Lessons in Orthopaedic Leadership: An AOA Podcast
Lessons in Orthopaedic Leadership: An AOA Podcast
Transforming Patient Care in Orthopaedics: Insights from Charlie Saltzman, MD
Charlie Saltzman, MD, a leader in foot and ankle surgery and former chair of the University of Utah’s Department of Orthopaedics, joins Douglas W. Lundy, MD, MBA, FACS, FAOA, to discuss the future of orthopaedic surgery. Dr. Saltzman shares insights on leadership, collective vision, and community engagement to create thriving teams and advance medical programs.
Join us as we discuss transformative innovations, from potential osteoarthritis treatments to trauma reduction via self-driving cars. Discover how advancements in bone healing and ankle replacements are shaping patient care and redefining the future of orthopaedics.
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 the vast spectrum of change that will occur as the future reveals itself 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 Charlie Saltzman. Dr Saltzman is the LS Peary Presidential Endowed Professor of Orthopedic Surgery at the University of Utah and also the Editor-in-Chief of Foot Ankle International and Foot Ankle Orthopedics.
Speaker 2:Dr Salzman did his undergraduate work in pre-medical sciences at Brown University. He went to medical school at the University of North Carolina and then did his internship and residency at the University of Michigan, followed by his fellowship in foot and ankle surgery at the Mayo Clinic. As I said, he serves on the field of orthopedics as editor-in-chief of Foot and Ankle International and Foot and Ankle Orthopedics. He's co-editor of Man's Surgery of Foot and Ankle and past president of the American Orthopedic Foot and Ankle Society. Past president of the International Federation of Foot and Ankle Societies. Past president of the Association of Bone and Joint Surgeons and past vice president of the American Board of Orthopedic Surgery, and served as the chair at the University of Utah Department of Orthopedics from 2005 to 2021.
Speaker 2:Dr Salzman, welcome to the podcast, sir. Nice to be with you, doug, and it's always good to see you again. Charlie and Charlie and I have been friends for a long time and it's really great to talk to Charlie because Charlie is going to give us insight into the future in foot and ankle surgery and all the things that are going to be coming down the pike in terms of that, and I would argue that Charlie knows that as well or better than anybody. But, charlie, before we go into that, you served for quite a lot I guess 16, 17 years as the chair at the University of Utah and you have a wealth of experience in leadership. What was your philosophy while you were chair at Utah and what were the key takeaway learnings that you took from that position and that experience?
Speaker 3:Thanks, doug. I had a great opportunity at Utah when they brought me on as chair to create an environment and a program in a direction that I thought that program should move, and my philosophy for doing that pretty simple, actually. The first was to see my job primarily as a person who was tasked with resourcing other people and giving others an opportunity to grow, to move into the shadows and not be in the limelight so that others could shine and I could basically rejoice in the reflected glow of others. And so my role I saw it as a fiduciary role to one extent, which is to make sure there was enough resources to share and to help everyone become the person they wanted to become within the department. I do think it's very important for a chair or a person in leadership to help pick the right people and to get the wrong people basically, as is commonly referred to, off the bus, and I took that very seriously and we were able to recruit wonderful people. We did remove a few people and the environment flourished as a result. I think it's very important to set a North Star for the group and to have this done mutually, but to make sure it's consistent with the leader's vision and, for us, the North Star was like it should be for most orthopedic programs excellence in patient care, excellent in education, concern about our community and trying to improve orthopedics by being engaged in the progression of the science of the field, as well as the national organizations of orthopedics, and we try to do that and involve everyone in some aspect of that so that everyone felt that they achieved their personal goals.
Speaker 3:And, as a leader, I think it's pretty simple. Actually, it's not about you ever If you take that job, it's never about you. It's about serving the other people. It's almost an upside down triangle, surprisingly, and that's what works. And I do think it's important to set a vision. I do think you should have a common set of ethical principles that you enforce and hold everyone to, or at least ask everyone to pay attention to it, and when they don't pay attention, that you act on those, on that.
Speaker 3:And I think it's that simple and it is not unique to say this, but I've heard this from others and I think it rings true and I'm just going to read you this Good people plant trees the shade of which they will never sit under, and that's the whole point of leadership. I do take my work very seriously. I don't take myself that seriously, but I love taking the work seriously and I'm enthused about the work. I've always been enthused about orthopedics. I think we are the most fortunate people in medicine and we have maybe the most fortunate people in anything, because we have this great job and we're able to help so many people. And I think that level of enthusiasm in a leader is also helpful to the esprit de corps of the group. So I'll leave it at that.
Speaker 2:We can close right here and thank you for being on the podcast. That was fantastic. Thank can close right here and thank you for being on the podcast. That was fantastic. Thank you, my friend, and I think people can clearly see why we were looking so forward to having you on the podcast and talking with you about that, and I know a lot of folks at Utah. Y'all developed a tremendous program there. It was a very historic program anyway, and so that would have been easy to be in a low and you picked it up and took it along and the facilities that y'all built out there the Orthopedic Institute is spectacular.
Speaker 3:Yeah, I think it's fair to say I was very fortunate, and I'll just make two points. One is that I moved into an area where the population was growing and so the economy is good and the population is growing. You got to be pretty bad to screw that up, okay, because businesses do well when things are growing. And the other point is when I looked at this job I didn't understand what I understand now at all, but I do think if it had been an A-plus program I probably would have driven it down If it had been a D program.
Speaker 3:I may never gotten out of the hole, but I was fortunate to come into a program that was very well managed and had a great trajectory, first really under unbelievable previous leadership here, including a past president of the AOA who was Dr Sherm Coleman, who is the person who first announced to the AOA that he thought the future of orthopedics was subspecialization, for which he got roundly criticized, and then by Harold Dunn, who was a historic and amazing chair. So I was very lucky to come in after tremendous leadership. So I think all that the environment helped. There are three things that matter in life in my view of things. Whether it's right or wrong, this is my view. One is preparation and the other two are luck and timing, and I had a lot of luck and great timing.
Speaker 2:That's fantastic, fantastic. Now, through your role you've had many roles in orthopedics, of course, within your specialty, and then also being editor of the big journal you can see a lot of the trends of the future. And I get it, brother, you and I were talking about it earlier. That predicting the future is, and you had a great yogi bear quote you threw in there. It's impossible, but to the best of your ability, with the tremendous knowledge base that you have, where's foot and ankle go and in the future, and you can define whatever that is in terms of 5, 10, 20, 100 years. I'm kidding. Okay, you're both thanks.
Speaker 3:Yeah, so I did bring up joe grieber's quote, which is the future ain't what it used to be, which is on the surface, just just humorous, but, as you, if you think about it, he's absolutely right. None of us really, or very few of us really, can see very far into the future because there's so many changes. The tectonic plates of engineering and science and geopolitical activity is are always moving and none of us can really us can really compute where we're going. And to give my perspective, which is one person's perspective, number one, I know I was incredibly lucky to grow up in the United States at a time where we were the dominant country and I was a white male. So there I start and I look out across my universe. At that time, the world and when I was starting my residency, I was no.
Speaker 3:I would not believe if you told me that the USSR would collapse, the wall between East and West Berlin would come down, they would become unified. I wouldn't believe that. Nor could I imagine in any way the internet. I could not have imagined it being real. I could not have imagined having an iPhone that works like a computer and not using a. I used a slide rule when I was in school to give you a sense of where it came from, and I don't think any of us, even 15 years ago or 10 years ago, could imagine what artificial intelligence is. So to give you some perspective on looking forward, the one thing you know is things are going to change and you don't know where that change is coming from.
Speaker 3:So I'll take this a little differently. I'll first start with a patient perspective. One thing that's not going to change is patients, like consumers, want something easy, want it quick, want it reliable and patient. And those features of medicine, those don't exactly fit with what our current medicine is. I guess. For foot and ankle patients, first of all, it's not so easy to get into the office. Then you have a surgery that's not necessarily reliable. It's got a 10% non-union rate across the foot for any fusion let's start with that. So you get one out of 10 patients who aren't going to heal and you're telling them to stay off their foot for three months, four months and they might have to have the surgery done again. So all those things are dissatisfiers to patients.
Speaker 3:So that's a concept that everyone should keep in mind. It's the same concept of I could go out and buy Christmas presents at five different stores, not have what's in place. Come back finally, get it, bring it home, wrap them up, put them under a tree or something like that, or a Hanukkah bush in my case. Wrap them up, put them under a tree or something like that, or a Hanukkah bush in my case. Or I can now go on Amazon and order it all wrapped and it'll be delivered. It's probably less costly actually to the world because of the system that they have for fulfillment. It's probably less pollution because I'm not driving all over the place three times. It takes no time for me, so I don't have to invest my time.
Speaker 3:So how is medicine going to move towards Amazon? And I would say we're not going to move quickly. We're a slow moving huge vessel with a lot of tugboats around us pulling in opposite directions. But those who figure out how to move in that direction will be rewarded and the patients will do better and will have a better experience. So for foot and ankle specifically, if I was to look at it, I say my biggest problem is I put patients out of work. I put patients who are 70 years old on crutches routinely and have them not in weight-bearing for a prolonged period of time and somebody's got to figure out how to avoid that, how to change that. So where is that going to happen? It could happen in bone biology, it could happen in bone mechanics, it could happen in boot mechanics. It could happen in ways I can't imagine, but it will happen. It will happen and it will shorten their recovery. So from the patient's perspective and I think that's what all of us should keep in mind as we look to the future what is going to make it better for them? And it may be that if we can make the surgeries more reliable, if we can get them recovering quicker, any of that stuff is going to make our world better. So if you look at what's going on now, mis surgery is booming in the foot and ankle world in certain areas of Europe, in certain parts of South America. It's coming to the United States and most of it tends to work and the patients have less pain, they recover quicker. They recover, say, in six weeks instead of 12 weeks, and to the surgeon it doesn't seem to matter that much, because you're going to see the patient back at 6 and 12. You're going to have to have your clinic full of the patients anyway, but to the patient it matters a lot, and so I think the field will move towards in that direction.
Speaker 3:Now all of us see robotics, some of us see AI coming in, and I am sure that for foot and ankle, either robotics or navigation will come in. Ai will help predict things. So where will it help us in the near future? Well, if AI gets smart enough to look at two orthogonal planes of plane x-rays and build a 3D model, then they can direct surgery. You can do all your planning off those x-rays in a reliable manner, and I think that's low-lying fruit, probably right now for AI, but eventually you can see where it's going. I think you can see where it's going, which is okay.
Speaker 3:Now you got the plan, now the tools. Now the tools relate to the plan and relate to the AI intraoperatively, and basically your job is to make sure you put the tools on correctly. But maybe it's even better than that. It already knows how to put the tools on correctly, and then you make your cuts perfectly. Your screws are all predetermined. You've done it in a third of the time because you don't have to think. Actually, all you have to do is set it up and it's more reliable.
Speaker 3:The basic for all of orthopedics approach. The other thing I'd say is we don't know what the future pathologies will be. Okay, so what we do know is what today's pathologies are. And to give you a broader sort of long review sense, I want to just take a moment and just explain this perspective. In 1900, orthopedic surgeons had trauma. They had syphilis to take care of because of the tabes dorsalis and the joints being destroyed. And then, if you take from that point forward and think about what has not, has gone away from orthopedics. So syphilis went away, polio went away, leprosy has mostly gone, at least in the world that we all live in.
Speaker 3:Hansen's disease 1900, hansen's disease was prevalent in Europe. It's called Hansen because Hansen was a scientist in Norway that determined the organism that caused the disease, to give you a sense of the prevalence of this disease. So it was across the world. You don't see leprosy in the United States. We don't take care of it now, but there was a huge need for that, especially in hand and foot and ankle to do tendon transfers. We don't do any of that anymore. We don't take care of polio and polio was a big disease for foot and ankle surgeons Triple arthrodesis at University of Iowa, where I was at, dr Ponsetti did 400 triples for polio alone.
Speaker 3:And then so we don't see that, so that's gone okay. Rheumatoid arthritis when I started in 1992, I was doing one out of 10 operations was on a rheumatoid forefoot. Now probably one in a hundred, maybe less. So it's gone okay. So what's the next disease to go? I'm guessing that somebody's gonna figure out how to slow down the progression of osteoarthritis pharmacologically. It can't be that hard to figure out, and it's such a big market, right? Somebody's going to get there. And just like GLPs, right? Glps never heard of that three years ago, five years ago. Glps are killing it right now and they're helping a lot of patients and beauty stars and GLPs. Imagine a GLP for osteoarthritis. Okay, that all of a sudden you've gone from rapidly progressing to half the speed of progression of your osteoarthritis. Well, that'll cut out half of the total joints, probably. And then so imagine that. But also imagine self-driving cars. Self-driving cars that are actually 10 times as safe as driving cars, so that the government says no more driving, you can't drive yourself unless you're under these circumstances and where there's no self-driving, because they're 10 times safer. Well, that'll get rid of 85% of our trauma here or 75% of our trauma here. So there's a lot of changes that we can't see, but we know one thing. We know one thing which is that if we focus on what making the patient experience better, we think deeply about that We'll make a difference and we'll embrace the changes that are coming towards us, because we know that's our goal, that's our North Star.
Speaker 3:Now I did talk before, just to take it a little further. I did talk a little bit about on the tissue level and on the anatomic level, and there's a few things maybe worth saying. One is, on a tissue level, bone healing. Bones love to heal in compression. Okay, if they could decompress, they'll heal. Okay, and that's just how it works.
Speaker 3:I think of it in my mind and I've seen a very high resolution EM that confirms this view, which actually I can't remember if I thought of it, or I bet I just saw it on the image and decided I thought of it. But the view that it's there are stalactites and stalagmites coming together and merging okay, icicles, you can think of coming up and coming down and merging, and compression doesn't hurt that. But shear kills it, tension kills it, okay. So anything we can do that can compress bone better is good in my mind, until a point where certainly at some level bone is gonna crush okay. So we don't actually know where that point is. That sounds crazy, but I don't think anyone really knows has defined that. Maybe I'm wrong. I've looked. But so some level of compression is better than no compression and continuous compression, which we see now with continuous compression staples, appear to be helpful. Certainly are easy to use, certainly are easier for the patients because less hard work. But so I think that's a direction.
Speaker 3:You know I'm talking about non-biological direction. Another just great big fat paintbrush stroke is biology. Can we have adjuvant biology that works? I don't think we really have much now. We got the beginnings of it. But if we had adjuvant biology that worked for cartilage, tendon, old tendons and bone, we'd be in a much better place. You can expect that eventually to emerge. You can also expect a lot.
Speaker 3:Subtail and joint can be partially incompatible. It's almost vertical. So anytime you step down they're trying to slide, they're trying to shear. And the foot we do a lot of fusions because we think it should be stable and we don't have a lot of options for replacement because the FDA only has ankle replacements, so as a lot of ankle replacements so far. So we have to fuse, so we need to figure out a better way of converting the forces of distraction, the forces of shear, or at least resisting those forces to get people up and walking early after these fusion procedures. So that's a direction.
Speaker 3:And finally, I think, total ankles. I've been on this total ankle bang wagon for too long so I'm almost believing myself, but I do think we've already breached the top and now we're on the downhill slide and people are seeing total ankles as a primary option for many patients with ankle arthritis. And the field has got to get better. We've got to get smaller ankle replacements, meaning we've got to take out less bone and get the same results or better results. And once we get there, then I think the younger patients will be able to have ankle replacements and be more active. So that's how I sort of see the future. But again, I can't see the future because something is going to come along that's going to just completely change how we look at everything, just like arthroscopy did, just like John Charnley did with figuring out low friction arthroplasty.
Speaker 3:That guy was unbelievable. And what does it take to be John Charnley? What it takes and I just like to leave with this to be John, charlie or my hero Ignacio Pansetti, who I got to know, who changed clubfoot treatment around the world. It takes a few things. One is incredible curiosity. So orthopedic surgeons can be non-curious people, they can just learn a recipe and you know all the recipe. But for those who have natural curiosity and tremendous perseverance, I think, and no consideration of money, neither of those guys cared a bit about money, not anything about money, neither of them. They wanted to make the world better and they found it interesting and I hope that this little conversation will stimulate others to realize that can be part of their life, that can be a fun part of their life, that doesn't have to be their whole life and they can make a big impact broader than themselves. It can make in the opera, on one by one page, one patient at time, as charlie and ponsetti did right, that's absolutely spectacular on that.
Speaker 2:so you think that it was interesting hearing what you were saying so I could see a demographic shift in the specialties that the residents are going into, based on the changes in disease characteristics as the future continues to roll out. I mean my beloved trauma surgery. We're going to become to your point, if motor vehicle road traffic accidents go way down with AI, then we are now becoming more fragility fracture surgeons, because that's really the only yeah we're not seeing true iss over 16 trauma patients, but older folks, utterly people with proximal femoral fractures yeah, no, I think that's it.
Speaker 3:Yeah, I, your skill set is very important for the world. Let me just make you and the aging population is where you can make a big difference and there's not a. All right, I'm going to go off script here. The way it works seems to work Okay. The way it seems to work to me is that the big companies in trauma go to the big trauma centers and get the big names to do big trials or to support their big products, but guess what? There's a lot of old people not going to the big trauma centers. This is the massive amount and it's probably much bigger than who's going to the trauma centers, but for some reason the companies haven't figured that out.
Speaker 3:Once the companies figure out that and this is my take, like, say, for LC1 fractures, get them up early, get them moving. Why not put a couple of screws in transacral screws in to get them moving? What is it about the world? That's ageist, that says they don't deserve the screws where they have the worst bone and some young guy deserves the screws. Okay, so that's how I look at things, okay, so I think there'll be work, but it will change.
Speaker 3:It could change when I was a resident and it's a little bit before you, doug, because I know your age and you know mine, because we were on the board together and it's about a decade before, when I was a resident, almost every night I was on call, somebody came in dead on arrival, right right, why? Well, because there were seatbelts who just started and there were no airbags. There were some airbags, but they were terrible and I think in my senior year I saw three PILONs. Why? Because the patients were killed Once the airbags popped up. Pilons popped up, wow.
Speaker 3:So the point is is, if cars get safer, if transportation gets safer, and what? Who's to think it's not going to get safer? Because certainly with seatbelts, which was basically pushed through by a New York state orthopedic surgeon and made a law in that state, by the way, and then became a national law, if seatbelts changed everything and then airbags changed everything, I am sure that there'll be another level that'll change everything for driving accidents Not going to get rid of everything, but it's going to change the demographics. And it's going to be true for us too, in the foot and ankle world, because we take care of a lot of post-traumatic Ankle work is basically post-traumatic and we do a lot of trauma in the foot and ankle area, so we'll probably see a diminished volume there. But there's always going to be work for good people and it's just a matter of realizing that the population is getting bigger. They're going to need to be taken care of. You just have to adapt with the change.
Speaker 2:Well, so much of your stuff is done in the inpatient sector. I would imagine that you're well above 80% is outpatient.
Speaker 3:Oh yeah, we don't want to walk in a hospital.
Speaker 2:So what would you guess?
Speaker 3:In Charlie Seltzman's. Well, in my world it's 90 something percent, and that includes children and adults, not babies, because I don't take care of babies, but children and adults. And yeah, so there's a group of patients who are comorbid enough that they really shouldn't have any surgery done in an ASC. They just, you know, you can't tell, it's just rolling the dice when they're going to have a problem in the operating room, and so they're done at a main hospital which has all the resources nearby, you still have the hospital outpatient department.
Speaker 2:You can still treat them that way within the hospital and still let them go home.
Speaker 3:Yeah, that's what, yeah, and that's what we do. Yeah, and that's the. That's the standard I. Utah is an interesting place to work that people here are really fit and they don't smoke. Well, some do, but very few smoke or drink. Diabetes is a lower prevalence in this population because they really focus on being fit and if we had a large diabetic population it would change that calculus a little bit because of their needs for inpatient care.
Speaker 2:It's been absolutely fascinating because you've gone into the effect that a lot of folks have not done to this point that as the pathology changes because I think that's one of the first times I've heard that come up. But to your point, especially with road traffic accidents, motor vehicle collisions, with AI and then with biologic advances to mute the progression of osteoarthritis and to your to your point earlier, that would be, oh my gosh, any drug company that got a hold of that would cease market share and the return on investment will be spectacular for them. But the combinations of all those will change demographics of our specialty, what we do, who we are and what disease processes we're taking care of. And I haven't heard that really elaborated to the degree and to the eloquence that you just did.
Speaker 3:Well, I think my view is embrace change, okay, right, you asked me about being chair here earlier and I came out for an interview, and so part of the interview process was to sit in front of the faculty. At the time there were probably 12 or 15 people in the room Now we're 60, to give a sense and one of the persons asked me something, and my response was and I believed this then and I believe it now my response was if you don't like change, don't hire me. Don't hire me. I think too much of the world was scared of change. I think too much of the world is scared of risk, right, just in general.
Speaker 3:And I believe the work that you know I think it's Kahneman Danny Kahneman got the Nobel Prize for on risk avoidance behavior is a real thing and Traversky and Conneman got the Nobel Prize for it. And I think that this is just for the members of the AOA Embrace change. It's coming. You can't avoid it. You know that the world will be inherited by those who embrace change and everybody else will be left behind. And so I think being agile is part of being a leader, and I think being willing to engage and keep up is required for all of us, and I just think that's the way the world is and it's foolish to think you can go back.
Speaker 2:Yeah, yeah. If nothing else, those changes in technology are going to force everything else on us because, to your point, it makes everything much, much different than it was earlier. As you made the shopping analogy, yeah, yeah, and I think it wouldn't make things different than it was earlier.
Speaker 3:As you made the shopping analogy, yeah, yeah, and I think it. It wouldn't make things different if it, if it didn't make things better. So temporarily you'll see these little blips in technology that actually hurt patients, and then they disappear and you try to trace down what happened and who published on it. You can't find a trace, like the company folded the docs, going on to another promoting another product for another company. That's probably a terrible product, and so you see that all the time in this field. So don't embrace all the change you see, but these big trends, the overall trend is things are going to have to change in both, in every direction, and you're bringing up changes in technology. That's out of our control and that's a good thing, because there are a lot of smart people around the world figuring out how to make things better for us.
Speaker 3:You know, just to take something simple, like when I started, we were using all the tools were plugged in. All the tools were most of them were on air compressor controls. That was horrible. I didn't know it. Then I thought it was great we didn't have a mini CRM. We had at the University of Michigan. I was excited when they got a CRM and then we got this. Now I wouldn't use a CRM for 90%. I want to use a mini and I get upset if I don't get the right mini. Like so we all love this stuff, admit it, okay, and just embrace it as it comes along and test it be skeptical but embrace it.
Speaker 2:And what a great conversation and I think you hit directly on what we're looking for and we certainly have discussed the future. So, dr Charlie Salzman, thank you very much for being on the podcast series. Sir, my pleasure. Always good to see him again, my friend and for all our listeners. Y'all please stay tuned for future AOA and future orthopedic surgery podcasts on this channel. Thank you.