The Ortho Show Podscript: An Interview with Don Buford on Orthobiologics

The Ortho Show

Interview with Don Buford, MD

Dr. Sigman: Hello world. Dr. Scott Sigman, your favorite opioid-sparing orthopedic surgeon back here for another episode of The Ortho Show podcast. We’re excited to roll back into orthopedics at this point post-pandemic. We have an awesome guest, an iconic leader in orthopedic surgery and orthobiologics, Dr. Don Buford. We’re thrilled to have him. Don is a sports medicine orthopedic surgeon, founder of the director of the Texas Orthobiologic Institute as well as a director of Orthotalk where he’s one of the leading educators on ultrasound news and orthopedics. It’s a real pleasure to have you on down. It can’t thank you enough.

Dr. Don Buford: Well, thank you for the invitation. I’m happy to be here. I’m looking forward to it.

Dr. Sigman: Yes, it’s my pleasure. So, before we roll it orthopedics, I want to talk about a little bit of our shared history. What year were you born?

Dr. Buford: I was born in 66.

Dr. Sigman: So, I was born in 64 and I think your father got traded to the Orioles probably in 67 if I’m not mistaken.

Dr. Buford: I think I think that’s right, yes.

Dr. Sigman: Yes, so bottom line is that you and I grew up together in Baltimore for most of our lives which is really pretty cool. I know that Terry Blair who was Paul Blair’s son was a good friend of mine went to high school with me. One of Jim Palmer’s daughters was running around in our circles. You and I never really got to meet but I have such fond memories of those days for the Baltimore Orioles when just to let everybody know Don’s father’s Don Buford Sr. who was one of the iconic Baltimore Orioles baseball players in the dynasty era of the Baltimore Orioles when we were growing up. And so, names like Frank Robinson, they’re probably your uncle’s, right? Like Brooks Robinson and Boog Powell. I mean Boog, what a great guy. And you know were hanging out and you got to spend time with those guys in the locker room and all that, how cool was that?

Dr. Buford: Oh, yes. Those are my earliest memories, honestly like in 70 being on the field. They used to have father-son games like once a year on the field for all the 5 to 12-year-old kids of the players. And I remember being on the field and running around and thinking I had made it.

Dr. Sigman: Yes, Memorial Stadium, I mean such amazing memories for us. We would go to all those games and then Sabatino’s for dinner and in Little Italy and all those great memories. And I guess all of your brothers play baseball too, right? You guys all went to the professional level and or no? Talk to me about that.

Dr. Buford: So, I’m the oldest. I’ve got two younger brothers. We’re all within about four years. So now the age difference doesn’t seem as great as it was, but my youngest brother Damon played for eight years in the big leagues for a bunch of different teams, including the Red Sox, including the Orioles, including Texas Rangers. My middle brother Darryl who’s the smartest one in the family became an attorney and became a sports agent.

Dr. Sigman: Awesome. That’s awesome.

Dr. Buford: – He picked a profession, yes. He doesn’t age out of his profession.

Dr. Sigman: That’s exactly right.

Dr. Buford: So, he’s an attorney back in LA. Yes.

Dr. Sigman: That’s awesome. And then you spent some time at Stanford and USC playing ball too, right?

Dr. Buford: I did. After high school, I went to Stanford for two years and had a chance to play under a great coach back then, Mark Marquess and Dean Staats. And just the luck of the draw was a year behind a fantastic, All-American middle infield where I wasn’t about to break in until those guys were graduated and gone. So, after my sophomore year, I did something that was rarely done at the time, which was I went to both athletic directors and got a release to transfer where I wouldn’t lose a year of eligibility because I transferred within Division 1. So, I transferred from Stanford down to USC which my parents somehow, I convinced them to do that and transferred back to USC and finished my last two years and played under another two great coaches, coach Rod Dado and Coach Mike Gillespie.

Dr. Sigman: That’s awesome. So, what a great couple of good schools there you got going on there Don. You did pretty good for yourself too. So, let’s move into orthopedics here a little bit now. So, one of the things that I find pretty amazing about you is that you have a complex named after you, the Buford Complex. I mean I think of people that get things named after, they’re either dead or they’re really old. I mean you got to tell us about the story because I think it’s really cool.

Dr. Buford: So, I know some of the listeners have heard it before, but I went to high school in Southern California, North Hollywood. And as a senior at this private high school, we had the opportunity to do kind of extracurricular work if we had kept up with our class work. So basically, I had enough credits to graduate high school. So, I was granted the opportunity to spend afternoons off campus three days a week. And there were parents of students who had their names on a list where you could pick from these opportunities. And a lot of them were music business, movie business because these were the parents of the students in this North Hollywood school. And farther down on the list were the attorneys and the sports medicine docs and I wanted to be a doc from that early age. And I found a sports medicine guy who was Jim Fox who was one of the founders of SCOI and when I showed up at the doorstep day one, he did what all good senior orthopedic practice people do is he found his junior partner and said, “I forgot I signed up for this. Here’s Don Buford. He’s a senior in high school and he’s going to hang out with you for six months.” And the junior partner was Steve Schneider. So, I met Steve at 17 years old. And this is back when they had the carousels and I made a sound slide carousel about the shoulder. And over the course of time developed a relationship such that when I first saw that anatomy called the Buford Complex now, I was just a curious kid in the operating room and said “Hey, what’s that? I haven’t seen that before.” And he said, “I don’t know, why don’t you look it up?” And so, I looked at videotapes from the SCOI docs, which was their early genius was recording everything they did arthroscopically. And so I was able to come up with some stats and some data and we tried to correlate it as you know with some pathology or not and he in his dry sense of humor named it that because I didn’t have anything to do with that part of it. But and then in true fellowship fashion, one of the fellows wrote it up and submitted it and we all got our names on it.

Dr. Sigman: That’s unbelievable. I mean for everybody that’s out there listening, Steve Schneider is one of the few guys that I still call Dr. Schneider. I mean, he’s just one of these guys that has really revolutionized arthroscopic shoulder surgery and all the things that we do that. That is just an awesome story from beginning to end. Then you were SCOI fellow, right? Then you went back, and you completed the circle.

Dr. Buford: Yes, they scared me because I interviewed for the fellowship and Dr. Furcal was the fellowship director and he was sitting there with me in the interview and said, “Well, what other places have you applied?” And I’d already had– at this point I already had maybe almost a decade of hanging out with them. And so I was kind of hanging my hat here guys, you guys are four blocks from my house.

Dr. Sigman: Don’t make me go, I want to stay here.

Dr. Buford: Yes, don’t make me go. I don’t want to go across town. The traffic’s terrible. So, I did the fellowship and it’s funny, we’ll get into it. But Dr. Schneider’s also really one of the first regenerative medicine orthopedic docs at least around the shoulder.

Dr. Sigman: So, one of the reasons that you’re my go-to guy Donnie iswe’re both on LinkedIn a lot. We have a lot of similar friends across the industry. And in this day and age with regenerative medicine, it’s the Wild Wild West. And there’s just a lot of publications of things that are happening or statements that people are making, false claims. etc. But what I really respect about you the most is that you are an established outstanding orthopedic surgeon that clinically operates on patients and stays state-of-the-art and yet you also cross over into the orthobiologic space and you are a leader in that orthobiologic space. You understand it and you can interpret it. So, the good news is for guys like myself because then I don’t have to do any of that. I just look for your post and then when I know whatever Don is saying that’s what I’m going to do. So, how did you get there? I mean because it really is pretty cool.

Dr. Buford: It’s an interesting story. Part of it even goes back to fellowship, just being inquisitive and having a mentor who forced you to continue to ask why. Why, why, why? Why do we do it this way? How can we do it better? And I should spend about 12 years now since that first little project I did using PRP or platelet-rich plasma for partial thickness cuffs. And the thought behind it was even at that point 15 years ago, we had pretty good anchors. We had pretty good mechanical repairs and the issue even at that point seemed to be biologic. These things take a long time to heal. We’re telling people six months back to work. Man, there’s so much room to get better there. How do we do it? And we use biologics in orthopedics and other areas with bone healing and things and isn’t there some way to help this? And so that’s where the thought process initially came from. And after some early actual failures clinically and some clinical research I just stayed on the sidelines for a while until we started to understand more and more about the nature of healing and how to enhance it. So, through the whole process, I’ve tried to stay evidence-based. But part of being in clinical practice as a surgeon is we kind of know where the defects are. We kind of know the areas where we do things that don’t have that 95% success rate. And we know the area’s now for example with degenerative meniscal tears, just to throw out a common example. Now, we know that just taking those people to surgery to do a partial meniscectomy really doesn’t give them any long-term benefit, over a PRP injection if we can get their pain under control. So, I think just knowing where there’s room to improve and using biologics if it makes sense, and we have some evidence in those areas, first, is how we push the edge of the envelope forward. Along with that there’s areas where surgery’s still required but man if we can kickstart that healing process or enhance it then we can use orthobiologics in conjunction with surgery too. So, I think having a foot in both areas helps because I can tell people. “Yes, I’ve seen that. It doesn’t do great. This may be a chance to enhance your healing.” Or, “I’ve seen that. It doesn’t do great. You may not need surgery. Let’s try this first.”

Dr. Sigman: Yes, I mean, I think your point of evidence-based is key and we’re going to come back to that at the end because I absolutely love one of your posts. You made it probably about eight or nine months ago. But I think that evidence-based is key and the problem that I have within the biologic space is that you get a lot of people that are way to the right and say, “Orthobiologics are the only thing that we should be doing. Surgery is obsolete. There should be no orthopedic surgery. It should only be injections and biologics.” And if you take a look at patients that have dislocating shoulders or hip labral tears or full thickness tear of the rotator cuff or a complete tear of the ACL, it seems to me that it would be difficult to imagine that orthobiologics alone would be able to get those things to heal. So, I think surgery is still– we’re still here. We still got a job. At least we’re hoping after the pandemic obviously, but I completely agree with you. I think the orthobiologics and the augmentation of surgery in particular I think is really where we’re many people are leading. So, we thank you for being the watchdog of LinkedIn in particular. So, talk to me. Why is the FDA so bad at being able to monitor this stuff and why can’t they police better?

Dr. Buford: Yes, the FDA, which is the regulatory body in the US that’s charged with regulating these orthobiologics is admittedly in a tough spot because you’ve got essentially no barrier to entry for these procedures. Anybody can call it anything and now we’re in a social media age where people can advertise and have these seminars and say things with very few repercussions. And so, as a federal entity the FDA does the best they can setting up guidelines and regulations. And they even have reporting mechanisms if something seems to run afoul of that, but they’re not an enforcement body and I think that’s the problem they really have. They can send out the untitled letters, the warning letters, but if somebody really needs to be stopped from doing something, they have to go to FBI or justice department or some other entity. So, when you think about even if it was just an orthopedic surgeon issue, that would still be a ton of us that they would have to regulate. Now you open that up to anybody with an MD or even worse than that, I should say worse than that, but anybody who has a medical background because you have naturopathic doctors, chiropractors, nurse practitioners, all of these people in some level can have a stake in doing these procedures. And so, the regulatory field is extremely broad. And so I think we need a few landmark enforcement decisions which have started to happen actually, actually accelerated by COVID interestingly enough, that will, I think, reign back in some of these clinicians, procedures, things like that, that are being done without really any evidence or basic science background behind them.

Dr. Sigman: Yes. I mean we got Donnie Buford on the case, man, we don’t got to worry about it. I’m like, I see these posts these people put up. The Wild Wild West, drink this potion and life’s going to be good with you’re exosomes. You’re all over it. I mean have you ever got in trouble? Is there anybody like called you out on it?

Dr. Buford: I have a wall of honor in my office, literally in my pod where I see patients where I post my cease-and-desist letters. Because you’re not in trouble if you’re telling the truth. So, if somebody saying that you can use this product to cure dementia. And I say, “No you can’t, there’s no evidence for it. You can’t do that.” And I get a cease and desist. I politely always respond and say, “It’s great to point out what I said that wasn’t factual and I will retract that part of it.” And usually, they want to go away because their interest is not in being regulatory compliant. So, I’ve had several of those letters. I think I’m up to a hundred percent where every company that sent me a cease and desist has now received a letter from the FDA saying stop.

Dr. Sigman: You got a job man. You’re going to go to work for the FDA.

Dr. Buford: Well, there’s a bunch of us. It’s not just me. But again, the barrier to entry is so low unfortunately and people can advertise so quickly and throw up a website and disappear just as fast so. So, kudos to the FDA for what they can do. They have been accelerating. It’s interesting with this pandemic. There’s been a lot of regenerative medicine advertising specifically towards pandemic illnesses like ARDS. And the FDA has been extremely rapid to respond and very aggressive in responding. And it’s been fantastic just to see them be this active in the field.

Dr. Sigman: So, you and I have some common ground in laser. I’ll tell you, we’ll roll into this story for the FDA and that I decided that I thought it would be a good idea to maybe repurpose the Laser and use it in the setting of COVID because of the really powerful anti-inflammatory effects that lasers can have at the cellular level. And so, I literally picked up the phone and called the FDA and six hours later somebody called me back and over a six-day window we got permission to use our laser in this field as a nonsignificant risk device. And so, it’s amazing to me in the setting of this COVID pandemic how the world has really changed in the regulatory process in particular. So that was a real feel-good story for us out of the FDA. So, how’s your laser doing, and I know we have some common ground there. You’ve been using laser in the biologic space too or what you been doing?

Dr. Buford: I do. I think I’ve got a hot sheet of about 10 ideas that I’m always trying to knock off for studies and using the laser in some aspect either alone or in conjunction with the orthobiologic treatments is like 4 of the 10 ideas I have whether prepping somebody or prepping an area or as a post-injection kind of longer-term treatment option. So, I’m excited about that. I’ll tell you the truth, the laser that I have right now is literally about 10 yards from me. I’ve been treating my back.

Dr. Sigman: We got a believer. We got a believer people.

Dr. Buford: So, I believe in it that strongly. And my son and my daughter know how to treat my back.

Dr. Sigman: That’s awesome.

Dr. Buford: So, I believe in it and it’s just like you said. There’s a lot of evidence behind it. It works at the cellular level. Gone are the days when a thoughtful clinician should just say no without looking at the data.

Dr. Sigman: You’re absolutely right. The basic science behind laser is actually quite strong and I’m right there with you. I think that it clearly demonstrates at the cellular level increased metabolism within the cell and increased the healing process and reducing inflammatory response. So, the idea of you know a PRP stem cell, augmented with laser to me I think would be very exciting study to sort of demonstrate perhaps, improved clinical efficacy with that. So yes, man, go with it for sure. So, let’s talk a little bit more about regenerative medicine. I mean, there’s no question the body of literature that’s out there, either pro or con, we’re getting to the point now where we’re really starting to see some literature that’s really pointing in the direction that orthobiologics is going to help and it’s going to make a difference. I think the problem is for a lot of clinicians and understanding is really how it works. I talk about orthobiologics and I say, “If you think about it, we’re doing it like you go in, you do your BMAC and you put it into the syringe and it’s like a shotgun. You got a thousand pellets in there and maybe three or four of those pellets are the thing that’s really going to make it work, but for now, this is what we have.” So, I think we really need some really good basic science to figure out what is in that BMAC that’s really making the difference. So, talk to it. Can you give us some examples of what you think and how that’s working for us?

Dr. Buford: Sure, there’s some things that are reasonably well known and well-studied, especially BMAC at this point and to a lesser extent they exist in PRP. Some of them are known very anti-inflammatory proteins or cytokines like IRAP is one, I-R-A-P. It’s an interleukin receptor antagonist protein. It’s a very well-known powerful anti-inflammatory. And that’s something that’s in very high concentration in bone marrow concentrate versus to start regular bone marrow or versus our blood or in PRP for example. There are other growth factors that have known effects in our bodies like vascular endothelial growth factor, fibroblast growth factor, a whole litany of things that we come across in residency and it’s just to get past the test at that level but it really works clinically when you see that it’s in these things that are used successfully. Another big one is Alpha2 Macroglobulin or A2M for short. There’s an entire company based around just harvesting A2M and using that as a separate clinical treatment. And we found that that exists in BMAC in a higher concentration than in just A2M alone, most of the time. So, for that example, BMAC seems to be enough to give A2M therapy to patients. And you’re right. How those work in conjunction and the interplay is not something we may ever be able know until we get quantum mechanics and quantum computing. But we can measure the clinical output and we can do that in a reasonably objective way. A lot of times there’s really two wings to this in my opinion. We have the regenerative side, which is someone’s got tendinopathy, someone’s post-surgical where we’re trying to accelerate a healing response or create one where there wasn’t one before. And then we’ve also got people that have chronic degenerative conditions like arthritic conditions. And here we’re looking more for palliative types of treatment. And so honestly, I use it much more for palliative care because my number-one patient is a patient with bilateral knee arthritis closely followed by back pain from facets or disc disease closely followed by hip arthritis or shoulder. And so those indications tend to be palliative. And then you get into the chronic tendinopathy. These were people who haven’t gotten better with other less invasive modalities and now we try an orthobiologic.

Dr. Sigman: Yes, it makes sense. I mean one of my favorite Star Trek episodes is when they come back to earth and Bones is walking through the hospital and there’s some woman on a stretcher and he’s like, “Why are you here?” And she says, “Oh I’m here for a kidney transplant.” He’s like, “Oh that’s just barbaric.” He’s like, “Take one of these.” And she takes a pill and five minutes later she’s running out of the hospital. “He gave a kidney in a pill. He gave me a kidney in a pill.” We may look back. “Oh my God, you’re really going to take that thing and stick that into somebody’s pelvis and take out the BMAC.” But you know, hopefully, we’ll be able to figure out the stuff that’s in there and be able to hone in on the science of that. But it’s there. I mean, you’re absolutely right. I think the clinical outcomes are really what we need to identify here. We see the same thing in the laser space. There’s no commercial insurance payers or CMS that has any interest in paying for laser therapy at this point. I get a sense that they have no desire to pay for anything more or new or different despite the fact that there is growing evidence that PRP for knee osteoarthritis for example can really help patients for pain relief and instead of some of the corticosteroids and viscose and the other things that are out there. So, it’s a real interesting spot. That’s something that definitely has to be studied more as we go forward. So, you keep on it, brother. You keep us informed. You keep those crazy people off the podium and make sure that we understand what’s going on. One of my favorite posts that you made, I don’t know, it was made six or eight months ago. You went through and looked at all the major orthopedic journals and I hear it all the time. “I am only going practice level one randomized control trials. That’s how I practice medicine and that’s the only way I’ll do it.” Right? So, you took a look at all the five journals, right? You put them all together. Tell us about the level of evidence that’s really being published out there right now.

Dr. Buford: Yes, so we took we took, I think it ended up being six of the most well-known orthopedic journals, JBJS, Arthroscopy Journal, Sports Medicine, basically six of the top 10 orthopedic journals as ranked by impact factor and we looked at a full year of every single clinical study in every one of those journals and we used either the author or the editor’s identification of the level of evidence which basically most journals now require us to list that and it’s reviewed. And we ran that data for all those journals for actually it would have been 13 months and what we found was that the average level of evidence in orthopedic journals was three. And that was independent of journal. So, for every journal that was the average. Every issue, that was the average. For every measurable time frame, that was the average. And so, I made the blanket statement, “The average level of evidence for Orthopedic Research right now is three.”

Dr. Sigman: How did you get some feedback on that one? How did that rollout?

Dr. Buford: Yes, I’m still getting feedback. I’ll probably get more after this.

Dr. Sigman: No cease and desist letter. That’s good.

Dr. Buford: Yes, when you think about it, doing clinical studies, it’s very hard to have an RCT. It’s great when we can get them, but it’s an incredibly difficult thing to run and manage and to have it have enough power to be relevant. Obviously so much of what we do is based on level three evidence, case-control study, or kind of a “look what I did” retrospective review compared to control.

Dr. Sigman: Yes, and that’s the reality and so especially when you’re in the innovation space as you’re trying new ideas and new things, you always get that same pushback. You need to show level one evidence before I’m going to make a change and move into something new. At the end of the day, however, most of us are using level three evidence to make clinical decisions on a daily basis. So, it’s a little bit of a conflict there, but really great stuff. Donnie, I can’t thank you enough. As I said, you’re our watchdog, you are the police officer out there in the orthobiologic space. You’re a leader as well as in ultrasound. We can’t thank you enough. And again, innovation within your orthopedic surgical space as well. So, we can’t thank you enough for being on the show today.

Dr. Buford: My pleasure. I really appreciate the invitation.

Author biographies

Dr. Don Buford founded The Texas Orthobiologics Institute as a research institute where patients can benefit from the latest evidence based orthobiologic orthopedic treatments. The most common conditions treated are arthritis pain, back pain, tendon injuries, and sports injuries.

Our Institute’s goal is to maximize our patients’ quality of life and minimize their disability from any musculoskeletal condition without surgery whenever possible. We typically perform our orthobiologic therapies in an office based procedures that takes less than an 1 hour. In some cases, we use these PRP and bone marrow concentrate/stem cell injections to assist, accelerate or augment the healing response after a surgical procedure.

Dr. Buford has been in an established orthopedic surgery practice in Dallas for over 20 years and has been voted multiple times by Dallas area physicians as one of the best orthopedic surgeons. He has been board certified by the American Board Of Orthopedic Surgery twice and is a sought after lecturer nationally and internationally on orthopedic surgery and regenerative medicine subjects.

Dr. Buford attended Stanford University for the first half of his college career. While at Stanford, he was a member of the baseball team and had a double major in economics and Human Biology. He then transferred to USC where he continued to play baseball and study economics and the pre-med curriculum.

In 1988 he received the Woody Hayes NCAA Division I Academic All-American Award for being the single most outstanding NCAA Division I male student-athlete.

After graduation from USC, he signed his first professional baseball contract with the Baltimore Orioles and also enrolled at UCLA Medical School.

Dr. Buford played professional baseball as a second baseman and outfielder in the Baltimore Orioles professional organization for 4 years. Dr. Buford’s father, Don Sr., played for the Chicago White Sox ('63 -'68) and the Baltimore Orioles ('68-'72) and played in 3 World Series, winning in 1970 over the Cincinnati Reds. Don Sr. is in the Orioles Hall of Fame. Dr. Buford’s younger brother, Damon, had an 8 year major league career which included 2 years as the starting center fielder for the Texas Rangers.

After graduating from the UCLA School of Medicine, Dr. Buford completed a 5 year orthopaedic surgery residency at the University of Texas, Southwestern in Dallas. Dr. Buford also completed a one year sports medicine fellowship at the prestigious Southern California Orthopaedic Institute (SCOI) in 1999 where he learned advanced arthroscopy techniques.

Dr. Buford’s interest in orthobiologics was a natural outgrowth of his training in minimally invasive surgery…..both are designed to help patients in the simplest, safest way possible.

Since 2008, Dr. Buford has been training clinicians on MSK ultrasound and now orthobiologics as the Director of the MSK Ultrasound and Orthobiologics Course. The course is held twice a year in various locations. Dr. Buford and his course faculty have trained over 1600 clinicians in MSK ultrasound.

Dr. Scott A. Sigman is a board-certified orthopaedic surgeon providing comprehensive care to patients at Orthopedic Surgical Associates of Lowell since 1996. Specializing in Sports Medicine, Dr. Sigman possesses the skills and experience to diagnose and treat sports injuries and conditions affecting the knee and shoulder. In addition to his practice duties, he has served as the Team Physician for the US Ski Jump Team, and serves for the last 20 years as the Team Physician at UMASS Lowell, and is the past Chief of Orthopaedics at Lowell General Hospital.

Dr. Sigman graduated cum laude with his Bachelor’s degree in Biology from Tufts University, where he played varsity lacrosse and was President of the Alpha Epsilon Pi fraternity. He then received his medical degree as a cum laude graduate of the University of Maryland School of Medicine and member of the prestigious Alpha Omega Alpha medical honor society.

Upon graduating with his medical degree, Dr. Sigman completed his postgraduate internship in General Surgery at St. Agnes Hospital, followed by a residency in Orthopaedic Surgery at Tufts Medical Center. Dedicated to furthering his training, Dr. Sigman also completed a fellowship in Sports Medicine at the prestigious Kerlan-Jobe Orthopaedic Clinic, during which he was responsible for the orthopaedic care of the Los Angeles Lakers, Los Angeles Dodgers, LA Angels, LA Kings, Anaheim Mighty Ducks, LA Galaxy and USC football.

In addition to his extensive training and practice experience, Dr. Sigman has also contributed to numerous publications and research studies regarding advances in the field of orthopaedic surgery. He takes great pride in remaining informed of the latest state-of-the-art arthroscopic techniques for both knee and shoulder surgery. He also gives presentations and lectures and instructional courses to fellow surgeons throughout the world in new shoulder and knee surgery techniques.

In 2019, Dr. Sigman was elected as a Fellow of the Royal College of Physicians of Ireland, Faculty of Sports & Sports Medicine. This certificate is a culmination of his ongoing efforts to change the paradigm of postoperative pain management.