As his term as NASS president comes to a close, Spinal News International caught up with Todd Wetzel to discuss his career to date, his society achievements and his hopes for the future of the spinal field. Like many orthopaedic surgeons, he began his career excited by the mechanical nature of the discipline. Witnessing some of the biggest advances in spine surgery—internal fixation and the development of biologics—his professional interests have grown to include everything from spinal cord stimulation to medical ethics to paleontology. He reflects on his year as NASS president, and on the highlights of his career so far.
How did you get into orthopaedic surgery, and what appealed to you in particular about spine?
Orthopaedic surgery was attractive due to the surgical variety and the mechanical nature of the problems and solutions. I also found neurophysiology to be extremely interesting, so the migration to spine was natural—fascinating biomechanics interfacing with the central and peripheral nervous systems.
Who have been your career mentors and what wisdom have they taught you?
During my time at Yale University (New Haven, USA), Dr Wayne Southwick instilled in me a love for research, while still remaining dedicated to compassionate patient care. He was a leader by example and by engagement. Also at Yale, Dr Michael Murphy is a gifted, fearless technical surgeon and extraordinarily insightful thinker, who was instrumental (no pun intended) in instilling a love for the operating room. My postdoctoral year under Dr Manohar Panjabi convinced me that an academic career was the way to go. He is an absolutely brilliant scientist and true gentleman.
My first chair at Pennylvania State University’s College of Medicine (Hershey, USA), Dr Robert Greer, was not a spine surgeon. He was, however, incredibly supportive of the programme. He was a gifted leader. I undertook an excellent fellowship with the late Dr Henry LaRocca at Saint Charles General Hospital and Tulane University, New Orleans, USA. A critical thinker and true lover of his work, he was an artist at heart.
Outside of academia, my wife Laura has been the world’s most outstanding partner.
What has been your proudest career achievement so far, and why?
My presidency of NASS has been the proudest part of my career so far. This represents the culmination of many years of work for an organisation in whose mission I deeply believe. I also look at this as an opportunity to work closely with some of the most outstanding individuals I have ever met—both staff and fellow volunteers.
A corollary would be the receipt of the Farfan Award from NASS rather soon in my career for my early work in biomechanics and contributions to nonoperative care.
What do you think has been the biggest development in spinal surgery during your career?
Internal fixation has been the biggest development. In my residency, the only instrumentation used was Harrington rods. I put in my first pedicle screws as Dr LaRocca’s fellow—this innovation has truly improved outcomes dramatically. Certainly, today, biologics are equally impressive.
You have been involved extensively with spine surgery research. Which piece of research are you most proud of, and why?
As part of my postdoctoral fellowship, I was able to develop what was then “advanced” technology: two-dimensional digitisation and quantitative imaging to investigate the healing of spinal injuries in animal models. This may be primitive by today’s standards, but it was a bit of a deal then!
What are your current main research interests?
At the moment, I am primarily interested in healthcare delivery and value-based care, as well as ethics in medicine. These two topics are intimately connected. Value equates to quality, in the context of cost. Thus quality of care is an extremely important driver. Unfortunately, in a fee-for-service system, such as that in the USA, quantity is rewarded more than quality. This tends to encourage unnecessary services and excessive provision of care. The ethical implications of this are obvious.
Outside of your own work, what has been the most interesting paper that you have seen in the last 12 months?
The work of Dr Zoher Ghogawala and colleagues on spondylolisthesis (“Laminectomy plus fusion versus laminectomy alone for lumbar spondylolisthesis”)1 was truly an outstanding piece of outcomes-based research.
A lot of your academic work has focused on interventional treatments for back pain—particularly spinal cord stimulation. More and more companies are marketing spinal cord stimulators to surgeons. Do you think that this therapy is going to become more popular among surgeons?
I hope that it will become more popular, so long as it is for the right patient indications, and by those with the patience and expertise to use it wisely. Spinal cord stimulation is an extremely interesting field at present with new techniques and in fact new types of stimulation available. For the right patient, particularly one with neuropathic pain and no surgically reversible problem, spinal cord stimulation is arguably the best solution for that patient. Additionally, a percutaneous trial is performed prior to permanent implantation. If the trial fails, and the patient is not a candidate for the device, at least no further anatomic injury has been added.
What are the main challenges spinal surgeons face today?
All physicians face the same major challenges—job satisfaction in an era of increasing regulation, decreasing reimbursement, and the overall loss of autonomy. Unfortunately, the pressure in care delivery seems to result in volume as a strategy for survival. As a result, the provider needs to remain focused on quality of care for the individual patient, rather than on quantity.
You are coming to the end of your year as NASS president. What achievements are you most proud of?
Continuing to lead medical societies in the most stringent management of conflict of interest for leadership is something I am particularly proud of. In addition, the growing the presence of NASS in advocacy is very rewarding, and important for members. I am also proud of the growing NASS Registry—a diagnosis-based outcomes data registry currently in the pilot stages.
What work does the society still have to do to support its members?
It is important for NASS to continue developing its advocacy efforts, and to carry on representing an inclusive range of specialities. The Society needs to be sensitive to changes in the learning paradigms, for example, by offering more digital educational material like webinars or online courses. As NASS expands, it needs to continue to contain its costs, while ensuring that more and more of its members participate in committee work.
Physicians around the world face regulatory changes and reimbursement pressures—the USA is going through a particularly uncertain period politically. How is this affecting spinal surgeons, and how can societies like NASS work to support their interests?
NASS has been extremely effective as a patient advocate with the government and with third-party payers and must continue to be. In addition, gaining perspective from other systems outside of the USA has been very helpful.
What are the three questions in spinal surgery that still need an answer?
- How can we get the unspecific out of “unspecific” low back pain? We need to continue to develop reliable subgroups in order to study the most effective treatments.
- What is the proper role of surgery—if any—in “pure” low back pain syndromes?
- How can we definitively get away from a fee for service or relative value unit-based model of compensation that simply rewards quantity service?
What do you think will be the next big development in spinal surgery?
I think there is a lot of promise in biologics; a development of stem cell technology that will be truly reparative.
What advice would you give to someone who was starting their career in spinal surgery?
- Learn the regulatory and financial aspects of your career for survival
- Always focus on quality
- Celebrate your individual victories (eg. an excellent patient outcome)
- Have a medical hobby (that is how my interest in spinal cord stimulation started)
Outside of spinal surgery and research, what are some of your hobbies and interests?
I have an avid interest in motor racing, which I have been doing for 40 years in total—with some years more active than others! I am also interested in palaeontology. Currently, I am working on a description of intervertebral structures in cretaceous hadrosaurids. Hopefully.
Philosophy is another interest of mine. At present, I am developing a practical handbook of logic for healthcare education. I also enjoy military history and walking my amazing dog, Whippet.
1. Ghogawala, Z, et al. New England Journal of Medicine, 2016; 374:1424–34
|1977||AB Biology, Harvard College, Cambridge, USA|
|1981||MD, University of Pennsylvania, Philadelphia, USA|
|1988||Fellowship, Spinal Reconstructive Surgery, Saint Charles General Hospital and Tulane University, New Orleans, USA|
Selected academic appointments
|1988–93||Chief, Section of Adult Spinal Surgery, Pennsylvania State University College of Medicine, Hershey, USA|
|1992–93||Associate Professor of Surgery, Pennsylvania State University College of Medicine|
|2003–04||Professor of Surgery, Section of Orthopaedic Surgery and Rehabilitation, Pritzker School of Medicine, University of Chicago, Chicago, USA|
|2004–present||Professor of Orthopaedic Surgery and Neurosurgery, Temple University School of Medicine, Philadelphia, USA|
|2008–present||Vice Chair, Department of Orthopaedic Surgery and Sports Medicine, Temple University|
Selected clinical appointments
|1993–2000; 2003||Medical Director, University of Chicago Spine Centre, Chicago|
|2000–03||Chair, Division of Surgery, Louis A Weiss Memorial Hospital|
|2009–13||Medical Director, Temple Spine Center at Jeanes, Jeanes Hospital, Temple University System|
Selected society involvement
|1994–2004||Fellow, American Academy of Orthopaedic Surgeons|
|1999–present||Oral Examiner, American Board of Orthopaedic Surgeons|
|2005–present||The College of Physicians of Philadelphia|
|2006–10||Spinal Arthroplasty Society|
|2012–present||Society of Vertebrate Paleontology|
|2015–16||President, North American Spine Society|
|2015–present||Member, Paleoanthropology Society|