Inaugural Charles L. Plante Lecture

Inaugural Charles L. Plante Lecture- Physicians as Agents of Transformational Healthcare Change-Five Lessons from the Life of Charles Plante

It’s an incredible honor to be the inaugural Charles Plante lecturer, particularly as I have so much respect for my dear friend and colleague Katie Orrico (Senior Vice President, Health Policy and Advocacy at American Association of Neurological Surgeons/Congress of Neurological Surgeons), along with her innumerable contributions to our specialty. 

This lecture is primarily targeted to our younger members, to whom I’d like to say, the prevalence and disproportionate global health impact of brain and spine diseases, combined with unprecedented innovation in the neurosciences, provides you the potential to produce greater benefit to society than perhaps any other class of professionals. But you’ll also face challenges in realizing that potential, chief among which are the following:  

First, a “perverse” incentive system that enables waste along with unsustainable growth in expenses, and often increases the risks of care without producing demonstrable benefit, at least compared to the remainder of “first world nations”.

Second, a morally intolerable lack of care equity, and healthcare outcome equality, largely related to the first item.

Lastly, a byzantine regulatory system that stifles rapid innovation, complicates medical education, mires care-givers in endless “below-license” activities, and prevents meaningful progress towards value and sustainability.

Charlie Plante spent most of his distinguished career trying to remedy systemic issues such as these, and encouraged his medical colleagues to join him in that battle. But it remains the case that physicians have, over the last several decades, largely abdicated operational, policy, and financial control of local, regional, and national medical administration to a separate professional class, many of whom have unquestionable domain expertise in various realms of medical business, but possess no direct experience in healthcare delivery or medical academics.   

Colleagues, our relative dissociation from meaningful processes of change in the larger medical ecosystem only serves to perpetuate this unacceptable status quo. If we, as physicians, assume we have no power to influence these elemental matters, that assumption will become a self-fulfilling prophecy, and society will suffer as a result. The status quo needs to be altered post-haste. This is a call to action.

I believe a collection of principles that defined Charlie Plante’s life and work, provide us with a general framework around which we might start to effect transformational healthcare change. Those principles include the following:

1)     All strategies and aims must derive from a patient first ethos. Charlie dedicated his career to tirelessly supporting the activities and values of physicians, but he did so principally to advance the needs of the patients we serve. This principle-that healthcare is an ethical issue first, and economic second, must be the bedrock of physicians’ greater influence.  

2)     Collaboration is an operational imperative. It’s hard to overemphasize this point. Charlie was fond of saying that “seldom does anything meaningful happen because of one person. As a rule, positive outcomes are achieved by many people working together.”  Routine collaboration magnifies our potential, and increases our collective wisdom.

3)     Humility. Charlie was supremely confident, but he was also keenly aware that no one possesses solutions for every problem, and he embraced intellectual humility as the only way to remain open to new ideas, and to avoid the practical irrelevance that results from believing only in our personal perspectives and intuitions

4)     Persistence. An attribute which Charlie understood was a professional and personal characteristic for which there is no substitute, and an absolute requirement of effective leadership

5)     Faith in the scientific method to produce change. Charlie was a strong proponent of medical research, but an even stronger proponent of scientific principles as a method to continuously learn and grow in daily professional life

I have witnessed, first hand, how the application, of what I’ll term the “Plante Principles for Healthcare Leadership”, can dramatically facilitate physicians’ ability to harness their collective potential, and effect broad systemic change. I’d like to provide a few concrete examples from what I’ve termed our national “information projects” to illustrate the point.  

In the mid 2000’s, value-based reforms were being increasingly adopted by most stakeholders, to help achieve sustainability in U.S. healthcare. A significant challenge to successful implementation of such reforms was a lack of valid methods to continuously collect and report high quality data related to the drivers of healthcare outcomes. In that environment, leaders of our specialty recognized that clinical registries presented a number of advantages as a reliable source of such information.  It was quickly resolved that we should create novel information systems to measure clinical outcomes of relevance to all healthcare stakeholders.  In 2008, a governing organization, called the NeuroPoint Alliance, was developed to help shepherd the development of our first cooperative national data system.

The ensuing process validated the power of the first 3 Plante principles-humility, collaboration and patient focus- in creating meaningful change.  

It’s important to note that organized neurosurgery approached this complex project from its inception, with a collective humility. Specifically, we acknowledged our relative inexperience in this field, and recognized that the development of a meaningful and sustainable national registry program would require broad collaboration, and involve harnessing the data science expertise of individuals both inside and outside of our specialty. We were incredibly fortunate, therefore, that several of the most influential national leaders in registry science at the time, who recognized the potential impact of these proposed programs on patient care, willingly lent their energy and knowledge to our efforts. Their selfless cooperation, conspicuously driven by a patient first ethos, has been essential to our success. The charitable and inclusive spirit exemplified by those collaborators has been incorporated into our own culture, becoming the NPA’s defining attribute. 

We named our registry program the Quality Outcomes Database, or QOD. Our Initial focus was on spine surgery, largely due to the predominant nature of spine care within our specialty. Spine care created data collection challenges that other early clinical registry programs had not faced, or had chosen to avoid for practical reasons. Simply put, most spine care stakeholders were predominately interested in assessing the sustainability of spine treatment effects, and direct measures of patient experience, as opposed to simply assessing major short term morbidity, as was the standard in most other surgical registries in that era. As such, a high bar for data collection was set from the beginning, involving for the first time, in a national surgical outcomes project, the routine, longitudinal collection of patient reported outcomes, or PROs.  Unfortunately, we had no idea at the time how high a bar we had set for ourselves.

This leads me to the fourth Plante principle, persistence. After years of preparation, the registry program was launched in 2011. Within weeks, IRBs in multiple institutions around the nation classified this program as human subjects research, requiring patient consent and local IRB approval, as they deemed the delayed collection of PROs as an activity lying outside of the existing standard of care. We immediately engaged other medical specialty leaders who, like organized neurosurgery, recognized that this interpretation of the human research protections policy, otherwise known as the common rule, represented an obvious and substantial threat to the practical realization of widespread, outcomes-driven quality improvement. Policy experts were retained, and what ensued was a remarkable series of conversations over an 8-month period, culminating in a White House summit meeting, during which the HHS offices of OHRP and OCR agreed, for the first time, to provide written and verbal guidance which largely exempted clinical registries like QOD from the jurisdiction of the common rule (https://www.hhs.gov/ohrp/regulations-and-policy/guidance/december-29-2011-letter-to-dr-anthony-asher/index.html). Our persistence had the immediate effect of dropping unnecessary regulatory burdens, and facilitating longitudinal registry use across the nation and across all specialties. This effort gave birth to a multidisciplinary registry consortium whose advocacy work continues today.

Finally, the last Plante principle, scientific methods embedded in daily practice: By 2012, QOD started in earnest. The technical aspects of the program are beyond the scope of this lecture, but what is important to note here is that growth of this program was rapid, and by 2019 involved 106 national programs, in 38 states, representing all surgical settings-private practice, academic, community, urban and rural. Consistent with our inclusive mission, orthopedic spine surgeons were engaged from the beginning. Practice administrators in particular were quick to realize the value of the data in value-based care, and drove adoption. Data coordinators from across the country, organically formed a practice improvement workgroup which systematically improved our methods. For the first time in our history, a cooperative national quality culture was created, and brought from theory, to reality, a concept we described just over 10 years ago, the science of practice (Asher et. al., Neurosurg Focus, 34, 2013), which anticipated a national community engaged in the systematic collection of data, inseparable from clinical activity, along with the cooperative analysis of that data to generate new knowledge. 

What I just outlined were some of the transformational programs that were brought about by applying the same principles Charlie Plante used to effect widespread, operational, cultural and policy change. Here’s a brief summary of the major outputs from those programs:

In 2020 the American Association of Neurological Surgeons and the American Academy of Orthopedic Surgery (AANS and AAOS) –formed the American Spine Registry (ASR), an unprecedented, multi-specialty cooperative endeavor that prioritized patient benefit over competitive professional interests.  Validation of the significance and importance of this partnership, which brought all north American spine surgeons under a common data platform, quickly followed in the form of substantive support of this program from bio-industry, and requests by regulatory and oversight agencies such as the FDA and the Joint Commission to participate with the ASR in important national data science collaborations.  

The NPA registry portfolio has continued to expand rapidly, and has now enrolled tens of thousands of patients in multiple subspecialty platforms. Beneficiaries of these efforts now include patients, care givers, healthcare institutions, bio industry and regulatory groups. The registry data has been purposed by these groups to numerous functions, including evidence-based quality improvement, medical operations, advanced payment models, policy development, and research. With respect to the latter item, these programs have arguably given rise to the largest cooperative quality and research project in the history of our specialty.

The total scientific influence of these programs was recently evaluated in a systematic literature review.  To date, over 200 publications have been derived from the QOD dataset. Importantly, an additional 413 publications, many in other medical specialties, medical administration, and healthcare policy journals, refer to the NPA and its various registry programs, a testimony to the growing influence of our programs in the broader medical community. The general scientific impact of registry influenced investigations continues to grow, and the significance of this research has been recognized with numerous prestigious awards from multiple societies.

Finally, the NPA and its programs have influenced and informed the development of other advanced specialty-specific data projects, one of which is ABNS POST, an advanced clinical data platform that importantly includes imaging data to aid with assessment of care appropriateness and clinical outcomes. To date, POST has now collected over 82,000 candidate case submissions. This program is now a core element of the ABNS certification program, and continues to be refined by the ABNS to serve its essential mission to society, and our specialty.

In summary, we as neurosurgeons have great potential to change the world for the better, but we also face great challenges in modern medicine.

We stand at an inflection point in medical history. It’s essential that we re-affirm, now, our commitment to providing meaningful leadership whenever and wherever possible in this current environment, and that we resolve, to diligently strive to reclaim many of the essential systemic responsibilities we have abandoned as a professional group over the last several decades. I suggest this course not for the sake of claiming power for power’s sake, but rather out of a conviction that care givers possess a singular perspective related to what ails American healthcare, and what needs to be changed.

I attempted to offer today a brief review of our national data programs, as concrete examples of how we can become agents of transformational change, by applying principles such as those that defined the life and career of Charlie Plante. The challenges of modern healthcare mandate that we think differently about our work- both in type, and in scope.  

To my contemporaries, I appeal to you that we are too few, and our professional challenges are too great, to not be united in our efforts to harness the power inherent in data from daily practice. Furthermore, our teaching and certification methods must routinely cultivate business, administration, policy, and leadership skills. Procedural proficiency, and technological innovation, are necessary but insufficient for us to meet the comprehensive challenges of modern healthcare. 

To my younger associates, I ask you to consider the power of these Plante principles, particularly those of patient first, routine collaboration, and intellectual humility. Think more creatively about the skills you need to compliment your clinical and academic expertise, particularly business skills.  Identify a cause you’re passionate about, study it, collaborate with likeminded individuals and gain new perspectives. Base your decisions first and foremost on what is best for the patient, and don’t give up until you make a difference.

Those physicians who possess elemental academic and business capabilities along with patient-first and collaborative sensibilities are, and will be, uniquely capable of expertly guiding medicine into its next chapter, in cooperation with all other healthcare stakeholders, including our many non-physician clinical and administrative partners, our patients, bio-industry, purchasers of healthcare services, and regulatory agencies. Only in that scenario can we practically hope to realize all of the potential that is widely perceived to reside in heretofore largely theoretical constructs, such as truly equitable, and truly learning healthcare care systems. It is time we make those dreams a reality.

Finally, it’s indicative of the scale of these truly remarkable collaborations that it is literally impossible for me to adequately, and appropriately acknowledge the hundreds of individuals in numerous domains who made these programs possible. Friends, you know who you are. Please know I have deep personal respect and appreciation for what you have done, and what you continue to do, every day for our patients, and for society writ large.  

Anthony L. Asher, MD, FAANS, April 21, 2023, Los Angeles, California