Taking up medicine was not a childhood dream, but a carefully considered decision. Fascination with the spine was partly a result of learning. From inspirational mentors to the challenges of helping patients with failed back surgery syndromes, spending time at home and helping children with free advice on sports-related musculoskeletal injury, Federico Balagué, current president of Eurospine, tells Spinal News International how he became a spine specialist.
What made you take up a career in medicine and has it lived up to your expectations?
Frankly speaking, my decision had nothing to do with a dream or a project that I had from childhood. When I was about to start university, I analysed my weaknesses and strengths without any self-indulgence and medicine appeared the way to go. Actually, I had a scientific background from secondary school, but at the end I realised that I did not have it in me to become a specialist in “real sciences” like mathematics, physics or chemistry. Moreover, I was not good at technical or artistic drawing, which ruled out careers like architecture or engineering. Among the biologically oriented possibilities (eg human medicine, veterinarian medicine, biology), medicine was my choice, probably because my father was a physician.
Why do you find the spine so interesting?
In my opinion, interest in any specific topic is partly developed as a result of the time devoted to learning about it. Many years ago, I asked my supervisor for an idea that would become my thesis and his choice was related to the lumbar spine. Initially I was very reluctant (as a rheumatologist, inflammatory rheumatic disorders like ankylosing spondylitis or rheumatoid arthritis were much more appealing to me!), but after reading quite a number of scientific papers on the topic, the spine appeared fascinating to me.
Tell us about some of the most memorable moments in your professional life…
The first one that I remember was a long time ago. When I was a medical student, my mentor included me among several other students as co-authors of a paper that was published.
Later on, becoming a member of some major organisations like Eurospine and the International Society for the Study of the Lumbar Spine, and currently being the president of both societies, my academic affiliations with NYU and University of Geneva, each accepted manuscript and some clinical encounters have been the highlights of my professional life.
Who have been your biggest influences?
As a medical student I had an incredible mentor, A Sanchis, Barcelona, Spain, who took care of our group. He spent a number of hours teaching us medicine both in terms of scientific knowledge, and also ethical principles and respectful behaviour with patients. Later on, during my post-graduate training, my first boss, the late I Radi, Fribourg, Switzerland, set such a fine example that I decided to choose rheumatology as a specialty, after working with him for a few weeks. I discovered the principles of methodology at NYU with M Nordin and M L Skovron, and my approach to clinical research changed irreversibly. Finally participating at one of the visitors’ weeks organised by the late Alf Nachemson, Gothenburg-Sweden, boosted my enthusiasm for the rest of my career. For several years now, I learn every day from specialists in different areas (eg Ch Cedraschi, psychologist; AF Mannion, researcher; F Pellisé, spinal surgeon) with whom I started a scientific collaboration that has now become real friendship.
Can you describe one of the most difficult cases you have attended to and the outcome?
Some of the most difficult cases we deal with are patients with the so-called “failed back surgery syndromes”. Most of the time we cannot help such patients very much. At the other end of the spectrum, a few cases of adolescents with either pain or progressive deformities due to benign spinal tumours have been among the most rewarding because all of them were cured by the spinal surgeon. In these cases the main challenge for me was the diagnosis.
What role do you think spine societies play in the field?
Their role is probably quite different if we consider national or international societies; while the former play a more political role supporting their members in their relationships with healthcare systems, the latter are probably more focused on education and research networking.
Research societies have helped achieve plenty of goals. If I think of Eurospine, the spine society of Europe, our annual meeting has become a must for specialists of different areas interested in spine. The Society also organises courses for future specialists and is clearly improving the quality of this educational programme. Fellowships have allowed young specialists to visit colleagues in other countries contributing to strengthening the relations between the medical communities of different European countries. Several spine societies have created prestigious research awards and contributed to facilitate international multidisciplinary collaborations.
What have you achieved as the outgoing president of Eurospine?
When I was elected, I tried to apply the motto from American president John F Kennedy to the service of Eurospine (“Don’t ask what your country can do for you…”). As I do not believe my personal opinion is more valuable than that of any other member, I launched a survey and gathered information from our members. Based on that, we have modified the procedures for the election of future officers to make it more democratic and transparent. I have also done my best to support all the educational activities of the society. Of course, the credit for that is not only mine. Nothing could be done without the commitment of the secretary and the rest of the officers as well as the administration of the society.
What are the most exciting technologies that have revolutionised treatment of the spine in your career? What are their major influences?
Well, do not forget that I am not a surgeon and thus “technologies” for me have been the modern imaging techniques (MRI, 3D CT-scan, PET scan, functional MRI, etc). The arrival of the modern biologic drugs (eg TNF-blockers) has dramatically modified the quality of life of many patients suffering from inflammatory rheumatic diseases.
In your opinion which is the most landmark clinical trial to have achieved amazing results in the last 10 years?
There are many. In the field of juvenile low back pain, S Negrini and R Carabalona’s study (Spine 2002) showing the role of subjective perception in the relationship between backpacks and back pain and GT Jones et al’s (Pediatrics 2003) highlighting the role of psychological factors in incident low back pain in adolescents, have influenced my approach of the topic. The Norwegian study by Brox et al (Pain 2006) showing comparable results of surgical and conservative management in chronic low back pain patients was very well received by the non-surgical community.
What are the major challenges facing treatment of the spine today?
There are some general problems which affect all the specialties similarly. The pressure from political authorities, and insurance companies has increased and will become even stronger in the coming years. We need clear evidence of the efficacy and effectiveness of our treatments, and need to take into account the cost too. Also, even though this is not directly related to treatment of the spine – having the concept of “spine specialists” both surgical and non-surgical would probably be a progress.
What is the focus of your current research?
My interest is focused on juvenile back pain and we have moved from epidemiology and risk factors to adolescents’ perception and quality of life. We also collaborate on multicentre trials in the conservative treatments of low back pain and sciatica in adults. Finally, we have performed independent evaluations of the surgical patients in our area.
Outside of medicine, what other interests do you have?
My family is the most important thing in my life and spending time at home is fundamental to my well-being. I also enjoy reading, listening to music, swimming and walking. For example, I join the masters group of our city for once-a-week sessions of swimming training. I also help a couple of sports clubs in our area which have very active junior sections, for example supporting the coaches with scientific information or offering free advice to adolescents with sports-related musculoskeletal problems.
Spain and Switzerland
1988 – Present
Vice-Head (Médecin-Chef adjoint) of the Department of Rheumatology, Physical Medicine and Rehabilitation, Cantonal Hospital of Fribourg, Switzerland
2001 – Present
Adjunct Associate Professor, Department of Orthopaedic Surgery, Hospital for Joint Diseases New York University, New York, US
1973 MD, University of Barcelona, Spain
1981 Doctorate, University of Lausanne, Switzerland
1982 Specialist, Autonomous University of Barcelona, Spain
1987 Swiss Federal MD, University of Lausanne, Switzerland
1987 Swiss Federal specialist
1973 – 1974
Resident, Internal Medicine, District hospital, St-Imier, Switzerland
1974 – 1975
Resident, Surgery, District hospital, St-Imier, Switzerland
1976 – 1978
Resident, Rheumatology, Physical Medicine and Rehabilitation,Cantonal hospital, Fribourg, Switzerland
1978 – 1980
Fellow, Rheumatology, City hospital, La Chaux-de-Fonds,Switzerland
1980 – 1982
Resident, Internal Medicine, City hospital, La Chaux-de-Fonds, Switzerland
1982 – 1987
Attending physician (six month acting Head) Rheumatology, Physical Medicine & Rehabilitation Cantonal hospital, Fribourg, Switzerland
1987 – 1988
Attending physician, Disability Evaluation Centre University Polyclinic, Lausanne, 1Switzerland
Division of Epidemiology and Health Sciences (Prof. Gary J Macfarlane). The University of Manchester, Manchester, UK)
Occupational and Industrial Orthopedic Center (Prof. M Nordin), New York, NY, US
Sahlgrenska Hospital – Department of Orthopedics (Prof. A Nachemson), Göteborg, Sweden
Children’s Memorial Hospital – Pediatric Rheumatology, (Prof. L Pachman), Chicago, IL, US
University of Illinois College of Medicine – Section of Rheumatology (Prof. J.L. Skosey), Chicago, IL (USA)
Northwestern University – Arthritis – Connective Tissue Diseases Section (Prof. F.R. Schmid), Chicago, IL (USA)
Rush Presbyterian St. Luke’s Medical Center – Department of Orthopedics (Prof. G.B.J. Andersson), Chicago, IL (USA)
Rehabilitation Institute of Chicago, IL (USA)
Milwaukee County Medical Complex – Department of Rheumatology