William C. Watters III, MD, is the first vice president of the board of directors of the North American Spine Society, where he has been a member since 1987. He practices spine surgery at The Baylor College of Medicine and the University of Texas Medical Branch, both in Houston.
Dr. Watters is a founding member of NASS' evidence-based guidelines committee and a founding member and former chair of the registry development committee. He currently serves as a member of the clinical care council and the council chair and director of research for the research council.Here Dr. Watters discusses his lengthy career in spine, the evolution of evidence-based spine treatments and the fulfillment found through helping patients receive long-term results.
Question: Why did you choose to specialize in spine?
Dr. William Watters: I began my orthopedic training with a somewhat unusual background. I had a graduate degree in human psychology as well as a residency in internal medicine. My internal medicine training had proven to me that I really desired to be a surgical interventionist as opposed to a medical physician. Once involved in my orthopedic training the most interesting problems to me and the most intellectually and technically challenging problems involved the spine. In addition, I was fortunate in being exposed to mentors who made this area an exciting one for me. The choice became easy. My background in both psychology and internal medicine has actually served me well in looking at spinal problems from more than just a surgical viewpoint.
Q: Have you worked with any other spine surgeons or mentors who shaped your practice?
WW: My early experience in Philadelphia was influenced greatly by two mentors: Richard Rothman, MD, and Henry Sherk, MD. Both were founding members of the Cervical Spine Research Society and both were early contributors to the development of the North American Spine Society. Dr. Rothman had a large spinal practice and wrote extensively in spine. He was an innovative, systematic thinker who was a technical master. Dr. Sherk was equally talented as a surgeon and a prolific writer. Both set standards for me as a practitioner and scientist that I continue to try to emulate today.
I currently live in Houston, which has a very rich tradition in spinal surgery extending back to the development of spinal instrumentation by Paul Harrington, MD [an orthopedic surgeon who designed the Harrington Rod for straightening and immobilizing the spine]. I have been greatly influenced in my practice here in many different ways by Michael Heggeness, MD, Charlie Reitman, MD, Steven Esses, MD, and Stan Gertsbein, MD. All have played a very active role in the development and growth of NASS with Dr. Heggeness being our immediate past president.
Q: How has the practice of spine surgery changed since you first graduated from medical school?
WW: The major change in the practice of spinal surgery in the last two decades, well documented in both epidemiological studies and frequent commentaries, is the continually increasing use of surgical interventions across many different groups and ages of patients. The advent of spinal instrumentation, disc arthroplasty, "off-the-shelf" BMP as well as disc regeneration technologies, facet replacement devices and stem cell implantation have provided a technological impetus for this change but indeed the incidence of even simple discectomies has increased at a similar rate in the U.S.
Also, previously spinal surgery was pretty much confined to neurological and orthopedic specialists, but today we are seeing increasing use of particularly minimally invasive techniques by radiologists and pain management physicians. In some areas, nurse practitioners have applied for privileges in these techniques as well. This proliferation of practitioners also drives interventions. Thus practitioner diversity and frequency of interventions in spine have grown greatly since I graduated from medical school.
Q: You were a co-founder of NASS’s evidence-based guidelines committee. What led you to help create that committee and what some are of the committee’s current goals?
WW: I was part of the NASS team that partnered with the American Academy of Orthopaedic Surgeons many years ago to develop treatment guidelines for lower back pain. These original opinion-based guidelines were well-received and NASS continued with additional guideline development after that relationship was completed. By the time I became chairman of the guidelines committee it was becoming apparent that the world was changing and that the structured use of evidence was becoming expected in the development of diagnostic and treatment guidelines. Opinion-based guidelines were rightfully seen as often being biased in favor of those giving the opinion. We shut the whole guideline-production process down at NASS for more than a year while a bunch of us went out and got educated in evidence-based medicine. The evidence-based guidelines committee was thus formed.
The current goals of the committee involve furthering education in evidence-based medicine by providing a course twice a year that membership can attend. We have continued to produce important evidence-based clinical practice guidelines to help delineate best practices. Because these guidelines reflect the quality of the current spinal literature, they often have gaps in high quality evidence which make them difficult to apply in daily practice. We have addressed this recently by starting a program to develop appropriate use criteria, which are evidence-based documents, built on systematic reviews but that incorporate the opinions of thought leaders and practitioners in the areas addressed in a scientific fashion to help guide practitioners in making appropriate treatment decisions in common practice scenarios.
Finally, the evidence-based guidelines committee has partnered with the advocacy committees at NASS to provide evidence in support of membership needs and appeals when dealing with governmental agencies and third party payers.
Q: How have you been involved in NASS's ongoing registry development?
WW: I was chairman of the registry committee when the committee was formed and for several years prior to turning that responsibility over to Daniel Resnick, MD, current chairman. I remain a member of the committee as we go forward with implementation in the near future and my practice will be part of the registry pilot project.
Q: What areas of the spine have the biggest need for evidence-based research? Are you conducting any research currently?
WW: Virtually all areas of spinal care can benefit from higher-quality studies and evidence-based analysis of treatment outcomes. Application of evidence-based research is more difficult in spinal care than in, for example, cardiovascular research where outcomes are often measured by mortality rates, a very "hard" endpoint that is easily measured. In evaluating spinal outcomes, we deal with pain and function as frequent measures and these are much "softer" endpoints in evaluating care and more difficult to quantify.
The spinal literature has been improving over the last five to eight years with the increased use of validated, patient-centered outcomes and improved rigor in experimental design and implementation of those designs. As this continues, the validity of the spinal literature across all dimensions will improve, providing the practitioner and his patients increased certainty in shared decision making. My own research interests are clinical and have focused recently in the area of evidence-based medicine as applied to spinal care.
Q: What advice would you give to spine surgeons just starting in the field who may be discouraged by reforms and dropping reimbursements?
WW: The uncertainties of ongoing healthcare reform in the U.S. and the reality of decreasing reimbursements for spinal surgeons is and will continue to prove challenging for all spinal surgeons, whether just starting out in their career or fully immersed in it. For those starting out, it remains critical that they chose the specialty for the traditional right reasons — a true interest in the discipline and its practice and the desire to help patients with spinal problems. Given these reasons, the practice of spinal surgery will continue to offer a rewarding career.
If, on the other hand, a young surgeon chooses spine as his career for economic reasons based on the recent high levels of remuneration for spinal procedures, then he is more likely to feel increasingly frustrated as we go through the next decade.
Q: What are the biggest challenges currently facing the industry?
WW: One of the largest challenges currently facing the spinal implant industry is the downward pressure on reimbursements across the healthcare system. Decreased physician reimbursements have increased the attractiveness of physician-owned distributorships (PODs), cutting into manufacturers' profits. Depending on how the regulatory questions associated with PODs play out, this might or might not be a problem for major manufacturers. This same downward pressure on reimbursement is definitely affecting the profitability of the industry's products directly as well. Furthermore, increased control on the healthcare system and increased scrutiny of industry's marketing and promotion of its products is likely to cut into profitability even further.
A more subtle challenge facing the industry at large is the reliance on horizontal technological development with the development of similar products across manufacturers to the detriment of innovative new products. Pedicle screw systems are a good example. There really is no dire clinical need for the plethora of systems on the market. Each represents at most an incremental improvement over others often with an increased cost to use and no significant benefit or improvement in comparative effectiveness.
The huge amount of development and marketing cost spent on these systems alone could well be applied to development in biologics or other advanced technologies.
Q: What is the most fulfilling part of practicing as a spine surgeon?
WW: The diagnostic and treatment problems in spinal care are interesting and can be challenging and certainly, as a spinal surgeon, I find the surgical interventions I do to still be exciting and very gratifying. But as a spinal surgeon well into my career, the most gratifying aspect of doing what I do is the gratitude that the majority of my patients have expressed to me over the years.
At my current age, it is not unusual for a patient to present with a new problem from that which I operated upon them for 10 or 15 years ago. It is not infrequent for these patients to apologize for not calling earlier to tell me how much I had helped them at that time and what a difference their surgery made in their life. This type of long-term feedback is most fulfilling indeed.
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