Dr. Andy Bush's backstory

My journey into bone health was not something that I can claim that I really planned on doing and was more a reaction to the changing medical landscape. So let me start off with something easier - how I decided to go into medicine.

My path into healthcare was pretty straight-forward. I went to medical school straight out of college planning to be a family doc. However, after doing an orthopedic surgery elective in my third year of med school and seeing that the ortho operating room looked a lot like the workshop in my garage, I was smitten. I was lucky enough to get into an orthopedic residency program and embarked on my 25+ year career as an orthopedic surgeon. To say that those 25 years were like a roller-coaster ride is an understatement! Coming out of residency I had planned on practicing as a general orthopedic surgeon in a community-based practice. I believed that I would not only practice in the community but that my family and I would live in that community and be part of it, and that I would stay my entire career in that community just like many of the surgeons that I trained with and that I wanted to emulate. However, my career turned out very different. It was after I weathered a practice closure, several consulting jobs and a stint as a surgeon in the prison system and as a locum tenens, that I finally had the opportunity to start my own practice in a small town in rural North Carolina. Things went well early on and my practice grew by referral and by word-of-mouth. It seemed that all would be well.

However, things began to change. The rising costs of healthcare became a hot political topic and dramatic changes to Medicine were instituted. Multiple unfunded mandates (expensive things that the government makes you do but doesn’t reimburse you for) hit medical practices. EHR, digital x-ray and data collecting and reporting started significantly increasing the cost to practice medicine. Also insurance companies began to put up incredible hurdles for docs to be able to properly care for patients requiring incredible amounts of paperwork for “pre-authorizations”. At the same time they started to significantly decrease payments for medical services including surgeries all in the name of cost savings. (As an aside - as many of you may have noticed, insurance premiums did not go down even as reimbursements for providers were dramatically cut - please refer to your EOBs - and denials for services became common-place and perversely, insurance company profits and insurance company executive compensation skyrocketed to obscene levels - and premiums continue to rise!) These dramatic changes put a tremendous amount of financial pressure on many independent practices.

Being faced with this financial pressure a lot of practices threw in the towel and were either taken over by larger hospital systems and groups (Medical monopolies? What could possibly go wrong?) or just disappeared. My situation as a solo-practitioner in private practice was not very different but, being incredibly stubborn, I was determined to stay independent. However, to do so required that I fundamentally change my orthopedic practice. Surgery would remain part of my practice, but due to unsustainably low reimbursement for surgery it could not remain the primary service that I provided.

This is when I began to investigate some other options, one of which was providing “Bone Healthcare” services. It wouldn’t be unreasonable to assume that bone healthcare should be part of the realm of orthopedics. However, in reality, orthopedic surgeons are taught to fix fractures, not keep them from occurring - prevention was never a Grand Rounds topic. However, there are a handful of Orthopedic Surgeons who committed at least a part of their careers to bone healthcare and fracture prevention. It was after I read several articles, in particular articles written by the late Dr. Andy Bunta who was a Professor of Orthopedic Surgery at Northwestern University that the idea of bone healthcare began to develop in my mind. Dr. Bunta urged us, his orthopedic surgeon colleagues, to take leadership roles in bone healthcare, not only through fracture fixation but with fracture prevention. I realized that much of what Dr. Bunta and others were promoting was correct - bone healthcare was not really considered a serious healthcare issue and no one was taking ownership of it in the community. After consulting with my medical colleagues in town who at first seemed surprised by what I wanted to do but soon were very supportive of my decision to provide bone healthcare, I started my personal “bone health retraining” program. Being an obsessive-compulsive surgeon I started my program with a structured and rigorous approach - hours reading and studying and listening to lectures, webinars and CMEs that resulted in my practice obtaining FLS (Fracture Liaison Service) designation and Bone FIt certification. Membership in the AOA Own-the-Bone registry and completion of the ISCD densitometry training course then gave me a foundation to get my bone health program going. But, the one thing that jump-started the development of my program happened through serendipity.

As I was clearing out my email folder one morning, right before I was about to download a whole bunch of emails into the trash, one email caught my eye. It was about some kind of ultrasound machine called Echolight REMS that could help predict if patients might be susceptible to periprosthetic fractures (nasty types of fractures above or below joint replacements - see previous FB posts). Instead of throwing it in the trash I read that email and I was hooked. After a couple of email exchanges, telephone calls, and Zoom meetings, the Echolight team was in my office installing an EchoS unit to trial. The Echolight team also recommended that I call an orthopedic surgeon up in NJ who had started using Echolight REMS just several months earlier. I called that surgeon - Dr. Kimberly Zambito, and as they say, the rest was history. With the Echolight REMS and a lot of good advice from Dr. Zambito, my bone healthcare program took off and the Bone Matrix and the Echolight REMS discussion group became a reality. Although the Echolight REMS group still remains a small group of doctors, we are committed to providing quality Bone Healthcare and understand the impact that a fracture can have on someone's life. Dr. Zambito and I have both fixed thousands of fragility fractures and have seen those effects first-hand. But the other aspect with which I agree with Dr. Zambito is that it is very evident is the fact that there are a lot of folks who are scared - not only scared of fracturing but also scared because of the uncertainty that often goes along with getting the diagnosis of osteoporosis and not knowing or understanding what that really means.

Often the diagnosis of osteoporosis follows a DXA test. To give credit where credit is due, DXA had basically created the current field of Bone Health Medicine by providing a method of quantitatively measuring bone density. But DXA is an imperfect test that is prone to errors, especially when it needs to be done in a manner that allows it to be “efficient”. Due to the same poor healthcare policy decisions and insurance company greed that have affected all physicians, docs who own DXA machines are often forced to sacrifice quality for efficiency and many times the DXA scans are poorly done. Unfortunately, it is the individual who is getting the test that is the casualty of that situation, having to make significant healthcare decisions based on a test whose results may be flawed. In our bone health programs, we feel that with REMS technology, that yields both a BMD and a fragility score (measure of bone quality) we can provide an accurate, reproducible and reliable method of determining bone densitometry and quality and therefore help give our patients the reassurance that the decisions that they are making are based on correct data.