Medicine, Health Care and Training the Next Generation of Surgeons: An interview with Dr. William L. Jaffe

You may listen to this interview from HERE. 

Dr. William L. Jaffe is a Clinical Professor and Vice-Chair, Department of Orthopedic Surgery at NYU Grossman School of Medicine. He is a fellow of the American Academy of Orthopedic Surgeons. Dr. Jaffe has over 60 years of experience in the medical field and his specialty is in hip and knee reconstruction. He received his medical degree from Temple University and did residencies at Lenox Hill Hospital and the Hospital for Joint Diseases in New York. Following his training in orthopedic surgery, he took additional fellowship training in hip replacement surgery in England and biomaterial training at MIT. Dr. Jaffe has published extensively, including books, chapters and scores of papers in peer reviewed journals.

Q1. Please introduce yourself and tell us about your current interests.

I have been practicing adult reconstructive orthopedic surgery and involved with resident and fellowship training for over half a century. My commitment to educating future generations in my field is a direct payback to the mentors who took the time and effort to train me and my colleagues during my residency and fellowship. Being exposed to outstanding young physicians in training benefits my own maintenance of skills as much as it enhances their skills. Whenever someone asks me for a referral to an orthopedic surgeon in another city, I suggest they call a local teaching hospital and specifically request a doctor in the appropriate subspecialty. The discipline and quality assurance in such an institution can be assured.

Q2. How did you get into medicine and what led you to specialize in orthopedics? You spent time in the military as a battalion surgeon. What was that experience like, and did it have any influence on your later career?

I was originally planning to go into cardiothoracic surgery at my medical school and took an internship with that in mind. During my internship it became apparent that the surgeons in that field were neither happy nor pleasant and I decided to find something where I could make a contribution and still enjoy my career. By declining my cardiothoracic training, I became eligible for the military draft, which was in place during the Vietnam War era, and entered the US Army for a 2 year obligation. The US Army Medical Corps is proud of the fact that it is entirely volunteer. You are either drafted as a private in the fighting force or as a physician given the option to volunteer as a medical officer to use your skills. Needless to say, I volunteered. During my tenure as a Battalion Surgeon with the First Cavalry Division in South Korea and Vietnam, I became exposed to orthopedic surgery and enjoyed working in the field with the potentially happy results of improving quality of life in my patients.

After a 13 month “hardship tour” in Asia, I was transferred to the First Army headquarters hospital on Governor’s Island in New York City. I recall one day where I received a call from a woman who described herself as “Mrs. General S…”. I enquired if that was her husband’s first name like “Sargent Shriver” who was a famous politician at the time. My light attempt at humor did not go over well and she immediately hung up the phone and I promptly received a call from the aide to General S… who was the commander of the First Army. I was to report to the general’s office at 6:00 AM the following morning, wearing my Dress Blue uniform and be prepared to explain why I insulted the general’s wife. The following morning, I arrived on time and was kept waiting for 7 hours before being called in to see the general. He then spent 30 minutes screaming at me, calling me rude and threatening to send me to Vietnam during the war to learn some manners. He then had me write a letter of apology to his wife, which I did. I was grateful when my military service ended 9 months later and was grateful for the experience and service but was most grateful that unlike the general, I did not have to come home every night to his wife.

Q3. Were there any mentors or notable individuals that helped or advised you along the way? Can you share any lessons, painful or otherwise, that helped you grow and mature as a surgeon and teacher?

I have been fortunate to have had several mentors over the course of my career. Dr. Henry Mankin, the chairman of the Department of Orthopedic Surgery during my residency instilled the importance of research, teaching and patient care as well as an enthusiasm and love for the field of orthopedics and the variety of options it included. He also taught me humility. One morning after a difficult weekend on duty, I stormed into his office to complain that the promised electrocardiogram (EKG) technician was not available and as the admitting resident for 20 patients, I was required to do all the EKGs myself. He calmly listened to my ranting and told me the following story: “Bill, I keep a small piece of paper on my bedside table which I look at every morning. On it is a list of all the people in the world I have to take shit off of. There is my wife, my older brother and my 2 children. Unfortunately, your name is not on the list” I quietly left his office humbled and smarter.

Sir John Charnley, the father of hip replacement surgery in Lancashire, England taught me the importance of intellectual honesty and how to safely develop new technology as part of my fellowship training. He required his registrars in evaluating preoperative patients to err to the less serious rating of pain, function and range of motion and the more serious evaluations post-surgical. This meant that when comparing a patient’s findings before and after the operation, you minimized the severity before the surgery and maximized the symptoms postoperative. This avoided any inherent bias in favor of his surgery.

Lastly, I would note Dr. Joseph Zuckerman, who is the current Chief of Orthopedic Surgery at NYU Grossman School of Medicine for the past 30 years. I credit him for reinforcing the importance of diversity while maintaining the meritocracy of the largest and I consider the best training program in the world. Dr. Zuckerman is an exceptional teacher, researcher, and surgeon, and an excellent administrator.

Q4. For those not familiar with orthopedics and how residency programs work, please share how residents at your hospital are selected and the training that they undergo over four years. What drew you to residency education and what do you find most fulfilling about training the next generation of physicians?

As the largest program in the US, we get several hundred applications from the best medical students in the country. We accept 14 residents per year for our 5 year program of which 2 are selected to serve a 6th year while dropping out for a year of research after their 2nd year. This total of 72 residents, culminating in a 5th year chief resident role prepares our residents for leadership positions in our field.

Patient responsibility increases annually and by the 5th year the residents are functioning as junior attending on clinic cases under the direct supervision of a faculty member and are actively involved in teaching more junior residents. Virtually all of our residents take additional subspecialty training in hand, foot, oncology, spine, pediatric, trauma, adult reconstructive, shoulder and sports medicine fellowships at leading centers. I cannot think of a more fulfilling experience than being exposed to and participating in the training of this exceptional group of young surgeons.

Q5. You’ve been selecting and teaching residents in one of the most competitive programs in the US and have no doubt developed a keen eye for talent. What are the qualities that you look for in a candidate? As a teacher and frequent lecturer, do you have any thoughts or advice to share?

Virtually all of the candidates who are selected for interviews are academically qualified for the position and sufficiently accomplished. What we are looking for is someone with a sense of humor, who it would be fun to work with and have on your service and would make a demanding job and schedule more pleasant and caring. We want someone who is confident in their abilities, humble and teachable. Basically, most interviewers are looking for someone better than ourselves.

In terms of what makes a good surgeon, it is important to have excellent hand eye coordination and an ability to anticipate problems before they occur. A useful personality trait is one in which the tenser a situation becomes, the calmer the individual gets. With regard to self-confidence, there is the old joke that “If you ask any surgeon to name the three greatest surgeons, they will have difficulty naming the other two.”

Lecturing and teaching are important skills, and I have spent much of my adult life lecturing in my field both at my own institution and nationally and internationally. I have developed a sense of what a successful lecture is and how to perform it. I try to avoid overpreparing so as not to lose spontaneity and interest, and I never read a text. I speak with the aid of PowerPoint slides and never have more than 10 words of text on any slide. I try to enjoy the experience and include humor, usually self-deprecating, and try not to take myself or my message too seriously. I attempt to bring something new and unique to the audience. For example, when lecturing to engineers at MIT I speak mostly about the surgical implications of their work, and not about their field. Similarly, when I speak to surgeons, I emphasize biomaterials and biomechanics as it relates to surgery. I like to think of myself as a very good surgeon for an engineer and a reasonable engineer for a surgeon.

Q6. As someone who has been a surgeon and educator for decades, what are the positive and negative changes you’ve observed over the years?

The biggest change in medical practice during my career has been the change from “doctor” to “health care provider” with young physicians being treated like civil servants and in danger of acting that way. There are fewer surgeons going into practice as entrepreneurs and are choosing to be either hospital or government-institution based. While there is nothing inherently wrong with this decision, working for a large, bureaucratic organization, whether it be a hospital or government, is less likely to be associated with an aggressive work ethic. There are also internal politics considerations at these organizations, which would not be present as an entrepreneurial practitioner.

The reasons behind this are many but it ultimately comes down to cost. In a system where more money is spent on health care with less than the best results worldwide some changes were inevitable. These changes have resulted in lower rates paid for medical care and a push towards cost savings, which tends to favor centralized structures.

In academic medicine we still adhere to the old standards of care. There are various reasons for this but with so many checks and balances, everything tends to be discussed and reviewed. Having residents and fellows present is also important and helps improve the overall quality of care. In smaller hospitals, less of this occurs.

Q7. How has technological change impacted orthopedics and medicine in general? The engineering and materials side is one aspect but what about new diagnostic or computer-aided innovations? Has the pace of innovation accelerated in recent years? What might serve as a deterrent to innovation?

Technological advances have had an enormous effect on orthopedic surgery. Navigation and robotics are increasingly being used in surgery, and material and metallurgical advances in prosthesis and trauma devices and bearing materials are increasingly seen in current practice. Three dimensional teaching devices and surgical simulations are also more commonly used as educational aids. One concern I have is that the advent of computer based medical records has lessened the personal interaction of physician and patient and lowered the number of patients typically seen during an office session. I discourage our residents from searching a patient’s medical data and x-rays before they interview and examine the patient. The reason for this is I don’t want them to develop a preconceived clinical plan before they see and meet a patient.

Interestingly, the pace of innovation has slowed due to the cost of new technology, and this is visible in the development of fewer new implants and protheses in orthopedics. One of the big challenges in artificial joints is to have a bearing surface that is very slippery. The best surface is healthy articular cartilage lubricated by healthy synovial fluid, and even the best artificial bearing materials are not as good as healthy human joints. There are different materials such as titanium and chromium cobalt that can be used to create artificial joints and each have their own strengths and weaknesses. In recent years, someone in California developed a diamond bearing that had both surfaces covered with a diamond material. While an excellent solution, it was so expensive that it would ultimately never be developed.

Cost will always be a deterrent to innovation. Unless new technology can be shown to be more effective in avoiding complications, and superior to existing technology by proven data, there is little interest in trying it and implant companies will not find a market for the product.

I should point out that there is a rigorous process by which new technologies gain approval in the US and these barriers include important steps like Food and Drug Administration (FDA) approval. However, once something is approved, doctors should be reluctant to be the first to try something new but also do not want to be the last to give up something established and successful.

Q8. What are your thoughts on health care in the US? How have things changed over the course of your practicing life and what are some recent trends in terms of health outcomes, insurance costs, etc.? What are you most proud of and most dismayed by when it comes to healthcare in the US?

The US has the most expensive health care in the world but only ranks 9th among the high income countries for quality of health as determined by factors such as life expectancy, infant mortality, safe childbirth and diabetes control. The top 4 countries are Singapore, Japan, South Korea and Taiwan. There are estimated to be 26 million Americans with no health insurance. We have still not determined if health care is a right or a privilege in America, but in my view, it is both, and it is very hard to justify that many Americans without health insurance.

I am most proud of what is possible at academic university hospitals in America which continue to perform at the highest levels in research, patient care and medical education.

Q9. The NYU Grossman School of Medicine is tuition free for all students, regardless of merit or financial need, and is one of only a few medical schools in the US that offer such a benefit. While this is undoubtedly fantastic for students and allows them the freedom to pursue less lucrative fields without sizable student debt to pay back, do you have any concerns that this is only possible through the endowment of a generous billionaire? Is private funding a necessity in medical education and do you see this increasing in the future?

The extraordinary generosity and humanity of our Chairman of the Board, Kenneth Langone, to endow not only free tuition at our medical school but capital advances to our medical center have allowed NYU to become the best hospital in New York and one of the best in the US. Ideally funds to accomplish these goals could be available to all medical centers, but currently only those fortunate enough to have world class donors can hope to accomplish these goals.

Lacking sufficient funding has a real cost, not only to students, but also in terms of being able to recruit top people, conduct research, and provide a higher level of care. I do not have any concerns about a philanthropic billionaire donating time and money to support a medical center, but it does raise the question of what you would do if these funds were not available.

Q10. Surrounding the work that you do is an enormous ecosystem of hospital administrations, insurance companies, Health Maintenance Organizations (HMO), medical device and drug companies, as well as government/oversight bodies. Where are the true levers of power in this system and how do these control patient outcomes and the overall costs of health care in the US?

Of all of the organizations that you mention, the unique factor in American medicine that contributes to the highest cost with less than stellar performance is the insurance industry. Insurance executives are among the highest paid individuals in the US and the share of the health care expenditures are higher for this industry than for any of the provider groups. They are less interested in quality of care in spite of their claims and by delaying or discouraging coverage for care they hope to often avoid the care being served. Either regulating this industry for the advantage of the insured or eliminating this nonperforming middle step in health expenditures would free enormous funds for direct patient care.

This is a complicated issue but the phenomenon of “cherry picking” and “lemon dropping” to determine who will or will not receive coverage is worth highlighting. For example, insurance companies in Florida are known to organize dance parties on second floor walk up locations and invite senior citizens to a free event in order to sign them up for health care. This obviously would not include anyone who could not walk up a flight of stairs or be able to dance. This is a subtle example of cherry picking the lowest risk individuals for coverage. An example of lemon dropping would be where people with existing chronic diseases would not be encouraged to join an insurance company. These are commercial decisions but there needs to be something to address those who fall through the gaps when insurers are unwilling to cover them.

Q11. In the past there were high profile corruption scandals in the implant sector with serious fines and penalties imposed on a variety of players. Can you share some of the practices that led to this situation and have things improved in the years since?

In the past, implant manufacturers were paying surgeons to use their products or paying royalties to surgeons for allegedly designing implants. Following an investigation by the Department of Justice, both practices were deemed unethical if not illegal and the manufacturers were fined and disciplined as were some of the surgeons. It took about a year to clean up the industry.

A surgeon’s contract is with the patient and all other compensation that impacts care should not ethically compromise that contract. This practice ended over a decade ago and happily similar abuses have not been made public since.

Q12. How has the status and role of doctors in society changed over the course of your career? With the growth of anti-vaxxers and the promotion of fringe theories and treatments by online influencers and political figures, do you worry about how this will impact the long-term health of patients in the US and elsewhere?

Physicians still hold a respected place in society but no longer are we blindly accepted as unerringly correct in all manners. This is reasonable and patients should be encouraged to seek second opinions whenever something critical is suggested. The advent of antiscientific statements by politicians or media sites is disturbing particularly when it directs patients to avoid what could be necessary treatment due to false, undocumented data. Hopefully government or respected experts will lessen the effect of these dangerous pronouncements.

Q13. While your career has been primarily focused in the US, please share some of the work you have done in Asia over the years in places like Japan, China, Hong Kong, Taiwan, etc.

I have been pleased to lecture in Singapore, Japan, Hong Kong, Taiwan and PRC during my career and have been universally impressed with the quality of research, clinical acumen and academic excellence. I often review several research projects in my field for Hong Kong and am consistently presented with world class work that is equivalent to that being funded in the US.

One experience that was especially meaningful was being able to perform surgery in Japan. A friend in Japan was a professor and chairman of orthopedics. I had met him in the US and he subsequently invited me to lecture in Japan and perform surgery. It involved a prothesis with which I’d been involved with developing and they were interested in learning and improving their own techniques. The surgery fortunately went well, and I was pleased with the quality of the staff and facility, and also very grateful for the trust they and the patient placed in the hands of a foreign physician.

Q14. Please share any favorite books, publications, blogs, podcasts or other resources that readers could use to improve their understanding of medicine, orthopedics, health care or any other related topics.  

There are many US Government publications that can be searched online regarding US heath data and world rankings and many online resources to get access to peer-reviewed articles and research. Two worthwhile books are “Which Country Has the World’s Best Health Care?” by Ezekiel J. Emanuel and “The Healing of America: A Global Quest for Better, Cheaper and Fairer Health Care” by T. R. Reid.

For those seeking online advice or information on medical issues, I would advise that readers check the credentials of the author, especially on important matters of health. Make sure the individual is certified in the given field and has a track record in the specific area in which he or she is commenting.

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