The path of the innovator

THE PATH OF THE INNOVATOR

Medicine is notoriously slow to react to the introduction of new technologies into the practice of clinical medicine for a wide variety of reasons that include fear of litigation, inadequate skills or knowledge of the new technology and fear of professional jealousy. These powerful forces have not however through the history of medicine prevented the inevitable progress of innovators who despite the many attacks on their professional reputations have continued with their groundbreaking work and in the process shaking up the status quo. It is because of these individuals that medicine has evolved to the relatively elevated state compared to a century ago. These obstacles and professional battles have occurred in all areas of medicine with the most recent and vicious one being in the field of spine.

At this point I must admit that time and history gave me the privelage and opportunity to be at the center of this momentous battle that for the most part took place in the US between the years of 1998 and 2014 and more specifically the state of New Jersey. I recognized the gift that had come my way and embraced it with the full gusto of that once in a lifetime feeling or alternatively as some colleagues mentioned I took the bull by its horns. However one describes the series of events leading up to and surrounding the suspension of my New jersey medical license it no doubt contains a cast of characters, plots, and conspiracies of which Tony Soprano would have been proud. Medicine has never struck the public as involving mafia like tactics but after experiencing this episode of my life I would suggest that the mafia has nothing on the organized crime factions of modern day medicine in which the financial stakes are very high. Each innovator throughout history has dealth with the specific challenges of his time and whose battle has been characterized by the technology of the era. It was the internet that for the first time allowed the innovator under attack,I, to more rapidly and effectively mount a counter defense and then attack.

Minimally invasive spine surgery is now the standard of care in the year 0f 2014. It did however take a rather long and viciously fought set of battles to bring it to this point with mine being the last and most vigorously fought. There are many ways to tell the story of what became commonly known in the media and on the internet as the Spine Turf Wars but the simplest way would be to arrange the key events and the role of the key characters in chronological order.

I graduated from medical school in London in 1988 and underwent 7 years of post graduate training in the fields of general surgery, anesthesiology, ainterventional pain and minimally invasive spine surgery in both the US and the UK with other training obtained in Korea and Germany. After my post graduate in the US in 1995 I returned to the US in 2001 and it was at this point that I recognized the very early elements of the minimally invasive spinal approach. I was fortunate enough to witness one of the busiest interventional pain physicians in New Jersey who encouraged me to obtain further training in this emerging speciality. It was his opinion that this would become the standard of care as it eventually did but not without. multiple professional battles.

The key and central component to the successful performance of MISS is the use of a mobile x ray unit for the purposes of fluoroscopic guidance and interpretation which simply means the use of x ray to accurately place instruments into the spine. The post graduate training I had received during the interventional pain fellowship focused heavily upon the utilization of this technology and therefore allowed me to acquire the essential skills of FGI to perform MISS. I therefore began to travel the world spending time with many physician innovators around the world observing and sometimes assisting on these cases. I brought these skill back to the US and continued to attend multiple hands on cadaver training courses to further expand the range of surgical skills and expertise. Simultaneously I developed a very busy and successful spine practice in New Jersey was able to help a lot of people with debilitating spinal conditions. The majority of patients were extremely appreciative of the many advantages of the MISS as it allowed them to return to work earlier as compared to the more aggressive approach used by traditional back surgeons. However the acquisition of the hand/eye coordination skills required to perform these surgeries possessed a steep learning curve that necessitated any physician wishing to carry out these surgeries to undergo further post graduate training most usually in the form of weekend hands on cadaver courses. The ability to use FGI came more readily to the Interventional Pain and Radiology communities as their training had principally involved this component. By contract the neurosurgeons and orthopedic surgeons were woefully lacking in these same skills and therefore had a harder time adopting the use of FGI and thus the performance of MISS.

As the practice grew so did the many jealous and bitter doctors who did not or could not perform these procedures and instead of taking the time to get trained in the art of FGI they decided to use the political process in New Jersey which is unfortunately known for being particularly corrupt. To cut the rather predictable story my physician competitors bribed a group of local republican politicians to exert pressure on the medical board to suspend my license despite the fact that my clinical outcomes and complications rate were superior when compared to the national average. The suspension of my license had nothing to do with effective patient care and everything to do with corrupt politicians and restrictive business practices. When my license was suspended in June 2012 the medical board ensured that the media assassinated my reputation hoping, I am convinced, that I would pack my bags and disappear under some overseas hole. Well I am still here and fought what many considered to be an impressive battle against a corrupt state, governor and a system that had been rigged from the beginning. It was this that prompted my then attorney to file a lawsuit in superior court requesting the appointment of a special prosecutor and an ad hoc medical board as the attorney, who obviously knew more than me, realized that the outcome had been pre-judged and there was no way I would receive a fair trial in New Jersey. Unfortunately that request was denied and I was left with the New Jersey administrative court ,the lowest in the land and not populated by the most insightful legal minds.

I therefore had no option but to deal with the already poisoned legal system but I also realized early on the importance of the public perception and how powerful that could be in effectuating change if not immediately then at some point down the road. The internet has changed the fabric of society and those that understand how to harness its power will possess an advantage that a physician would not have 10 years ago. The internet gave me the ability to fight back against the multiple falsities and misrepresentations printed and posted in the papers and on the internet. I was able to begin the process of crafting a narrative that I felt was closer to the truth than just allowing myself to be victimized at the hand of ill intended parties for whom in many instances the truth was an obstacle to be avoided. I therefore erected a website and created a social media prescence and was effectively able to use these to bring the gross injustice of my case to a global population and thus gaining support. No longer would the physician under attack ever have to retreat into the shadows and have his well earned reputation torn to shreds. Each time an article was published I would respond on my website with piercingly truthful pieces. Other than demonstrating to the attackers that I would fight back with everything at my disposal it also established my reputation as a fighter who would not let an out of control medical board, governor and press behave with impunity.

Although I was cautioned by many as to the potential folly of this strategy I had been forced by the draconian actions of the medical board to literally fight for my life and that is what the internet enabled. It acted as a true tool of democracy and I was successfully able to bring the truth of the matter to a wider and uneducated population that first of all have never heard of the medical board and secondly blindly assume that just because they are the board they must be correct. History is replete with despots and dictators that were at one time held in great respect only to have that façade shattered when their misdeeds became too overwhelming. There is therefore no reason to not suspect the medical board of malfeasance. They have the power over a physicians license and will use it for the business interests of themselves and their close friends. In life whenever any entity or group of people begin on the slippery slop of demi-godism there is only one outcome and that is total destruction which as I will explain later actually happened.

Without getting too distracted at this point regarding the political foul play the innovations that I created led to me successfullly performing the first ever outpatient lumbar interbody fusion in 2005. This event was remarkable for several reasons:first it was performed by a physician that was not trained in either orthopedic or neurosurgery and secondly it was performed in an ambulatory surgical center with the patient going home the same day. I was clearly way ahead of the curve. This clinical practice has now in 2014 become the standard. The inspiration for the procedure came tome one day while I was attending a spine course in Chicago and witnessed a physician placing a bone graft into a fractured vertebral body using a percutaneous approach. As I watched the procedure I realized that this same tectnique could be modified to use as an interbody device for the purposes of lumbar fusion. Approximately one month later I contacted the company that manufactured the devices and met with the local sales rep who demonstrated the instruments. A week later I scheduled a patient and successfully performed the procedure. A question that often comes up is what training did I have prior to this surgery and I always give the same response which is that the most critical part of the operation, which is the radiologically guided placement of the instruments I had been performing for many years but with slight smaller instruments. The essential component of the surgery was the appreciation of the anatomical landmarks and their radiological correlates and using the 2 D images on the X ray machine to create a 3 d model in ones head which formed the mental framework which the physician used to safely and effectively place the key instruments.

It is always a difficult thing to explain a concept without actually demonstrating it in real life and it was this understandable ignorance of the medicine that unfortunately led to the grossly inaccurate articles written in the press. I was however lucky enough to have the digital wherewithal to respond. The key component going forward is to educate both the public and the legislators in the state of New Jersey on the advantages of this approach and the fact that these procedures are more naturally aligned to the specialities of interventional pain and radiology. A very clearline has as a consequence of my case been drawn in the sand from which there will be no retreating and from which 5 years from now the majority of spine procedures will be performed by the two aforementioned groups. I am often use the example of the interventional cardiologists who 25 years ago began to encroach on the work of the cardiac surgeons with the use of fluroscopically guided catheters to treat coronary artey disease. Today the unequivocal standard for the management of CAD is the placement of stents. This is exactly what will happen with spine.

To briefly return to the politico/legal events surrounding the case I had always maintained my innocence and in fact asserted that I was the party that had been victimized by a corrupt medical board and governor. Time is a powerful ally and those that can patiently wait eventually prevail allowing the truth to be fully told. The governor of New Jersey, Chris Christie, allowed himself to get involved in a professional medical battle and in my opinion foolishly accepted monies from special interest groups that wanted to put me and physicians with my training out of business. I was able to gather enough intelligence on this matter through multiple conversations I had with numerous colleagues in New Jersey. The joining of the dots was not difficult and once I was fairly certain I had my information close to the truth I unloaded all of the data in the forms of essays charts and diagrams illustrating the relationships between the different parties. I displayed all of this material on my website for the world to see and without question it caught the eye on several occasions of Christie.

Nothing ever happens in a vacuum and what I am about to describe can only be viewed as a miracle. Christie had presidential aspirations and was spending a lot of time polishing his image in preparation for the 2016 Presidential run and wanted no dirt on his doorstep. As happenstance would have it one of the biggest scandals of his tenure erupted at the end of 2013 which has been called Bridgegate likening it somewhat to the Watergate scandal that brought down Richard Nixon. The national press went haywire and his ratings dropped. There were allegations of gross governmental misconduct and multiple state and federal investigations began. Almost overnight his world had changed and he was no longer the great Republican hope. His political capital began to depreciate rapidly and the chance of him winning the US presidency became a pipe dream. Humbled and embarrassed he then commenced a program of cleaning up all of the corrupt entities in his backyard with one of the first being the New Jersey Medical Board. In what can only be described as an administrative blitzkrieg he fired the entire medical board almost overnight and in doing so did me an immense favour in getting rid of the doctors and one specifically, Steven Lomazow, who had caused me the most harm and had advocated staunchly for the revocation of my license. This twist of fate came about, I believe, because of the vigorous campaign I mounted in my defense which painted Christie in a very negative light. I believe there was a part of him that felt used and betrayed by the medical board and I am sure this was his way of sending them a clear message. Christie however will never become the US President. He does not possess the character and more importantly his reputation has been irreparably damaged by the Bridgegate scandal. There are also other matters that have not yet been disclosed that if he chooses to run will find their way into the public domain.

I am now working on getting my license back and things are moving in the right direction. I have been fortunate to have the support of many of my colleagues and my work to ensure this never happens again to an Interventional Pain or radiology physician has only just begun and will involve educating the medical board and public on all of the issues discussed above. Hopefully we as a group will succeed in creating guidelines and regulations that clearly delineate the scope of practice which has without question been significantly advanced as a consequence of the way I fought my case. Had I instead chosen to take the path of acquiescence there is no question that many other doctors who were on the hit list of the old medical board would most likely have had their professional careers and businesses impacted in the same manner. That now will not happen. There is a new medical board and a humbled governor who would rather stay away from the muck of professional battles, regardless of how much money is presented.

The moral of the story is that we have one life and when injustices occur we must act immediately and with a clear vision. If one choses to hide away he gives up that precious opportunity and the chance to restore his reputation for he cannot return several years later to then contest the battle. So I would therefore say to my younger colleagues it is important to be a man of principle who fights for what he believes is right and it is this quality that strengthens and defines your character and the one that people will remember when you are long gone.

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