In this conversation, Dr. Shah and I discuss what led him to a career in healthcare, specifically pediatric orthopedics. We also discuss how advanced technology in surgical techniques has led to better patient outcomes and how he is sharing this knowledge with surgeons around the globe. Enjoy the conversation.
Todd Schlosser: Thanks for joining us here on Scrubbing In. Today I’m joined by Dr. Suken Shah, the Division Chief for the Spine and Scoliosis Center, here at DuPont. Actually, the hospital name throws me. So is it-
Suken Shah: Well, it’s undergone a lot of evolution.
Todd Schlosser: Oh, okay.
Suken Shah: It started out as the Alfred I. DuPont Institute back in 1940 at the bequest of Alfred I. DuPont’s estate. Upon his death, he donated his entire fortune to the care for crippled children.
Todd Schlosser: Wow.
Suken Shah: That’s taken on an entity that now rivals the Mayo Clinic for care for children. We have multiple sites here in the Delaware Valley, as well as Florida, as the Nemours Foundation. So, this place is now called the Nemours Alfred I. DuPont Hospital for Children and we serve at least the tri-state area of Delaware, Pennsylvania and New Jersey, as well as parts of Maryland and then our southern partners in Jacksonville, Pensacola and Orlando, sort of a much larger population of Florida.
Todd Schlosser: Excellent. I’d like to start off with the similar question every time and that is what is it that happened in your youth or young adolescence that sort of drove you to have a passion for healthcare?
Suken Shah: Well, I’m the fortunate son of Indian immigrants and my brother and I were fortunate to gain opportunities in this country that my parents came here for. But I was exposed to medicine early through my family. Not my parents, but uncles, aunts, my grandfather was pretty formative in that time and when I would go to visit, I would see how he was taking care of a community of people as a family doctor in India and got exposed to medicine pretty early. I saw how he touched lives and ran a small hospital and really wanted to be a part of something like that.
Todd Schlosser: Would you say that they were sort of mentors for you in that, even though they were in India at the time and … I realize you were here.
Suken Shah: Yeah, I think role models are so much a part of it and so I really identified with careers like that. I can remember wanting to be a physician for my entire life.
Todd Schlosser: It is one of those careers that kids will say, “I want to be a doctor, a lawyer, or a fireman.”
Suken Shah: Or a police officer, yeah.
Todd Schlosser: Yeah, it’s one of those careers that it’s just not everyone always sticks with that for the rest of their life.
Suken Shah: Yeah, I think I’ve pretty much stuck to it here and there. And orthopedics was a little bit of a revelation to me.
Todd Schlosser: Yeah, I was going to ask you how you got into that as a specialty?
Suken Shah: In medical school, I went to medical school wanting to be a surgeon. I liked the decision-making, the critical nature of it. It’s very black-and-white to me and I wanted to have a role in the operating room as well as outside.
Todd Schlosser: Absolutely.
Suken Shah: So, surgery, I really identified with that. Now, orthopedics was a revelation that didn’t happen until the first or second year of medical school.
Todd Schlosser: Okay.
Suken Shah: Where I got involved in research in orthopedic lab and met orthopedic residents. They were great people. We were doing really exciting stuff and I gravitated toward orthopedic surgery as a specialty and then ultimately the care for children mainly because, at that time, they had many disorders that we didn’t know the cause of. We didn’t know the proper treatment. We didn’t know the biology or the genetics behind it. And those areas in pediatric orthopedics have really expanded.
Todd Schlosser: You said this is like treatment of scoliosis and things like that or?
Suken Shah: Hip problems, scoliosis, how do fractures heal more effectively and the technology in those areas has really expanded and it’s been great to be a part of that as it’s grown.
Todd Schlosser: Yeah, sort of laying new ground for surgeries that have not been, I guess, attempted yet or maybe not surgeries, but techniques that have not been attempted yet.
Suken Shah: Right. And they were attempted, but we weren’t satisfied with the outcomes. Now those outcomes are better, surgery is safer and we’re making an impact in a child that hopefully will last 40, 50, 60 years.
Todd Schlosser: Absolutely. So, let’s talk a little bit about that because you’ve been doing this a little over 20 years now and a lot of things have changed, I would imagine, in those 20 years, especially since digital technology came in. It seems like things are changing much more rapidly than they had in the past. So, what are some of the things that have changed in that time that have been making surgery safer, as you said?
Suken Shah: Well, specifically in scoliosis surgery, I can pretty much assure a patient and their family that the surgery will be carried out in a pretty efficient manner, they leave the hospital pretty reliably in a matter of days rather than weeks, they’ll return to school in weeks rather than months, and return to sports in a couple of months rather than wait a whole year.
Todd Schlosser: Wow, okay.
Suken Shah: So, from a teenager’s perspective, and that’s typically our patient population for adolescent idiopathic scoliosis, there’s not a big disruption in their life and they can go back to being a kid or a teenager again. But, in the operating room, the surgery is safer, people lose less blood, don’t need a transfusion, and paralysis which is the biggest scare in spinal deformity surgery has been mitigated to a risk that is very safe. Not zero, but mitigated to a risk where we can really approach complex surgery and be confident that we’re going to get a good outcome.
Todd Schlosser: So, what sort of technologies has led to making those sort of things safer?
Suken Shah: Well, in spinal deformity surgery, we want to be protective of the neurologic elements, so the spinal cord is at risk when we produce a large correction of a scoliosis, a curvature of the spine. And we need real intraoperative data that is obtainable during each step of the operation to make sure the spinal cord stays safe. During instrumentation insertion, those are implants that connect to the spine and then we use those implants to correct the curve. Well, during that time, we need realtime information, just like your dashboard on your car. I want to know how fast I’m going, how much gas I have, what the temperature in my car is, this intraoperative monitoring can tell us that without having to wake the patient up and having a very stable anesthetic. So, we work together with our intraoperative neuromonitoring personnel or anesthesia and the operative field to all maintain good communication during critical steps in the operation, where things need to be monitored very carefully.
Todd Schlosser: And you mentioned this earlier and you just touched on communication, so I wanted to touch on that as well. So, you’re in the operating room, you have the perfusion anesthesiologist, neurophysiologist, all sort of acting as your dashboard and it’s you that makes those black-and-white decisions, as you said before. Those decisions can be life-altering, so that’s a lot of pressure to take on. Is that something that you think about in the operating room or is it you’re just so trained that you don’t even … it’s sort of second nature to you?
Suken Shah: I think there are some cases we obviously approach with a lot more stress and anxiety than others and in a high-volume center like ours, every patient is unique, but we’ve done it so many times that it’s very standardized, it’s very protocolized, there’s very little variability from most cases we do. And that team is very important. We’re familiar with each other. We have good communication. We call each other by our first names and we socialize later, outside the operating room. And so, I need that confidence and familiarity to act appropriately and reduce the stress.
Todd Schlosser: Yeah. Do you listen to music or anything in the operating room?
Suken Shah: And it’s very appropriate.
Todd Schlosser: Yeah, a lot of people do.
Suken Shah: And a lot of the team has contributions in there. I don’t want to say, “Hey, I only like this.”
Todd Schlosser: It’s Vivaldi or nothing.
Suken Shah: Well, I don’t like country and everybody knows is, but I’ll listen to anything else.
Todd Schlosser: Nice. So, you veto Florida Georgia Line, per se?
Suken Shah: Yeah, except that one song. Our team is so important in getting a good result and we need that every day.
Todd Schlosser: Yeah, well communication is such an important part of any decision-making process, whether it’s in the O.R. or with your family or anything. So, how would you say that intraoperative neuromonitoring has a hand in that?
Suken Shah: Well, even before we’re in the operating room, we have a monthly spine meeting in which we discuss all the cases we’re going to do the next month. In fact, that happened this morning.
Todd Schlosser: Oh, okay.
Suken Shah: And in that room, we discussed the x-rays and the care plan, what other diseases the patient has that need to be managed appropriately. So, there are people from the operating room there, our nurses are there, our research team is there, and our monitoring folks are there because they want to anticipate any challenges they might have from their end and a lot of times, we need their input in how to position properly and how to do the potentials properly and carry out the operation in a successful way. And some personnel on their side might have an expertise in that particular area that they want to make sure are scheduled for that case, so that’s very important on a planning aspect.
Suken Shah: In the operating room, we have a preoperative huddle. We discuss what the patient needs that morning, all the cases throughout the day and how we’re going to approach the plan and then we execute that in the operating room during the case. And, throughout the case, there are critical steps where we need their feedback as to what we’re doing is safe and then ultimately when we’re closing we want to make sure the patient came in as good as or better than when we started.
Todd Schlosser: Yeah. I do know that, because I’ve talked to a lot of neurophysiologists and perfusionists, so I know a lot of times that they will communicate with each other before communicating with the surgeon in the room because something that a perfusionist is doing may impact the electrical impulses or the way it’s being read, at least, what the neurophysiologist is seeing, more or less. Is that something that you encourage for them to work it out before it comes to your attention or do you more prefer a sort of open communication in the room.
Suken Shah: Well, I think that early troubleshooting is really important and the most frequent conversation is between monitoring personnel and anesthesia because they have an intimate connection with the anesthetic depth and how the patient is metabolizing that anesthetic and what that anesthetic has on their electrical potentials, so they work that out very frequently, but when that conversation seems to be taking on a different tone, it does get my attention and so I want to be involved and it’s a three-way communication, you know, that Venn diagram where everyone’s interacting?
Todd Schlosser: Sure.
Suken Shah: And we need to exchange information. What am I doing that could have affected something? What are they doing on their end to troubleshoot that? And we have a checklist in the operating room in which everyone’s got some designated responsibilities and we work together to resolve the alert.
Todd Schlosser: So, what is intraoperative neuromonitoring allowing you to do now? Is it more surgery techniques or just pushing that field forward?
Suken Shah: Well, I think at a very basic level, it gives us tremendous confidence that what we’re doing is safe. There were periods of the operation prior to contemporary monitoring where you were flying blind. You would have a critical part in the case and have to wait for that information and I emphasize how important it is to be realtime. Sometimes there would be a delay of 30-60 minutes until we found out that a particular intervention did or did not create a problem. That can be pretty stressful. But, we are able to do sophisticated deformity correction now, that was even possible before. Resect vertebrae, decompress the spinal cord, remove tumors, remove and correct very significant deformities because with the realtime monitoring and various channels, monitoring the front of the spinal cord, the back of the spinal cord, the individual nerves, how the brain reacts to that is much more sophisticated than they ever were and allowed us to do more complicated surgery safely than ever before.
Todd Schlosser: So, it’s really just the advent of that realtime data that allows you to move more quickly?
Suken Shah: Yup.
Todd Schlosser: Is that what reduces the amount of time it takes for them to recover, you know, get out of the hospital and recover?
Suken Shah: Maybe not directly that, but it’s an early warning system and I often tell the residents, “Fellas, this is like having a smoke detector in your house before your house catches on fire. Wouldn’t you rather know early than wait until something devastating or irreversible happens?” Of course. So, that’s where this comes in to being much safer. And then having that ability to map out the spinal cord in its regional variability or the front and the back, now we can almost get a full view of every component of the neurologic elements, rather than just one part.
Todd Schlosser: Excellent. Are there any advances that you see coming down in the near future that could make surgery even safer on top of that?
Suken Shah: Well, in the monitoring category, I would love to see an ability to look at spinal cord perfusion. What that means is blood flow and oxygenation to the spinal cord again in realtime. Because I think a lot of what we do first stretches the spinal cord and limits the blood and oxygen to the spinal cord, which is then reflected in the electrical activity that’s abnormal. I want to able to see that before that happens.
Todd Schlosser: Yeah, so we’re sort of looking at what happens because of the lack of perfusion in the spinal cord and we want to be able to-
Suken Shah: Let’s trace the cause, not the effect.
Todd Schlosser: Right, not the effect, absolutely.
Suken Shah: Now, in other parts of the operating room, we’re going to see virtual reality, we’re going to see robotics and navigation take on much better roles than the infancy that they’re in right now and this is all getting to a point where we limit variability and do complicated surgery more safely.
Todd Schlosser: So, being that surgery is getting so much safer with the advent of technologies like intraoperative neuromonitoring, is it also allowing people who were told that nothing could be done to help them before, is allowing them to have an option?
Suken Shah: Yeah. Not that that was common, but it was an approach that would still keep the patient safe, because when we take the Hippocratic Oath, we want to do no harm. Now, sometimes when we’re approaching a very complicated deformity, we may harm somebody. Now, I think we feel more secure and safer in approaching those complicated surgeries. Where there was no option before, now we have options and now we can assure the patient and their family that their outcome will be quite good.
Todd Schlosser: Excellent. So, are there any projects that you are working on that you’re passionate about?
Suken Shah: Well, we’re at a large academic center and we train lots of residents and fellows to take on the torch after us and we have a very large active tradition of training fellows. Those are residents who have already completed their residency and taking on another year of additional training, just to treat children and children with spine problems. We spent a lot of time with them in the office, in the operating room, at conferences, teaching them every aspect of that care. And so, we are trying to give back and mentor these young people to do better than we did and carry on the tradition of this great institution. Other projects we’re involved in is providing global care, either to populations without access, either for monetary reasons or technology or talents, and I think the best way to leverage that, that has worked well for us when I go to India or when I go to China, is not just operate on a couple of children during the week and provide really good care to them, but during the course of taking care of an individual child or family, is teaching other surgeons how to do that.
Todd Schlosser: The surgeons there, I would imagine?
Suken Shah: The surgeons there. And also broadcasting that on the internet or in an auditorium where, perhaps, many hundred surgeons can learn, so it’s really leveraging our experience to help many more people than we could ever touch in a week or a month. But then also provide safe care to them afterwards. When we leave, we don’t want anything bad happening. They’ll know how to handle any issues and take care of patients again in the future. And it provides great continuity and it is also self-sustaining so that when we go back, they are showing us what they’re doing, we’re doing more quality improvement, continuous improvement and then we can leave that site and it’s going to be sustaining itself and we can move on to the next one.
Todd Schlosser: Yeah. I know you have some long-term research initiatives that you do here, specifically, that you wanted to talk about.
Suken Shah: Yes, well, we’re doing stuff here specifically, but the other way again to leverage large populations is we’re involved in some really exciting multicenter projects.
Todd Schlosser: Oh, wow, okay.
Suken Shah: So, we’re in a group with the Setting Scoliosis Straight Foundation. These are a collection of rather large volume spinal deformity centers. We pool our data, our techniques, our successes, our failures, and we’re trying to learn from that and then publish those studies in formats that other surgeons can learn from, too. So, we’re trying to set the standard for spinal care for the future.
Todd Schlosser: You mentioned this beforehand, but you’re looking not just a week out, two weeks out, three months out, you’re looking years out.
Suken Shah: Yeah, and that’s very important. We can learn a lot from the 30 to 60-day or 90-day results, but what patients and families are asking about is how is my daughter going to be in five years, 10 years, 20 years? Is she going to have an active life as an adult? And I can reliably assure them that yes, and we have the data to prove it.
Todd Schlosser: Yeah. Excellent. So, is there any reason you’ve chosen the team you have for things like intraoperative neuromonitoring?
Suken Shah: The area of intraoperative neurologic monitoring is so critical to what we do. We have to be the ones that are asking for better, that are asking for the best and, fortunately, our monitoring team has been the best in the region and now in the nation for so long. They did it by being innovative, teaching and training the best, involving people from various different disciplines in science and healthcare to be part of their team with a diverse background, but then also collaborating with surgeons who were doing high-end innovative work and each building together to get to that peak. How can you do better surgery? How can we do better monitoring. And they pushed the field. They educate people. They talk at courses. They publish their work and many of that work that’s been published in prestigious journals was done in collaborations with surgeons.
Todd Schlosser: When you do talk to people who are looking at entering the field that you entered, what is some advice that you like to give them?
Suken Shah: Well, I’m optimistic about medicine and I’ve been blessed with a great career. I love coming to work every day and I think that the folks who think that medicine is being sort of taken over by corporations and all that? I mean, that’s just a natural evolution. This is a large field. There’s a lot of dollars invested. It’s constantly changing with regard to technology and big data, but I think the future is pretty exciting. So, I would encourage young people to go into this career and I think that the intersection of technology and innovation with the human side of providing care to a patient is always going to be at the central part of that and I think it’s a great collaboration.
Todd Schlosser: Excellent. Well, thank you so much. Dr. Suken Shah, thank you so much for joining us here on Scrubbing In. We really appreciate your time this morning.
Suken Shah: Thank you.