Lessons in Orthopaedic Leadership: An AOA Podcast
Lessons in Orthopaedic Leadership: An AOA Podcast
Beyond Surgery: How Leadership Shapes Orthopaedic Oncology's Future with Terry Peabody, MD, FAOA
What happens when devastating cancer diagnoses transform into manageable chronic conditions? Dr. Terry Peabody, Chair of Orthopaedic Surgery at Northwestern University and past AOA president, takes us on a compelling journey through the evolving landscape of musculoskeletal oncology.
Dr. Peabody shares profound leadership wisdom gained from mentors who taught him that true leadership means "bringing people along with you, not pulling up the ladder." This philosophy has shaped his approach to both patient care and professional development throughout his distinguished career.
Whether you're a healthcare professional or someone whose life has been touched by cancer, this episode offers valuable insights into how leadership, technology, and compassion are shaping the future of orthopaedic oncology.
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. 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 Terry Peabody.
Speaker 2:Dr Peabody is the Edwin Warner Ryerson Professor of Orthopedic Surgery and Chair of the Department of Orthopedic Surgery at Northwestern University Feinberg School of Medicine. He also provides care for patients at Lurie Children's Hospital and is a member of RH Lurie Cancer Center. He's a native of Southern California. He earned his Doctor of Medicine degree and his residency at the University of California, irvine, and did his fellowship on oncology at the University of Chicago. Dr Peabody is past president of the American Orthopedic Association, former chair of the AOA Academic Leadership Committee and vice president of the Orthopedic Residency Committee of the ACGME. He was a director of the American Board of Orthopedic Surgery. He was a director of the American Board of Orthopedic Surgery and he has significant research and clinical expertise on benign and malignant bone and soft tissue tumors, including limb salvage surgery and functional restoration for adult and pediatric patients. And also it's important to note that Dr Peabody is an AOA pillar of the orthopedic profession. So, terry, dr Peabody, welcome to the podcast, sir.
Speaker 3:Thank you, Doug. Appreciate the invitation. Hope you're doing okay.
Speaker 2:Yeah, man, it's good to see you. All right, my friend. So, as you know, we've been talking about the future in orthopedic surgery and you are a very well-known oncologist. You and I served together just one year apart for 10 years on the American Board of Orthopedic Surgery. I've got to know you and your lovely bride, jane, for quite a while and you are certainly an expert on this, but you're also an expert on leadership, being an AOA pillar and a former president of the AOA. So, dr Peabody, can you give us a pearl, some wisdom as you see it in terms of leadership and how it can affect us, especially as we look forward into the future?
Speaker 3:Well, I think. Thank you, Doug. I think the number one thing was we were all inspired by people in our careers who we looked up to, who seemed to always want to do the right thing. We're fairly selfless in how they did things and really were more interested in their legacy in many ways than what they were actually accomplishing on a day to day basis. They wanted to bring people along with them. To bring people along with them. They're not pulling up the ladder, they're facilitating them to get on the ladder and looking back for the people behind them, trying to bring them forward.
Speaker 3:And I appreciate that so much from people like Mark Hoffer and Mike Simon that that's the kind of leader I wanted to become and hopefully I have. I think the AOA is a big part of that. I learned how to work with other people and like minded people, you know, who wanted a great residency, who wanted great departments, who wanted to facilitate the profession and sort of fulfilling what it was meant to be, and so it's been an honor to be part of the AOA. It was an honor to lead them for a year. Part of the AOA. It was an honor to lead them for a year, but for me it was all about the mentoring I received when I was younger and the sense that it was about something bigger than I was. So that's the pearl. That's the only pearl I have. Honestly. It was a tremendous experience to be part of that and the board as you said, it was a highlight of my professional career being a member of the board. So those two things it's been. It's been a terrific, it's been an honor.
Speaker 2:Thank you. Yeah, and you, we had a good time together doing that. It's a lot of work but it's worthwhile. Also, got to know you through the AOA as well. All right, my friends. So, as you know, we are talking about the future in orthopedic surgery and going to you about your chosen profession of oncology. You know, it seems like all the time we're hearing about these really devastating cancers which are now being treated extraordinarily successfully with biologics and other things that have really turned the tide on a lot of these illnesses. Tell us if you could be so bold where do you think the future is going in terms of musculoskeletal oncology?
Speaker 3:So, I think you know we think about diseases burdens.
Speaker 3:Perhaps you know burden of disease if you will, but it's not that kind of burden anymore. The initial, when I started someone with metastatic disease had a dismal outcome within a matter of months to maybe a couple of years, and so you would treat people in that manner. But these targeted therapies and it's really remarkable have had a tremendous impact, affect not only longevity but also quality of life for those individuals. Even with advanced metastatic disease breast cancer, kidney cancer, lung cancer Patients oftentimes can live years with those diseases and live reasonable quality of life and want to continue with the same activities they did before. And so orthopedic oncology is going to continue to grow, not just because of the numbers you have more patients with more disease living longer but also there's more to do because you want to treat not only the impending fracture per se or a lesion that requires some sort of treatment. But we're being a little bit more aggressive, I would say, about things that we used to we couldn't really help, like pelvic fixation for patients with fractures, percutaneous fixation, interesting sorts of techniques to improve the quality of a patient's life, doing more elective total joint replacements on patients, even in the face of metastatic cancer, because again, they're going to live a long time, many of them, and with these therapies it's really extended the amount of function that these people have and our ability to improve that function. So we're doing a lot more surgery, I would say, on patients with metastatic disease, and not so much just for fractures but for other reasons.
Speaker 3:The other thing that's going to grow is reasons. The other thing that's going to grow is, you know, our prostheses for primary tumors sarcomas have gotten pretty good and have expanded beyond the tumor world. But within the tumor world, the ways to fix things, you know, as opposed to cemented stems, some of this compressed technology is very interesting, seems to have good results A lot of 3D printed materials, a lot of cutting guides, custom processes for pelvic reconstructions. I think they really improve the situation, more so than when we gave up on them early, when they would fail earlier, get infected. We understand what else has to happen plastic surgery, things like that but you know my work extends sometimes into the bad fractures or the horrible total joints. You know the worst tumor you can get right, the revisionoma, where you have to use these tumor prostheses to try to salvage a limb that doesn't have cancer but it looks like it does. Sometimes it's just been destroyed.
Speaker 3:So those are probably the two fastest growing areas, I would say. Another area of interest is osteointegration, which I think is going to see a little bit of resurgence in this country, especially for above-knee amputees who are otherwise healthy. The sense of an osteointegrated stem with a prosthesis that's going to continue, I think, to improve and be associated with better outcomes for patients. So I'm hopeful in those three general areas. I think it's a good thing we're educating more people in orthopedic oncology because I think they'll be needed going forward.
Speaker 2:You know a couple of insights that I had on y'all. You know I just hired an orthopedic oncologist here a year and a half ago and you know, in terms of expense, I mean you guys do some incredibly expensive surgery as compared to you know some of the more bread and butter kind of things that come through. But you guys are kind of the marquee of completeness or quality or sophistication of the department. It's like, well, we've got an orthopedic oncologist, therefore we rock and all this other stuff. I mean you guys kind of bring that. I hate to blow your ego up a little bit, but it seems like you kind of bring y'all, bring that to the table.
Speaker 3:Yeah, nobody's really accused me of being sophisticated Doug. Well, that would be true, I think. You see what I'm saying. Excuse me being sophisticated Doug. Well, that would be true, I think.
Speaker 2:You see what I'm saying.
Speaker 3:I do you know. I think orthopedics has nine subspecialties, right, we all have our strengths and the things that we bring to a department.
Speaker 3:I think the oncologist in general feels reasonably comfortable with a whole lot of different things and is capable of doing a fair number of things beyond oncology. I think it's somewhat in orthopedics. I don't want to say it's dividing, but, you see, a move towards the outpatient surgeon and the inpatient surgeon, the trauma, the spine, the tumor person. They probably have more in common with their colleagues in, say, sports, shoulder, elbow, some of these other specialties which are largely outpatient and don't really require a hospital at all. But certainly for hospital-based systems or for academic medical centers, an orthopedic oncologist is pretty important, I would say. You're right, though, when it comes to cost of prostheses and the expense associated with it. If it truly was a high volume business, we would be losing a lot of money. But I have seen some of those costs decrease over time as things have become more modular and, like everything, there's more competition in the market. So I think it is balanced, but I think an orthopedic oncologist does bring something to a department. Obviously, I'm biased.
Speaker 2:Right. One thing I've noticed specifically in terms of trauma surgery what we saw as trauma systems got better as people started using more advanced trauma resuscitative techniques and patients started surviving. And in addition to this, you look at all the safety features in cars now with airbags and all the safety features that people were surviving we would see now constellations of injuries that people survive and we have to deal with where they used to be attached to people who are in hyperboleic shock and died at the scene or died in the trauma bay.
Speaker 2:Now they're surviving and we're being presented with these disastrous injuries. We're like, wow, we've never seen this. Where were these injuries? Well, they were people who passed away before they got to us. Let me make the analogy, so, with the advance in the stuff that y'all are doing and the medical oncologist and radiation oncologist. How is that changing the presentation of the orthopedic oncology patient to y'all as the musculoskeletal surgeons?
Speaker 3:I think we see it more as a chronic type of issue. I don't want to say chronic disease, but a lot of patients I will follow for years with metastatic disease, as opposed to similar to trauma where it was an acute intervention and then never see them again. I have a long-term relationship with most of these metastatic patients Because rarely is it so. I mean occasionally it's bad at the time of presentation when the patient first shows up. I mean occasionally it's bad at the time of presentation when the patient first shows up. But once things are sort of managed in that acute phase, over time it's just things bubble up.
Speaker 3:I don't mean to indicate people live forever, because they don't, but they live a long time and they live long enough to develop other problems. So it's become a broader field as opposed to this is problem A. We're going to do this Now. It's manage A and then anticipate what's going to follow and keep your eye out for other things. Imaging is so much better than used to be. Pet scanning. We know more detail about more people than we ever have. How do you follow that? How do you monitor it? How do you intervene early before there's another issue? So I'd say it's a much closer relationship with my patients I ever had and a much longer term relationship.
Speaker 2:What would you tell a young like one of your fellows? What would you tell one of your fellows if they said what do you think my career is going to look like relative to yours? How would you tell them that would be the same and or different?
Speaker 3:I think the patient interaction will be largely the same. I don't think that's going to change, but get used to the intensity of it, because you're still breaking bad news on occasion. You have to tell patients and be honest with them about what you can do and what you can't do for them. That's not going to change. All that stuff is good, but you're going to have more tools than I had to make things better. For example, horrible S tabular disease.
Speaker 3:In my day we had one option which was a Harrington reconstruction cement pins. Put it in hope it works. If it worked great. A lot of times it never worked. It fell apart. You ended up taking everything out. Now there's options. Now there are actually things you can do earlier to head it off or, if it's gotten bad, to make it better. They'll have a lot more options. They'll also have a lot of non-operative options. You know we do a fair amount of cryotherapy now, radiofrequency, ablations, things that are percutaneous therapies. They have to get used to doing that Image-guided surgery, which I did not do. They need to be good at Navigated surgery. They need to be good at Navigated surgery. They need to be good at, they have to get used to this idea of 3D printing and developing cutting models that they will use in surgery. It's going to be, I think, a higher tech field than the one I'm leaving. I didn't learn all that stuff. My hope is that my successor certainly will.
Speaker 2:That's very interesting. So the big metastatic diseases that y'all I imagine you see are breast and prostate right.
Speaker 3:They're common, but they don't tend to fracture as often as they used to.
Speaker 3:Why is that the bad one now is actually kidney cancer. Why is that? I think they're caught early. For breast and prostate they tend to be, at least on occasion, sclerotic disease, so they tend not to fracture, but the treatments are so numerous for both those diseases. There's been a lot of research and money into breast cancer for the last 30 years, so there's a lot of options for women and men that have breast cancer. Prostate cancer the same.
Speaker 3:The struggles we still have are kidney cancer. That's a hard one to manage operatively and a hard one to get control of. There's immunotherapy for it, but it tends not to work well in bone. So those are the challenges that are repetitive over time and the hardest things to get. Stability in Thyroid cancer is still around and that's a hard one to manage because it tends to progress in bone regardless of what kind of treatment patients get. Colon cancer, you know, increased so much in numbers that we're seeing more colon cancer in bone now. It's just so common. But you know those are sorts. It's changed a little bit and then I'm not sure, but it seems like myeloma is more common than ever. Anyone in their 50s and 60s with lucid lesion it seems like there's a lot of myeloma out there and there's a lot of effective treatments stem cell transplants, car T therapy but they still get a fair number of bone issues. So the diseases are kind of the same, but the ones that are more challenging for us are actually the kidney cancer, thyroid cancer, some of the myelomas.
Speaker 2:Do you feel that there's a general increase overall or in what y'all, as musculoskeletal oncologists, are seeing, or is it staying the same?
Speaker 3:I think, it's.
Speaker 2:I'm trying to figure out where the future is.
Speaker 3:It's staying the same, but I think kidney cancer may be on the rise a little bit. What I see, a little bit too, is my colleagues in town don't really want to do any tumor work, and that's fine. I don't blame them. But very few people feel comfortable even rotting metastasis, which wasn't true, I would say, 20, 30 years ago. I did not do nearly the amount of metastatic work then that I do now. I think we get a fair amount transferred in.
Speaker 3:I just think again there's this a little bit of a divide between inpatient, outpatient orthopedics and as I deal with a lot of private groups that are largely outpatient, that aren't attached to a hospital, if they see something that just doesn't make sense it won't be easy for them to care for, they'll send it to the academic medical center. So I'm not complaining, that's the way it is and I think that'll continue to happen going forward. They shouldn't. You know. If they don't feel comfortable they shouldn't be caring for the patient. Feel free to ship it. But I do see that transitional, but I'm sure you feel the same thing and that's true, I think, for trauma, infection and tumor.
Speaker 2:Yeah, I've built my career basically on saying yes. What was the question you?
Speaker 2:know trying to keep saying because doctors are like water, right, they take the path of least resistance. So if you're the one that accepts everything and you don't keep score of insured versus uninsured, versus whatever, before long you're their go-to for everything and they call you for their family members when they get hurt. So, as you know, I was on the board with you when I had prostate cancer. I've been very open about it. I had a lot of men along the orthopedic surgeons along the way reach out to me and talk to me about it.
Speaker 2:Where I was going was I was treated at MD Anderson, because that's where one of my best friends who's a urological oncologist is, and I was stunned at how well the system worked and I compared it to the hospital system I was in at the time. I was like we should be doing what these folks are doing. I felt as big as MD Anderson was, and my wife and I kept talking about it. It seemed like they had built the building and the whole system for me, which of course I knew was not the case and I kept talking about it. It seemed like they had built the building and the whole system for me, which of course I knew was not the case, but I was like this seems so much focused on me and what I need that I was. We're not doing this at my practice and my hospital, where we don't provide that level of individual care.
Speaker 2:So where I'm going is do you feel that as we progress as cancer or as musculoskeletal cancer, going to become more and more focused in these mega centers like yours MSK, md, anderson, fill in the blank, mayo, whichever or is it going to now diversify out into the as we make more and more musculoskeletal oncologists? Is it going to go out more into the community and where are we going with this?
Speaker 3:I think it's actually going to get more centralized over time. As you pointed out, it's an expensive undertaking for the institution. Sometimes there's imaging profits or some other things that come downstream, but as far as the surgeries go they're expensive and costly compared to doing routine total joints, primary joints. It's a tough, tough business if you're doing those sorts of volumes, so, but I sense, even though we're educating a fair number of people, that those people are congregating at the major centers. I don't see a lot of this moving into the community. I don't think community orthopedic surgeons really A feel comfortable or B want to do this type of work, and so I don't see that really occurring.
Speaker 3:Again, I hate to keep using the trauma analogy but I think big poly trauma will always be at big centers and it should be right. You're made for it. You can manage those issues. It's hard to do in a community hospital. What I have seen and what, frankly, I see works a bit, is for maintenance therapy, radiation oncology, imaging medical oncology for your daily treatments. That does seem to get exported into the community hospitals, but they tend to be affiliated with the major centers and MD Anderson does that a bit, I believe, so that you may go for your event, a surgery or something significant, you know, some intervention, bone marrow transplant, whatever, but for your surveillance, may be exported to a less intense environment. I think that's probably the future right.
Speaker 2:Yeah, like I said, I went down there because that was where my friend was. I didn't know anything about it, but uh great play yeah, I guess our good friend valerie was down there all right however, once again I mean, there's a tremendous.
Speaker 2:I remember when I was in atlanta there was a tremendous amount of competition between ctca and emory, and then you know, all the outside ones are always telling you that there there's so much competition for the cancer patient out there from the systems. How is that affecting the care of the cancer patient out there from the systems? How is that affecting the care of the cancer patient? Is that making them better or worse?
Speaker 3:I think the number one challenge of patient with cancer encounters and you may correct me is there's a lot of confusion at the start.
Speaker 2:Oh yeah, no question.
Speaker 3:You. You get this horrible sort of news and somebody is presenting it to you who's trying to help, but everybody else is trying to help too, and so you have a lot of input and there's no clear path. You know, and I think patients struggle with that, and I understand that. I think, though, everybody wants to have a cancer center, everybody wants to care for patients that have cancer A lot of volume issues there, but I think, particularly in musculoskeletal work, there's only a few places that have a track record and really do it well. There are three locations in Chicago.
Speaker 3:You would probably go, I'm one of them, there's two others.
Speaker 3:There are three locations in Chicago.
Speaker 3:You would probably go, I'm one of them, there's two others and we all sort of know each other and we know what you're doing, and I know any city in the country. I can pretty much tell you where you would go for our level of musculoskeletal oncology care or breast cancer, prostate cancer, the more common diseases where all the faith-based hospitals and health networks have cancer centers and will keep those sort of self-contained. But I think, when you talk about orthopedic oncology, there's really only a few recognized places to be and people that take care of these problems and my job is to sort of clarify that they don't have to be with me but they should only be at these other couple places if they're considering this type of care and trying to provide that clarity I think is really important. It's just so you know, so overwhelming the inputs they're getting and they have friends and colleagues who are telling them oh, you got to go here you got to go, there you got to go to the best place wherever, and what I have found is there's probably no best place.
Speaker 3:Every place has pluses and minuses. Patients will never know that and if it makes them feel better to get opinions at some of the big cancer centers in the country, god bless them, but the treatment will be the same likely at any major centers you go and you know the cancer group has really tried to have these centers of cancer excellence. It's like everything the ranking systems and things. But there are some criteria for these cancer centers and you probably want to find one that's actually got the designation as a cancer center. So I you know it's. It's confusing. It's not perfect. You were fortunate. There's a lot of good places you can go, but having that kind of, you need people who actually manage those problems on a regular basis.
Speaker 2:And when I started looking into it myself, I realized that I think that a lot of those rankings you may correct me, but those rankings were based on things that really were not important to me, and the important thing to me was that's where my friend was, so I trusted him and that was the end of that, you know, okay, terry? So when we look at the future in orthopedic oncology, just moving forward, is this going to be sunshiny and good? Is it going to be cloudy? Is it going to be rainy and bad? When you talk about, I mean, we all see these horrible cancers which devastated families, which you know destroyed the lives of young children and I mean broke everybody's heart that was anywhere around it. And now some of these tumors and some of these cancers are now being cured and these kids are going on and living with cures or near cures and significant remissions where they're able to get on with their lives. Where do you see the future in orthopedic oncology in reference to the overall spectrum?
Speaker 3:Well, I'm not one to certainly not in my lifetime will there be a cure for cancer. I don't think that's coming. I think they're all different diseases and but there are better treatments and we will make continued headway, not so much on the surgical side but on the medical side. And you know, there's a new drug, it seems like, every week, that they're finding is effective against certain types of cancer, and I think that they'll continue to hone that down and get combinations of drugs that don't wipe people out, you know that, allow them to live their lives and have some quality of life and at the same time keep the tumor under control.
Speaker 3:And so my goal is to make again this sort of a chronic disease, Not like hypertension or diabetes, but sort of like hypertension or diabetes. You check it, you monitor it. When it gets a little out of control, you change your medications a bit and just move on from one drug to another. You'll always be on some sort of treatment always, but you know you'll have a high quality of life and hopefully some length, Cause I think that's what people really care. They want, they want to live a good life. They'd like a long life, but it's more important to have a good life, I think, time with your family and be able to work and do the things you like doing. If you can give them that gift, that's a wonderful thing.
Speaker 2:Absolutely. Thank you All right. Well, it's been my distinct pleasure to discuss the future in orthopedic surgery as it relates to musculoskeletal oncology with our past AOA president and pillar of the AOA, Dr Terry Peabody. Terry, thanks for being on the podcast.
Speaker 3:Doug, thanks very much, great seeing you. Best of luck.
Speaker 2:Yes, sir, y'all stay tuned for future episodes of this podcast and this series on the AOA future in Orthopedic Surgery. Thank you.