Karam Paul Asmaro, M.D.

On May 8, 2025 I underwent spinal fusion surgery, a 6 hour procedure in which I was filleted from front to back. First, my abdomen was opened up so that the surgeon could scrape out the disc between L5 and S1, replacing it with a perforated cage containing bone grafting material that was screwed into my vertebra. Then I was flipped over and opened up on my back so that my surgeon could screw vertical rods into L5 and S1 to secure my spine position to ensure the fusion sets properly. The procedure was successful, correcting 15 years of lower back debilitation due to severe Spondylolisthesis. However, the recovery process demanded I endure far more than I bargained for, debilitating me in ways I thought might handicap me permanently. For the first 3 months I could barely move. For the first six months my activity was limited to walking only. Pain was constant. At nine months I was still in so much discomfort, still so limited in my range of motion, still too unstable to do anything to elevate my heart rate. My weight ballooned. My muscles atrophied. My mood plummeted. And I was becoming resigned to the idea that my athletic identity (let alone performing extreme feats of ultra-endurance) was a thing of the past, a memory well behind me. But very slowly after that I began to turn a corner. At ten months, I finally felt stable enough to resume a very modest non-spine compressing return to fitness exercise regimen. Zone 1 indoor cycling, gentle core work, extremely low weight / high rep resistance training. Proceeding on a ‘less is more’ mandate in late November (which demands discipline for someone like myself prone to taking everything to the extreme, I just showed up every single morning to do what I could, and stop well before doing more than I should. Today I am down 35 pounds from November (207 to 171) including a body fat reduction from 20% to 11%. More importantly, I am beginning to feel like myself again. Grateful and hopeful. I still have a long way to go—it takes 12-18 months for the fusion to fully set. My surgeon was not optimistic that I will be able to run again. Time will tell of course, but I’m confident that provided I continue to proceed patiently that I have a future in which running can become part of my new reality. Towards that end I have a goal—which is to celebrate my 60th birthday this Fall by participating in the NYC Marathon. But here’s the thing. I’m not trying to return to who I once was. I’ve leaned into the stillness this experience has demanded of me to become someone new and better. I am posting this story not for external validation but rather to say that change is always possible. And the way to do it is the same way I have navigated every one of my many life transformations, from alcoholism to sobriety, from sedentary to middle aged ultra endurance athlete, and from a corporate lawyer career to becoming an author and podcaster: getting sober and staying sober: by taking contrary action consistently and religiously—one day at a time. As Chris Paul said on my podcast, “keep stacking days.” And remember, every obstacle life presents you is simply an opportunity custom-designed for your growth and evolution.

I have logistical questions for the full body MRI + AI interpretation crowd. What do you do with that report? Take it directly to a surgeon? Expect them to operate without a radiologist interpretation? Will the hospitals allow it? Who pays for it? Gonna need ironclad research to convince surgeons, hospitals, and payors to take on that liability.

Ah, Stark Law… For those who don’t know, this is the law that governs physician self-referral. If your doctor owns their own MRI machine, there are very strict rules about how they can use that machine on Medicare patients. It’s also how the Affordable Care Act banned physician-owned hospitals. Of course, anyone can see a few problems with the legislation right off the bat. Notably, it doesn’t apply to health systems. So while doctors can’t refer to their own MRI scanners, labs, or physical therapists, a large hospital system is allowed to. In fact, most large hospital systems will punish doctors for referring patients externally, even having a term, “leakage,” that they try to reduce. So it’s okay for the large hospital systems, but not for doctors. Which means Stark is just another rule that gives large systems an advantage over independent doctors, driving up the cost of care as systems consolidate. Secondly, you’ll notice it only applies to Medicare patients. Why can a doctor refer a privately insured patient to their own MRI but not a Medicare patient? The flaw is in Medicare. It lacks utilization control. Stark is a classic example of government creating a flawed program (Medicare) that’s vulnerable to fraud and instead of fixing the vulnerability, making a new rule that just distorts the market further. If you want to limit self-referral, create a system that has some form of utilization control. Private insurance does this, but so does making patients stewards of their own healthcare dollars. Are patients going to spend their money perfectly? Of course not. But we have to recognize the tradeoffs of a large government bureaucracy. Because we don’t trust patients to spend their own money, we’ve created a massive system that has increased prices, distorted the market, and led to worse access to care.