Twenty percent of NASS members are international. This has obviously required a great deal of outreach from NASS members and staff, not an inexpensive proposition. At the last NASS SIG meeting, I was gratified to learn that this remains viable financially (read: profitable). Even if it were not, I would hope that I would have the intestinal fortitude to continue to support this truly amazing initiative.
As President, I have been covering some miles. Each meeting to date has been valuable in many ways. Certainly one can always learn from one’s peers; arguably this experience is enriched when the context of culture is added. Perhaps a latent naivete has surfaced but I feel enriched by these experiences on professional and personal levels. Collegiality has many rewards.
In December, the Deutscher Wirbelsäulenkongress (DWG) was held in Hannover, Germany. This city, severely damaged in Word War II, has been rebuilt in a remarkable manner and is now known as the “City of Museums.” The meeting schedule precluded extensive museum visits but was well worth it. The DWG and NASS have agreed to partner in fellowships in the United States and Germany, hopefully to begin in 2018. Another benefit of the meeting was the opportunity to peruse one of the largest exhibitor areas outside of the NASS annual meeting. Several exhibitors have not displayed in North America and are eager to do so—at our annual meeting. I left Hannover with the conviction that the DWG and NASS should grow closer as both display the intellectual and economic vigor that combine to deliver excellent experiences to their membership.
In March, the British Association of Spine Surgeons met in Manchester, UK. This was an exploratory voyage, as NASS had exhibited there only once before and podium time was not scheduled. That situation changed after I met with the leadership and was asked to speak briefly about NASS. That was not an issue—I always have plenty to say about NASS. Next year, we will be invited to speak at the conference and will be starting discussions this year on North American–UK spine fellowships.
A very interesting aspect of the BASS meeting was the opportunity to learn about a health care delivery system quite different from our own—the National Health Service (NHS). In an attempt to increase efficiency, and perhaps, coincidentally, value, the British government established another arm of the NHS, the National Institute for Health Care Excellence (NICE). One initiative involved a “pyramidal” approach to patients with low back pain, requiring evaluation by a primary and other specialists, including cognitive behavioral, prior to surgical consultation. In an initial group of 10,000 patients, not one “required” surgical consultation. This obviously raises many questions, which we hope to address in symposia at the annual meeting in Orlando.
The next stop was the World Orthopaedics Innovation Summit & EXPO 2017 (WOISE) held in April in Shanghai. This focused on new technology and proved to be not only informative in that regard, but in the manner in which innovations come to market in China and in which health care is delivered. When Dr. David Fish lectured on interventional management, he asked for a show of hands as to how many surgeons practiced any nonoperative care. No hands were raised, but Dave soldiered on (and gave an excellent talk). The scale of health care in China is truly incomprehensible and will be a major global factor in health care for years to come. Obviously, NASS must stay involved.
The most recent trip in May, to Dubai in the United Arab Emirates, was truly astounding. This was the fourth time that NASS has been invited. It was a long trip—eight days in my case—but the experience was incredibly worthwhile, and not necessarily for the reasons that I had anticipated. The first four days consisted of the ArabSpine Diploma Course, a series of lectures and cadaver labs constituting a comprehensive, accredited review of spine surgery, followed by a three-day scientific meeting, the Dubai International Spine Conference (DISC). NASS sent numerous faculty (12 to be exact ) and all were quite involved. Personally, I gave seven talks during the diploma course, a keynote during the DISC meeting and two additional talks thereafter including the last one of the meeting. And no one left.
The diploma course was memorable, and in a sense quite moving. I confess that my eye may have become a bit jaundiced in recent years, attempting to cope with what seem to be pervasive and unpleasant issues, eg, patient entitlement, poor compliance and lack of gratitude sometimes seem to be stalwarts of clinical medicine. When these are added to increasing reimbursement pressures and a health care system that seems to have forgotten to appreciate or reward aspects of medical care that do not specifically generate revenue, one does on occasion find it a bit difficult to maintain a uniformly optimistic outlook. I believe I found a respite or even a potential cure for this ennui: the Arab Spine Diploma Course. The enthusiasm and hunger for knowledge of the course participants was the ultimate refreshment. Questions were frequent and insightful. The lecture halls stayed full until the very end of each day. Take this enthusiasm to the lab and square it. In a pre lab poll, it turned out that some participants had never put in a pedicle screw. Most of these surgeons, from markedly underserved, even destitute areas, considered this to be no real disadvantage as they never expected to have a pedicle screw available. Others were extremely advanced and accomplished in current techniques, including minimally invasive surgery and navigation. Hence, at each session, the material had to be tailored for the expertise and experience of the audience. As in the lecture halls, lab stations were full for each session, some not ending until 8 pm.
The DISC meeting was no less memorable. The quality of the presentations was high and the engagement of the attendees was extraordinary. While all of the presentations were unique in their own right(s), one in particular bears mentioning. Dr. Phillip Sell from Leicester, UK, presented his experience with a rare and debilitating problem—Gorham’s Disease. In this instance, the disease involved a patient’s cervical spine and became apparent only after operative treatment of a cervical fracture suffered after falling down stairs. With ongoing osteolysis, the patient required many surgeries and will require more.
While the academic interest of this case was high, what really attracted my attention was the manner in which it was presented with references to the patient’s needs, suffering and humanity. In one instance, the main concern of the patient was whether his spine was stable enough to go on holiday, while knowing full well that additional surgery would be required at some point.
This presentation was quite unique—very few scholarly programs will allocate podium time to case reports, particularly those in which no resolution has been attained. Dr. Sell’s patient continues to have persistent problems for which he continues to care. His final slide was no less memorable: “Does anyone have any ideas?” A lively discussion then ensued. Perhaps, not surprisingly, no definitive recommendations were forthcoming.
German poet Christian Morgenstern said, “Home is not where you live, but where they understand you.” I felt at home at all of these meetings, in the company of fellow travelers, spine care professionals. One thing I have taken from my travels is that we are all in this together. And what good company.*This column originally appeared in the May/June 2017 issue of SpineLine. To read more from that issue, click here.