Orthopedics is broken. How can we fix it ?

Don’t get me wrong. I love the orthopedic industry. One of the best careers one could possible have in medical devices. We are making a difference helping people every day.

However, we have many issues. We need some new companies to fix orthopedics.

Below are a few issues I can think of:

1/Clinical data is not available for the hundreds of new ortho and spine and bio products launched each year.

2/The devices with great long term data (eg: original medial pivot total knee) are no longer commercially available to surgeons/patients (what ?).

3/True device revision rates don’t show up in the data.  Device revisions are not highlighted at conferences because surgeons like to talk about their “wins”.  Revision patients often defect to another surgeon for their 2nd or 3rd procedure.  150,000 knee revisions done every year in the US. 15% of US total knee cases are revisions (what?).

4/Sales are driven by relationships or volume contracts or robot contracts. Sales are not driven by better product offerings.

5/There is not enough “original thinking” in ortho because of the cross-pollination and churn of the same people (read about true innovation here.)

6/30% of the price of an implant is the “built in” sales rep service, not the product.

7/An FDA clearance does not mean “safe and effective”. The FDA is a politically driven government bureaucracy that thinks they are protecting the American people (I can say this. You can’t).

8/There are too many implant size options, trialing options and instruments for most new systems (note: the patient-specific trend with disposable kits may slowly fix this.)

9/Alignment of incentives in the OR (added by Streams reader Nick Berger.) In the operating theater, there is a circulating nurse, a tech, a leg holder, a rep, a PA, and a surgeon. 

Nurse– plays by the book, no matter what. All about the checklist. Doesn’t care who the doc or rep is. Doesn’t play favorites. Paid hourly and loves overtime. Likes long boring cases to catch up on the current novel. 

Tech– full time. Hourly plus benefits. Not there to impress anyone. Waiting for their next break which usually comes just before cementing components. BUT, is in the most important position in the room because they affect EVERYTHING. They are underappreciated and because of that they seem to dread their job.

Leg holder– full time traveler tech/RN on contract for 2 more weeks. Paid hourly but 50% more than the tech or nurse that’s been there 5 years. Never done Ortho before. 

PA– salary and dreading the night and weekend ahead because of all the charting they need to catch up on. Takes on as much or more of the work in clinic than the doc with very little opportunity for growth. In the case, they are just a retractor holder, in charge of smoke evac, and closer. Also underappreciated. I see happier teams when a doc can have a PA for surgery and a PA for clinic but only viable with high volume. 

Rep 100% commission from use of implants. Years of specialized experience in these cases. Knows ins and outs of the case and where everything is in the hospital. Tries to help wherever they can including running Hana table, opening disposables or wrapped trays, quickly grabbing anything that wasn’t pulled by staff beforehand, or finding the right music station to set the mood. Not allowed to touch or do anything but stand against the wall. 

Surgeon– having to worry about every little detail of each person’s job so that case can go as smooth as possible. Paid per case so they demand efficiencies and consistency so they can pack in as many as possible. 

The biggest problem in orthopedic surgery in my opinion is that every single person in the case is incentivized in a different way. Docs want as many cases as possible, but PA, tech, nurse all would rather keep things to a slow and steady, manageable pace. Including SPD. The rep is seen as an outsider that is more of a liability than a help. They can be a huge asset if allowed to be. A team is supposed to have a common goal, but so often it seems like the players are all on their own team and get points for doing completely different things. 

We need to create a model for these roles to have a common goal and be incentivized for those same goals.  

10/What am I missing ? tiger@tigerbuford.com