Sultans of Spine #1 - Sharad Rajpal MD, F.A.C.S.
big professional setup man that's right okay you ready to dig in yeah dude all right welcome to the sultans of spine podcast i'm your host Jameil Pendleton and I am so excited to introduce our guest. before I do, the the Sultans of Spine is basically meant to just have a little bit of "under the hood" in terms of the Spine and Robotics industry which is one of the fastest growing spaces in med tech. And what better way to to learn about the industry than from one of the surgeons who's pioneering these new technologies in his practice today so Dr. Rajpal without further ado you can introduce yourself to our audience well great thank you first of all for inviting me today Jay. I'd like to thank
that you invited me simply because we're both equally bald that's right but perhaps that's not what it is so I've known jay for a long time here and I'm a neurosurgeon my name is Sherad Rajpal, I'm a private practice neurosurgeon over in Boulder, Colorado, I've been in private practice since 2010. I did a neurosurgery residency at the University of Wisconsin in Madison where I trained and grew up in the midwest, so I'm a midwestern guy and a Badger at heart. Then I did a one-year fellowship combined orthopedics/neurosurgery with Dr. Ed Benzel and his group over at Cleveland Clinic for one year after that I came over to Boulder Colorado and performed you know now in private practice so that's where we are where we are today. So it's fascinating for me, I've been a guest
on a couple of podcasts and now I'm starting my own - and it's fascinating to me because one of the things that I think was interesting for me to just vocalize my path how I got to this point and so that's that's kind of what I'd like to start with like, what what was it that made you want to become a a physician a neurosurgeon? what was that path and did you always know? Yeah that's actually great uh so you know I'm actually Indian by birth and you know generally our destiny is written when we're when we're born you know either going to be a doctor an engineer, so that's kind of how it began. But in all reality you know I was actually when I was growing up we used to go back to visit my grandfather back in India so every three years growing up we'd go back to visit my father's father right and he was a very small community general practitioner and uh it was fascinating to me to be able to play in his clinic so i would spend the days with him all summer we would sit at a table he would see patients all day long I would get to help him you know i would just grab the bandages grab the syringes just things like that he was sort of his assistant for a long time and uh what I really saw on him was his dedication the guy was so dedicated to his patients um and so you know we would spend two or three months in India my whole summer with him watching that come back to the states so just growing up I really watched this this gentleman he became really in my opinion he was somebody I really looked up to right so really want to be a physician from that standpoint so that is where the influence came in to become a doctor in fact my aunt was a doctor as well so um the interesting thing is he's actually a general practitioner very well respected in his house but he never turned anybody away right. I was following that pathway and then, I always tell people you can either go the path of medicine or the path of surgery - that's just that's sort of two generalizations and I have a "Type A" personality just like you, I like to be in control, Yeah I'm laughing because of just the setup of this room we were trying to figure it out like where to sit this is normally done in separate quarters but we're here together in Miami anyway Yeah I'm glad we able to do this together so you know the the things as a type a personality in general what I learned doing through you know through my rotations in medical school you know which I got into I realized that in in medicine itself so just people that are your general practitioner your primary care doctor right a lot of people keep coming back through the door you know they get the diabetes and the high blood pressure and things like that and you know come back through check and then they may or may not have done anything differently so it's just kind of a it's a lot of social sure some people don't want to take control of their health care those kinds of things and it was frustrating to me to watch that process because I felt like there was a lot of desire to help people right and unfortunately a lot of people and that's a terrible generalization a lot of people don't want to take care of themselves it's reality that's reality so I just did a surgery rotation in college and uh and I realized you know surgery is instant gratification generally right you go in there and if it's a tumor you take it out or whatever it is you know and i'm in control yeah if we go to the or and i take something out it's done usually one and done if that's possible you fix the problem and you move on so I tell people it's terrible generalization there's thinkers and there's doers yeah and the medicine doctors as smart as they are there there's a lot of thinking going on oh yeah from a surgery standpoint it's a doer you fix it and move on that's sort of my my sort of initial pathway it's fascinating yeah and thanks for sharing that because I think that that like whether you're watching this and you're a surgeon hopefully you are we would love to have surgeons watch this um or if you're if you're someone that's selling on to surgeons or trying to get into this industry it for me it's it's always been very important to understand like what makes people tick what why your why kind of why you do what you do as it relates to your practice as it relates to how you take care of your of your patients how you structure your day so that that we can ultimately provide the most value that's on point with where you'd like to receive that would call it solution right yeah you're right i've heard you talk about that before as well you know knowing your audience that's what you're talking about absolutely knowing your audience and what do you where do you see kind of i mean if we could talk a little bit about healthcare today or this maybe spine surgery today just just you know where do you see it today what are you excited about tomorrow just kind of your overall thoughts on the industry i mean i think coming into you know we're actually currently at a course you know called future spines leaders and really i think you know i've been coming to this course ever since i was a resident fellow that was going to be coming out as well so i saw that and it's kind of interesting to be reflecting back now and being sort of on the other side of the podium now teaching right these people that are coming out i think that you know healthcare in general it's always changing but really for spine we're at an amazing time i think in fine it's really exciting to be into it i mean neurosurgery in general is the youngest surgical field as you know right it was it's only about 120 years old compared to most surgical specialties so first of all we don't understand much about the brain if you look at it that way so we have so much to learn and so much to do if you look at spines by technology we are really i think at this i call it the inflection point um where we're really starting to become like other surgical specialties right sure in regards to technology like we have technologies that we have in eor currently but now the new integration of so many things like robotics and we talked about all these things ar vr starting to be integrated right ai so use all these terminologies but these are all the things right i mean you got the mako for for orthopedics which is around for a while you've got the da vinci robot for general surgeons urologists kinase all those kinds of people we finally now have robotics that have really sort of started entering the or so we're at this really infancy of technology which is just so fascinating because think of the things that we can do so much better than what we've been doing for you know decades you know for me when you hear robotics you get that kind of like terminator 2 like they're going to take over but it's really it's it's a robotic assist initially in the or we'll park that for a second because i do want to talk about your workflow relative to robotics but i think for me what i've learned talking surgeons like yourself seeing it from an industry standpoint it's really the pre-operative plan that at least now is such a game changer and and what i mean by that for those people that don't that don't truly understand what this gentleman does and people like him uh every patient has different anatomy and every uh patient has a certain what's called pathology so like why their leg or arm hurts right yeah and you have to just based on your skills yeah based on what you know on in your hands what works you have to come up with a unique plan for every single patient and it's always changing so pre-operative planning like where does that fit into that like your your algorithm your kind of yeah and it's interesting one of the great mentors you know you always say the beginning of your training you learn how to operate so that's what we spend all our days doing it's just learning how to do it technically and as you get older in life you you learn when not to operate great okay because it's really sort of making it's the decision making before you get to the or that's really critical not everybody with back pain needs a spinal surgery and so that's sort of one important thing so that's what we have to develop right first of all is learning who's an appropriate candidate for a surgical procedure that's your pre-operative evaluation once you sort of catch that patient say okay you're a good candidate for us to intervene from a surgical procedure what i think we can do now you're asking me about the future and the technologies and the ai and the data collection things like that we have surgical techniques that we do but even as we've discussed and you've heard lots of times even amongst multiple surgeons in one patient we always say you have five opinions from five surgeons you'll get ten opinions absolutely yeah so even one even one surgical procedure one pathology or problem for a patient could have multiple solutions sure but what we don't do well i don't think today is we do a lot of things really well but what we could do better is trying to figure out if you sort of take the patient as almost like an onion and you peel apart because there's socio there's psychological absolutely the biology of the individual so the pathology the problem that why they're in your office a lot of those factors actually play into it as well as we just you know is it workman's competition or is it not so what's what's the extrinsic motivation for somebody to show up in your office that's amazing but but those are those are all part of the game absolutely right that's what you're saying is you have to learn when not to operate when somebody has secondary sort of gains here they're not going to get better with what you do that's right so that's a sort of a long way to get to the point of we can really do a better job here of saying now we collect all this data on people so you know jay this age this height this bmi this socioeconomic he shows up in your office with this problem you take the data set of all these thousands of people that have treated it say okay you know if i'm the surgeon say jay you need a cervical fusion right and then we plug it into the database and says actually he doesn't need a cervical fusion he needs an artificial disc or needs something called a foramin where we come in through the back that would be the better surgical solution so we should hopefully be able to navigate with the technologies we're talking about maybe it can be the guardrails for where we are and do things better and i think that's where that's where the excitement comes maybe we can become more homogeneous with our treatment not because people are homogeneous correct but then we have a better understanding with how we can treat them it's absolutely because you're able to in that scenario which you just described which is brilliant is is is taking the training like nothing's going to replace you seeing a patient right and and and all those onion layers that you talked about you're now adding the power of data in ai and just mining that and categorizing that into like a better potential option or maybe just whittle down all those potential avenues yeah i mean i think we talk i talked about homogeneous but really what the answer is it's actually customized let's put it that way it's customized care so right you and me are not the same person you know even though we look very similar we're not the same person that's right i do have the bow tie i i do not sorry yeah it just you outdid me i mean but um but you know even though we're very similar people in terms of age size all these things you and i literally could have a very different pathway for a similar problem that may come up so it's customized but homogeneous does that make sense so it's kind of counterintuitive but i think that's where we would win yeah you and i might have different outcomes with the same surgery and should have done something differently that's brilliant that's the way i think that that's where that's going to go with yeah right that's where all this stuff genomics right the robots the ai all these kinds of things so that's that's not even surgery yet right we don't talk about in surgery but that's the pre eval that's right right and to improve your outcomes and that's that's exciting too because as he said like we're at such an inflection point of this industry it's growing fast um there's a lot of competition but like really when you look at it the the sky's the limit in terms of where we can go and and and it's exciting because when i started in this industry in 2008 it it it still felt like there was a lot of and there has been quite a bit of advances advancing since that time yeah and we're going to say the same thing in five years now i mean in the last year or two alone we've had this explosion in in technology right yes i mean there's been explosion in just the last couple years and there was an interesting statement by when i did my plastic surgery residency a surgeon told me once and i never believed him he said you know 80 of what you're going to do in your career you'll never have done in your training if you think about that and i was like whatever nothing's going to change we do front back cervical surgery we do thoracic we do so we trained in everything i was like i'm going to do all this stuff what could possibly come out and be different right yeah but literally every spinal fusion i do now or surgical procedure includes navigation interoperability or a robot slash cobot whatever you want to call it so even the fact that i use a navigation system even if it's the same procedure i've been doing i never did it before that's true right or you talk about the lateral approaches things like that so he was right and we're probably thinking the same thing for the next generation you know who knows maybe it's just stem cell injections patients don't ever need spinal surgery yeah you know sky's the limit like you said i mean where can we go so where can we go is right and and as it relates to this conversation you know we have a short period of time you know there's there's so much that we i'm fascinated and kind of like uh to a couple different ways that we could talk about the one is is is kind of like your routine like i'm big into that what's your surgery day clinic day routines it's just potential question and then uh you know the other one is is kind of like your uh your brand like as a surgeon as a neurosurgeon in boulder as a very uh good practice and one that's you're intentional about everything that you do yeah you get the word a lot of like in that regard as well so there's a couple areas i'd like to talk about is what just kind of yeah i mean i think that probably you and i are very you know from a routine standpoint we're very much routine based you know we don't we don't deviate a lot from where we are it goes back to that type a personality being in control you know i don't i don't get up at five o'clock in the morning and work out like like my man jay here does he's you know he's definitely got me beating that arena but i try to you know i try to do my work and try to spend time with my family like that's really my avenue here so you know work is primarily targeting patient patient care that's what i want ultimately good patient care i live in a community if i see them in the grocery store or the post office or you know the waiter or waitress or somebody else to take care of my kids i want to have a good reputation for myself because i want patients to do well i mean ultimately that's why we're here it's not for me and it's for them 100 but then we have sort of the other competing factors as you do to you have families at home you know kids and wife and things like that so you know the routine is work is work and then home is home so we try to separate the two as much as possible it's a challenge to do because we're always on the clock people start always phone call you things like that so you know from a routine standpoint i don't really have a routine the key is really to get the work done focus on the work get home spend time with the family that's sort of my routine internally let's just one step further into the or routine do you like to do your tough cases first do you like to get a couple like decompressions or maybe a smaller surgery out of the way what's that look like sure so you know generally i'll do two days of clinic and then generally two or three days of or so i have a flex day on fridays but generally because i'm so busy well i had a friday surgery day right in terms of surgical procedures we generally try to do the smaller cases in the morning because those patients in general will go home so if it's a small surgery they can go home so rather than keeping somebody without food so npo for seven or eight hours through the end of the day when you finish the long day yes that poor patient has been sitting there hungry all day long so we can get them sort of fed after surgery get them home ultimately then then the long cases then sort of come in and usually after you've done a lung case you're exhausted and you don't want to do a long case and then being like okay i got one more small case to do on there you know you're there is a mental fatigue you should just do a physical fatigue you know we're standing there and uh you know it's just by the end of the day you're a wreck because you know it's it's it's an intense thing to be there and i was having a conversation with somebody yesterday you know there's very few jobs out there where you have somebody's life in your hands and that's not to be dramatic but oh but that's when that patient wakes up when that patient wakes up they have to be perfect and if they're not perfect the complication lies generally in your hands whether it was directly or indirectly a result of what you did so you know that's a tough thing to swallow every single time so just the stress level of that which is why i think there's a lot of burnout is yeah absolutely is the intensity of what we do you know i think that's something that we as an industry need to be cognizant of and i've said this before and i say it again just realizing that how much you guys have at stake and how much at the risk and all of that is is is literally in your hands and and if something doesn't go right you know i there's a certain separation of you may become really good friends with your with your interoperative sales consultants right i have great relationships with surgeons that i worked with and but there's a level of like you know we you walk to see that patient and we're we don't have any like that's just that separation i don't know if i'm making sense but it's no it's true but i think that the the reason why i have people like you and the company you work for i tell my guys or girls that work with me you know i'm i'm 110 there 110 it's not a show up to work with 80 you can't show up with mental fog and fatigue or not be into it like you can't turn it off when you're in the or you are there and committed so very true guys like you the reason i like you the reason we're friends the reason we're in the same industry is because you're going to show up and you're going to give me 110 so every day but i expect that out of you you just like you would expect that out of your doctor so when we're in the or we're actually a team it's not me alone because the success of the surgery is mine plus yours so if you show up and you're 50 get on get out of my room it's not fair but that's but that's why it's that's why you are successful from what you do and people in industry need to understand that that's so great you said that yeah there's a reason there's it is a privilege to stand in in the ors it is a privilege to be a spoke on the wheel and to be part of their team and it's competitive for a reason because i think that looks there's many different ways that industry can can approach this but if if you learn nothing else if you're if you're in sales or if you're trying to to get into medical sales or whatever if you learn nothing else from this little talk that's it you need to show up every single day prepared ready for a long day and because that that's that's basically just gets you in the door is being prepared and being ready and being physically and mentally there and i mean to your point working out in the mornings that helps me get ready yeah for my job and i think it's just like everyone has their own their own routines but i'm glad you said that um because that's really you know profound but somebody's it's somebody's family member on the table imagine if it was your mother and you heard that hey the surgeon was tired or b the rep didn't have the right equipment so if we're going to do a cert you know surgery on your neck right and i'm in the middle of case and i'm like okay jay i need the the cervical plate or the inner body cage well i don't i didn't bring the right sizes for you doc i'm like so you want me to do a subpar surgery on this individual because you were not prepared right and of course we would have had this conversation before so we don't encounter this and generally this doesn't happen in my or because we're having this conversation beforehand to ensure that this doesn't happen but you have just screwed the patient on the table that's right and so i have to live with that because that's my patient but you if that happens i will definitely have a conversation with you on the side to let you know what your decision to do or not do that day and your failure to show up has affected somebody's life life life in patient-centric is when i figured that out it wasn't it wasn't difficult but it was early when i figured out okay nothing else really matters this is someone i remember vividly there was a surgeon we were working with and everybody was just not really bringing their 110 stuff wasn't in the room it's normally in the room basic stuff and and just things weren't really meshing it just so happens that the surgeon was operating on like a family friend right and and and he he basically said timeout like this is not how this is gonna go everyone needs to up their game and he used different language yeah but in a very direct way like this stops now and from that point forward it was just the necessary just and so i didn't wasn't planning on asking you this how do you handle intraoperatively when you need to course correct that team because you're the you're the captain yeah i mean again we talk about being calm you know that's a that's a really important feature so you know you have to be you are the leader of the ship right the most important from in my room always my rule is anybody can speak up uh we don't run an or where i am i am definitely in charge but i am not one of these people that will punish i actually appreciate if somebody says hey you forgot to do something right there i'm like thank you very much for speaking up so it in our room actually it's a level playing field and everybody knows that so first of all that's that's that's been shown scientifically and proven so many ways to prevent complications and problems for patients so everybody has the ability to speak up so even if my rep says hey doc i got a problem over here okay i'm not gonna yell at you right let's figure out the solution what happened perhaps something to get sterilized okay how long do we need until that kit comes out 30 minutes okay it's fine go ahead and work on that i'm going to continue to work or i'm going to deviate my plan so i'm going to buy you 30 minutes not going to change what we're going to do for patient outcome but we're going to change the game here so that we can okay i'm going to do maybe my decompression before i do my hardware so we'll continue that pathway so i haven't really encountered a space where we've not been able to perform a surgery because of that inability but that's again where the relationship comes absolutely so my reps are almost like my friends you know we we treat each other as like equal absolutely i want you to speak up for me so course correcting is also part of it that's what we talk about as well you know being a good surgeon means that you can sort of you know it's the day should be linear yeah but but we all know it's not like that so the deviations it's okay if we ultimately are able to do what we need to for the patient and and i think probably 99.9 percent of the time we are playing we are planning for anything that's going to deviate and we're ready for it as a team you and i have chatted about okay oh yeah what if we can't do this okay do you have a backup set yes i got a backup set all right don't i'm gonna go get that ready so that's i think what helps to improve our patient outcomes absolutely because we're ready right you're ready you've got the back of the plane styled that's sounds like a great o.r environment honestly try yeah yeah it's important again it's patient-centric that's why
we're there that's right we want to be running all cylinders what let's let's take a i sent you a couple of these questions beforehand but what what what do you think is a myth a common myth about minimally invasive surgery mis because that's that's part of your practice you're in a big party right so i actually was going to just broaden that question yeah not even just mis surgery it's just spine surgery yeah it's funny because i i you know i i was going through your questions and i was like miss surgery i'm like we have a broader problem here yeah yeah yeah it's spine surgery so um what's you know in general spine surgery is a bad rap nobody wants spine surgery right the problem is we actually have great outcomes and what people don't do is they don't accept the fact that we have great outcomes so there's definitely bad surgeries right there bad surgeons and not everybody does great but the bottom line is that's sponsors got bad rap period not just miss or not dr google right it's it's there's so much people are gonna find information yeah and i would say the loudest patient who's not doing well is the one who's going to be speaking out so like if you're a neighborhood picnic the guy who had surgery he's going to be like i did terribly yadda yadda but you're not going to hear from the five patients that are doing great right people that have a great go to the internet complain people that are doing great don't say anything that's a good point so for anything for anything but especially that's reality yeah yeah yeah that's interesting so yeah um yeah so i think spine surgery in general has got a bad rap not just mis no it's well and and hopefully these types of discussions and conversations that we have the industry if there's people out there sharpening their saw listening to to what dr roche paul is saying um maybe listen to some of the things that i've learned over my career i'm not as credible of a source but having lived this this world for for a lot of my professional life like it's an honor and a privilege to work with surgeons like you and and thank you for for sharing a little bit of of your world of your vision and of um you know just kind of this uh this unique little space there yeah i appreciate being on here man i appreciate it i appreciate all that you do thank you so much thank you thanks for joining appreciate you guys tuning in sultan's spine and uh come back next week thank you thanks