By Audrey Walton, Knee1 Staff
Dr. James Lubowitz is the founder of the Taos Orthopaedic Institute and a member of the medical staff for the U.S. Ski and Snowboard Team. He also holds the prestigious position of Associate Editor Arthroscopy: The Journal of Arthroscopic and Related Surgery. He is currently practicing medicine in New Mexico, specializing in knee injuries and arthroscopy at the Institute which he founded.
Knee1: You’ve mentioned that you’re quite proud of your work with the journal Arthroscopy: The Journal of Arthroscopic and Related Surgery, where you’re currently serving as Associate Editor. Can you tell us more about the journal?
Dr. Lubowitz: Arthroscopy is the official journal of the Arthroscopy Association of North American as well as the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine. My relationship with the journal is really exciting. It happened really fast, and I say this with some pride. When I finished my training, I was presenting a paper at the annual meeting of the Arthroscopy Association of North America. While I was at the meeting, one activity that interested me was a journal reviewer’s course, a course we still offer. And then I started reviewing articles, and after doing it for a few years, was chosen as a Reviewer of the Year; and the next year, they asked me to join the Board of Editors; and then they asked me to be an Associate Editor.
I feel my greatest contribution to orthopaedic knee care is in affiliation with this journal. The peer-review process in editing scientific literature is an often-overlooked final step between investigation and publication. But research which is biased, either in the study’s design and methods or in its interpretation of results, can be misleading.
Knee1: It sounds like promoting objective research is your greatest goal as associate editor. How does one achieve this objectivity?
Dr. Lubowitz: Especially in medicine, where human protection and human variability and patient care are all important factors, it’s almost impossible to totally eliminate bias. I mean, you could take a hundred red shirts and a hundred blue shirts and find which one people find more appealing, but if you take a hundred people with arthritis and give them Surgery A or Procedure B, even if you carefully match the two groups, it’s hard to achieve completely objective results. We do everything we can to manage this by minimizing the loss of patients; by randomizing patients; we try to make sure the procedures are each conducted by a single individual. But some of this cannot be prevented. What can be prevented is bias in interpretation of the results. In my opinion, most authors who present articles for our review, and to other journals, want to present findings based on their data, but they sometimes fall prey to a desire to share their knowledge and their opinions, and sometimes fall into mixing their conclusions as a result. As Associate Editor of Arthroscopy, and with the support and mentorship of Dr. Gary Poehling, Editor-in-Chief, I am directly responsible for ensuring that our published literature is evidence-based and presented without bias.
Knee1: You’re also on the medical staff of the U.S. Ski and Snowboard team, along with Dr. Richard Steadman, a previous knee hero.
Dr. Lubowitz: Dr. Steadman put it all together. He’s the head team physician, and he’s created this medical program, and also this medical staff, which is a pool of about forty physicians who volunteer one to two weeks a year to travel with the team. A new generation of orthopaedic knee and sports medicine specialists are benefiting from the special knowledge and tutelage provided by mentors like Steadman.
Knee1: What kind of "knowledge" and "tutelage" has he passed on?
Dr. Lubowitz: Well, the first thing that I think separated Dr. Steadman was that he was one of the first to recognize the importance of early motion and aggressive rehabilitation after orthopaedic surgery. The second thing was that he invented microfracture. Back when I was in my medical training, in the academic centers where I trained, most were skeptical about that type of procedure, but time has proven that it has real merit. The third thing that Dr. Steadman has achieved is to lead the way in reconstructive surgery for ruptured ACLs, a common ski injury. He was one of the pioneers who showed that the outcome of that surgery could be complete recovery to full function. He’s done more than twenty reconstructive surgeries on skiers who’ve gone on to the podium. So what used to be a career ending injury has been shown by Dr. Steadman to have the potential for full recovery. If I’m a hero, he’s the hero’s hero.
Knee1: You were a serious college athlete yourself: co-captain of the squash team at Harvard, and All-Ivy player. Does your own athletic background fuel your passion for sports medicine?
Dr. Lubowitz: Definitely. The only doctors I saw in high school and college were orthopaedic surgeons. And I was fortunate that I never required surgery, but I suffered a broken ankle, where casts and rehab were necessary. The trainers and the team doctor for Harvard, who’s been there for years and years, were mentors for me.
Knee1: You’re in an unusual position for a physician: you work with a very elite cadre of athletes, but you’re also devoted to providing health care to an underserved population. Can you tell us about the Taos Orthopaedic Institute, which you founded?
Dr. Lubowitz: While Taos, New Mexico is known as a destination ski and summer resort, New Mexico as a state is known for its lack of available healthcare and health insurance. When I started a solo practice in August of 1994, I had ambitions for Taos, and, to quote Paul Simon’s Graceland LP, I called myself “an Institute.” Now, the Taos Orthopaedic Institute really lives up to its name as an Institute. We attract and serve patients from the Colorado border to Santa Fe; from Los Alamos to Las Vegas, NM; and from points beyond. As we continue to specialize, people are coming from further and further away.
Knee1: Is it your increasing specialization, then, that’s bringing more and more people to the Institute?
Dr. Lubowitz: If I had to pick one factor, it would be outcome: the results of surgical and nonsurgical interventions which we can achieve for our patients. But I think that the more specialized one becomes, the better results one can achieve. We also participate in research, and while some patients may know about our research, they’re really interested in outcomes. But by participating in research, in studies, in publishing, which are all pieces in the puzzle, we see improved clinical results. Our Fellowship trained faculty is growing, and we have established an affiliated nonprofit orthopaedic sports medicine and arthritis Research Foundation as well as our own Fellowship Training Program. We have also established a state-of-the-art physical therapy and rehabilitation center and provided a fixed extremity MRI unit in association with our local, community hospital.
Knee1: You mentioned that you are currently researching your Total Knee Arthroplasty costs and outcomes. Can you tell us more about what this entails?
Dr. Lubowitz: When I started at Taos Institute, perhaps naively, and perhaps following a great historical lineage of doctors in the U.S., I believed that the only thing that mattered was patient care, regardless of cost. And while I still believe this in my heart, and I believe most doctors do, in some ways this belief is naive, because there are constraints. While we don’t limit care based on costs, based on a patients’ ability to pay, I think that we have an obligation to our society both from a public health standpoint and resource allocation to find the most cost-effective way to develop the highest level of care. So cost is something that can’t be ignored. I’m very interested in the idea of value (cost as related to quality of patient well-being over time). It’s a part of our mission to bring the best care to the greatest number of people, people who otherwise couldn’t afford it. With regard to knee replacement, I challenge the Federal center-of-excellence concept which asserts that costs and outcomes could be best if specialized surgery (joint arthroplasty or cardiac surgery, for example) were restricted to a few regional centers-of-excellence.
In terms of knee arthroscopy, we are establishing a Data Registry to evaluate short term recovery, long term outcome, cost, and value of arthroscopic knee procedures (with the assistance of the research departments of Smith and Nephew Endoscopy). We are proceeding with extreme care, prior to initiation of data collection, to ensure that we have best defined our measures of recovery, outcome and costs. This process is essential to guarantee that our efforts will provide valuable and unbiased information for years to come.
Knee1: So, current federal policy is to encourage the development of specific areas of excellence only in particular regions of the country?
Dr. Lubowitz: The federal government is a payer for patients over 65, through Medicare, and they’re interested in controlling costs. And one theory that they have been interested in testing is a "center of excellence" concept, the concept being that for certain surgeries like knee replacement (other examples could be hip replacement or heart surgery) that if the procedures were combined to a limited number of centers and the procedure was done at a very high volume, then cost-effectiveness could be achieved, and perhaps better outcome as well.
I have a different hypothesis, which I am testing for knee replacement, (and I believe that the American Academy of Orthopaedic Surgeons could support this hypothesis)—I believe that equal outcomes can be achieved by managing patients closer to where they live. There are a lot of advantages in having patients closer to home. If patients, especially in a geographically rural and remote region such as Taos, can receive healthcare near their homes, they may benefit in many ways (convenience, doctor-patient relationships, post-surgical and/or complication management) which a regional center-of-excellence hundreds or more miles from their homes would undermine. It’s a burden to travel, and family support is important, and if complications do occur and they’re back home, it changes patients relationships with the local providers. So theories or hypotheses need to be tested; that’s what the research process is all about, and in Taos we’re preparing for publication of a manuscript that considers the cost and outcomes of total knee replacement and compares our results to those reported by major urban and academic centers of medicine.
Knee1: What kind of predictions do you have for the future of orthopaedic knee care?
Dr. Lubowitz: I foresee, as the important new trend, a focus on improvement in the already dauntingly excellent outcomes currently being achieved as a result of surgical intervention. Specifically, as a result of incredible clinical and basic research in the areas of arthroplasty, arthroscopy, and orthopaedic sports medicine in the last three decades of the twentieth century, the Results of procedures such as knee arthroscopy, anterior cruciate ligament reconstruction, or total knee replacement are better than 90% excellent over long term follow-up.
However, as scientists and clinicians, we always strive to improve. Less invasive procedures will continue to develop with fewer and smaller incisions, better and safer anesthesia, and faster and gentler surgery. Better understanding of causes of our rare poor outcomes will be appreciated. An example could be comorbidity (combined problems) in patients with knee ligament insufficiency. Advances in biomaterials combined with our growing understanding of genetics will lead to an era of molecular medicine. Finally, as we learn we must teach. Advances in our skills in sharing and disseminating knowledge will result in improvements and radical change in our educational processes. The goal, in each case, is to improve care for our ultimate benefitionary, our patients.
I believe that new molecular technology is going to have a great impact on orthopaedic surgery.) Our knowledge of genetics, and our ability to use technology to improve outcomes may redefine what we consider surgery. These advances may be costly, but I believe that the invasiveness of orthopaedic procedures will be significantly diminished.
Knee1: Visco-supplementation, which involves injections into arthritic joints that improve the joint fluid, has been used by many doctors to reduce arthritic symptoms. Have you found visco-supplementation helpful in your practice?
Dr. Lubowitz: It doesn’t help all patients, but some get dramatic relief. I have a number of skiers in the middle-aged and senior population whose x-rays show significant damage and who present with significant pain symptoms and restricted motion, and these patients come back annually for their injection and swear by it. I use viscosupplementation on patients with cartilage damage. I feel that if the patients have mechanical symptoms in their knees (swelling or catching or buckling) as a result of torn cartilage, that visco-supplementation may not achieve the benefit that it’s supposed to deliver, because visco-supplementation simply relieves the pain associated with bad cartilage. So I think those patients benefit from arthroscopy to smooth or remove the torn cartilage, and then if they have further symptoms, visco-supplementation is recommended.
I think it helps the condition of the knee for the right patients, and I like to think of our treatment options as a very wide range of possibilities. We have pills, we have shots, we have braces, we have active physical therapy, such as exercise and hands-on stretching and strengthening, and then there’s shots and visco-supplementation, the judicious use of steroids, and then there’s a whole range of surgical options and interventions.
Being a surgeon requires years of training to develop technical skills, and then, through the practice of medicine, those skills continue to develop. Education does not end once we finish formal training.
But equally important to technical skill is making the correct diagnosis, and then matching the indication for any intervention to the diagnosis for that patient. And I think that’s the art of medicine. A number of people can achieve proficiency in Procedure X, Y, or Z. But making the right decision to do Operation Y on Patient B, that’s really what it comes down to. And that’s really knowing the patient as a person, what their goals are and what their preferences are; that’s the real challenge!
Access the Taos Orthopaedic Institute's web site.