Ray Baker, 2009–2010 president of the North American Spine Society tells Spinal News International that in this age of austerity, new treatments must be better and less costly at the same time. He also says that despite the “glitz” of new products and procedures, trust remains the foundation of the patient/physician relationship
How did you become interested in medicine?
When I entered college, I was initially drawn to engineering, but quickly changed my major to pre-med after determining that engineering did not suit my personality. I have always been a “people person,” and the idea of helping others as a physician appealed to me.
Why anaesthesia for the spine?
During my residency electives in regional anaesthesia, and during my fellowship, it became evident to me that many patients suffer from spinal pain, and that I needed a more complete understanding of spinal anatomy and pathology. Upon graduation, I spent one or two days a week working alongside a neurosurgeon, John Oakley, who taught me physical examination techniques, how to diagnose spinal conditions, read MRIs, CTs, and myelograms.
Can you tell us about the importance of the role for anaesthesiologists for spine care?
I believe strongly in a team approach, and often use the analogy of the elephant in the dark. Each individual comes to an understanding of the part of the elephant that he or she is exposed to. While each of us is correct about the part that we touch, none of us has a complete understanding of the elephant. As a team, we can work together to overcome the deficiencies that we have in understanding.
Who were the people who inspired you in your career, and what advice of theirs do you remember today?
Many people have inspired me along the way. Rick Derby, a renowned interventional pain medicine specialist, was kind enough to allow me to “shadow” him. I am grateful to Rick for sharing his practical knowledge of treating complex conditions and for his patient-centric approach. My terrific partner, Paul Dreyfuss, has taught me a lot about the need for balance in life. Stan Herring precipitated my involvement with NASS, and has mentored me as I have risen in the organisation. His wonderful sense of humour and terrific people skills have highlighted the need for me to keep having fun along the way.
What is your personal philosophy/approach to care of the spine?
My starting point is this: the milieu is as important as the method. How you treat someone and the context of your treatment is just as important as the treatment itself. Treating spine conditions is humbling—there are so many things that we either do not understand well, or we cannot treat well. There is little room for ego, as we must continually question even our most basic premises. It also means that we must strive daily to push the envelope of our understanding and extend our knowledge.
Could you identify some exciting developments in treating the spine today?
The trend towards minimally invasive treatments is exciting…our “footprint” is smaller, patients are returning to their lives sooner, and they have less musculoskeletal disruption. Also, having a multitude of restorative/reparative treatments is fantastic, including the new biologic treatments. Lastly, new imaging technologies, such as MR spectroscopy, hold the promise of diagnosing spinal conditions in a non-invasive and objective manner while providing a much-needed gold standard.
Could you describe some memorable cases you have treated, and the outcomes?
In a 20-year career there are many cases that stand out. But two are particularly poignant. Recently, a 30 year old policewoman came to see me for a back problem. She said, “You don’t remember, but you treated me 10 years ago for a different problem.” It ends up that I had previously treated her for severe pain related to a herniated disc. She had a basketball scholarship, and really needed to keep playing to retain this funding. You can imagine how rewarding it felt to have her say that if it were not for my treatments, she would have had to quit basketball, would have lost her scholarship, and would have never graduated from college. I also remember a grandmother who was confined to a wheelchair after developing complex regional pain syndrome following spine surgery. It was very exciting to see her progress; within six months of treatment she was taking dancing lessons.
What is the most interesting paper you have come across recently?
Howard Brody’s NEJM article, The Top Five List, was fascinating, and should give us pause. Brody’s premise is that medical societies have a duty to determine the top five tests or procedures that their members perform that have little or no patient benefit. He recommended that the Top Five list essentially be a prescription for how, within each specialty, the most money could be saved (as fast as possible) without depriving any patient of meaningful medical benefit. It really highlights the fact that medical societies need to begin to look at appropriateness criteria and best practices, not just guidelines.
Which technique or technology had a profound influence on your career?
Cervical radiofrequency neurotomy—it is a technique for lesioning (cauterising) nerves that supply painful joints in the neck and back. It is particularly helpful in the neck and can offer patients a minimally invasive treatment for neck pain and for headaches stemming from the neck. Many of these patients have been in pain for years, and it is extremely gratifying to be able to offer them relief.
What do you hope to achieve as the President of NASS this year?
I want to impress upon our membership the importance of value (quality/cost), and to have value principles integrated throughout our committees, in all of our educational activities, and across our membership. As I am fond of saying, we are now in the Intel era of spine care. New treatments must be better and less costly at the same time. While this is a tall order, we are already seeing some progress. And, despite the “glitz” of new products and procedures, trust remains the foundation of the patient/physician relationship. Safeguarding this trust is essential in maintaining our good standing as professionals.
Do you have a message to your colleagues who are treating the spine?
You will always be successful if you treat the patient, not the disease. It seems so basic, but it was really an epiphany when I realised that some of the best patient advocates were those people that I did not “cure;” they were patients who were grateful for the time that I spent talking with them, educating them, and trying to understand them.