Macro Talent, Micro Power
Orthopedics This Week | 03/12/2009 | Elizabeth Hofheinz, M.P.H., M.Ed.
Dr. Bray was once told, “You’re a smart guy. Go invent what you need to build the field.” And so he did. One of the world’s most experienced neurological spine surgeons, Dr. Robert Bray, Founding Director and CEO of Diagnostic and Interventional Spinal Care (D.I.S.C.) in Marina del Rey, California, is a pioneer in the development of spinal microsurgery. Having performed over 9,000 such procedures, Dr. Bray reflects on a time when he was just learning to write his name…and yet knew that medicine was his calling.
Dr. Bray: “I grew up in Connecticut and Massachusetts with a dad who was a metallurgical researcher and a mom who counseled high school students. My father later became Dean of Engineering at California State Polytechnic University in Pomona, so he moved my mom, my two sisters, and me out West. I was gearing up for medical school even as I was a little boy learning to spell. As early as four years of age I was looking forward to a life of medicine, full of scientific inquiry and adventure. I never wavered from this path.”
Years later he would put his hockey dreams on ice for his ultimate passion. Dr. Bray explains, “While pursuing my undergraduate degree at Colgate University I was goaltender for the ice hockey team. I was told that no one had ever played and graduated premed from Colgate, so I left the ice after two years. I later transferred to the University of California, San Diego to be near my family.”
Robert Bray then headed for the Lone Star State and Baylor College of Medicine, where he completed an internship and six year residency in neurosurgery. “I enjoyed all of my surgical rotations in medical school, so I found it difficult to select just one. At the time there was a famous neurosurgeon at Baylor, Dr. George Ehni, who selected me for the neurosurgery program (this was before the match process existed). After he retired, I trained under Dr. Rob Grossman during the time he was building the neurosurgery program. An ingenious physician, Dr. Grossman made us take off our glasses and perform every surgery under a microscope. ‘This is the future,’ he would say. ‘One day you will thank me.’ Microsurgery did not exist then, so, among other issues, we didn’t have the proper equipment. The instruments didn’t fit under a microscope, making the process a bit clumsy. Dr. Grossman launched my career with the words, ‘You’re a smart guy. Go invent what you need to build the field.’ Over time I developed an ‘Out of Africa’ type passion with regard to developing microsurgery for spine.”
Prior to becoming a force in his own right, Dr. Bray would join a team effort…the U.S. Air Force. “I signed up for the military in 1986 because I lacked the funds to go to medical school. I had worked as a machinist through college. My dad was retired Air Force so the Health Professions Scholarship was a natural fit. I was just out of residency and was made Chief of Neurosurgery for the Western U.S. This gave me an incredible chance to do a wide variety of cases at a level that would never have been available to a first year. In addition, the chance to practice medicine without any business constraints left me with a philosophy that one should treat the problem simply with the best approach, something that has carried throughout my career. After leaving the Air Force I went to L.A., where much of neurosurgery, brain tumors and vascular work was being done in hospitals with residency programs. I was in private practice so spine was a better fit. It was 1989, a time when no one in L.A. was doing spinal microsurgery. I was vigorously criticized by a number of other local surgeons, who called such work a ‘sham.’ After 27 years of surgical success, however, I am pleased to say that it is now widely accepted as the standard of care in L.A.”
Dr. Bray would then partner with other luminaries, all of whom could see that bringing together a number of fields of expertise would be the best way to help patients. “In 1991 I founded the West Coast Spine Institute along with Ed Dawson, Elliot Blenderman and Rick Delamarter. We took our knowledge and desire to create a new field within spine, and opened what was the first multidisciplinary spine group in L.A.”
Taking the lessons from this experience, Dr. Bray left for Cedars-Sinai Medical Center in 1996, where he founded the Institute for Spinal Disorders. “During the 10 years I spent at this facility, the length of stay dropped from 6 days to 1.5 days…‘just’ because we used a microscope for spine surgery. The post operative care needed a complete redesign. All aspects of care from pain management to urologic treatment, from wound care to mobilization, were written into protocols that allowed us to track results and modify treatment to improve the outcome. It was this multidisciplinary approach that led to my conviction that the ‘out of hospital’ environment was the most beneficial to patients.”
Recognized by the industry as a thought leader, Dr. Bray was called upon to create instrumentation for his field. Dr. Bray: “The original Zeiss microscope was designed for brain surgery. To modify this tool for spine work, I flew to Germany and met with the Zeiss engineers. After a lot of back and forth, the prototypes were created and then the final product, a spinal microscope, was brought to fruition. I then began working with J&J to redesign the instrumentation, resulting in tools that are today used for all spine dissection. As my devotion to this work continued, I became the first—or one of the first—neurosurgeons to do 100% spine. At this point, I don’t do a spine procedure without the aid of a microscope. All procedures are amenable to a microscope; you have much better visualization, decreased blood loss, increased accuracy, and a more minimally invasive procedure. And the insurance companies are pleased because we have driven down the costs involved.”
Having helped the field turn a corner, in 2006 Dr. Bray decided to create an institution where he could focus all of his energies on advancing and promoting motion-saving, minimally invasive spinal microsurgery. “I could see that although most surgeries were being performed in a hospital setting, that it would be not only possible, but beneficial to patients, to perform minimally invasive surgery in a non-hospital environment. Traditional outpatient centers did low acuity, high volume cases such as breast biopsies and colonoscopies, i.e., in and out procedures. But high acuity, low volume things such as spine surgery or knee replacement have until now been considered to be something that should be done in a hospital. After much consideration, consultation, and planning, I built D.I.S.C., the first facility in the country that provides multidisciplinary care with a full spectrum of services under one roof. These include spinal neurosurgery, orthopedic surgery, physical medicine, pain management, soft tissue mobilization and chiropractic services, along with the alternative treatments of acupuncture and oriental medicine.”
Dr. Bray’s dedication and knowledge were enhanced by an unfortunate life event. “While planning for DISC, I had a minor procedure done in a hospital setting that resulted in a virulent infection that nearly cost me my leg and my life. This was an extraordinary wakeup call and was the final impetus I needed to move forward with developing DISC This is also why I have put such care into minimizing the risk of infection in the facility. Our ORs, which are 600 square feet, contain 100% HEPA air, and have a UV treated high volume exhaust. After 30 months of operation and more than 3,000 procedures, our facility remains “‘infection-free.’”
At Dr. Bray’s institute, compassion, focus, and efficiency come together to create a medical experience that few facilities can provide. Dr. Bray: “We have one-on-one nursing and 98-99% patient satisfaction at a time when most other facilities have at most 50% satisfaction rates. We make things exceptionally convenient for patients, which helps reduce the stress that accompanies having a medical problem. For example, someone goes to her GP, who then refers her to a back specialist or neurosurgeon. She goes to that appointment, where the specialist then sends her for imaging in another facility. The patient later goes back to the specialist’s office, where, depending on the complexity of the problem, she may have to go to a hospital for surgery. This whole process can last from 6 to12 weeks and involves the patient running all over town. As an example of the efficiency that a multidisciplinary facility can provide, we had a movie executive with severe back pain come to D.I.S.C. He arrived at 10am. By 11am he had had an MRI, and by noon I was upstairs looking at his scan. I then delivered an epidural block and he was discharged that day…and running his business the next day. One place, one day…now that’s powerful.”
Being the best means that the world—including industry—finds its way to your door. “As a sports medicine aficionado, I am pleased to say that DISC is the official medical center of the L.A. Clippers, the L.A. Kings, and the USA Men’s Volleyball Team. It has been exciting to work with athletes with this level of motivation and it is my belief that sports medicine needs to step up a notch to include injury prevention and performance enhancement as well as top notch medical care. As for my design work, I am proud to hold multiple patents on a wide variety of spinal implants and surgical instruments. The fact that no two cases are exactly alike means that I can always learn something new…and then apply that knowledge to my design work, lectures, patient care, and business-related activities. As an example, along with two colleagues I started RSB Spine, LLC, built around my surgical instrumentation and implants. One of these, a cervical spine implant, is for fusion at one or more levels, and is the first PEEK plastic plate and interbody device for stabilizing the spine. It is translucent on X-rays, meaning that you can see the bone growing through it. Over time the metal/bone interface can erode, so I designed the implant to have the same softness as bone. This first-to-market product is doing well, as is the outcome study.”
With a predilection for proof, Dr. Bray is, in fact, at the forefront of those championing the new “show me” mentality in orthopedics and neurosurgery. “I have written over 50 papers and posters, and delivered as many podium presentations. The majority of my research is focused on clinical outcomes analysis in which I investigate how patients fare with different techniques. I am particularly interested in validating outcomes for the field of microsurgery and have to date found that it results in quicker recovery and a lower complication rate. We have done this for a number of different systems, including microsurgery for discs in the back and cervical spine fusion. I have developed a cervical spine disability index, with my partner Dr. Neil Anand, because there was no effective tool to evaluate how these patients fared. This questionnaire, now the national standard, is a standardizable outcome tool. Too many surgeons don’t pay close attention to their results and when asked how their patients fared, say, ‘Oh, they do great.’ But yet they do nothing to follow them. We actually wrote a computer program so that we could track every patient and their outcome. When patients come in they fill out the questionnaire, something they also do at 3, 6, and 12 months. If they are involved in a study we will follow them out to three years.”
If you go looking for meaning, it may elude you. Better to follow your path and see what meaning you encounter along the way. Dr. Bray: “I have had several cases that meant a lot to me. Perhaps the most memorable was a Chinese gentleman who answered an ad in the paper and wanted to work for me. His educational degree was not recognized in the U.S., but he was persistent as he had a family to support. As it turned out, he had been the Chief of Orthopedics for Beijing Hospital and had fled China during a period of political turmoil. I told him that given his extraordinary background I could not justify hiring him into a clerical position, something he was in fact willing to do. He became a research associate and helped write a number of important papers. This gentleman had a limp resulting from a spinal cord tumor that went over his thoracic spine. He had sought treatment in England, but had not been able to find help. We performed a 27 hour surgery on him to remove the tumor. It was a terrific success. Many years later he is an acupuncturist and has put his children through college.”
Dr. Bray was also moved by Melanie Roach, an eight-time U.S. weightlifting champion and mother of three. “Melanie Roach, an athlete with an incredible amount of heart, drive, and passion, had been forced to retire because of a herniated disc. In the fall of 2006, my team and I performed a 45-minute minimally invasive outpatient microdiscectomy to remove three fragments pressing on her disc. Within five days of the procedure she began working out and within two months was back doing Olympic lifts. A remarkable seven months later, she had her best results in nine years at the U.S. Championship, lifting 406 pounds and followed that up with a bronze medal at the Pan American Games in July. In the summer of 2008 she set a new record in Beijing. It was just amazing to see a woman who is not even 5 feet tall lift 260 pounds over her head in less than a year after surgery.”
Dr. Bray has a number of other energetic go-getters in his sphere. “I train both orthopedic and neurosurgical fellows, many of whom tend to think they are fully schooled once they leave residency. I have to show them that in fact they need this year of transition where they can learn what was not covered in residency. Most of them did not learn microscopic surgery. After repeated use of the microscope, however, all of my fellowship graduates continue to use microscopic surgery. At times it is challenging to manage their enthusiasm; they want to get on with things…to the point where they almost want to show you how to do a case. I try to temper this enthusiasm as I help them develop the appropriate skills. I start them fresh and slowly give them increasing responsibilities. Although many surgeons say that having a fellow in the OR makes things easier, I completely disagree. When I operate with a fellow I must watch every single move the person makes…Where is his hand going? Is he at the right angle?, etc. You must constantly analyze what they are doing…this is what it takes to keep patient safety at the forefront of one’s practice.”
Having experienced the success inherent in the multidisciplinary approach, Dr. Bray is hoping that others will adopt such as philosophy…and practice.
“My dream is that minimally invasive surgery would fully transition to multidisciplinary centers like DISC I think we will see centers of excellence around the country take over in spine, general orthopedics, and sports medicine.”
“Another movement coming down the pike is one we’re already involved in, namely, performance centers where all aspects of treating athletes are brought together. This includes nutrition, hydration, strength testing, and cardiovascular care, among other things. At D.I.S.C. we have assembled a variety of professionals to meet the needs of athletes, including an Olympic coach and a Hall of Fame strength and conditioning coach. We are currently building a specialized training center and hope to hook up with the U.S. Olympic Team and marry the performance and medical aspects of training. This movement has started in a small way at different physical therapy centers around the country. In the future things will accelerate as the pro teams and Olympic teams are very interested in this.”
Dr. Robert Bray…macro talent, micro power.