If a patient wants to discuss Oscar Wilde or deliberate about Roman sculpture, Dr. James H. Lubowitz, founder of the Taos Orthopaedic Institute in New Mexico, is up to the challenge. But this native of suburban Philadelphia could never have run from a medical career…his family history wouldn’t let him. Dr. Lubowitz laughs, “You know the old joke—the Jewish parents say to the son, ‘So, what do you want to be? A doctor or a lawyer?’ My medical path was also influenced by the fact that my grandfather was the first orthodontist in Philadelphia and my father was an ophthalmologist. Their first goal for me was that I attend a top college; fortunately I had a high aptitude for academics and a disciplined personality.”
A twist of fate (and of a lower extremity) would help lead James Lubowitz to orthopedics. “As a result of my time on the soccer field in high school, I had a minor ankle fracture, and went to see an orthopedist who worked with the Philadelphia 76ers. This led to a fascination with sports medicine that I carried into my undergraduate days at Harvard. I continued playing sports, including squash, knowing that medical school was in my future. Because of this, I chose to take a minimum of premed courses so that I could round out my studies with things such as English literature and art history. Throughout the years I have found that such knowledge helps me communicate with my patients in a more thorough manner. It has also made me a better writer and editor in that I can think critically in a different way from a pure scientist.”
But time spent meditating on Mycenaens meant less time for polymers. “When I arrived at the University of Pennsylvania for medical school, I was surprised how much catching up I had to do. Having been an art history major, unlike my new classmates, I didn’t have the benefit of having taken anatomy, biochemistry, histology, etc. And it was shocking to find that after class we’d have to do clinic time, followed by an evening of reading and studying. Despite the rigors of the program, I enjoyed it, in part because ‘Penn’ was one of the first schools to diversify in terms of gender and race.”
To a large extent, weather would make the decision as to which residency program Dr. Lubowitz would attend. “I did my interviews in January, visiting the Mayo Clinic and Hospital for Special Surgery, both of which were blanketed in snow. When I stepped off the plane for my interview at U.C.L.A., however, it was 72 degrees and sunny. Then, after running into a friend from college, something just clicked. My transition was smooth and I felt well prepared.”
Although the weather was easy on Dr. Lubowitz, his coursework was rigorously: “The training at U.C.L.A. was tough, with long hours and high expectations. I worked with an orthopedic oncologist named Dr. Jeff Eckhardt, an incredibly thorough physician who never missed anything. He always dictated progress notes in front of the patients, thus allowing him to review things one more time with them. I saw how impressed the patients were and have, when possible, done this myself. In the joint replacement arena I learned from Dr. Burt Thomas, an extraordinarily nice guy who achieved excellent outcomes, never rushed his teaching, and checked everything in the OR twice. Spine guru Dr. Rick Delamarter was just starting out when I was in my residency, and taught me the value of being incredibly organized and efficient. While spine was not my primary area of interest, I was still able to learn the fundamentals from him.”
To refine and pull together all that he had learned, Dr. Lubowitz returned to his home turf of Philadelphia. “My choice for a fellowship was The Rothman Institute, which was at that point affiliated with the Pennsylvania Institute. I spent time with the renowned Dr. Arthur Bartolozzi, who has this magical allure that makes patients fall in love with him. They are willing to patiently wait to see him, even if it means having to spend extra time in the waiting room. Dr. Mike Ciccotti, a physician who had just started his practice, was a great role model for how to make the transition from fellowship to practice. The most important thing he conveyed about this was achieving a balance between teaching, research, patient care, and family. Dr. Larry Miller, now Chief at Cooper University Hospital across the river in New Jersey, was a sublime technician who measured his surgeries in millimeters, while Dr. David Rubenstein, who remains at Lankenau Hospital, was the height of efficiency.”
“It was a very hands on, high volume experience with great training in knee and shoulder arthroscopy and open sports surgeries, ” adds Dr. Lubowitz. “Perhaps the most important thing I walked away with was the concept of subspecialization. Their focus on knee and shoulder, accompanied by a meticulous approach to surgical techniques, led me to see that subspecialization was indeed the wave of the future.”
Leaving fellowship, the last official step in the metamorphosis of becoming a fully trained orthopedist, can be jarring to say the least. Dr. Lubowitz: “In the months leading to practicing on my own, I focused on developing autonomy and confidence in diagnosis and surgical treatments. You are also expected to display a higher level of professionalism, in part regarding how you communicate with patients. Being involved in medical training is such a long process that you essentially have a prolonged latency or childhood compared to other professions. You’re not ultimately responsible for patients for quite awhile, but this ultimate lack of accountability evaporates after fellowship.”
Getting used to this level of responsibility, says Dr. Lubowitz, is not something one accomplishes by reading a textbook. “The higher level of stress that comes with your new role is not something that is easy to prepare for. You must experience it yourself; no one can really explain it. There are tools, however, that can alleviate some of the anxiety, including positivity, something that can be helpful, for example, when you get frustrated with other personnel. Conflict is not in the best interest of the patient so we must learn to keep our emotions in check and find a way through the issues. Years ago surgeons would scream and even throw things when they were upset, behaviors that are no longer tolerated.”
If there was going to be any screaming, Dr. Lubowitz thought, the only appropriate place would be on a double-black diamond trail. “When I began looking for jobs I focused on places that had a mountain ski resort, and where I could be clinically productive and academically involved with fellows. I was interested in a ski resort for professional, athletic, and social reasons, and because I was tired of pollution and traffic. I also had the impression that a lot of orthopedic surgeons worked hard for 50 weeks a year so they could ski one week a year and go to the beach one week a year, so I figured, ‘Why not live in a ski area?’ Besides, I knew that because Western mountain resort areas have such active populations, they were a proven model for orthopedic sports medicine as far as staying clinically busy. Being academically productive was not difficult either because there tends to be a lot of sports medicine training programs in these areas.”
So in 1994 Dr. James Lubowitz found his way to Taos, New Mexico where he would display a bit of moxy in unveiling his future plans. “It was a small town with a hospital that was old and even crumbling in some parts. They were just opening a new hospital with the idea that their marquis service would be orthopedic sports medicine. I answered their ad in the Journal of Bone and Joint Surgery and the hospital helped me get started in private practice. Boldly proclaiming my 1500 square feet entity, ‘The Taos Orthopaedic Institute, ’ I in fact was running a three person show…me, someone who answered the phone, and an X-ray technician. Fifteen years later we are living up to the name, with three attending surgeons, two fellows (three beginning in August), four satellite clinics (in Santa Fe, Los Alamos, Raton, and Las Vegas, New Mexico), and a total of 25 employees.”
“We’re beyond rural, ” someone once said to Dr. Lubowitz of his outlying clinics. “We’re remote!” Dr. Lubowitz: “Our goal is to have only one standard of care, no matter where the patient is being treated. I want to provide the same quality of outcome, clinical attention, ambiance, and service that someone receives on Park Avenue. We manage to do this despite being at a smaller hospital where we are sometimes required to transport level one trauma patients to centers in Albuquerque or Denver by air. Working with people in rural areas is a unique experience—especially in the West where people drive long distances to see a doctor (sometimes four hours), but don’t seem to mind. And this is not only for surgery, but for things such as getting stitches removed, as well as follow up appointments.”
“Also unique about practicing in rural areas is being exposed to some unusual ways of making a living. We treat ski instructors, fishing guides, golf pros, ranchers, and bullriders, among others. Instead of the prototypical older person who does gardening in the city or suburbs, we have someone who might tend to an apple orchard containing hundreds of acres.”
Dr. Lubowitz may look at averages, but his research is anything but. “In 2008 my colleagues and I were honored with an award by the American Journal of Sports Medicine for our research involving a meta analysis on outcomes of single bundle versus double bundle ACL reconstructions. Historically, the general recommendation has been a one bundle procedure, but anatomically there are two bundles. Many thought leaders, including the visionary Dr. Freddie Fu, advised that double bundle procedures be investigated further. In our research we found that the clinical outcomes of each procedure are equal; however, it may be that we need improved ways of measuring outcomes. We have this impression because although both procedures seem to stabilize the knee anteriorly and posteriorly, there is also a rotational component involved. At the present time, though, we have no tools to quantify rotation. There is a pivot-shift examination, but it is subjective and particularly hard to do on someone while he or she is awake.”
“In 2008, ” continues Dr. Lubowitz, “we also received the award for the best innovation in arthroscopy from the European Society of Sports Medicine, Knee Surgery and Arthroscopy. Using methods previously found in economics, namely decision analysis, we asked the question, ‘Should patients over 40 have surgical or nonsurgical treatment for an ACL tear?’ Interviewing hypothetical patients, the norm for decision analysis, we found that those individuals over the age of 40 would prefer the surgical option. This, the research revealed, was because they were willing to assume the risks associated with surgery, but unwilling to accept that their knee might buckle on them when engaging in pivoting activities. This work was also awarded the Richard O’Connor Prize by the Arthroscopy Association of North America.”
As always in research, there are limitations and modifications that could be made to improve future investigations. Dr. Lubowitz acknowledges, “One of the issues with the research was that the people in the Taos area would likely have different activity levels than those living in downtown Manhattan. Then there is the issue of the hypothetical patients. This approach was undertaken because we were looking for patients who had not torn their ACLs, been to a doctor and been biased. But what using hypothetical patients means is that these individuals may find it easier to say, ‘I choose surgery’ because they know it’s not reality.”
Dr. Lubowitz continues, “In the future, I would like to do a study involving patients who may have torn their ACLs and get them to complete a survey before they talk to a healthcare provider. I did attempt something like this already, having fellows go to a ski resort clinic on the slope and ask the nurses to distribute the surveys. Patients were asked to complete them during the few minutes while they were waiting to see a physician. It was a failure, however, because patients got upset at the thought that they might need surgery…and had not even seen a doctor yet. We also listed all of the possible risks involved in surgery, including loss of life. That was also alarming to the patients. I will try again next year and plan to take a more hands on approach and spend a lot of time explaining the benefits of the research to the clinic staff.”
Of his current research, Dr. Lubowitz notes, “The project I am most excited about now is my work comparing standard single bundle ACL reconstruction to a modified technique that is slightly less invasive. Known as the all-inside technique, this method was pioneered in the ‘90s by Dr. Craig Morgan. The way he was doing it, however, was technically challenging and so his fellows didn’t use it. In 2006 I described the transtibial all-inside technique in Arthroscopy: The Journal of Arthroscopic & Related Surgery, in which we use allograft and only need three ‘portals.’ Our hypothesis is that this technique will result in less pain and faster recovery times with equal long term outcomes.”
Having spent years involved in journal work, Dr. Lubowitz has had ample late nights to think about the process and implications of good—and bad—research. “I started out as a reviewer, keeping in mind the words of Dr. Thomas Byrd, a pioneer in hip arthoscopy, who wrote that the best way to become a good scientific researcher and writer is to be a reviewer. I then moved on to Associate Editor and am now Assistant Editor of Arthroscopy. What we are learning as a field is that most medical literature is of a low level of evidence, with most surgical literature being a level 4. This particular level, a case series study, is flawed because there is no control group. How, then, do we know that the treatment we’re studying is superior to any other treatment, or for that matter, to no treatment at all? This topic is timely because one of the first federal laws that was proposed by our new President and approved by Congress was to spend over a billion dollars for comparative effectiveness research.”
He continues, “Some in the medical community fear that this may result in evidence-based treatment algorithms that will advise doctors as to the best way to treat patients. We need to keep in mind that research trials conducted on large numbers of patients create broad averages and result in treatment algorithms that don’t take into account the individual patient. Each person brings to the table a different race and gender, as well as activity level, medical comorbidities, social, economic, and cultural differences. We as physicians need to lead and not be led or misled. Even randomized trials that are well conducted may draw the wrong conclusions. Today, the government says that such results would not be used to determine how to treat patients; a concern is that, over time, this could change.”
With such a strenuous schedule, and weighty issues to manage, it’s good to have a little comfort…and a little comfort food. Dr. Lubowitz: “I am spoiled in that my significant other of 10 years, Gina, is a chef. This works out well because I exercise a lot—meaning that I can eat a lot. There was a period in which I took call every night and she worked every night. I would call her restaurant from the hospital at 10pm and order up a salad, steak and chocolate cake to go. When my call schedule lessened and I began lecturing and traveling she was still working all the time. I begged her to sell her half of the restaurant, which she eventually did. Now she just cooks for one private client—me.”
