Charles Fisher (University of British Columbia, Canada) was honoured in 2016 as one of the top 28 spine surgeons in North America, a highlight of a career spanning four decades. Head of the Combined Neurosurgical and Orthopaedic Spine Programme at Vancouver General Hospital, former president of the Canadian Spine Society and current chair of the AO Knowledge Forum Tumour, he speaks to Spinal News International about his research interests, forming the Canadian Spine Outcomes and Research Network, and what advice he would give to someone starting their career today.
When did you know you wanted to go into medicine, and what drew you to spine surgery specifically?
When I was doing my undergraduate studies at UCLA, my major was Kinesiology. I loved the human anatomy and biomechanics, so that drew me towards medicine. My first rotation in residency was the spine service and I instantly liked it. Probably what I liked most was the range and challenge of the surgical techniques; the immediate gratification of complex deformity correction along with the delicate techniques around neurological decompression. Surgical decision-making is also extremely challenging [and] thought provoking.
Could you explain your current research interests?
Over the years, my research interests have spanned spine trauma, oncology, outcome measures and research design.
My two current areas of research focus are with the AO Knowledge Forum Tumour – a multidisciplinary International Spine Oncology Group of Physicians and Surgeons, which I chair. We have created a Spine Oncology Network and focus on multicentre prospective studies. We also have baseline registries for metastatic and primary spine tumours. Because spine tumours are relatively rare – especially primary tumours – it is essential to have a network of many centres to get adequate numbers to do impactful research.
My second focus is with the Canadian Spine Outcomes and Research Network, which I also chair. The primary focus of this network and registry is degenerative conditions of the spine. In Canada, because of our one payer system, we have unique opportunities to do multicentre clinical outcome studies.
Have you had important mentors throughout your career? What have they taught you?
Yes, I have had many mentors, but probably three stand out. Clive Duncan, a hip and knee arthroplasty surgeon and my chair when I started who convinced me to get my MPH [Master of Public Health] and pursue clinical research excellence. Marcel Dvorak, my colleague for many years in our Spine Program who taught me the value and importance of clinical research. Alex Vaccaro for the importance of asking practical clinically relevant research questions.
What is your proudest career achievement to date and why?
Being considered by my peers as an international expert and leader in spine oncology and the research that goes with it.
As chair, what are your plans for the AO Knowledge Forum Tumour in the next year?
- To partner and/or collaborate with some oncology societies to integrate and expand multicentre research.
- To begin work on our most recent grant looking at expectations in Spine Oncology Patients.
- To expand into Latin America and more into Asia to increase AO Knowledge Forum Tumour’s international presence and enhance the generalisability of our research.
- Start to analyse early results from our primary and metastatic tumour registries.
You initiated the Canadian Spine Outcomes and Research Network (CSORN) in 2013: what drove this?
The incredible potential we have in Canada to do quality research. With [the] one payer system, the competitiveness of medicine is eliminated so there is a more collaborative spirit among spine surgeons and researchers. We provide world-class care that is generalisable and have a very manageable patient population. This is an ideal environment to produce high impact research that will make a difference in spine care around the world.
How has the field changed since you started your career?
Dramatic changes in technology: not just surgically, but diagnostics, anesthesia etc. This allows us to do more and take better care of our patients. We must always be cognizant that the technology is cost effective however.
Accountability with respect to patient reported outcomes, adverse events and costs. This is imperative.
Industry taking an interest in good objective research and facilitating thought leaders getting together to educate and plan good research. This initiative produced study groups that evolved in [and] after 2005, and have had a really positive impact on patient outcomes.
The integration of neurosurgical spine and orthopaedic spine has had a dramatically beneficial impact on spine care and professional development.
Outside of your own research, what is been the most interesting paper that you have seen in the last 12 months?
The two The New England Journal of Medicine randomised control trial studies on fusion vs. laminectomy in spinal stenosis/degenerative spondylolithesis from 2016. I think the two studies typify the problems with randomised control trials in surgery. Two studies that took an incredible amount of effort and time and I am not sure we are any further ahead with respect of what to do in these patients.
In your opinion, what are the most exciting new developments in spine surgery that we can expect in the next five to ten years?
- Better surgical decision making that will improve outcomes and decrease adverse events.
- Expanding research on patient expectations so the surgeon can deliver on what the patient is expecting.
- Better surgical technology such as robotics/navigation to reduce intra-operative adverse events.
- Genomics in spine oncology.
What is the biggest challenge in spine surgery at the moment?
Controlling costs and improving surgical decision-making. We need to make big strides in knowing whom we should operate on and how we should operate. This will lead to cost effective care and better patient reported outcomes.
What advice would you give to someone wishing to start their career in spinal surgery?
This would depend to some degree on if they were going into academic or community/private practice. From a clinical perspective, I would encourage them to do some extra training after their fellowship that provides them with a subspecialty interest. It doesn’t necessarily have to be a whole other one-year fellowship, but experiencing more visiting centers for a number of weeks to gain insight into different ways surgeons approach things and to broaden their perspective. This also provides future connections and networks. It is very important as a young surgeon to have mentors and people to discuss cases with – decision-making is so difficult.
Academically, I would strongly support doing a graduate degree – MPH [Master of Public Health], health care economics and develop a niche research interest. I think we have an obligation working in academic health science centers to give back and invest in clinical research. If you perform one operation, that helps one individual, but teaching a resident may influence many. Publishing impactful research may influence clinical practice around the world.
What are your interests and hobbies outside spine? You attended UCLA on a soccer scholarship – do you still play?
I don’t play anymore; the knees will not take it. I do coach however. I have coached youth soccer for the past 25 years at a high level. Won several provincial championships. I also coached baseball. I am an avid golfer and enjoy spending time with my family at our summer home on Vancouver Island. Lots of gardening and water sports. I also enjoy snow skiing with all our great local mountains.
1997–81: Bachelor of Sciences, University of California, Los Angeles, USA
1982–86: MD, Dalhousie University, Halifax, Canada
1997–99: MHSc Health Care and Epidemiology, University of British Columbia, Vancouver, Canada
Selected special professional qualifications
1984–85; 1987: Diplomat, National Board of Medical Examiners (American) Parts I, II
1986–87: Internship, Lions Gate Hospital, North Vancouver, Canada
1987–92: Residency, Department of Orthopaedics, University of British Columbia, Vancouver, Canada
1992: F.R.C.S, Royal College of Physicians and Surgeons
1992: Reconstructive Surgery Fellowship, Department of Orthopaedics, University of British Columbia, Vancouver, Canada
1997: Visiting Spine Surgeon, Mini Spine Fellowship, Professor Jurgen Harms, Karlsbad, Germany
Selected academic appointments
1993: University of British Columbia, Department of Orthopaedics, Clinical Instructor
1993–03: University of British Columbia, Department of Orthopaedics, Clinical Assistant Professor
2003–09: University of British Columbia, Department of Orthopaedics, Assistant Professor
2000–13: Vancouver General Hospital, Combined Neurosurgical and Orthopaedic Spine Program, Director of Spine Fellowship Program
2009–14: University of British Columbia, Department of Orthopaedics, Associate Professor
2013–Present: University of British Columbia, Department of Orthopaedics, Head, Division of Spine
2014–Present: University of British Columbia, Department of Orthopaedics, Professor