By George W. Wiley

The Southern California Orthopedic Institute is built on a foundation of respect and tolerance among its partners. That is what the partners themselves say - and in 27 years, not one of them has left the group.

From left, Jonathan S. Jaivin, MD, FACS; Stephen J. Snyder, MD; and Richard D. Ferkel, MD, of the Southern California Orthopedic Institute (SCOI), Van Nuys, Calif.

Synergy, energy, diversity, dedication - the list could go on describing the Southern California Orthopedic Institute (SCOI). Somewhere along the way, one would have to toss in a little obsession, for it has taken something like an obsession to create SCOI. After 27 years, the Institute has 27 partners, and each of them is what founding partner James M. Fox, MD, describes as "not exactly a shrinking violet." Partnership meetings can be raucous and acrimonious. But when the dust settles, everyone agrees on majority rule.

"This is a democracy," says Fox. Adds current managing partner, Jonathan S. Jaivin, MD, FACS, "There’s no question our meetings are lively, but there’s a lot of respect for seniority in our group, for those who have ‘been there and done that.’ On the other end, the older guys have a vested interest in the younger doctors as their own practices slow down."

A Featured Player

SCOI (it rhymes with "Joey") is big, one of the biggest orthopedic clinics in North America - and the largest on the West Coast. If UCLA, USC, and the Kerlan-Jobe Clinic rule on the other side of the mountains in Los Angeles proper, SCOI is the featured player in the San Fernando Valley. (Note: If the San Fernando Valley had succeeded in its bid last year to secede from Los Angeles, SCOI would have become part of the fifth largest city in the nation. That gives some idea of the domain in which SCOI has established itself.)

The mother ship in the SCOI network is the 90,000-square-foot, four-story headquarters in Van Nuys. The headquarters sits adjacent to Valley Presbyterian Hospital. SCOI is not affiliated with the hospital, but it is a convenient locale for patients who need overnight care following minor surgery, and it is one of the hospitals at which SCOI physicians perform major surgery. SCOI had its headquarters specially designed and built in 1991. It is home to a series of functionally designed enclaves providing an array of services - from an MRI suite to physical therapy to pediatrics, from vocational rehabilitation to physiatry, from pain management to arthroscopic and other ambulatory surgeries. The whole fourth floor is a surgery center. Live reptiles and a tarantula are on view behind glass to entertain children in the pediatrics waiting room. Hand surgeons, plastic surgeons, spine and pediatric specialists - SCOI physicians run the gamut. But from the beginning, the core focus has been sports medicine. "The only thing we don’t treat is orthopedic bone tumors," says Richard D. Ferkel, MD, one of SCOI’s first five partners. "We feel those cases are better left to the universities."

In addition to its mammoth headquarters, SCOI has seven satellite offices. Most are in outlying areas of the San Fernando Valley, but one is in Bakersfield, a city of 175,000 about 80 miles north of Van Nuys. The most recent satellite to be added, manned largely by Fox, is in Beverly Hills. The idea behind the satellites is to broaden SCOI’s catchment area, but it is also to extend care to patients who may not otherwise have access to the specialists SCOI provides. "In some of our communities, we have been the first to do ACL [anterior cruciate ligament] arthroscopy," says managing partner Jaivin. Jaivin, who travels to the West Hills and Valencia satellites, says he loves "the joy of the small office feel" in the satellites as opposed to the "industrial" setting of the headquarters. Ferkel, one of those who journeys to Bakersfield, adds, "People bring in their pies and their pickles - I enjoy it very much."

It would be a mistake to think of SCOI as homespun, however. That is only one of its facets. Another facet can be seen in display cases that line the halls in the headquarters building. On view are dozens of textbooks or chapters of textbooks authored by SCOI physicians. Also on view are dozens of devices and appliances invented by the same doctors, who hold hundreds of patents. The group has international impact. SCOI physicians travel the world lecturing on surgical techniques they have developed. Jaivin calls this focus on research and education "a university setting without the controls," and he says young physicians admitted into the practice are conditioned to think they should publish and lecture. "We generate more papers per year than we did out of our residency programs," says Jaivin. So pronounced is the emphasis on research that one of SCOI’s 400 employees is a medical editor who helps the doctors get materials ready to publish. Jaivin says SCOI is too businesslike for true academics, and too academic for pure business doctors. "This place isn’t for everybody," says Jaivin, "but becoming part of SCOI has surpassed my own expectation of what my career would be in orthopedics. I can practice what I’m best trained for, foot and ankle surgery, with highly skilled and available partners in the other specialties."

Hand, upper extremity surgery, and fracture care specialist Gregory J. Hanker, MD, in the OR.

The Vision

In the 1970s, Fox was one of the first sports medicine fellows ever, when he completed a fellowship at the Kerlan-Jobe Clinic in Los Angeles. Fox, the son of a physician, says he has known since third grade that he would become a physician. A year after his fellowship, Fox spent 2 years in the Air Force as a surgeon at Kessler Air Force Base in Mississippi. He was one of four fellowship-trained orthopedists on the base. He says the experience changed his vision of how orthopedics should be practiced.

According to Fox, "Back then, everybody was trained to do everything. At Kerlan-Jobe everybody had done everything. But in the Air Force I was grouped with subspecialists. I thought what a phenomenal situation for the patient and what a security blanket - why should I do a hand surgery, for instance, that I might do once every 6 months, when down the hall was a guy who did it twice last week. I realized this was the way I wanted to practice in my professional life. I wanted to surround myself with talent that could supplement my abilities." By 1976, Fox, a knee specialist, was back in Van Nuys laying the groundwork for SCOI. In the service he had been given access to an arthroscope - and he was captivated by the device and determined to learn how to use it. Fox’s father had been a medical professor and an expert on infectious diseases. Fox wanted the same sort of intellectual rigor he had observed as a child to characterize SCOI.

SCOI Fellowships

Within a year of its founding, SCOI had its first fellow. For several years, it offered only one fellowship. Now it offers five fellowships per year in sports medicine. Two other hand surgery fellows it cosponsors with the University of Southern California Medical School. The fellows are selected from more than 140 applicants annually. Richard Ferkel was one of SCOI’s first fellows and one of only three SCOI fellows to later join the practice. In addition to conducting his shoulder, foot, knee, and ankle sports medicine practice, Ferkel is in charge of the SCOI sports medicine fellowship program. He calls it a labor of love. "As you teach, you have to be better. Teaching makes you a better doctor. You need to have a scientific basis for what you are saying or you’re going to be challenged."

A look at Ferkel’s range of activities is one example of why the word obsessive can be applied to SCOI doctors. Ferkel does not sleep much. He says he is up every night until 1:30 am and then rises again at 5:45 am. "I’ve been doing it for years and years," he says. Ferkel needs the extra time. He has published many articles, authored a textbook on foot and ankle arthroscopy, and co-edited a text on prosthetic ligament reconstruction of the knee. He also has his own practice. He teaches at UCLA. He runs SCOI’s fellowship program, pairing the five fellows one-on-one with mentor doctors. Ferkel started an athletic training program at SCOI, and he still acts as team physician for three high schools and a community college. "Some weekends I cover three football games," he says. Between them, SCOI doctors, with the help of the fellows, provide physician coverage for 14 high schools and two community colleges. On Saturday mornings, SCOI holds a free diagnostic sports clinic with free x-rays and examinations. On Wednesdays, there is a similar free clinic for members of the student football teams.

Ferkel says working with the teams is great training for the fellows. "As a sports medicine doctor, you have to take care of athletes." For SCOI, it is a way of building a patient base also. At least it used to be. "As you’ve been in practice with these young kids, they come back to you years later with their wives and families," Ferkel says. "Now, it doesn’t affect my practice, but initially it was a practice-building exercise. I do it now because I love doing it."

The SCOI fellows also are expected to do research and write it up. This year the research projects involve follow-ups on SCOI patients who have undergone reconstructive shoulder surgery and cartilage reconstruction. "We want the fellows to become experts in the techniques that we use," Ferkel says, "and you need to have a big commitment to do what we do."

CLAS - Meet Alex

Put Stephen J. Snyder, MD, back in the Idaho farm country where he grew up and he might look right at home on a tractor. He has an easygoing, casual way of relating with people. But under the surface, Snyder is not all that easygoing. He is driven. He is a world-renowned arthroscopic shoulder surgeon. He might also be the most obsessive of SCOI’s physicians. Snyder’s obsession has been to find a way without using cadavers to teach hands-on shoulder arthroscopy - a difficult art he says it took him 10 years to learn. "The shoulder is a complex joint," he says. "You can get lost in there. It’s real tough. When it comes to anchors, knots, and sutures, there aren’t a lot of shortcuts."

Snyder joined SCOI in 1981. He was fascinated by arthroscopy after he saw Fox using the device on knee patients. "I thought, what an opportunity for the shoulder." That was in 1991. By 1994 , Snyder had done enough of what he jokingly calls "practicing on a side of beef at home." He became one of two physicians in California to do shoulder arthroscopy. He has just published a textbook on shoulder arthroscopy that he says is already a best-seller for his medical publisher.

In his quest to learn shoulder arthroscopy, Snyder had all along been readying himself to teach it. "I just love to teach," he says. He says that with only 2 days in the OR, he does not see enough patients to train students. Cadavers are expensive and they deteriorate quickly, he adds. His solution has been to pioneer the use of "dry cadaver" shoulder models and simulators.

K. Bhattacharyya, MD (left), and JoAnn Connair, co-technical director of CLAS Room (SCOI’s shoulder arthroscopy teaching laboratory), work with a virtual reality surgical simulator.

A year and a half ago, Snyder and SCOI opened a shoulder-arthroscopy teaching laboratory called CLAS. It is open to doctors, to technicians, even to manufacturer’s reps who want to learn arthroscopy in order to sell equipment. CLAS stands for Center for Learning Arthroscopic Skills. The CLAS Room is a converted library at SCOI headquarters where mock-ups and 3-D video consoles allow students to learn and practice skills in shoulder arthroscopy. Snyder convinced his partners to donate royalties from patents and publications to build CLAS. He estimates the cost so far at "under $1 million" but it is approaching that figure. The CLAS Room is one of a kind. Hundreds of students every year spend 3 days to 2 weeks studying and practicing shoulder arthroscopy. Snyder hopes soon to add simulators and models for other joints, so that more than shoulder skills can be taught. CLAS is not meant as a profit center. The cost to students is $200 per day, which does not meet the overhead, Snyder says. He solicits donations from equipment manufacturers and others to try to keep CLAS in the black.

At CLAS, students can use computers to access and interact online with other centers. From the SCOI surgical suite, they can follow live surgeries as they are performed. The feeds that go to the surgeon’s video screen go into CLAS also. Beyond that, CLAS contains several simulators that have been given affectionate names. ALEX the shoulder professor is a lifelike model that can be used with an arthroscopic scope and camera to practice surgery and suturing.

SAMMY is a virtual reality arthroscopic simulator that gives a 3-D video simulation of the shoulder environment. It teaches hand-eye coordination, triangulation, anatomy, and technique. It is complete with fluid and "blood" when a vessel is cut in error. Procedures like subacromial decompression and capsular shrinkage can be performed on SAMMY, and Snyder will soon have simulation for cuff and labral reconstruction and capsular plication too, he says.

MISTY is yet another video simulator. MISTY is used with hand tools to teach surgeons how to be efficient and precise when operating while watching a screen.

In addition to CLAS, Snyder also conducts an email chat room for arthroscopic shoulder surgery where he responds to queries and posts updates. Snyder says he would like to see other CLAS Rooms pop up around the world. "We have all the plans and dimensions of our stations, and anybody who wants them can have them for free."

As for the impact of CLAS on SCOI, Snyder says one thing it is meant is that SCOI’s sports medicine doctors "are the best trained in the world."

"I’d send my own mother to any one of them," he says.

The Next Phase

Add to CLAS SCOI’s Center for Orthopedic Surgery (COSI), which occupies the fourth floor, and its 9,000-square-foot Center for Rehabilitative Medicine (CRM); its pediatric wing; its 900-square-foot therapeutic pool; its many offices and examination rooms; and the scope of SCOI comes into focus. But for all its size, SCOI is growing. Co-founder Fox says three more doctors are on track to join the current partners.

Wilson Del Pizzo, MD, specializes in arthroscopic and reconstructive knee and shoulder surgery, as well as total joint replacement and sports medicine.

Both Fox and managing partner Jaivin are pushing SCOI hard into the age of the electronic medical record (EMR). Fox already attends his patients with a small touch-screen laptop in hand. He says SCOI has a mainframe computer linked to its own servers and its own "intranet" of hard-wired transmission lines to all of its satellites.

Jaivin says one reason he ran for his 2-year term as managing partner was his desire to "adequately use the modern technology that’s out there to increase our efficiency and improve patient care." He says SCOI is considering digitizing its x-ray units. Like Fox, he would like to see a laptop EMR environment develop, although for now, he adds, all electronic records will be backed up by paper charts for legal purposes if no other.

Both Jaivin and Fox say it has been a feat to keep SCOI intact all these years given the strong personalities of physician and surgeon partners. Fox particularly seems to have a pedal-to-the-metal attitude when it comes to growth. "I’m surprised we’re not bigger," he says. "I would love to see us join together with other groups so we could learn from one another. I think there are a lot of benefits to sharing resources and economies of scale." The research done at SCOI could not have been done without a patient base to support it, he notes. Nor could SCOI have added the ancillary services it has. "I would hope we would grow and reach out and improve care."

George W. Wiley is a contributing writer for Orthopedic Technology Review.