Shoulder Snowflakes

If you have read my introductory story, you already know that I am quite comfortable with uncertainty. The beautiful simplicity of the standard model of particle physics, with its mise en place of ingredients waiting to be formed into all forms of matter, betrays a complexity that is exemplified by the reality that we accept the uncertainty of not knowing the location or velocity of quantum particles until we measure them. When we measure their location, we do not know the velocity. When we measure their velocity, we do not know their location. The deeper you dig into this, the more clearly confusing it becomes.

The world of shoulder pathology is equally complex. One key difference is that 99.99% of the population can completely ignore particle physics and life goes on unperturbed, meanwhile there are millions of people in the United States every year who must collapse their wave function and decide on a treatment for their shoulder problem. One key similarity is that much like in the observation of quantum particles, once we decide on a treatment plan, we cannot go back and see how life would have been if we had chosen a different plan. This is where where someone who has the proper expertise can help patients to “virtually fast forward” and get an idea of where they will be at the end of their treatment, after choosing from each of the potential options.

Quantum physicists treat the fuzziness problem by presenting data that embraces the uncertainty, focusing on the coexistence of future potential realities. Shoulder surgeons treat the fuzziness problem by any or all of the following methods:

1. Ignoring the uncertainty all together. I call this the “teflon ego” that deflects any threat to its perceived ability to give perfect recommendations for patients making difficult decisions.
2. Controlling the uncertainty with collapsed wave function data. This is a necessary but insufficient component of shoulder care — for sure we must contribute to our knowledge of which treatments work and which treatments do not work — but this only informs our decision making and does not dictate in any way which treatments will be successful for each individual patient.
3. Embracing the uncertainty by recognizing each shoulder as a unique snowflake. One of my favorite patients came to see me, in his mind, to discuss surgery to repair the torn rotator cuff on his right shoulder. One of the reasons he was so sure that this is going to be his best course of action is because I repaired the torn rotator cuff on his left shoulder, and he is very happy with his outcome on that side. This was my opening to give him my “shoulder snowflake schpiel” in which I eruditely, cheekily inform him that even though he is the exact same person, the fact that he has a rotator cuff tears in both shoulders does not in any way mean that their treatments will be the same. In the case of his left shoulder, all the data we have (see method 2 above) suggests that he will probably do best with a rotator cuff repair. In the case of his right shoulder’s irreparable rotator cuff tear, the wave function of probabilities is much fuzzier, so we had a long conversation about what potential future reality he found most appealing from a risk/benefit standpoint. We tried several months of physical therapy, which gave him some improvement, but after hitting a plateau in his progress, we are soon moving forward together with a novel tendon transfer procedure described by Dr. Bassem El-Hassan at the Mayo Clinic.

So where do we go from here both as shoulder specialists and as other clinicians who deal with difficult problems? You will not be surprised to hear that I am uncertain. We can ignore the uncertainty problem altogether. We can keep doing what we are doing, sloshing through patient visits with collapsed wave function data. Or, maybe … just maybe …we can find a way to treat patients that embraces the uncertainty. Lawyers are smart in that they don’t ask questions that they don’t know the answer to, and in this case, I am trying to take a page out of their book, in that I have some answers for myself, my patients, and other clinicians who want to share with me in embracing the uncertainty we face in treating patients with shoulder problems:

1. Do not try to escape the tension of the uncertainty.
2. Try to help patients make good decisions based on what you know.
3. Try to add to the existing medical knowledge with proper studies.
4. Try to create outcome tracking tools that build in a respect for uncertainty.

There will be much more to say on each of these four plans of action. Perhaps I should stop here, and give both of us a chance to reflect on each of them. Perhaps you will share with me your thoughts before I write about them again here. Thanks for sharing with me in my decisive uncertainty.