The old cliché says that engineering types are not gregarious people, but Dr. Alan Hilibrand, a spine specialist at The Rothman Institute at Thomas Jefferson University in Philadelphia, certainly doesn’t fit that mold.
“My early years were spent in southern New Jersey, where I heard stories of my dad’s work as an electrical engineer and tales of my mom’s days as a pharmacist. I was always interested in how the human body works.”
While homemade engineering projects such as making toilet paper roll telescopes won’t throw open the doors to MIT, having superb grades and talent will. “I entered the MIT undergraduate program in 1982 and decided to major in biology. Since MIT focused on engineering, my course load was heavy on math and science. I think this gave me a deeper appreciation for the role of engineering in orthopedics.”
Orthopedic Training
Entering Yale School of Medicine in 1986, Alan Hilibrand became class president and got a bird’s eye view of different specialties…but he didn’t need to look far.
I was very impressed by the enthusiasm displayed by the orthopedists at Yale. It is one thing to say, ‘Pursuing XYZ field makes sense to me, ’ and another to say, ‘These are the kind of people I want to spend my time with.’ I was sold on orthopedics.
Then, being considerate and a bit gallant, he followed the ambitions of his future wife. “She was applying to law schools, so I applied for residency programs in areas that had top notch law programs. Although I initially applied to The University of Michigan because of their great law school, I ended up loving the residency program and went on to match there in orthopedics. At Michigan there was a strong focus on residency education and on faculty taking individual responsibility for residents. They really emphasized training residents rather than having them just be of service to the attendings. One of the nice things was that there were no fellows—meaning that residents covered all of the operations.”
While at Michigan Dr. Hilibrand’s mentor helped him find the calm in the middle of the residency storm. “Dr. Robert Hensinger, who was President of AAOS during that time, was a very influential person during that phase of my training. He always had an interest in talking with residents about issues that we faced as doctors, and also had a good sense of where orthopedics was headed. I had my mind set on academic orthopedics and Dr. Hensinger was able to provide me with a lot of support as I started out. He remains a mentor to this day.”
Also leading Dr. Hilibrand through the training vortex was that master of spine, Dr. Henry Bohlman. “I did my fellowship at Case Western, where my ‘apprenticeship’ under Dr. Bohlman greatly expanded my understanding of spinal and neuroanatomy. He taught his fellows in a way that enabled them to work with new technologies and procedures that they had never performed during their training. As a result, they obtained detailed, ‘hands-on’ knowledge of spinal anatomy and physiology. After my year with Dr. Bohlman and his partners at Case Western, I felt that I could work my way around the spine with complete ease.”
Dr. Hilibrand then headed for a southern nerve center of spine.
I joined the faculty at Vanderbilt University in 1996 under the guidance of the Chair, Dr. Dan Spangler. Dan was the perfect person to help a junior partner, as he took a lot of time to provide me with academic and emotional support for all the things we go through when starting a spine practice. Spine is higher risk than a lot of things in orthopedics, and those starting out need to be supported.
Although Dr. Hilibrand found a comfortable home and good friends in the orthopedic surgery department at Vanderbilt, he found that it wasn’t long before the Medical Center administration began to tighten its control while failing to meet its commitments to the department. “In the fall of 1998 I left Vanderbilt and returned to the familiar landscape of Philadelphia. The two spine surgeons I knew, Drs. Alex Vaccaro and Todd Albert, both of the Rothman Institute, were so productive academically that I thought, ‘These are the kind of people I want to work with.’ It was clear to me that they were the group for spine in Philadelphia, and I had confidence in Dr. Richard Rothman that no matter what changes came along in medicine, he and his practice would always end up on top. And I have never been disappointed.”
Pioneering Studies and Research
Dr. Hilibrand soon delved into a major national research project…and became known for being the third highest enroller of patients. “I was fortunate to find myself working on the Spine Patient Outcome Research Trial (S.P.O.R.T.) study, an effort undertaken at 13 institutions around the U.S. to examine the top three back conditions that lead to surgery. This solid clinical research, done in a prospective manner, stands as an important contemporary example of comparative effectiveness research. The enrollment process was interesting, although not perfect. While it was clear to all of the investigators that we wanted people to randomize, we were willing to take people who wanted to choose their own treatment. The goal, however, was to have them allow us to randomize them.”
He continues, “One weakness of the S.P.O.R.T. study was that although people were randomized they had the opportunity to cross into the other group. If, for example, someone was in the nonsurgical group and did not improve, you could not deny them surgery. We would say to participants, ‘We’d like you to allow us to assign you to a group. In the end, if you are assigned to nonsurgical treatment and you do not improve, we will never deny you the opportunity to ‘cross over’ into the surgical group and have an operation if necessary.’”
Elaborating on the value of the seven year study, Dr. Hilibrand notes, “The S.P.O.R.T. study provides solid evidence of the very significant benefit of surgery in terms of patients’ improvement in physical function, reduction in pain and reduction in disability when compared with continued nonoperative treatment. Perhaps more important in this era of healthcare reform, we have now been able to show the cost effectiveness of these surgical treatments. For example, using the outcomes from S.P.O.R.T., we have been able to measure the value of the patient’s improvement in their quality of life and assign a dollar value to that. Many of the treatments have a quality-adjusted life year (QALY) cost of $50, 000 or less at the four year follow-up. This means that surgical management of a herniated disc or spinal stenosis has at least as much value as the medical management of cardiac disease.”
Dr. Hilibrand adds, “Overall, one of the most fascinating things about the S.P.O.R.T. study is not only all of the data available to be ‘mined, ’ but the infrastructure that was put in place at Dartmouth by Dr. James Weinstein, the Principal Investigator of S.P.O.R.T. As a result, this data continues to be collected. We plan to take it out to 10 years.”
In his other research, Dr. Hilibrand investigated whether solving one spine problem creates another. “As a resident, I loved the concept of using survivorship analysis to assess the durability of hip and knee implants. Back in the ‘90s people were beginning to do these analyses, but no one had applied the concept to spine. In 1995 I began to examine the durability of cervical spine surgery by reviewing the long-term outcomes of hundreds of Dr. Bohlman’s patients. I created a database of all his cervical spine operations from 1973 to 1992 and then went through all of his patient charts and looked at people who had operations and whether they developed problems in adjacent levels after fusion.
We found that the operations were ’durable;’ however, a small but consistent number of patients, approximately 3% per year, developed symptoms related to degeneration at adjacent levels. I published a paper on this topic in 1999, and for the first two or three years afterwards it was rather well hidden in the Journal of Bone and Joint Surgery. Then, when surgeons began studying the potential of lumbar and cervical disc arthroplasty, the subject became more popular, and I learned that a lot of people were dusting off my article.
“Regarding my biomechanical work, ” adds Dr. Hilibrand, “my team and I looked at the entire cervical spine, including the upper cervical spine, to consider the mechanics of fusion and changes in motion in the cervical spine. Surprisingly, our team determined that the motion eliminated at a fused level is not transferred to the adjacent levels. Rather, it is transferred to the upper cervical spine and the base of the skull. I also designed a study where we measured the range of motion of all patients who had cervical spine fusions. We were fortunate to collaborate with Dr. Sorin Siegler at Drexel University’s biomechanics lab, who had developed a very sophisticated testing apparatus that could be used to evaluate motion without constraints. We found that patients’ motion was greater after surgery than before the fusion, something that went against conventional wisdom.”
Advice for Life and Medicine
No matter what topic of research you select, says Dr. Hilibrand, think outside the lab.
Unfortunately some young doctors who want to do research tend to look around for an attending who is doing interesting work. Their starting point should instead be, ‘What in orthopedic surgery interests me?’ and then come up with their own hypotheses and ways of testing them. That is how you think outside the box…and that is how orthopedic advances occur.
A member of the AAOS Leadership Fellows Program in 2005-06, Dr. Hilibrand furthered his involvement with the organization by taking up the post of Vice Chair of the Communications Cabinet in 2006. The following year, Dr. Hilibrand was chosen as one of five orthopedic surgeons to represent the United States and the American Orthopaedic Association as an ABC traveling fellow. “It was a tremendous opportunity to meet orthopedists around the world and learn about the practice of spinal surgery under different healthcare systems. Those six weeks traveling literally around the globe truly was a transformative experience.”
Although he limits his practice to orthopedic spine surgery, Dr. Hilibrand also believes that all orthopedists must be united to have a stronger voice. “People have a great deal of loyalty to their subspecialties, and in spine there are orthopedic surgeons, neurosurgeons, etc. In the end, however, our focus of advocacy—our voice—should be through AAOS.”
And when he slows down? He speeds up. “For nearly 20 years I have been happily married to my wife, an attorney, with whom I share two wonderful children. My avocation to which I have committed a great deal of personal time for the past 25 years is middle to long-distance running (races and marathons) which, during my academic travels, provides a great opportunity to see the sights in cities around the world and stay physically fit at the same time.”
Dr. Alan Hilibrand…with whom excellence is academic.
