Thursday, June 27, 2013

185 Orthopaedists Walk Into a Bar...

I have a friend who does improv in New York City, and she told me about the traditional “walk into the bar…” joke or as they call them “185 jokes”.  The jokes are always along the lines of 185 something or other walking into a bar and being refused service.  The punchline, fast and furious, is generally groan-inducing.  A recent contribution from her goes like this:

185 Scoliscore tests (gene test for scoliosis) walk into a bar.  The bartender says “We don’t serve your kind here.”

              The Scoliscore tests respond, “Well, that sure threw us a curve!”

This month, June, has been Scoliosis Awareness month as always.  I have had the experience of giving four talks, writing three papers and two articles and being interviewed twice on media, always about scoliosis and mostly about Scoliscore, which I am championing.  Earlier articles in my blog have discussed the test which can determine the prognosis of a mild to moderate scoliosis with up to 99% accuracy, making it one of the most effective prognostic markers currently available in clinical medicine.

One of the reasons I have had this luxury is my self-imposed (and hopefully temporary) sabbatical from clinical care.  In three months, I have not seen a single patient (which has been unquestionably painful) and have not done a single surgical operation, which has been surprisingly refreshing.  Being out of the OR has allowed me to reflect on medical care from an entirely different perspective than my previous busy surgical practice allowed.

Doctors are an interesting lot.  We tend to define ourselves very strongly in terms of the composition of our practice.  We place ourselves by geography (“urban” vs. “rural”), by referral pattern (“primary” vs. “tertiary”), by complexity of the patient we see.  Surgeons, that most superstitious of groups, tend to define ourselves by surgical parameters – how busy are we, what is our caseload, what types of surgery are we comfortable with and what will we refer out?

The old adage from residency days is “a chance to cut is a chance to cure.”  But being outside of the surgical sphere made me realize that surgeries actually define a failure of a kind; the failure of non-operative treatment.  And in the bustle of being a busy surgeon, we run the risk of losing sight of the patient attached to the surgery.  No surgeon defines him or herself by the number of clinic patients seen, or the number of times that operative care was not invoked.

Humans also tend to define themselves in broad categories.  When it comes to medical care, they will often group themselves by their diagnosis, and will often carry the stigmata that go along with that diagnosis.  In adolescents and children, that is a particular issue, since placing yourself in a “diseased” category makes you somehow “other” or “different”.  Scoliosis is particularly pernicious in this regards.

Thinking, writing and speaking about Scoliscore through the eyes of a non-surgeon as much as I have over the past several months has led me to see the strengths of the test differently.  To be sure, a high score is very helpful.  It can define referrals and govern treatment plans.  It can give the doctor and patient a chance to explore more aggressive treatment options up to and including surgical intervention.  There is that surgical angle again (no scoliosis pun intended).

But the low score is inarguably most important to the patient.  With a 99% negative predictive value (only 1% or less of kids with the low scores will progress to need treatment) it will remove the fear and the stigma of having the diagnosis.  A child with a low score does not need to define herself as having “scoliosis” at all, since it so unlikely that there will be any consequence.  She can go on to other more congenial definitions like “preppy” vs. “Goth” or “athlete” vs. “artist”, and fit in more readily into the difficult vagaries of adolescent society.

 So, 185 low-risk Scoliscore tests walk into a bar.  The bartender says, “We don’t serve your kind here.”

The tests say, proudly, “We are not a kind.  We are as individual as anyone else in this bar. Serve up the drinks!”
That little effort would surely get me booed off the improv stage, but for a child with the diagnosis of scoliosis, it is surely a punchline to be cheered!