As the incoming president of the Spine Society of Australia, Matthew Scott-Young details how his experience as an Emergency Department intern sparked a life-long interest in spine care. He addresses current challenges, warning against the dangers of cost minimisation, and talks about the sense of responsibility he feels towards the next generation, urging aspiring spine surgeons to find a good mentor. Now involved in many aspects of spine care, from surgery and teaching to research and policy, he explains why his surgical role remains the “most rewarding” aspect of the job.
While you knew from an early age that you wanted to be a doctor, what drew you to orthopaedics and later spine surgery in particular?
The attraction to orthopaedics came from my days as an intern in the Emergency Department, where I saw trauma, fractures and spinal injuries. The orthopods would attend, make an assessment, and were decisive. They would take the patients to theatre and make them better. They were pragmatic and, despite what some may say, they were approachable and friendly. Through orthopaedics, I was introduced to the treatment of the spine—stabilising my first cervical spinal trauma as a registrar sparked my love for spinal surgery. When I look back, it was 1988 when technology was starting to get traction, surgeons were starting to get results and evidence based medicine was in its infancy. Even though it sounds like you are treating one thing—the spine—the subspecialty is full of diversity and you are exposed to a multitude of pathologies and treatment modalities. Really, at the time, I could see the potential and future of the treatment of the spine and I was excited at the prospect of being part of that.
Have you had important mentors throughout your career? What have they taught you?
First and foremost, my father, Norm, a general surgeon and mother, Olive, a registered nurse, were my mentors. They were instrumental in guiding me through my formative years. I watched my father, a veteran of WWII and the Vietnam War, take care of a regional community in North Queensland as a general surgeon and superintendent of the local hospital. It was the time in the 60’s and 70’s when, if brain surgery was required, the general surgeon performed the surgery. These were times when there would be no doubt a severely injured patient wouldn’t survive a transfer to the big city, Brisbane. My Father’s surgical skills were second to none and watching him in theatre as a teenager taught me that your craft is not about how much you knew but about getting to that higher plane of surgery; a place where your hands are decisive and efficient and when the surgeon can anticipate complications and make adjustments as they go.
Those orthopaedic surgeons I met in Emergency, later became my mentors—David Morgan, John Morris and Tony Blue. They had my back when, as an orthopaedic trainee, my less than diplomatic approach to hospital administrators got me into hot water. Their advice and assistance got me through my training programme. My surgical skills have certainly improved since my training days, but I cannot say my diplomacy skills have matured at the same rate.
Specifically, in relation to my journey towards becoming a spine surgeon, I benefitted from the mentorship of Geoff Askin, Bruce McPhee, John Tuffley, John Lonstein, James Wilson-McDonald, and Jeremy Fairbank. I am also thankful today to many of my peers and brothers around the world who stood with me as we pressed the boundaries in anterior approaches to the spine.
While completing your postgraduate fellowship in spine surgery at the Nuffield Orthopaedic Centre in Oxford, you met some leading surgeons who introduced you to evidence-based medicine. How did this experience shape your career? Oxford in 1996 was the home of evidence-based medicine, where David Sackett, a Canadian, physician at the John Radcliffe Hospital was already talking about “external clinical evidence and individual clinical experience” when formulating the philosophy of evidence-based medicine in the care of patients. What I found was that my fellowship supervisors at the Nuffield Orthopaedic Hospital, James Wilson-MacDonald and Jeremy Fairbank, were already applying those principles to their practice of spine surgery.
On returning home, like my Father, I found myself setting up practice in a regional area—albeit paradise—the Gold Coast. Coming from Oxford, it was just common sense that I should track the outcomes of spine surgery, so that I could modify my behaviour in the future to maximise a result and minimise the problems. Hence, the collection of patient reported outcomes (PROMs) formed the foundation of my practice back in 1996. Collecting and reflecting on my individual clinical experience and evidence allowed me to provide patients with well-informed responses about what they could expect, when asking those important questions: how much pain will I lose? How will the surgery help me? And for how long do the benefits last?
What would you say is your proudest career achievement to date?
I am not sure that I can narrow it to one particular moment. I think for me, overall, my proudest achievement is the understanding of the nuances related to the anterior reconstruction of the spine. So, this is not a single moment or event but about reaching that volume performance moment when, maybe, my Father would look down on me and see something of himself.
What has been the greatest disappointment?
My greatest disappointment is not with any particular procedural failure or implant failure, as I have been lucky enough to follow the right path. My greatest disappointment is when I do not get a patient right or have a poor clinical outcome. There will always be cases of technical success with clinical failures but they are hard for both the surgeon and patient. My goal is to try and work out how to minimise this discrepancy.
What is the most interesting piece of research you have read recently?
The most interesting piece of research I have read lately is in relation to the MRI spectroscopy by Nocimed. This new technology promises to change the paradigm for diagnosis of degenerative spinal conditions and I certainly look forward to understanding its sensitivity, specificity and its utility in clinical practice.
You are involved in many different aspects of spine care, from surgery and teaching to research and policy. Where does this desire to go above and beyond a clinical role come from?
From my point of view, even though I have long left the Australian public system, the traditional place of training for our surgeons, I understand my responsibility towards the next generation of spine surgeons. It is with some considerable pride that I see my fellows reconstructing the anterior spine, achieving disc height, correcting the sagittal balance and correcting deformity—and then returning to their homes and communities around the world. I admit it is hard work, one on one mentorship, every year I question whether to take on another fellow but ultimately, it is my fellows who keep challenging me, keep me on my toes, and keep me relevant.
As to public health policy, I guess I will claim like everyone I was dragged into it reluctantly. The percentage of GDP that goes towards healthcare will vary from country to country but, essentially, it is about 10–15% and that slice of the pie will not get any bigger. Most clinicians are too busy just getting through their day to notice what is going on behind closed doors—we end up being reactive and, usually, by then it is too late and the decision has been made. Australia is at the tipping point over who will control private health care decisions—clinicians or payers (private or public). I see my role in medical politics over the next few years to make sure that when hard decisions need to be made about the future of medicine in Australia clinicians at the coal face have a voice and it is heard.
Is there a role you find particularly rewarding?
I think the role I find most rewarding is actually my surgical role. Being able to unravel the nexus of pain and decide whether surgical strategy is appropriate or not, implementing that strategy and seeing the results. There is nothing more rewarding than a happy patient.
What do you think are the main challenges facing spine care at the moment? What are the potential solutions?
Without doubt the main challenge facing spine care is dividing up the healthcare dollar. Our patients expect the newest and most advanced treatments and they are told by their governments confidently that they have the “best healthcare system in the world.” But as clinicians we have seen funding being chipped away everywhere we look, mostly under the guise of efficiency, but if we are honest it is for cost minimisation. I think my generation are going to get some unpleasant surprises about what we cannot expect from our healthcare systems as we age.
First, the solution is for governments and insurers to stop the “fake news” about what does not work and own up about what needs to be done to fund our healthcare into the future. Secondly, we must take responsibility for leading healthier lives—more focus and funding needs to be focussed on education and the prevention of chronic disease.
What do you hope to achieve as president of the Spine Society of Australia?
I am looking forward to taking on the role of president of the Spine Society of Australia. The society has grown from what was “the facet club” in 1990 to fast becoming the peak body for those specialising in the management of spine in Australia. The Society is a bridge between neurosurgeons, orthopaedic surgeons, academics and allied health professionals. While our size is dwarfed by the likes of NASS and Eurospine, that has never stopped Australians (and New Zealanders) from boxing above our weight.
As president, I hope to build on what presidents over the last few years have started; building a strong voice in Australia for our patients and our profession. I also want to galvanise our craft group towards recognition of the fellowship trained “spinal surgeon” as a sub speciality, though that journey may take some time.
In your opinion, what are the most exciting developments in spine care that we can expect in the next five to ten years?
I think one of the most exciting developments will be having a better understanding of the constrained disc replacement. In the past, the discs had too much movement and, of course, we have seen the negative effects of the static fusion. I think we will develop devices that will give some motion but not have the effects of fusion. Such devices could be applied to multiple levels and potentially correct deformity. I envisage this happening over the next 10 to 15 years.
What advice would you give to someone wishing to start their career in spine care?
The best advice I can give is what my wife keeps telling our kids—start how you want to finish. To that end, young aspiring surgeons need to find mentors and stick to them like glue. They need to realise that you are going to make some mistakes but persevere, document your outcomes, and modify behaviour accordingly. Do not worry about being busy; that will come in time. Certainly, do not worry about the fast cars and luxury homes. Keep your moral compass close when challenging ethical decisions need to be made. Put simply, focus on your patients and on achieving the best outcomes for them and everything else will follow.
What are your interests and hobbies outside spine?
Golf, golf and more golf. Oh, and wine, wine and more wine. But seldom together, if my handicap is to stay single digits!