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Becker’s Healthcare Podcast
Dr. Tan (Dan) Chen, Assistant Professor of Orthopaedic Surgery at Geisinger
00:22:40
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- [00:00]
A
This is Carly Beem with the Becker Spine and Orthopedics Podcast. I'm thrilled to be joined today by Dr. Dan Chen. Geisinger. Dr. Chen, thank you so much for being here today.
- [00:11]
B
Thanks for having me.
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A
And so, before we dive into our questions, could you introduce yourself and tell us a bit more about your background?
- [00:18]
B
Of course. So, like I said, my name is Dan Chen. I'm a double board certified orthopedic spine surgeon at Geisinger Health. We're based primarily at Northeast Pennsylvania and Central Pennsylvania. I serve in a couple of different positions outside of just my clinical role. I'm an assistant professor and senator at the Geisinger Commonwealth School of Medicine. I also do a lot of core faculty teaching for the orthopedic residency programs both in the Northeast and Central Pennsylvania. In Danville, my clinical focus is mostly on minimally invasive techniques, outpatient surgery, and then complex spinal reconstruct. Most of my clinic deals with a lot of these degenerative and deforming pathologies of the spine, as well as a sprinkling of trauma and infections and some spine oncology here and there. In terms of my educational background, I did my undergraduate studies in neuroscience at Dartmouth College and Harvard University. I went to medical school at Michigan State University College of Human Medicine, and I completed my orthopedic surgery residency at the University of Toronto. I stayed in Toronto to complete a combined orthopedic and neurosurgical fellowship in complex spine and trauma surgery thereafter.
- [01:46]
A
Great. So it sounds like you've done a little bit of everything throughout your entire career.
- [01:51]
B
Yeah, a little bit of everything. Traveled, you know, to a lot of different places, you know, meet a lot of different people, different background. I think, you know, it's been a, it's been, it's been quite the ride, you know, but I think it's been, you know, it's eye opening, definitely.
- [02:06]
A
And, you know, when you're looking into the second half of 2025, what are some of the biggest headwinds you're anticipating?
- [02:14]
B
Yeah, so I, I kind of think of, you know, there's kind of two different categories that I see in terms of kind of the challenge, the upcoming challenges. And I kind of broke it down into, you know, the, there's like this, the individual and the surgeon challenges, like the ones that I have to deal with myself, and then also the ones that are, you know, more systemic or hospital based issues. So, you know, with the first, with the first challenge is just individually as a surgeon, you know, I've kind of one of the biggest Challenges that I see is to figure out how to continue to push the envelope in terms of developing these new minimally invasive techniques and to find you my own surgical repertoire to better help my patients. Over the past couple of years, I've. I've been a pretty heavy proponent of the mis TLIF technique. It's become a very powerful technique in my hands with pretty strong outcomes. But I think there are times when there are alternative fusion options that may actually better serve a specific patient's pathology. And so one of the biggest challenges for me in the last year or two is to develop some of these other alternatives and fine tune those skills, one of which has been to develop a more minimally invasive prone lateral spine surgery. So, you know, I think pro lateral surgery has been growing in the last couple years with, you know, growing in popularity for, you know, a whole bunch of different reasons. I think there's, you know, many benefits of prolateral surgery because it allows simultaneous access to both the posterior and anterior columns of the spine. So it allows you to do all your decompression work or screw and rod placement, as well as access the disc space in the front all in one go instead of having to reposition the patient more like so for an alif or for a traditional lateral surgery. So I think that certainly helps with operative efficiency. And then the second kind of front that I look at for my own, my own personal development is developing a orthopedic endoscopic spine practice. We've, we've been working with our local same day surgical center to try and build up this program. I think, you know, certainly there's regulatory and financial difficulties with that, but I think endoscopy, you know, endoscopy has come a long way since, since its first development many years ago. And certainly there are benefits that I can see. You know, if we can bring this program to our, our system. You know, certainly that's, that's another area that, you know, it's another treatment option that patients, patients can have versus our traditional open techniques.
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A
Could you dive into how you're tackling some of the regulatory and financial challenges both with endoscopic and anything standing in the way of prone lateral spine surgery?
- [05:13]
B
Yeah, so I think, I think for prone lateral surgery, so, so the, the. I think one of the biggest challenges is to bring in the right vendors to have the right retractors and the right implants. A lot of the prolateral work that I'm doing right now is in many ways it's kind of MacGyvered from more traditional lateral or, or posterior lumbar surgeries that I'm kind of putting together to make, to make it work. But there are companies out there that are very focused purely on pronatal surgeries. And, and so they have these like, you know, these very specific implants or very specific retractors that make this, make the technique a lot easier. But of course, one of the biggest problem with adopting that is to bring, you know, especially in a, in a cost healthcare system that's as big as Geisinger, you know, there's a lot of moving parts and, you know, there are, you know, major contracts that have to be changed in order to bring these smaller companies in. You know, then of course there's the financial aspects too. You know, how much is this going to cost? You know, what exactly is the reimbursement? What's the return on something like that? So certainly, you know, right now it's, I think it's still a bit of a MacGyver technique, but it does work. It just may not work as well as I would like it to. So certainly that's, that's a one area, you know, for development later on in the year kind of this. I would say it's about the same thing with, you know, the endoscopic side of things. You know, endoscopy is upcoming. I think there are still major issues with figuring out the CPT codes and the exact reimbursements. Some of these insurance companies is still calling it experimental. Certainly that's going to cause a lot of issues for reimbursement. And so when the healthcare administration, when they look at whether or not they're going to approve of bringing such a program into the system and they start looking at the returns on that, it, sometimes it can be very hard to justify why we should spend, you know, six, six figures to bring in these trades and these, these, these instruments and these towers when the return, the financial return doesn't really make any sense. So that's, that's, that's certainly a fight. That's an ongoing fight. I'm sure that many, many places. So we'll see, we'll see how that goes.
- [07:46]
A
Yeah. And then turning to. You mentioned some systemic headwinds as well in healthcare. How are you thinking about that in, in your work?
- [07:57]
B
Certainly, and I'm sure this is going to sound like a broken record at this point, but, you know, I think, you know, this is, I think this is an interesting time, right? We, we live in a, in a period where the, you know, the, the, the, the regulatory environment is constantly changing and evolving and, and you know, physician reimbursement, at least the relative physician reimbursements continue to drop. You know, now we have kind of these, you know, questions about what's going to happen to a lot of the, you know, the patients that have like government insurance, you know, are they going to get kicked off of it? Are they going to, you know, how many people are, are, are going to, you know, have insurance. Right. And so that's, I think for some, for a system as big as Geisinger, it certainly is going to be a, I, I foresee it as a, being a problem. You know, Geisinger overall is a rural healthcare system and we have a pretty large government payer mix. You know, and I think that's the truth. And, and so, you know, if all these patients are, you know, are they going to lose their insurance? I think it's going to cause a lot of issues in terms of staying financially viable. And so I think ultimately what is that going to translate to? Well, typically, you know, when that, when something like that happens, it often means, you know, major staffing cuts, it means cutbacks on the services that we can provide. And typically from a physician standpoint, it often means that we're expected to do more and more, but with less and less. So certainly that can be a strain on, you know, the whole system and hopefully we have some plans in store in place to, to counteract that. You know, I think, I think there's, you know, I'm all for running like a, like a lean, efficient practice. I think that's great if it's possible, but I think it's, we have, we have to be really careful to, you know, not let the, the quality of our patient care and outcomes like, suffer because of that. You know, with a limited resource, it's always this kind of careful balance between being efficient but also having good outcomes.
- [10:03]
A
Like a tightrope.
- [10:04]
B
It sounds like it is absolutely. Especially for, for a system like Geisinger. You know, I, I, I think, I think, you know, with the number of government, government insurance patients that we have in our, in our, you know, in our overall patient population here, you know, I think that's going to be a major headwind, you know, in the next six months, year, two years.
- [10:28]
A
So, yeah, and you know, you think ahead. How are you talking about these developments with your residents that you work with? How are you preparing them to face these challenges then when they go on either in private practice or with a health system like Geisinger?
- [10:48]
B
You know, that I think that is an excellent question. When I, When I was going through residency and fellowship, I. I really had no, no training on any of this stuff, like about, you know, the healthcare, like, you know, healthcare policies and the reimbursements and all that, like, all the, like the, the practical matters. I didn't get any of that stuff, and I think most people don't. But I think nowadays, you know, not only do these residents have to learn all the, all the medical and surgical education, the techniques and all that stuff, but I think it's really important that they just like the, the different, you know, the different types of practices that they can join. The, the pros and cons of each one, whether, you know, it's a, a major academic hospital, whether it's an employed model, whether it's private practice, you know, and not to say one is better than the other, but, but they all have their own pros and cons. And I think it's really just about. It's about informing them of, like, these, you know, just try to give them as much of the information as possible and kind of let, Let them make their own decisions on, on what they want to do with their life and their career, but just try to keep them as informed as possible.
- [11:58]
A
Absolutely. And then obviously, you know, we're discussing a lot of the challenges, but I also wanted to pick your brain on some, one of the most exciting areas of spine technology for you. I know you touched someone endoscopic and endoscopic and prone lateral. But like, what other areas in spine surgery make you optimistic about the next coming years?
- [12:21]
B
Yeah, so I think, I think, you know, from, from a technology and, and implant. Implant standpoint, I think spine surgery is at least in the last maybe five, ten years. I, I feel like it's a kind of undergoing a renaissance of, you know, all these, like, small and large companies. You know, they're all coming up with these new, new toys and new new devices. You know, they're all kind of experiment. They're all trying to innovate. And it kind of reminds me of, you know, maybe about 50, 60 years ago when, when, when hip and knee or when the hip and knee arthroplasty field was kind of like the same thing where, you know, everybody's coming up with their own designs for, for, you know, the ball and stem, you know, you know, and then they're all just trying to, To. To find what's the best thing. And I feel like spine is kind of in that. Kind of entering that phase now, which is really exciting for me. You Know, I, I see. I kind of see three areas of major growth for spine that I'm pro. I would say I'm the most excited about. First one we kind of talked about already is, you know, endoscopy. Endoscopy, you know, it's been around like the, the idea of endoscopic spine surgery. It's, it's been around for like, I don't know, like 40, 50 years or so. But really, I think only in the last, like maybe five to 10 years has like, the technology really grow. You know, we, nowadays we have much better visualization. We have, you know, all these new techniques. We have these new expandable implants that, that can go down the tube to help you produce, you know, not only do a decompression or a discectomy, but also do like, like an endo lift or like endo, endo endoscopic fusion. And then on top of that, you couple that with all the navigation technologies nowadays. I mean, I think endoscopy is, I'm hoping. I think it's gonna, it's here to stay. I think it's going to continue to develop. You know, right now, most people, when people think endoscopy, they think, you know, laminectomies, decompression, discectomies. But I think later on as, as the technology continues to grow, I think it's going to become the new minimally invasive lumbar fusion surgery. You know, the, the new mis telif or the new MIS lift. I think at some point, once, once the technology gets there, it's gonna, I think it's gonna grow a lot. Especially with, you know, if, if the, you know, from an insurance and reimbursement standpoint, all that stuff gets figured out, I think there's going to be much wider adoption of these techniques. So that's really exciting. For me, the second area is a cage design. So, so I'm, I'm a. I'm really. One reason or another, I'm really into talking about cages and like, like different technology involving, you know, interbody cages. And there's. Nowadays, I feel like there's been like this explosion of variability in cage design. Every company has so many different types of cages. You know, different footprints, different materials, different expansion mechanisms. And I think, I think the fact that there are so many different options available right now means that nobody really knows what, what the right answer is. And so, you know, everybody kind of, you know, it's like a renaissance. Everybody's, Everybody's experimenting, everybody's trying to see what's the best.
- [15:44]
A
Yeah, I was gonna, I was gonna just interject here real quick. So without like naming names, if you can give just kind of like an. When it comes to spine cages, can you kind of just give like a real quick 60 second overview of the most exciting change or improvement you've seen in these designs? Again, without necessarily naming company names, but just kind of overall, what's like a general trend in design that's.
- [16:13]
B
I think, one of the biggest as a, as a mis surgeon, what I've noticed is that, you know, the traditional expandable cage, it goes in and it expands only in the cranial caudal direction. So basically it gets taller and that's it. But nowadays there are more and more companies developing these, like, what we call bivector cages where it goes in, you know, it essentially goes in as small as possible and it's able to expand not only in the cranial caudal direction, but also the medial lateral direction. So the thing starts to open up, its footprint starts to like double to the point where it's almost the size of an alif. And so, you know, there, there are many, many benefits of that. So one is you get a lot, theoretically, you get lower substitance rates. You have a much bigger graph window. You know, if you have a bigger footprint, it means that you have, you're usually able to put more force on your reduction. So when you expand, you might be able to produce more lord doses or a better correction for the patient.
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A
That's fascinating. That's fascinating. And then can you dive in into the last area of spine technology that you're going to discuss?
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B
Yeah, so the last one, I think is arthroplasty, and specifically lumbar arthroplasty. I think, you know, I think cervical and lumbar arthroplasty ideas have been around for quite a while. Kind of like, kind of like endoscopy. I think at this point cervical arthroplasty is very well accepted, you know, because we already do ACDFs all the time. It's quite simple to just, you know, instead of putting in a cage, you put in a, you know, an artificial disc. That part, I think is more or less, I would say, well accepted. I think the thing that's not as well accepted nowadays is, is lumbar disc arthroplasty. And I think, you know, there are some major centers around the country that are doing them routinely. But I would say for the average spine surgeon, I don't think it's a common thing to See, and I think the evidence is not quite there yet in terms of. I think the biomechanics is not quite the same as a cervical arthroplasty. But I think for me, what's really exciting about this motion sparing technology is that nowadays there are these companies that are coming out where not only are you trying to change the disc in the front, you're also addressing the pathology in the back. So, you know, the way. The way I think about lumbar arthroplasty is kind of like, you know, if you. If you have a tricycle, right? So you got a big wheel in the front, you got two little wheels in the back. Well, if. If those wheels are starting to wear out, usually it's not just the front wheel that wears out. It's. It's the front and the ones, the little guys in the back. So when you do a disc arthroplasty, all you're doing is that you're addressing the pathology in the front without. Without addressing the stuff in the back. So nowadays there are companies that have facet replacement or facet arthroplasties where you're addressing the pathology in the back. You have other companies that are actually, you know, purely through. Through a pure posterior approach and sometimes even minimally invasive approach, you can address both the front pathology and the back pathology. So, you know, it's like. It's like changing out all three wheels of the tricycle instead of just replacing the big wheel in the front.
- [19:35]
A
A great way to put it. And my last question is just worse. Are there any other big opportunities that you're seeing that you're excited for in terms of growth?
- [19:46]
B
You know, I think outside of. I think outside of the implant. Implant space, I think, you know, artificial intelligence is certainly, you know, it's been kind of like this hot topic and, you know, everybody's kind of publishing on, you know, the benefits and pros and cons of AI. AI. You know, I think. I think the overall consensus is still up in the air about how great AI is. But I think, you know, with more and more of these studies coming out, looking at how AI can be. Can help us predict patient outcomes. I think at some point down the line, once we have enough data, once we have a strong enough system or predictive system, I think one day we may be. We may be able to use that, you know, we can input patient demographics or radiographic out, you know, radiographic numbers and have AI essentially recommend to us, like, hey, based on these things. We think that, you know, if you do, you know, A, B, and C, this patient is going to have the best outcome. You know, if we can get to that point, I think that would be. That'd be amazing.
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A
Absolutely.
- [20:55]
B
We can then standardize. We really standardize spine care because I think, you know, unlike. Unlike hip and knee arthroplasty nowadays, you know, spine care is just. There's, like, so much variability in, in, in what a spine surgeon would recommend. You know, my, My mentors have always told me, you know, if you have. If you ask 10 spine surgeons for, for an answer, you're going to get 11 answers. You're going to get 11 answers. And, and I think that says a lot, you know, like, because nobody really has. Like, I don't think there's much of a consensus right now in spine surgery, which means that. So does that mean that everybody is. Does that mean everybody's right? I don't think so. Right. It can't. That can't be right. So I think, I think at some point down the line, you know, with AI, with, with better outcomes, with better outcome measures, I think at some point it's going to become a lot more standardized, like, kind of like the hip and knee world, you know, whether or not somebody should get a hip replacement or knee replacement, I think it's going to start to eventually head in that direction, definitely.
- [22:00]
A
And hopefully you'll get there sooner than later.
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B
Maybe. Maybe. I don't know. I mean, I, I would say, you know, it took. It took hip and knees like, 40, 50 years.
- [22:12]
A
Yeah.
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B
Kind of get there. I think. I would say maybe in my, in my career. I think it's going to come, but I suspect it'll be kind of near the tail end, maybe.
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A
Yeah.
- [22:23]
B
So we'll see. We'll see. But it is exciting.
- [22:26]
A
Definitely. Definitely. Well, thank you, Dr. Chen, for joining us today. This has been a great conversation, and I look forward to connecting with you again down the line.
- [22:35]
B
Awesome. Thank you so much. I really appreciate it.