Lessons in Orthopaedic Leadership: An AOA Podcast
Lessons in Orthopaedic Leadership: An AOA Podcast
Navigating Ethical and Transformative Physician-Industry Relationships with Hassan R. Mir, MD, MBA, FACS, FAOA
Douglas W. Lundy, MD, MBA, FACS, FAOA, sits down with Hassan R. Mir, MD, MBA, FACS, FAOA to discuss the ethical dynamics and transformative potential of physician-industry relationships. Through his wealth of experience in leadership roles, Dr. Mir guides us through the intricacies of aligning personal passion with professional commitments in the medical field. He opens up about maintaining integrity through transparent, fair market value agreements, and how the "front page test" can serve as a guiding principle for ethical business interactions. Prioritizing patient care while cultivating meaningful industry partnerships stands at the forefront of our discussion, offering a blueprint for those navigating this complex landscape.
As we delve into the evolving roles of physicians as educators, advisors, and innovators within the industry, Dr. Mir sheds light on the balance needed for those aspiring to leadership positions. We explore how younger physicians can effectively engage with the industry through teaching, networking, and research, while also addressing ethical considerations and the importance of transparent disclosure practices. This episode is packed with insights on navigating the rewarding world of physician-industry engagement, the challenges national organizations face in maintaining funding, and the mutual benefits that arise from these vital partnerships. Join us in this compelling conversation to learn strategies for harnessing the potential of physician-industry collaborations.
Welcome to the AOA Future in Orthopedic Surgery podcast series. This AOA podcast series will focus on the future in orthopedic surgery and the impact on leaders in our profession. These podcasts will focus on a vast spectrum of change that will occur as the future reveals itself. We will consider changes as they occur in the domains of culture, employment, technology, scope of practice, compensation and other areas. My name is Doug Lundy, host for this podcast series. Joining us today is Dr Hassan Mir Meir is a professor of orthopedic surgery and medical education and associate dean of cultural enrichment and environment at the University of South Florida and director of the orthopedic trauma research at Florida Orthopedic Institute. He's previously served as residency program director.
Speaker 2:Dr Meir completed his orthopedic surgery residency at the Campbell Clinic in Memphis, tennessee, and then went on to do his fellowship in orthopedic trauma at Tampa General Hospital. He also obtained his Master of Business Administration degree at Auburn University. Dr Mears' clinical interests include care of polytraumatized patients, pelvic and acetabular fractures and complex periarticular fractures. He also has interest in clinical and health policy research, medical education and involvement with multiple national orthopedic organizations. He served as the chief financial officer for the Orthopedic Trauma Association. He was on the American Association of Orthopedic Surgery Diversity Advisory Board and the Council on Advocacy, and on the American Orth of Orthopedic Surgery Diversity Advisory Board and the Council on Advocacy, and on the American Orthopedic Association Board of Directors. And on the American College of Surgeons Committee on Trauma. As a consultant reviewer for multiple journals, he also consults with multiple industry partners on innovative projects to improve patient care, projects to improve patient care. So Dr Mir is with us today to talk about the future of physician engagement with industry. Hassan, welcome to the podcast my friend.
Speaker 2:Thank you for having me Doug, Really happy to be here with you, and if y'all hadn't picked up, hassan and I go way back. We also did our MBAs together at Auburn University, warrior Eagle.
Speaker 3:I learned a lot from you back then and continue to Not much left.
Speaker 2:So there you go, appreciate you. Well, hassan, you've done a tremendous amount. So you, after you did your fellowship at Tampa General, you did quite a stint at Vanderbilt and the trauma service there, and there's, you know, vanderbilt is just covered with strong leaders in the orthopedic department there, especially in the trauma division, and from there you went back to Tampa to do many great things. There You've been, you've done the JOA fellowship and what was the? You did ABC. I think it was, is that right? Yeah, I didc as well, abc fellowship. You've done a tremendous amount of leadership development and leadership activities in your career very, very respectable cv in terms of your involvement in these organizations. On this, do you have any pearls of wisdom or anything that you've learned along the way that has inspired you or made you a better leader?
Speaker 3:Yeah, so a few different things that I've kind of noticed along the way and picked up from people that I look up to, like yourself and several people in the AOA, and I think the first thing is you know to show up.
Speaker 3:You got to be there and be present, to be actively engaged and then you kind of truly the organizations that interest you and inspire you are the ones that you want to commit yourself to, because, as we know, there are several organizations you can get involved in, but you kind of want to, early on, figure out what you're passionate about.
Speaker 3:And then, I think, early in your career, you get offered opportunities and you want to really sign up for what you can deliver. And then, if you deliver, people will then ask you to do more and more. And then you at some point have to learn when your bandwidth is met. You sometimes have to turn things down because you don't want to keep saying yes and not be able to deliver on something that you promise. So those are just some of the things I've learned along the way. And then people that I think of, that I've worked with, who really, you know, have inspired me to continue doing this stuff, are those who are selfless, who care more about the profession and the organization beyond just what can enrich them and try to make things better for our field and our colleagues, and those who treat others with kindness and open doors for them are really those who I try to emulate.
Speaker 2:Very good, and I would attest, as being a good friend of yours for many years, that you certainly do live up to those things and you've certainly emulated them yourself. So we've talked about a number of things on the series in the future in orthopedic surgery, and one of the ones that I was inspired to talk about was where are we headed with engagement with industry? So what's currently? What's your philosophy Because I know you've done some stuff with the industry what is your philosophy for ethical involvement in orthopedic surgery, orthopedic surgeons, with our industry partners?
Speaker 3:Yeah. So it goes back to my kind of early training in Memphis and had some of our faculty and mentors there, and I remember Jim Beatty specifically saying that you know you never want to do anything in when it comes to business or industry relations that doesn't pass the front page test, and so I've kind of stuck by that mantra. But with that in mind I worked a lot with Tony Russell, who has done a lot with industry and saw the way he did things and how it was all about passion for improving patient care and making things more efficient for our colleagues. And then you know, as long as you have those overarching goals in mind, then how you do the. You set up your structure of the relationship contractual relationship you have with your industry partners. That should just follow suit and that it's ethical, it's above board, it's all fair market value. There's clear delineation of the services you're providing and how you're being remunerated for those services. That would stand up to muster in any format. So that's kind of where it started and kind of where we're at present day with all those things.
Speaker 3:The types of projects are somewhat changing as we go forward, though. How so Well, whereas early on everything and still there are a lot of things in orthopedics that are about implants and implant-related technology and instruments, and that's been the dominant force and, frankly, where a lot of the money is in the industry, where they get their shareholder value and they need surgeon input to develop those things. But now there's a lot more technological advancement on enabling technology such as image guidance, such as robotics, and then also on the biologic side, to try to get patients to improve without necessarily undergoing surgery. Then there's other avenues that relate to orthopedics, such as patient engagement and monitoring and various other related technologies and fields that certainly need surgeon input and input of those of us who are in active practice so the engineers and business people can can get it right for us and, for, most importantly, for our patients very good.
Speaker 2:Yeah, that's intriguing how that that all seems to work out with us. So I've known and we've heard people do this from the podium right where they would say I have no conflicts. If anybody would like to get me some, I'd appreciate it, trying to make a joke and things like that. Um, and so sometimes you, you feel that some of these folks are just in it for the money. Other people are in it for making you know they have great ideas they want to see get brought to fruition. Other people seem to be much more altruistic on it. What's your take on the current trends in industry? Because not too many years ago there was a big reset. In the early 2000s there was a huge reset among the big companies about some of the questionable behaviors and intents that were going on.
Speaker 3:Right. I mean, I think, like a lot of things, with time things evolved and some early contracts and relationships probably were based more upon surgeon usage and volume and, as we learned in back in at Auburn, anytime, there there's healthcare services going in one direction and remuneration going in the opposite direction and they're proportional and related. That's not legal or shouldn't happen. You can't just have surgeons involved on teams to get royalties who aren't actually contributing and are getting exorbitant amounts of royalties without truly helping to improve product. So I think that now there's still to this day.
Speaker 3:There are certain scenarios that will pop up in the media and the press where that a usually with smaller companies or players and not with the major industry partners who are very much by the book.
Speaker 3:But I think that, you know, with any of these relationships, there has to be a justifiable reason why surgeons are picked for the teams that they're on. You know, usually people's CVs are scrutinized and case mix is scrutinized to see hey, are you going to be a valuable contributor to what we're trying to do here, especially when it's part of a design team that is partnering with engineers and industry executives. Now, when it comes to having your own original idea and starting it up and really, really going from scratch. That's, that's a whole, you know different ball game and different scenario and there, truly, it is out of out of interest and innovation and because that's going to be a very difficult path to take but but still can be done and is being done so it's maybe a little late to the conversation, but I think we both agree that physician involvement with industry and the development and refinement of products is absolutely integral.
Speaker 2:The practicing physician who's actually touching the implants, or the technology or whatever the biologics, whatever you're talking about? You really can't do it without us, right.
Speaker 3:No, it's absolutely critical. It's absolutely critical. When you meet the engineers, they're brilliant, but many, especially junior engineers, have never been to an operating room and even some senior engineers have limited experience. Right, they're not surgeons. They don't have the experience of operating on human beings, even if they've participated sometimes in cadaveric labs or something. It's very different than doing live surgery and then seeing patients long-term and seeing their outcomes. And then even on the tech side, you know we are the end user, or our patients are the end users, and we can certainly give the perspective of what is clinically relevant, what's feasible, what's easy and what actually adds value to our practices and to our patients' outcomes.
Speaker 2:So if physicians are going to continue being involved with industry and in development and refinement of products, where do you see things going over the next 5, 10, 20, whatever years you're comfortable pushing it out five, 10, 20, however many years you're comfortable pushing it out Because we've had a rocky past and I'm not exactly sure the current state, where is it? Where are we headed?
Speaker 3:Yeah.
Speaker 3:So I think that positions are still going to have to be involved, you know, and where.
Speaker 3:Where it's going with a lot of the bigger companies, for some of their R&D and innovation is really being outsourced to startups, right, rather than spend a lot of time, energy, effort and money developing stuff in-house, they're actually letting a lot of the truly innovative stuff happen at startup companies and then just acquiring those startups, whether it's for their whole portfolio or really mainly for their IP, and then they can take it from there because it's already been vetted, tried and true and there's some traction gain. So I think that that change is already happening, that a lot of the truly differentiating technologies and innovation has moved to the startup side, but that still definitely involves physicians. And when you see those acquisitions happen, though, when it comes to the back end on the business, it makes it a little cleaner sometimes for those companies and acquisitions to do things on an equity basis rather than on a royalty basis. So that gets a little bit into the weeds. On the contractual negotiations that happen, but they're still completely done above board and within, you know, within federal guidelines on those issues.
Speaker 2:Okay, so we've got startups and smaller companies taking on a lot of the R&D and development stuff. What opportunities do you still think will? What will the current state of the opportunities be with the big companies, the big, big, huge ones that we all know about?
Speaker 3:Yeah, the big ones still are doing some right, but it's more you know they are doing some truly unique technologies but for the most part, for the stuff that's really out there, that's going to be at the smaller scale. But the bigger companies are still, you know, coming out with newer generations of all of their existing technologies and platforms and implants and instruments and they need surgeon input and design teams to help push those things forward. And you know the days of people getting huge royalties for those are probably done, but they're, you know. But there still is a fair market value of royalties given to surgeons who are working as part of those project teams with those engineers to improve their systems for the next generation.
Speaker 2:So, with the big reset that occurred back in the early 2000s, when all the big companies had to go through all the compliance agreements and do all those regulatory things to keep themselves out of hot water, is this going to be just a continual revolution back and forth of the pendulum to where industry pushes it, pushes it, it pushes it? The government comes in and says enough too far, we're going to put you on compliance agreements, push everybody back, and then the the momentum will come back the other way. Or do you think we're just going to figure it out finally and industry and the physicians will run in a happy state without this cyclical mess that we had in the past?
Speaker 3:I think it's going to stay in this in in the current state. I don't know. You know it's relatively happy, right, and I think that everybody is still making neat innovative products and coming out with new types of technologies to help us. Every year. If you just go to any of our major meetings, you know for you know combined or subspecialty meetings there's new stuff every year that is being done with partnerships with industry and physicians. So I think that you know, I don't know and I personally am not aware of anybody. I don't know and I personally am not aware of anybody signing it and talk to you know folks who are my generation doing it or folks who are starting out and want to get involved in on how to do that Cause I don't think it's a shameful thing now within, you know, but you have to understand that it can potentially bias you.
Speaker 3:It, it, it, it does right, because if you really believe in something that you're working on, you're going to be biased towards that. Otherwise, why are you doing it if you don't believe in it? And because of that, sometimes you do give up potentially opportunities and organizations for major leadership roles that require you to recuse yourself of all these sorts of relationships and things. So there are. There is there's somewhat of an opportunity cost with it, depending on where your interest lies, if it's more on the higher end leadership side with certain organizations, or if it's more on hey, I want to continue to work with the partnerships and relationships it took me several years to develop and I don't want to go on a hiatus from those for a few years and risk not being able to get back in yeah, we've talked about that before in terms of the significant opportunity cost to a lot of these folks that do this consulting agreements.
Speaker 3:Now some of the organizations still allow royalty agreements but don't allow consulting agreements, which to me doesn't pass the front page test personally, but those organizations have felt that it does. But there are certainly times where, if you are nominated or considering participating at the higher level, that you may have to give some of these things up.
Speaker 2:What are some of the current relationships or roles that physicians can play in industry in current times now?
Speaker 3:So there's various roles you can. Clearly you can teach right. That's one of the easiest ways to do things. Industry runs a lot of great educational events and courses and I think frankly that orthopedic education needs industry partners. Now many of us who work at universities have seen our budgets cut that allow our trainees to go to events or to do cadaver labs or to do skills labs and having industry partners help. So working as faculty and some of those things can can you know be a way to partner with industry without doing stuff.
Speaker 3:On the design side. There's obviously then the being part of evaluating teams where you're at a site that's an early release site, or you go and do labs so you can be part of the design process there. With some of the smaller companies you can be on the scientific advisory board or the medical advisory board, and typically those relationships with smaller companies may involve hourly consulting but also could involve some equity if you're giving your time to really advise them on their strategy on a more global scale than just the one particular small project, and then really you can be a founder right. You can do your own startup. You got your own idea, you found your own company and take it the whole way there.
Speaker 2:We know folks that have done that. That's a big risk and a lot of engagement there, because it's not as easy and as romantic, I think, as people think it is.
Speaker 3:No, it's really challenging and I've talked to a lot of people who have done it and they're happy at the end, but it can be a very difficult road to travel.
Speaker 2:How do you see these relationships changing in the years ahead? Is there a happier state that industry or the physician workforce or the federal government would like to have and influencing people in a certain direction?
Speaker 3:Yeah, no, I mean, I think that for the surgeons who do it right, I think that most of the surgeons I talk to who do this truly have an interest in innovating and improving patient care, improving search, workflow, and so I think the surgeons will always be involved. Would they like to be, you know, continue to be compensated for it, of course, but I bet there's several who would do it even if there was nothing in it for them. But I don't think that's fair. I think it's fair to compensate people for work they've done, especially if they're on the industry side. They're going to monetize it, which they will, and most of our industry partners also, right, they're ultimately private companies that are responsible to their shareholders, but they can't do what they do without us, and they get it. And I think the government's role is just to make sure that things are done above board and fairly and that there's again sticking with federal regulations, that people are not doing things for unethical reasons.
Speaker 2:So if somebody, a younger physician, was interested in starting to engage with industry and partner up to some of these things, what would you recommend folks do to become more involved in this?
Speaker 3:yeah. So I have a lot of my former residents and fellows who have asked me about it over time and now you know are doing some of these things and so so I think it's you know, first be good at what you do and be a good physician, be a good surgeon, get your practice taken care of and then, as you do those things and you can talk to your mentors about getting involved in teaching and courses and introducing you to people that way. I think that's a really good way to do it. And at the various meetings that we have to get to get to know people. And then, once you've kind of gotten in through the education route or through letting people know that, hey, you're willing to do labs, so to think that day one graduating from fellowship, that I'm going to be put on a major team to redesign a major system and get a bunch of royalties isn't really practical right. So you got to kind of work your way into it and show that you've got a passion for our field, show that you've got knowledge base, show that you have respect amongst your peers, that you're someone who can then present and talk about the work that you're doing and that then, based upon your volume and your knowledge and your experience that you can then innovate in that space.
Speaker 3:I think that's typically what our industry partners are looking for. One additional way that people can get involved with industry is through academic productivity, and research found the same thing that those surgeons who have greater involvement with industry and more industry funding and compensation have a direct correlation with how productive they've been academically when you look at their H index and M index, which are different available metrics to look at and see how much they have published, and also if you look at their grant funding. So while you do these academic pursuits not necessarily for the purpose of engaging with industry they do tend to make you more visible and someone who industry may be more likely to engage with, because it shows that you have a good knowledge base, experience and also are someone who is at the podium and in the journals and can convey your message about what you believe and how you can improve patient care.
Speaker 2:So many times in the different organizations that I've been involved, especially at the national level, there's been there's no secret about it there's been a slow, progressive shrinking of the amount of funds and the investment that industry is making into our national organizations that you and I both belong to several of the same. On that, Any thoughts on? Because obviously clearly bottom line motives or the value paradigm is affecting that. They just don't feel there's value in it. They may say one thing but their checkbooks are heading a different direction. And if that's the case, how does that somehow impact on the surgeons who are then loyal members of these organizations, who are also engaged in the speaking and consulting areas?
Speaker 3:organizational perspective and organizational leaders.
Speaker 3:We obviously need industry support to help carry on our meetings and carry on our functions and serve our members.
Speaker 3:But from the industry side they kind of want to see that their investment towards research, education and the organizations is getting the maximum value for their dollar.
Speaker 3:So in talking to some of them over the years you were the CFO before, I was the CFO at the OTA and now you're in the PL there that we engage with our industry partners to support that organization, amongst others and a lot of their feedback is like look, we love the organization, we need the organization to succeed and we'll continue to support it.
Speaker 3:But on the other hand, when you talk to them separately, they also have their own educational events that they put on separate from our meetings and they see sometimes that they get more value out of those because they're not competing with other companies there, they're the only show and they feel sometimes that their return on investment is better on those events. So it's kind of tricky because you kind of can see their side of it too and if you were in their seat it might be hard to justify one versus the other. But I would hope from being a member of the AOA and other organizations, that our industry partners still continue to see value and can help us to improve the value that they're getting for their donations to us, so we can continue those partnerships.
Speaker 2:So, Hassan, you know, when we go to the OTA, the academy, different meetings that you and I attend and you see the guys up there with their, the men and women up there with their disclosures, and there's all different ways of doing it right. It's on the AOS website. I make a joke about a slide. It's got you know 30 things on there in a size eight font that nobody can read. What's the current state of disclosures, how relevant is it and where do you see things going in the future to a better state, if there is one.
Speaker 3:Yeah. So you know, when we see the slide pop up for literally even if it's 10 seconds, right, sometimes it's really easy to read I have no disclosures. And sometimes you're like, wow, I, there's no way I can take all that in. So is it really valuable to have us have them on the Academy's app available to anyone who wants to look them up? I think that that's probably the best way to go about it just saying, hey, I do have some relevant disclosures, they're here.
Speaker 3:And then, in particular, though, if you're given a talk where there is a really pertinent disclosure really relevant to that talk, I think that should be highlighted separately.
Speaker 3:I think that if I'm giving a talk on a product that I've designed and used on a series of patients, I probably should disclose that specifically rather than saying all my disclosures are on the app. And then I think that the question then is, what is relevant and what is not, gets a little gray and a little tricky. But I think that there are some that are clear, like the example I gave, like that's very relevant, and there's others that may not be so relevant and clear. So having them all listed somewhere centrally can help others to discern what's relevant or not. I think that future state I don't know that it'll really be much different. I think that there is a lot more, you know potential scrutiny, especially when you get up to the higher level organizational leadership, where you may own stock in different company, and things like that that you don't necessarily think as much about when people are, you know, just giving a talk or something that come into play. But I think that all these things are relevant and should be listed somewhere.
Speaker 2:Very well said. It's been a real pleasure talking with my friend Ahsan Mir, who's an orthopedic trauma surgeon at the Florida Orthopedic Institute at Tampa General and very well known throughout our profession in multiple fields. From the very well known throughout our profession in multiple fields, from the AOA through the academy through the OTA and many others.
Speaker 3:So, hassan, thank you so much for being on the podcast, sir.
Speaker 2:Thanks for having me, doug. It's always great chatting with you and hope to see you again soon. Yes, sir, me too, and y'all stay tuned for future in orthopedic surgery on this podcast channel.