the following into account when developing successful strategies for our profession. Clearly our patients are getting smarter. They are more in-tune with the Internet and wish to be well-informed on their treatment. They wish to remain active and desire surgical therapies that lead to long-term effective outcomes and quick return to activities of daily living. We need to keep our patients well informed and educated.

My goal and strategy for each patient is to only perform one spine surgery that will last the patient a lifetime, if at all possible. I believe that anatomical preservation while performing adequate treatment can help to achieve this goal by preventing adjacent level disease, scar and/or other unwanted surgical sequela. To achieve this we have to direct surgeons more toward understanding the pathophysiology of spinal disorders then toward how to perform a procedure to make an X-ray look better. This is no small undertaking. This will require long term studies correlating outcomes with treatment modalities and a better understanding of how radiographic and clinical findings can be interpreted better so that focused effective care can be delivered.

Lastly, leaders need to show the value of what we do for our patients and society as a whole. Spinal disorders are estimated to cost $25 billion to $50 billion a year in direct cost. It is estimated that 10,000 individuals will enter Medicare each day for the next 20 years. We want to direct care that keeps these individuals active contributors who can enjoy life as they age. Thus leadership strategy should focus on cost effective, high quality spine care. This will require that we remain politically active to support and advance the interest of our patients.

Kenneth Pettine, MD, Co-founder, The Spine Institute, Loveland, Colo.: My ideas to leadership in spine are to aggressively move forward with researching the use of autogenous bone marrow concentrate for the treatment of spinal disorders. We are pursuing this through the Orthopedic Stem Cell Institute. In addition, we continue with a busy surgical practice, averaging 10 spine surgeries a week. I think one of the exciting futures in the treatment of spinal disorders is biologics.

Frank Phillips, MD, Director of Minimally Invasive Spine Surgery, Rush University Medical Center, Chicago: Leadership in spine surgery requires setting aside one's personal agenda and committing to advancing goals that benefit our patients and the spine community as a whole. Strong leadership involves balancing a spirit of negotiation with a sense of determination and commitment to an ethical and evidence-based approach to dealing with the challenges that we face.

Raj Rao, MD, Director of Spine Surgery, Medical College of Wisconsin, Milwaukee: Leadership is about setting standards of excellence for oneself personally and for the entire team to emulate. It's about integrity and clarity in a mission, and a drive to "get the job done." It's about the ability to maintain a sense of old-fashioned fairness in dealing with colleagues and staff. And, finally, it's about the ability to put all of this together in a forward-looking vision for the enterprise.

David Rothbart, MD, Medical Director, Spine Team Texas, Southlake, Texas: Cost, quality and patient satisfaction are going to be of paramount importance moving forward. As a leader of a multi-disciplinary spine center, it is critical to embed within the culture of the organization a focus on the entire patient experience, creating the least invasive and most effective treatment protocols and providing care in facilities that are philosophically mutually aligned in terms of excellence, safety and cost containment. In addition, we must continue to foster a sense of innovation in order to provide the most comprehensive, cost-effective treatment alternatives for our patients.

J. Rafe Sales, MD, Founder, Summit Spine Institute, Portland: In today's ever-changing landscape, being a spine surgeon leader means being involved in all facets of spine care, including policy making. This includes working with the insurance companies and hospitals, as, like it or not, they are shaping our ability to provide care to our patients. Being involved early allows us to have a seat at the table, which in turn allows us to determine what options our patients have. With the implementation of the new healthcare law(s), it is conceivable that much of what we can offer could change rapidly. However, with spine leaders at the table, we should be able to create a well-rounded policy that benefits all parties and allows us to provide excellent spine care.

Thomas Schuler, MD, CEO, Virginia Spine Institute, Reston: Leadership is a combination of vision, communication and delegation. In order to lead effectively one must have a clear understanding of the bigger picture and how that impacts all of the parts. Not only is communicating the essential message critical but also delegating necessary action items to all constituents for implementation. Furthermore, community-wide leadership requires the physician to publicize the truly life improving treatments that modern spinal surgery provides. The physician leader must also strive to preserve access to these great advances to enable people to receive proper treatment thereby overcoming their suffering and disability.

Nick Shamie, MD, Chief of Orthopedic Spine Surgery, UCLA: The key to being a leader in spine surgery today is to stay current with the politics of healthcare delivery in the U.S. and globally, staying active in societies that advocate for spine surgeons and not losing sight of the most important goal of providing the best and most cost-effective care for our patients. The three pillars of academic medicine — research, education and patient care — should be high on the priority list of policy makers as they make tough changes designed mostly to contain costs. It is our job to communicate with them regularly and help guide their decisions for the betterment of our field with the patients as the main beneficiaries.

Khawar Siddique, MD, Co-Founder, Beverly Hills Spine Surgery, Los Angeles: Leaders in any industry are visionaries; namely, they have the ability to correctly identify and adapt to changes in the industry. There is no question that healthcare is in the midst of a dramatic overhaul. Surgeons and healthcare leaders that fail to recognize and adapt to these changes will be left behind. As one business school professor once told me, competitors will "eat their lunch."

The billion dollar question is what the effect of "Obamacare" will on the industry over the next several years. Obviously no person knows for sure, but that's why these are exciting times. Uncertainty creates opportunity. Our group has decided on a course of action. Don't be left behind. I encourage all surgeon leaders to be proactive and set a course that is right for their specific situation.

Kris Siemionow, MD, Chief of Spine Surgery, University of Illinois in Chicago: Being a good doctor who presents, publishes and innovates constitutes a solid foundation for any spine surgeon leader. But it is crucial for today's leaders to have a thorough understanding of the mechanisms by which healthcare works, the anticipated changes to the healthcare landscape and how spine surgeons fit into the new model of healthcare delivery. The leader should use this knowledge to become politically active and represent his constituents and the spine surgery community.

Paul Slosar, MD, President, SpineCare Medical Group, Daly City, Calif.: Leadership today in the field of spine surgery requires a tactical plan to address the immediate day-to-day challenges of maintaining an independent and fiscally solvent practice, while forging a pathway into the future with a keen focus on the changing landscape of reimbursements. We must devote time and energy to critical issues of access to care, patient advocacy and advancing surgical technologies to deliver cost efficient and clinically effective care.

I have been fortunate to have experienced, firsthand, the remarkable advances in spine surgery and improved patient outcomes over the past 10 to 15 years. We truly are standing on the shoulders of the pioneers in our discipline who lead us into this century. The leaders of today's generation of spine surgeons are charged with refining these surgical techniques while demonstrating the cost benefits delivered to our society with the remarkable caliber of spinal care available today.

Mark Stern, MD, Southern California Institute of Neurological Surgery, Escondido, Calif.: A modern spine surgeon leader today must be able to adapt new technologies and create safe, novel approaches that over time have lasting benefit to the patient, the payer and society at large. The present and future of surgery depends on delivering tangible and intangible quality units of value to patients that are synergistic with criteria set by organizations that define benefits to patients.

A surgeon must be able to coordinate and educate all constituents in the clinical service paradigm — suppliers, facilities, payers, associated providers of care for the patient, i.e. therapists, dieticians, families, etc. Commitment from all constituents and participants in the continuum is critical to successful outcomes for patients. Healthcare reform has dictated that a surgeon must have a strong knowledge of the financial aspects of the healthcare environment in order to flourish and maintain a competitive station in this modern post-affordable healthcare environment.

Staying abreast of innovations that drive quality for patients is critical. As a surgeon advocate and leader in the field of spine, we must constantly advocate for our patients and continually support the advancement of care through research.

Brian Subach, MD, President, Virginia Spine Institute, Reston: First and foremost, lead by example. Know your outcomes, publish your results, advocate on behalf of your patients and strive for technical perfection.

Daniel Sucato, MD, Chief of Staff, Texas Scottish Rite Hospital for Children, Dallas: Being a spine surgeon leader in the field today to me means first, always putting the patient first and at the center of all we do. This leads to three things leaders provide: first, great patient care; second, important and quality research; and finally, education of residents, fellows and colleagues.

Spine deformity is both challenging and rewarding as the deformities are complex and take significant thought to identify the exact problem, to understand the patient's concerns and to develop an effective and safe treatment plan. Research is the vehicle by which we answer the clinically-important questions and the reporting of your results to your colleagues helps to educate them as they face similar problems. Ultimately, we best learn from our complications and an honest and up-front reporting of those complications. What we have learned from them is what a spine deformity surgeon leader does.

William Taylor, MD, Vice-Chairman Academic Affairs, University of California San Diego: I believe it is no longer enough to be recognized as just providing superior patient care. The modern spine surgeon is now responsible to develop new techniques, validate their use, test them in the lab, document outcomes and finally ensure the availability of excellent service and care for each patient. Working with all stakeholders that may, often with good intentions, limit the options for patients is our only choice. Not all of those can possibly be done by one person, staying active in our "responsible" societies can help ensure this access and growth of our specialty.

Eeric Truumees, MD, Director of Spine Research, Seton Spine & Scoliosis Center, Austin, Texas: In the rapidly changing world of American medicine, and spine care in particular, a leader's greatest tool is information. With many unresolved issues and potential changes, we have to understand which issues are solvable and identify the most practical approach. This process begins with keeping an ear to the ground. For example, the government and payers often hint what they have in store for us by floating regional trial balloons. Usually, these trials attempt to restrict patient access to care or physician reimbursement for services rendered. In other cases, the changes increase bureaucratic hurdles impeding efficient and timely care.

On the other side are our colleagues "in the trenches." They are fighting for their patients and to maintain practice viability. Unfortunately, the trenches don't always offer a great vantage point to see what's on the horizon. An effective leader both keeps his colleagues apprised of coming changes and remains accessible to physician concerns. Leaders in spine care are expected to passionately advocate for their colleagues and for continued access to high quality spine care for patients.

The biggest problems lie in the delicate balance of maintaining credibility with both physician colleagues and with payers and regulators. This credibility means picking battles carefully. With new procedures and coding, support is meaningless if advocates are seen blindly supporting each new widget. Clear guidelines and supporting evidence make this process more transparent and effective. Finally, the effective leader instills passion in his colleagues. In spine care, none of us can stay on the sidelines. At a minimum, we should each be contributing to our PACs. Consider calling your elected representatives. Both North American Spine Society and the American Academy of Orthopaedic Surgeons offer guidance in how to be effective in these endeavors, and I would encourage everyone to step up and get involved.

Alexander Vaccaro, MD, Vice Chairman of the Orthopedic Surgery Department & Co-Director of Spine Surgery, Thomas Jefferson Hospital, Philadelphia: The key to being a spine surgeon leader in the field today is to prioritize patient care as the number one driving force in all clinical and business decisions. Due to contemporary financial stresses in practice, very important decisions have to be made on various investment and resource allocation issues. By prioritizing optimal patient care as the guiding principal in all decisions, ranging from insurance negotiations to implant selection and choice of surgical procedure, satisfactory outcomes are routinely experienced by both patient and medical staff.

Robert Watkins Jr., MD, Co-Director, Marina Spine Center, Marina Del Rey, Calif.: The key to being a spine surgeon leader in the field today is continually improving patient care. There are a lot of impediments to proper patient care in the form of declining payments, unrealistic expectations and denial of tests and treatments. Spine surgeons need to be resilient and stay focused on the only priority that ultimately matters: delivering high quality care to each individual patient.

Todd Wetzel, MD, Vice-Chairperson of the Department of Orthopaedic Surgery and Sports Medicine, Temple University School of Medicine, Philadelphia: Flexibility, while never wavering from our core values of excellence in patient care, education and scientific advancement, is the key to leadership. To an effective leader, one must also be willing to be led; in the current political, economic and regulatory atmosphere, the surgeon leader must sacrifice some measure of traditional autonomy and be willing to function as a key member of the larger healthcare team. This in no way diminishes the critical role of surgeon leadership, but refocuses it to maximize our effectiveness in a changing world.

Richard Wohns, MD, Founder, Neospine, Puget Sound, Wash.: The key to being a spine surgeon leader today involves multiple synergistic factors. The foundation of being a leader is empowering those with whom you work with scientific and clinical knowledge, technical skills, passion, ability to work as a team and dedication to excellence. In other words, you can't be a leader without a first-class spine team.  

The next characteristic that is important in being a leader is your personal skill-set in the operating room, the clinic exam room, the lecture hall, the boardroom and at the table with media, government agencies and insurance companies. Leaders must be multi-dimensional and fully understand then be able to implement all of the intricacies of providing state-of-the-art spine care. Leaders must be innovative, aspirational, and future thinking.  Living in the now means living in the past.  

A spine surgeon leader today must recognize the neuroeconomics of choice and valuation: what we choose to provide to patients has many ramifications not only to the patient and his/her family, and employer, but also to the hospital and/or outpatient center, the insurance company, the leader's reputation, the spine team's prowess, public perception of spine surgery and the macroeconomics of healthcare.

Douglas Won, MD, Director & Founder, Minimally Invasive SpineCARE, Irving, Texas: Today, the key to being a leader in spine doesn't just take knowing the art of medicine. One has to understand the state of healthcare reform in this country. Physicians typically react to changes forced upon us rather than being proactive to make the changes. Physicians are the infantry in the healthcare industry and we need to be more engaged in shaping the reform.

Anthony Yeung, MD, Founder, Desert Institute for Spine Care, Phoenix: Being a leader requires more action than words. Others will follow if they recognize the leader's dedication and can see the results of his work. Leadership not only involves participation in the leadership of spine organizations, presenting at spine meetings, participating on panels and symposiums, publishing in peer-reviewed journals and writing chapters in text books, but most important, advocating for our patients. Ultimately, leadership will result in a following recognized by your peers.

Christopher Yeung, MD, Desert Institute for Spine Care, Phoenix: Being a leader is spine surgery requires a dedication to advancing our knowledge of spinal disorders in order to continually develop better treatment options for our patients. This can be accomplished by participating in research projects and being active in international spine organizations and your local community. Despite our current knowledge, there is still much to be discovered and developed to help our patients.