Latest / HER / A Woman Orthopedic Surgeon’s Got a Bone to Pick!

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A Woman Orthopedic Surgeon’s Got a Bone to Pick! · HER

0:07
Pam Peeke, MD: Hi, I'm Dr.
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Pam Peeke, and this is episode number, da da da, 560 of the
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Bold and Brave Her podcast.
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Now, today I'm joined by a woman orthopedic surgeon.
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Yes, they do exist.
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They do.
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Yes, of course they do.
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And, uh, we're gonna be talking about the fact that she has a bone to pick with you.
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Just a little bone, okay?
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Now,
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today we have Dr.
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Kimberly Zambito.
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Now, she's a strong believer in providing individualized
0:53
care to every single person.
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You are not taking a number.
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There you have it.
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So she earned her undergraduate and graduate degrees in exercise and
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sports science from the University of Florida, and her clinical interests
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include comprehensive hand and upper extremity care and bone health.
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She's published research in the field, um, and she successfully developed
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a comprehensive bone health program.
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Uh, and so she is all about bones.
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And, uh, here's something I love.
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She has experience in private practice, academic practice,
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and on multiple deployments.
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Hello.
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Deployments to very interesting environments with surgical teams
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in the United States Army Reserves.
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Thank you for your service.
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So these experiences, well, what can I say, give her that no-nonsense approach.
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So Kimberly, welcome to the Her podcast.
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Kimberly Zambito, MD: Thank you so much.
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Thank you for having me
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Pam Peeke, MD: Look, I stumbled upon you, uh, through a good friend of ours, um, Dr.
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Doug Lucas, um, who is Really been pushing this whole issue about can we just please
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stop forgetting about the fact that we own bones here, you know, in a big way.
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And, uh, then also the fact that you're really looking at a very special way
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of being able to scan bones and to be able to interpret them so that people
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know whether or not they're losing a lot of bone mineral density, if
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they're falling into tough categories.
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Let me ask you a question.
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You know, just as a physician, you to me, what got you
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involved in orthopedic surgery?
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Why didn't you do something else?
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I'm an internist, in case you didn't know.
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Kimberly Zambito, MD: I found in medical school the first, the first
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divergence is are you somebody who loves the OR or are you somebody
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who could give or take the OR?
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And for me, being in the operating room was, was just-- I loved it, and I couldn't
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see myself not being in an operating room.
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So that's the first, the first, uh, part of that.
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And then once, once you're in third year of medical school, as you-- if
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you recall, you're rotating through different specialties and you even
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have an opportunity to rotate through different surgical specialties.
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And for me, orthopedics was hand-hands down the top.
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I did love OB-GYN.
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Maybe a little bit.
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Maybe a little bit.
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Um, I, I loved OB-GYN too, so I loved women's health.
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The thing that I liked about OB-GYN is you're taking care of everything.
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You're-- You have to have medical knowledge, you have to have
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endocrinology knowledge, you have to have surgical knowledge.
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Um, so I loved that too.
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So I combined the fields of women's health as well as orthopedics, which
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some people thought was kind of odd, but I don't-- I didn't find it odd at all.
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Every human being has bones, and I felt that women were kinda
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getting the short end of the stick when it came to orthopedic care.
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So that's why I combined the two
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Pam Peeke, MD: What was it like going through orthopedic residency?
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I mean, were there other women just saying
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Kimberly Zambito, MD: I was fortunate enough to have a
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program that welcomed women.
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Now, I, I finished medical school 25 years ago, so now we're seeing a, a different,
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um, approach to how candidates are recruited into the residency programs.
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But I was very fortunate at the time.
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We had one woman per class, so we had a-- Yeah, the classes
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were four people per class.
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So it was, it was a nice representation.
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So I had a, uh, group of women who supported each other, and
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I'll say for the most part, the, the men were supportive as well.
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I had an excellent class of guys, um, and we all just kinda took care of each other.
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Pam Peeke, MD: Okay.
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So why not just keep chopping on people?
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Why did you decide to pivot, um, and to, you know, look a little--
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take a deeper dive into what goes on with, uh, diagnosis, um, and as
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well as treatment of bone health?
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What made you take that different turn?
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Kimberly Zambito, MD: Yeah.
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I, I still operate.
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I still love operating.
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Uh, when I was in private practice, I started adding, uh, bone
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health into the private practice.
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I didn't like the phrase, uh, fragility, uh, fracture clinic or
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fre-fragility fracture liaison, so we turned it around and, and made it into
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something more positive as bone health.
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And as orthopedic surgeons…
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Pam Peeke, MD: that, and I applaud that.
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I've never liked that fragility thing.
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You know, immediately what comes to mind is I'm just a little
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potato chip that's ready to crack.
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You know, it's like, well, wait a minute.
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That's not the way I feel.
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I feel strong.
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And, you know, according to my DEXA, I've got pretty good bones and everything.
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So, hey, um, why you do that?
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So I'm glad that you rephrased it so that it was more representative of
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a proactive and positive approach.
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You know, so kudos to you.
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Kimberly Zambito, MD: Thank you.
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Thank you.
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I, I think we need a little more positivity in this world, um, and to
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empower people to make good decisions for themselves in terms of their health.
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So, um, so I started looking into other ways.
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I had a practice partner, um, who had left the practice, who reached out to
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me and told me about a new technology.
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And so I was like, "Oh, let me dig into this and find out
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what this technology is about."
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And the technology I'm referring to is REMS, or people refer
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to it as Echolight REMS.
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Echolight is the company.
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So I started…
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Pam Peeke, MD: please tell everyone what REMS stands for?
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Kimberly Zambito, MD: Yes.
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Radiofrequency multispectrometry.
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Hold on.
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R- . Give me a second, Pam, because it's, it's a tongue twister.
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Uh, radiofrequency echographic multispectrometry.
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And so what it do- is, is an ultrasound technology which is used to evaluate
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bone mineral density, but also gives a reflection of the bone quality.
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because as we know that we're just not density-- Our bone strength is
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not just density, it's a combination of the density with the bone quality.
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And I like to take it a step further when I talk to clients and tell them,
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or even my patients who I take care of in, uh, following wrist fractures, that
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you have to consider the entire person.
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So you're more than just your T-score.
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You're more than just the report on the test.
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You're an entire human being, and we have to take that into account.
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Because as you know, there's plenty of people who have normal bone
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density who fall and break a bone, and there's plenty of people who've
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been diagnosed with osteoporosis who fall and never break a bone.
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Uh, so we-- what that tells me is that we have to look at the entire person and
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not just a DEXA report or a REMS report.
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Pam Peeke, MD: Okay.
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So when did you get wind of the fact that DEXA was probably not gonna--
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Let, let's, let's talk about DEXA.
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Okay?
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So back up.
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Um, the standard of practice, the gold standard right now is the DEXA scan.
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Explain that
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Kimberly Zambito, MD: Right.
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Well, DEXA's been around for decades, so about four decades.
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And, um, it is a tried and true standard that we've used, uh, for so long.
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But with any technology that we use, there's bound to be pros and
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cons to use of that technology.
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And also, we have to consider that as human beings interpreting these
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tests, we're also-- we also have, uh, failures too, or have areas
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where we lack in the interpretation.
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And so what I feel is over the decades, we've relied so heavily on
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DEXA and the T-scores or Z-scores that we haven't really taken a stance
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in terms of how do we look at the com-- the person as a comprehensive
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being, look beyond just a T-score.
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And so when I take care of a person who has had a wrist fracture, because let's
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face it, I'm a hand surgeon, and that's, that's how these people come to me, is
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they have a wrist fracture, and I take care of it as an orthopedic surgeon.
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I always start with the question, how did this happen?
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And oftentimes it's a fall.
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Okay, well, how did you fall?
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And so I start digging into it.
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Sometimes it's a issue of, "Oh, I wasn't paying attention."
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Oh, some-- for some people, it's a balance issue.
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I had one patient who had a foot drop, and nobody ever addressed her foot drop.
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So unless we're addressing those things and addressing the fall, it doesn't
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matter what their T-score is or what their DEXA results or REMS results are.
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We're missing, we're missing the boat in terms of treating them as an entire person
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Pam Peeke, MD: So you looked at them more holistically.
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You asked all the right questions, right?
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why didn't you just feel comfortable with DEXA?
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Um, because again, that's what OB-GYNs and family practitioners and everyone
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else are using as the gold standard to be able to determine, uh, what's
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going on with bone mineral density.
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Kimberly Zambito, MD: That's, that's a great question, Pam.
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And so we in traditional medicine have, uh, treatment algorithms that we follow.
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And there are some physicians who stick to that treatment algorithm to a T.
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You-- Not to-- not as pun intended with T-score, but they
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stick to that algorithm to the
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T.
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Pam Peeke, MD: that to a T, you
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Kimberly Zambito, MD: And then you have other physicians who say, "You know what?
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I know there's, there's problems with DEXA, and let me just look at this person
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beyond that," because they wanna look at-- They-- You know, these physicians
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really wanna treat a patient holistically.
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And if you think about the way our medical system is designed,
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Pam, you know, we're seeing a high volume of people very quickly.
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And so sometimes those algorithms can be very useful, but sometimes
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those algorithms just don't fit a particular patient's scenario.
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And so that's when we have to bring in the art of what we do in medicine.
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Pam Peeke, MD: Mm-hmm.
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And, uh, on the DEXA scan, so we can-- Again, I wanna make sure everyone's
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super clear about what's going on.
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So on a DEXA scan, you classically get a T-score.
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Explain the T-score.
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Kimberly Zambito, MD: Right.
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So let's, let's talk about the DEXA in general.
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For those who have never had a DEXA, what the DEXA does is it's used to
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estimate your bone mineral density, and it's two X-ray beams that are targeted.
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And, um, what they do is they look at the absorption of those,
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those X-rays or those photons.
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And so you get an estimated value for your bone mineral density
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in the spine and in the hip.
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Now, there are other areas of the body such as the wrist, but in general,
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we're looking at the spine and the hip.
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For the spine, it's L one, two, three, and four.
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And then for the hip, we get the values of the femoral neck, the
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trochanteric region, and the total hip.
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So really the, the proximal femur.
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So based on those values that come to be, uh, the bone mineral density
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is then compared statistically.
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The T-score compares your bone mineral density to a thirty-year--
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roughly thirty-year-old Caucasian woman, whereas the Z-score is age,
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gender, and ethnicity matched.
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So for post-menopausal women, we ty-typically use the T-scores.
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For women who are pre-menopausal or, uh, below, uh not in the perimenopausal
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phase, we use the Z-scores.
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And we don't use the term osteoporosis or osteopenia, we use the term, um, low
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bone density for expected age range.
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So that's T-score and Z-score in a nutshell.
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Pam Peeke, MD: So that's what we've had forever.
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Now we also have added into, uh, the DEXA, well, as it were, extra
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software, which, uh, tells us about a trabecular bone score.
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Explain that
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Kimberly Zambito, MD: Yeah, the TBS looks at just the spine, not
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the hips, so it's L1, 2, 3, and 4.
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And what it does is it looks at the pixels of the grayscale of the
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pixels and determines whether or not your bone quality is normal,
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degraded, or partially degraded.
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So the whole purpose of TBS is to gain a more comprehensive view of our
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bone health, and it's moving us in the right direction in terms of, hey,
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we wanna treat people better and not just rely on bone mineral density.
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Um, so I applaud the, the developers of TBS.
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The
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Pam Peeke, MD: So again, the TBS gives you how much more data?
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What are you getting extra?
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Kimberly Zambito, MD: bone quality.
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So if we recall from
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Pam Peeke, MD: to bone quality.
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That's what I wanted you to…
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Yeah, because this was something that started the conversation that
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you, you know, were really interested in looking at quality, not just
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quantity, as it were, um, in a big way.
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All right?
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Have you seen DEXAs that were problematic?
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Kimberly Zambito, MD: Yes.
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I see DEXAs that are problematic, but I also see DEXAs that
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are done really, really well.
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Pam Peeke, MD: Mm-hmm.
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So, um, the reason why this is important is because all of
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this technology is moving along.
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You know, we have so much, so many new ways to be able to now, um,
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well, typify what's going on with our bones because no one cared before.
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We just kept getting DEXAs and calling it a day and, and whatever.
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So is, is the DEXA interpretation problem more with the spine or the hips or both?
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Kimberly Zambito, MD: It can be both.
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So all of these, all of these DEXA tests, um, are dependent
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on appropriate positioning and what we call edge detection.
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So being able to correctly identify the bone as bone, um,
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whether it's the spine or the hip.
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Um, so some of it is the technique, uh, that is problematic.
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Some of it is the interpretation of that, that DEXA.
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And oftentimes, you know, these reports are going to clinicians.
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We know what the treatment algorithm is, right?
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So if your T-score is -2.5,
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here's a medication for you.
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Um, if your T-score is -2.5
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or more positive, okay, maybe we'll keep an eye on it.
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Um- But yes, it's both the, the actual acquisition of the DEXA that can be
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problematic as well as the interpretation to answer your question, Pam.
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Pam Peeke, MD: Okay.
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What, what I've seen are, you know, as women course through, uh,
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their 60s especially and 70s and beyond, um, but it could be earlier.
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It could be in their 50s, that women could have issues, uh, in their lumbar
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spine which involve, uh, curvature of the spine, something we call scoliosis, um,
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compression of the, uh, vertebra in the spine which can cause some angling, um,
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in strange ways, as well as osteoarthritis which can form extra mineralization,
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um, which can kick off a more positive finding on a DEXA because it's reading
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through thicker bone, but the thicker bone is coming from osteoarthritis, not
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from high-quality bone mineral density.
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So when these kind of women show up, I, I think that many times they may be
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getting, um, falsely good reports on their lumbar spine, and that's an issue
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because then what's the real truth here?
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more and more women have read about this new, um, REMS, modality to be able to,
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uh, garner more clarity about what's actually happening because they actually
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even hear it from their physicians, "Well, you've got a tough spine to read."
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Um, okay.
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Well, what are we doing about that?
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Um, and I would imagine, I, I'm not quite sure what happens in hips.
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It makes it worse maybe.
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Again, osteoarthritis could show up again or, you know, once you have implants, um,
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things get a little in-- more interesting in there and all the rest of it.
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What does a DEXA look like with an implant anyway?
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Kimberly Zambito, MD: in short, you shouldn't be doing a DEXA
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on an implant to begin with.
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So th-that's, that's all I'm gonna say about that.
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Um, if you happen to have a DEXA which shows an implant, then that really should
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not be interpreted because the implant itself is gonna give you a false reading.
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So again, this is where the art of medicine comes in, in interpreting these
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tests in the context of the patient.
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So I really wanna stress that people are more than the results
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of their DEXA or even their REMS.
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We really have to look at the entire human being
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Pam Peeke, MD: completely agree.
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And a lot of women have also had, uh, spinal surgery.
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Uh, everything from stenosis to, you know, maybe some correction of compression
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of fractures and all the rest of it.
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And so that's gotta make things a little hairier there too.
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I've always been fascinated with this, as I s- uh, shared with Dr.
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Doug a while back, um, when I had, uh…
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My hips are fairly clean, very straightforward, very healthy,
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you know, straightforward.
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Okay, fine.
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Not so much my spine.
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Um, you know, as a lifelong athlete, you know, I picked up some osteoarthritis
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and at the same time, a little curvature.
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so now all of a sudden, I have a spine, um, whose DEXA I don't trust
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because I'm not sure what it's reading.
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And so I went out of my way to, um, find, uh, a technician who,
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uh, was experienced with REMS.
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I love the fact that there's no radiation, uh, which there is with DEXA.
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Um, but I was thinking if I combine DEXA and REMS together, then I get a more
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holistic picture of what's going on, and that's, that's precisely what took place.
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It gave me a much more accurate reading of my spine, something
20:25
that would make more sense to me.
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It was, it was a good reading, but it wasn't, uh, you know, falsely
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very positive, you know, for me.
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Um, it was much more realistic.
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Interestingly, my score on my hips were precisely the same,
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um, both on REMS and DEXA.
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So I was kinda happy with that.
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I was like, "Okay, there's no confusion there."
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But it seemed to clarify what was going on in my spine.
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And so, uh, let's get into REMS.
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Now, how long has REMS been around?
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Kimberly Zambito, MD: it's been around for about a decade now in Europe.
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In the United States, it gained FDA approval late 2018.
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Um, they s-- were starting to get a foot on the ground in terms of bringing
21:18
it here to the US when COVID hit.
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So in 2021, I, I, uh, got the first, uh, REMS, uh, unit in the United
21:29
States that had the bone mineral density as well as the fragility score.
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And I found that there were a lot of people who were very interested in
21:38
getting a REMS scan simply because they had an issue with their DEXA report.
21:43
They just didn't believe, similar to you, like, "This
21:46
DEXA doesn't make sense to me."
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And so I found women reaching now all across the country to
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try to get a REMS, REMS scan.
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So now it's starting to gain, uh, footing here in the United States.
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Um, hopefully we'll start to see it, uh, more prevalent in every state.
22:04
It, it does h- it is helpful in terms of early screening.
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As you mentioned, it is an ultrasound technology.
22:12
There's no radiation.
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So to start to engage women before they're in that perimenopausal
22:18
phase, I think is gonna be key.
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And as you know, we, you know, when we're younger than 65, we- we're
22:25
not getting DEXAs unless there's an absolute medical indication for a DEXA.
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Pam Peeke, MD: I got a real problem with that.
22:34
And I've mentioned this on other podcasts.
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I think it's completely asinine that we start worrying about bone
22:42
mineral density when it's too late, and that's at the age of sixty-five.
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Where did sixty-five come from?
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It's, it's the age at which, uh, Medicare will pay for a DEXA.
22:52
Now, private insurance will pay for it too.
22:55
Um, I actually started getting mine in my forties, um, because of a strong
23:00
family history of osteoporosis and my…
23:03
You know.
23:04
So, you know, given that, um, I was lucky, you know, in that regard.
23:11
I believe that DEXAs should start with the age of forty.
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I think you need to understand now why, um, many women say, "Well, why are
23:21
you worrying about your bones then?"
23:23
Well, girlfriend, I gotta tell you something, you know.
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Hold on now.
23:27
Sit down.
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Grab a chair All right?
23:30
Your bone mineral density starts falling around the age of thirty.
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Somewhere between twenty-five, thirty-five.
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It's a bell-shaped curve.
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But it starts going bye-bye, and if you are someone doing resistance training,
23:45
getting all your calcium, vitamin D, et cetera, you can actually slow down that,
23:49
that curve, very significantly and still hold on to a goodly amount of excellent
23:55
bone, et cetera, especially with the strength training and the nutrition, okay?
24:00
But, you know, it's relentless.
24:02
It just keeps going on until the very end.
24:08
Um, and it really accelerates at the time of menopause because of, you
24:14
know, typically the loss of estrogen.
24:16
Now, if you're on an estrogen patch or, you know, whatever else, that
24:20
helps mitigate it big time, and we'll get into that in a second.
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But, uh, you know, I'm like a nutcase about, you know, you've got
24:29
to get out there and get a scan.
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I, it just makes me crazy when I see a sixty-year-old woman who I just say,
24:37
"Hey, have you had your DEXA yet?"
24:39
"What?
24:39
What's a DEXA?"
24:41
Okay, well, shame on that medical provider for not bringing it up
24:45
and not insisting that she gets something, for crying out loud.
24:49
Otherwise, all these beautiful women out there are just circling the drain.
24:54
And this is why we need to kind of, you know, hop on this in a big way.
24:58
So, okay, I'll get off my little sa-- you know, my soapbox here
25:03
Kimberly Zambito, MD: I'm gonna support you on your so-soapbox, Pam.
25:05
I, I do believe that we need to start screening earlier.
25:08
As you mentioned, you know, we reach peak bone mineral density
25:12
around the age of 30, and for some people it starts to slowly decline.
25:15
For others, they plateau.
25:16
But once you hit that perimenopausal phase around 40, some women can lose up
25:21
to 20% of their bone mineral density.
25:23
So, it- if we're addressing this when they're in their 60s, we've missed the
25:28
mark We've missed the mark completely.
25:31
So I think I'm with you on the soapbox.
25:33
I'll, I'll toot the horn too.
25:35
Um, we need to
25:36
start scr-- Yeah.
25:38
Thank you.
25:39
I think, I think we need to
25:40
Pam Peeke, MD: scream.
25:41
Well, there's more and more of us, especially as women physicians who are,
25:46
who are getting to be crazy about this.
25:48
This is absurd.
25:51
You know, you need to-- And if your provider hasn't brought this up, whatever
25:55
provider it is, whether it's a nurse practitioner, PA, you know, physician,
26:00
OB-GYN, family practice, internal medi-- you know, you wag your little
26:04
finger at them and say, "How come I'm not getting, you know, my very first,
26:08
you know, scan one way or the other?"
26:11
And of course, they're gonna write for a DEXA 'cause, you know, hopefully
26:14
it's-- mine, again, was covered by insurance, and many people do
26:19
have excellent insurance coverage.
26:21
Medicare will not cover it until sixty-five.
26:23
Shame on Medicare.
26:25
Um, but I believe the US Preventative Task Force, about a year ago or so, uh,
26:33
presented Medicare, um, with a report that said that DEXAs should be covered,
26:42
um, starting with the age of menopause.
26:45
Okay, I'll go with menopause.
26:47
That's around the age of anywhere from fifty to fifty-two.
26:50
I'm good with that.
26:52
That's a great start.
26:53
You know, the Holy Grail is the beginning of perimenopause, one
26:58
way or the other, and that's it.
27:00
Now, listen, when we come back, I wanna really get down and dirty about how REMS
27:08
works, how you access it, the science behind it, and all those good things.
27:15
So hold on.
28:15
And we're back.
28:16
Okay, let's get down to it about this REMS thing and where this
28:22
might fit into the paradigm.
28:23
Now, I'm gonna step back for a second and ask you, have there been human trials
28:29
published in peer-reviewed literature that show efficacy, meaning that it
28:35
works, um, and that the, uh, results and the outcome of what the REMS, uh,
28:43
report is, um, are, are excellent and up to, you know, excellent standards?
28:52
All right.
28:52
So tell me about that
28:54
Kimberly Zambito, MD: absolutely.
28:55
There are peer-reviewed articles out there.
28:58
Uh, the research was done in Italy.
29:00
The company is based out of Puglia, Italy.
29:03
Um, all the research, the initial research was done in Italy with, with human beings.
29:08
Okay?
29:09
Um, their initial database was five thousand people.
29:13
Um, they compared, uh, REMS results to DEXA results and found
29:19
that there was a high sensitivity and specificity when it came to
29:22
determining the bone mineral density.
29:25
Now, when it comes to bone quality, the fragility score is
29:29
what REMS deems as bone quality.
29:32
There was nothing to compare with in terms of DEXA.
29:35
You know, we can talk about TBS, but really nothing in comparison.
29:39
And so what these really smart people did in Italy is they said, "What is,
29:45
what is it that we're trying to prevent?
29:48
Or what is the marker of weak bone?"
29:50
And that marker of weak bone is fracture, right?
29:54
And so what they did is they, um, took their five thousand individuals,
29:59
roughly five thousand individuals.
30:01
They tracked them over five years, and they asked the question, "Did you have a
30:05
fracture or did you not have a fracture?"
30:08
And so what happens with the REMS technology is the technology collects…
30:15
Let me back up.
30:16
The ultrasound waves go down to the bone, interact with the bone,
30:20
bounce back to the transducer.
30:22
The computer or the AI in the, in the processing device then evaluates that,
30:28
and it asks the question, "Do the sound waves coming from this person's bone,
30:34
are they more similar to people who have had a fracture, or are they more similar
30:38
to people who have not had a fracture?"
30:40
And that's essentially the dividing line in how the device
30:43
works in terms of fragility score.
30:46
Um, if you really wanna deep dive on the physics of it and how that technology
30:51
works, there is an excellent webinar.
30:54
It is probably the best explanation I've read or listened to, um,
31:00
on how the technology works, and that is on the IIMHE website.
31:05
So it's iimhe.org,
31:08
and the presenter is Dr.
31:09
David Tognarini.
31:11
Excellent, excellent webinar, um, going into the physics of
31:15
it and how the technology works
31:19
Pam Peeke, MD: And the other thing, um, that people need to know is that
31:23
when you do a DEXA, you go into kind of a radiology looking room, um,
31:29
and you lay on your back, and they position your legs certain ways, you
31:34
know, for the hips and the rest of it.
31:36
Uh, and then again, to your point, um, you've got those rays, uh,
31:41
coming in and capturing bone mineral density, um, uh, for the report.
31:48
Now, for the REMS, they actually run the little ultrasound
31:53
right Right over your tummy.
31:55
So you're, again, you're on your back again.
31:58
However, um, you just have ultrasound.
32:02
Uh, and so it's, it's not coming in from the sides, it's from on top.
32:08
And when it's not coming in from the sides, then you're not seeing all the
32:12
extra noise that takes place, which is the curvature and the extra, you know,
32:18
osteoarthritis and, and whatever else was going on in your wild and crazy spine.
32:24
Um, it just tends to clear through that.
32:27
Uh, and I think that that's, you know, one of its, uh, winning, um, capacities too.
32:33
But that's what you do with ultrasound anyway.
32:35
You always roll it over the area that you're most interested in, in a big way.
32:41
Now, what does that report look like?
32:43
Tell everyone.
32:44
Kimberly Zambito, MD: it's, it's a colorful report, so I think it's
32:47
a, a very good-looking report.
32:49
Your first page is essentially a summary.
32:51
It has your, um, bone mineral density, uh, graph.
32:55
It has an image, or, uh, I call it a cartoon image or an ani- animated
33:00
image of your spine or your hip.
33:02
When it comes to the spine, um, it'll show each vertebra as a color.
33:08
If the color is gray, that means data was-- enough data was not acquired
33:12
to process that, and oftentimes it's because there's gas in the abdomen
33:16
blocking, uh, our view of the, uh, the vertebra at that particular level.
33:21
Um, page two includes the fragility score graph.
33:25
Page three combines the, uh, bone mineral density with the bone quality
33:31
or the fragility score, uh, in order to, uh, come up with a risk
33:35
calculation or a risk factor for you.
33:37
Uh, so it is a co-- it offers a combination of the fragility score with
33:42
the bone mineral density to provide you with a five-year risk, uh, fracture risk.
33:49
Yes
33:55
Pam Peeke, MD: And how accurate is this REMS testing
34:01
Kimberly Zambito, MD: any technology you use, I'm always cautious to say
34:04
accuracy because there is a component of the technologist's skill in
34:09
providing whether the DEXA or the REMS.
34:12
So in the hands of a skilled technician, it can be very accurate.
34:19
That being said, whoever is reading or interpreting it must
34:23
interpret it in ter- in, in the context of your personal health.
34:28
You gave an excellent example of your DEXA in comparison to the REMS, and
34:34
you've mentioned with the REMS, if somebody has scoliosis or somebody has
34:39
arthritis w- you know, what we call osteophytes or bone spurs in their spine,
34:43
um, these can give us a false, uh, po- a false reading on a DEXA, however,
34:48
REMS eliminates those, um, issues.
34:52
So I feel in some instances it's more accurate, um, than a DEXA.
34:57
In other instances, it's…
34:59
the DEXA and the REMS run parallel and, and they're correct.
35:03
So you have to take, uh, the accuracy part into context because everybody
35:08
wants to compare it to DEXA.
35:11
I hope I answered your question.
35:13
Oh
35:14
Pam Peeke, MD: this is important because now my question is, it's
35:19
not part of the standard operating procedure for bone health REMS.
35:25
What's it gonna take to achieve that milestone?
35:31
Kimberly Zambito, MD: gosh, it's, it's gonna take, um, acceptance or curiosity
35:36
in the traditional medical community.
35:40
Um, I think that's gonna be the first thing.
35:43
The, uh, other component is patients and clients pushing for an alternative,
35:49
uh, especially if they're not interested in having radiation exposure.
35:52
Even though DEXA is such a low-dose radiation, there are people
35:56
who have absolutely no interest in, uh, exposure to radiation.
36:01
Uh, so I think it's gonna be…
36:03
it's gonna have to come from patients and from the traditional medical fold in
36:08
terms of, "Hey, let's, let's offer people another, another option for screening."
36:13
And also, you know, advocacy.
36:16
I think advocacy in terms of let's start screening people at a younger age, and
36:22
REMS is, is the perfect technology to begin that screening because you're not
36:27
worried about cumulative radiation dose.
36:31
Uh, so, so those are the three, the three arms as I see it
36:36
Pam Peeke, MD: Okay.
36:37
So I have one other challenge, and that's important.
36:41
You mentioned it yourself, and that is, it's the expertise of the technician.
36:46
You know, we've all had, you know, radiology technicians who've maybe
36:51
had an issue with, um, correct positioning or whatever the issue
36:56
may be, many times requiring us to have repeat X-rays, et cetera.
37:02
Um, and when it comes to REMS, uh, one challenge I think right now to the
37:10
movement as it, as it were, is, is to have more standardized, uh, training, uh,
37:17
and technicians, because right now it's a little bit of a Wild West, and that
37:22
is, um, you have some people who are just sort of wandering, um, with their machine,
37:30
and they're not really that accurate in terms of, uh, being a technician.
37:36
Their background is not particularly great, et cetera.
37:40
Whereas, you know, with someone like yourself, I know that you're associated
37:45
with a REMS group and, um, I can imagine that your, uh, technicians,
37:52
you and your technicians have, um, high level, um, experience and
37:59
training in standardizing and keeping uniform, uh, how you perform this.
38:06
How do you see this challenge being resolved?
38:11
Kimberly Zambito, MD: That, that's a great question.
38:13
Um, about a year ago, I shared a document with, uh, Doug's group.
38:19
Uh, we mentioned Doug Lucas earlier in the, the discussion, uh, the
38:24
Osteo Collective group, um, so that people can ask questions.
38:29
Like, these are the questions you're gonna ask if you have concerns about
38:34
your REMS, uh, scan technician.
38:37
You know, go in there, ask these questions because most of these people
38:41
are charging an out-of-pocket cost.
38:44
The other thing, like you mentioned, I am involved with the IIMHE, the International
38:51
Institute for Musculoskeletal Health Education, and we are developing a
38:56
standardized training pr- uh, program.
38:58
While EchoLight does provide training for those who purchase the device,
39:04
we wanna take this training above and beyond, um, so that we can
39:08
maintain a, um, a standard, uh, for anybody who's providing REMS scans.
39:14
But at the, the, at the very basic level, you should have somebody, a
39:18
technician who understands anatomy and also understands proper, uh, use of
39:25
the, of the device or the technique.
39:28
Pam Peeke, MD: a national certification?
39:31
Kimberly Zambito, MD: We're hoping for international certification
39:35
Pam Peeke, MD: okay.
39:36
And so is REMS being used in Europe?
39:39
Kimberly Zambito, MD: Yes.
39:41
A-as I mentioned, it was developed in Italy.
39:43
Uh, the individuals I'm partnering with are Dr.
39:46
Nick Burch, uh, Dr.
39:48
Paul McGee.
39:49
We have Dr.
39:49
David Tognarini, who's in Australia.
39:52
So there's-- A-among others, but, um, it, it's an international group, and so
39:57
we really, we really want to establish standards for use of this technology.
40:04
Pam Peeke, MD: And so right now, if someone wanted to get a REMS and they
40:08
were somewhere in the United States, wherever, and they weren't lucky
40:12
enough to be near where you are, where they could go and, and have this done
40:17
by people who are highly trained, how do you find a REMS practitioner?
40:22
How do you find someone to do a REMS test?
40:26
Kimberly Zambito, MD: Ecolight keeps a list of their, uh, the
40:30
people who have the device.
40:32
And so you can start off with, with that group, and then-- or
40:36
that website, and then ask those questions, uh, that I, I had mentioned.
40:42
Ask those before you schedule a REM scan and spend the money
40:46
to have the REM scan done.
40:49
Um, so tha-that's where I would start, Pam, is just start with the Ecolight
40:54
website and, and ask the questions.
40:57
Pam Peeke, MD: website.
40:57
Okay.
40:57
Um, you said that, uh, the
41:02
Kimberly Zambito, MD: I
41:08
Pam Peeke, MD: device.
41:09
Class two usually requires prescription or something else.
41:13
Kimberly Zambito, MD: believe it's Class I, Pam.
41:17
It doesn't require a prescription.
41:18
Pam Peeke, MD: Okay.
41:18
So no prescription, um, but do you have on the radar the ability to get
41:28
insurance reimbursement for this?
41:31
Kimberly Zambito, MD: That, that's a great question.
41:32
So right now, as far as I know, I'm not involved with Ecolight,
41:36
so I don't know the, um, ins and outs of where they stand with this.
41:40
Uh, but they have, uh, a T code or a temporary CPT code.
41:46
And in terms of reimbursement, reimbursement is, is all over the place.
41:50
Um, so if you're looking to do-- From a business perspective or, you know,
41:55
a hospital business perspective, if you're looking to get a device but
41:59
you don't have, you know, a good, uh, reimbursement rate to pay for the
42:04
device and the technician, you're, you're not gonna, you're not gonna
42:08
get that So, so yes, the, the short answer is yes, there is a T s- uh, T
42:13
code, a temporary code for CPT code.
42:16
It's just most of the people who have these REMS devices are not taking
42:20
insurance, um, A, because they're, they're not medical professionals and
42:24
are not credentialed in such a way.
42:27
But B, there's such a variety or variability in
42:31
reimbursement of these T codes.
42:34
Pam Peeke, MD: you see REMS, um, taking the place of DEXA?
42:39
Kimberly Zambito, MD: I see it as an adjunct, um, test, adjunct technology.
42:44
I
42:44
think it's…
42:44
Pam Peeke, MD: saying is, you know, I'm trying to understand how this would work.
42:48
You know, as a practitioner, I'd kind of say, "Okay.
42:50
Well, how is all this working together?"
42:52
So do you first get a DEXA if the DEXA is problematic or if the patient already
42:57
says, you know, "I've got like, you know, prior, uh, vertebral fractures, and I have
43:03
a lot of osteoarthritis and blah, blah."
43:06
So you already know it's like, uh-oh.
43:07
Um, so do you-- do-- Is it a one, two-step?
43:12
Is it a like first a DEXA, then a REMS?
43:17
Kimberly Zambito, MD: So I think it depends on the patient, right?
43:19
So if you're looking at a 40-year-old woman who can't get insurance to pay
43:23
for a DEXA, then what's your option?
43:26
It would be, it would be a REMS test to at least begin the screening process.
43:30
If you're looking at somebody who has a fixed income, such as somebody
43:34
who is, uh, retired, who doesn't have a source for income and relies on
43:40
Medicare, then you would go for a DEXA.
43:43
So I, I think it really depends on, on your patient or your client, um, in terms
43:49
of where their comfort level is in terms of, you know, their financial wellbeing.
43:54
I, I have clients who come once a year to get a REMS study.
43:58
I have clients who will do the DEXA one year, and on the opposite
44:01
year do the REMS so that they have two methods to track bone health.
44:06
Um, and I have clients who, you know, they're curious about REMS, but they
44:09
just say, "I can't afford to get it.
44:11
I can't afford to pay out of pocket."
44:13
So I see it as a useful, um, tool in our toolbox, um, to
44:18
engage people on, on bone health.
44:22
Pam Peeke, MD: cost of
44:30
Dexa stack up next
44:31
Kimberly Zambito, MD: Yeah.
44:31
So if you have insurance paying for it, then you have insurance paying for it.
44:35
If you're paying out of pocket, I've seen ranges from like
44:39
$200 up into like $1,200 out of
44:42
pocket.
44:43
DEXA.
44:44
Pam Peeke, MD: REMS?
44:44
For which one?
44:45
Mm-hmm.
44:45
Okay.
44:45
And how often do you get
44:45
Kimberly Zambito, MD: For REMS, on average, I would say it's
44:47
about two to $400 for a REMS scan
44:52
Pam Peeke, MD: a REMS?
44:57
How often would you recommend it
44:58
Kimberly Zambito, MD: it once a year.
44:59
Um, as I mentioned, I do have clients who decide to do DEXA and REMS, and
45:04
so in that instance, they'll do the DEXA one year, and since DEXA is-- can
45:09
be prescribed every two years, on the opposite year, they'll do the REMS.
45:13
So if they see a change in their bone health, like a drop in their bone mineral
45:17
density on both technologies, then you say, "Hey, something real is going on here
45:23
and we need to do something about it."
45:25
Um,
45:26
Pam Peeke, MD: Okay.
45:26
Now,
45:27
Kimberly Zambito, MD: I hope that answered your question.
45:30
Pam Peeke, MD: where do you practice?
45:31
Kimberly Zambito, MD: Where do I practice?
45:32
So I have-- I work-- I'm an employed physician, and I work
45:36
for a large university health network for hand surgery.
45:39
I do not do bone health for that large university network unless I've seen
45:45
somebody and taken care of a fracture.
45:47
Then I'll engage them with regard to their bone health, and I partner
45:51
with the endocrinology team for that.
45:53
In terms of providing REMS scans and education, I work in
45:57
Bucks County, Pennsylvania, and I have my own, uh, business.
46:01
It's called Qualis Os.
46:03
So that's Latin for quality bone
46:08
Pam Peeke, MD: Excellent.
46:08
Fantastic.
46:09
So what you're really doing is you're living in two worlds right now, the
46:14
world of a lot of the standardized care surgery and all the rest of it.
46:18
And then you're also on the cutting edge with, uh, with
46:21
REMS, um, which is interesting.
46:24
And the reason why this whole show was important to me was because
46:28
REMS is starting, you know, to become more mainstream, as it were.
46:33
Um, and I'm getting a, a ton of questions about it, uh, 'cause, you
46:37
know, we talk a lot about the usual standard of care, which is, uh, DEXA.
46:41
But a- again, so many women especially have issues and challenges with trying
46:49
to interpret especially their lumbar, uh, DEXA, and constantly ask me,
46:55
"Isn't there another way to do this?"
46:57
Or, you know, uh, "I can't trust what I'm reading here, and I
47:02
really need an accurate reading 'cause it's making me crazy."
47:05
And that's when I began to go down the REMS route just to
47:09
understand what that was all about.
47:11
So I think that right now, this is, uh, currently evolving, that I hope
47:20
that there is a in- a national, let alone international certification
47:24
for the technicians so that we know that everything is standardized
47:30
instead of the way it is now, which is, uh, a little more…
47:34
You know, it's, it's like if you have the machine, well, good luck, and, you
47:38
know, we hope you know what you're doing.
47:40
Um, and clearly in your hands, um, I would have no problems with that.
47:45
But, again, there's a lot of variability in the field, and we
47:50
need to decrease that significantly and get it to where it belongs.
47:55
I would also say that, you know, if they could do more and more studies, because
48:00
you know how we are as practitioners.
48:03
Show me the science.
48:05
Make me feel comfortable, especially if it's brand new, uh, and,
48:11
you know, I, I don't know much about it as a provider, right?
48:14
So I had to go out of my way to, to learn all of that myself.
48:18
But all my brethren are out there saying, "Well, what is this again?"
48:22
And, "How do you do this?"
48:24
And, "What's the science?"
48:26
And the first thing out of their mouth is, "Where's the-- Where are
48:29
the studies so that I can sit down and at my leisure just read the thing?"
48:35
So that's kind of, I think, where we are right now.
48:37
Does that make sense?
48:39
Kimberly Zambito, MD: I agree.
48:40
I agree wholeheartedly, Pam.
48:41
I, I tell, uh, patients whenever a new surgical procedure comes in, I
48:46
say, "Look, let's just wait and see."
48:48
You know?
48:48
I, I like to give it five years before I even consider doing
48:52
it on a f- on a family member.
48:54
So I, you know, I felt the same way about REMS.
48:56
So you know, I was like, "Gosh, I'm curious about this."
48:59
And it, you know, I dug in.
49:00
I dug in and, um, found that I, I thought it was, it was a valuable
49:05
tool in our armament, especially when we wanna engage people about
49:09
their bone health at an early age
49:11
Pam Peeke, MD: Excellent.
49:12
Can you share with everyone, um, your website so that if they could-- they
49:18
wanna learn more about your wonderful work and if they have any questions
49:24
or if they're actually lucky enough to be, um, somewhere, um, uh, near
49:29
where you are, that would be fantastic.
49:32
What's your website?
49:33
Kimberly Zambito, MD: It is www.qualisos.com.
49:36
That's Q-U-A-L-I-S, hold S-O-S.com.
49:41
So let me say that again.
49:43
Q-U-A-L-I-S-O-S.com.
49:45
And the website is, um, it's dedicated to empowering you with knowledge so that
49:53
you can make good decisions for yourself, decisions that are right for you.
49:58
Um, the resources on the website are free, so dig in.
50:01
Have a good time reading.
50:04
Pam Peeke, MD: Okay, that's fantastic.
50:05
I'm all about education.
50:07
I need to, you know, I need to see the education in a big way, um,
50:11
because there's, there's so much junk out there, you know, TikTok and the
50:17
rest of it, and I can't stand that.
50:19
That makes me absolutely nuts.
50:21
So Once again, everyone, we've been enlightened about a new therapy,
50:27
a new-- Well, actually, a ther--
50:30
Kimberly Zambito, MD: Technology.
50:30
thank you
50:31
Pam Peeke, MD: a modality to be able to measure bone mineral density and quality,
50:39
uh, that could be used adjunctively to your DEXA, and it's called REMS.
50:45
R-E-M-S.
50:47
And, uh, I really feel like, um, it's important for all of us to stay on
50:53
the cutting edge of what's out there, especially if you have one of those
50:58
problematic DEXAs where you can't quite read it and you're not quite sure
51:02
and, you know, and there you have it.
51:04
So, it's an issue.
51:06
So we've been talking with, Dr.
51:09
Kimberly Zambito, an orthopedic surgeon who is in the know and is actually, uh,
51:17
prescribe-- Well, when I say prescribing, using, uh, the REMS, um, in her practice,
51:23
um, to be able to, get a more holistic, comprehensive picture of what's going
51:30
on with each individual's bone health.
51:34
And I think that that's super important so that we don't just take a number
51:38
and we're like everybody else.
51:39
That's never gonna work.
51:41
So Kimberly, thank you so much for being on the Herb podcast.
51:47
Kimberly Zambito, MD: doing what you do, Pam.
51:47
I really
51:51
Pam Peeke, MD: yeah.
51:52
Well, listen, you know, it takes, it takes an entire team,
51:55
squad, you know, the whole thing.
51:59
We all have to do this.
52:00
This is why bringing on experts like yourself to help enlighten
52:04
is terribly, terribly important.
52:06
So thank you Kimberly.
52:09
And I also wanna thank my sponsor, Skin Safe.
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So Skin Safe has it all.
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Okay.
53:33
Now, take a moment and leave us a review because we love to hear from you, and
53:38
this was a wonderful, wonderful episode.
53:42
Ah.
53:42
So this has been a production of Podcast Health.
53:46
And I just wanna leave you with a couple little thoughts today.
53:49
One is a Persian proverb: "Seek truth in meditation, not in moldy books.
53:57
Look to the sky to see the moon, not as a reflection in the pond."
54:03
Get outside.
54:05
Stop, you know, sitting around in, in, in a dark corner somewhere.
54:09
You know me by now.
54:11
I'm an outdoor nutcase.
54:12
Get on out there.
54:14
Look to the sky to see the moon.
54:17
I love that.
54:18
All right.
54:19
Get out there and seize the day, everyone.
54:21
Thanks for listening.