For as long as I can remember, my dad’s side of the family has complained or joked about the “Frank back.” My 94-year-old grandfather, Pop, is the patriarch of the family and beleaguered owner of the original Frank back(TM), having experienced major back surgery before I was born. Besides Pop, at least a dozen blood relatives on that side of the family have experienced varying degrees of back- or neck-related pain and even surgery.

With my complicated medical history, I collect diagnoses like some people collect Pokemon, so it seemed inevitable that I too would inherit the Frank back. When I was 23, my back did not agree with a new mattress, resulting in morning muscle stiffness. Not long after, I was at the gym doing a core workout, mistook muscle strain in my back for “the good kind of pain,” and did a few miles on the rowing machine; I could barely get out of bed the next morning. I recovered, but a couple years later, I pulled a back muscle during softball that would take a year to fully heal.

A decade later, now 33, I’ve tweaked my back more times than I can count during sports but also by stretching, sneezing, and even writing this essay while laying on the couch (ugh). As my career has blossomed, low-level chronic back and neck pain has always been in the background. I only realize now in retrospect how my work in space exploration has influenced my search for an answer.

What spacecraft taught me

Over the last five years, I’ve had the pleasure of working with brilliant engineers from whom I’ve learned the tenets of spacecraft systems engineering. Spacecraft are complex machines that must operate in extreme environments. NASA missions can have hundreds or even thousands of people working on them. On top of that, there is little room for error: there’s no repairman in space once spacecraft are launched.

To ensure spacecraft work the first time, the principles of systems engineering are infused into the organizational culture of these teams. Systems engineers typically have discipline expertise in a field such as mechanical or electrical engineering but operate as generalists skilled in interdisciplinary communication. Here are some of the philosophies I’ve internalized over the years about systems thinking:

Communication is Key. Systems engineers are the glue of space missions, ensuring the right information flows to the right people at the right time. Good communication between parts of the system and the people responsible for them is critical to mission success.
Everything Is Connected. Systems engineers may not be the experts in subsystem A or subsystem B on a spacecraft, but they would be the ones to ensure that subsystem A’s operation doesn’t accidentally break subsystem B. They have to have enough knowledge of each part to understand how the parts interact.
Look for the Root Cause. When there’s a problem, sometimes it’s actually just a symptom of a deeper problem. If you don’t treat the deeper problem, then the symptom will never fully go away. Keep asking “why?” until there’s no more answer, and you’ll find yourself at the root cause.

By analogy, primary care physicians should be the systems engineers in medicine: in theory, they manage a patient’s care with the big picture in mind, while the specialists focus on the function of different parts of the body. Unfortunately, it turns out that the only person incentivized to keep the big picture of my health in mind is me.

Where is the systems thinking in medicine?

As I sought treatment for my back pain over the years, interesting tidbits would pop up. For example, the physical therapist I saw after my softball injury noted that I had asymmetrical back muscles. Weird, right? In grad school, I was also developing acute neck pain that was no doubt exacerbated by my many hours in front of a computer. The physical therapist I saw for that noted I had restricted mobility between two cervical vertebrae. Interesting.

When I was 28, I developed a deep, sharp pain in my right shoulder from rock climbing. Ignoring it didn’t work, so I made an appointment with an orthopedic surgeon. I was living in DC at the time, and the doctor I saw was a shoulder specialist at the Georgetown School of Medicine. Oddly, while I was getting x-rayed, the radiologist asked me if I had ever injured my neck in a car accident. I had not, and when I asked the surgeon about it, he off-handedly said it looked like degenerative disk disease and left it at that.

I ended up requiring surgery to repair torn cartilage in my shoulder. It was successful, and I was able to go back to climbing after a few months. Unfortunately, a few years later, my other shoulder started to throb with a familiar pain, which led to the same surgery in 2019. Concurrently, I had also developed chronic pelvic pain, and my low back pain was getting worse.

I was too young for everything to hurt this much! I couldn’t shake the feeling that there was a grand unified theory of everything. I had also undergone a foot surgery in 2009—was that related? What about my teeth grinding and headaches? The stabbing knee pain when hiking downhill? The stiffness when I wake up in the morning? Really tight hamstrings? I felt like I needed a doctor who would look past my individual maladies to investigate whether they were connected.

An actual picture of me trying to self-diagnose using WebMD.

At my post-surgery follow-up visit, I broached the subject with my orthopedic surgeon. He acknowledged the limitations of his discipline—see a problem, fix it with PT or surgery—and suggested I see a particular spinal doctor who thinks the way I was describing. Rather than an M.D., her degree was a D.O., which stands for doctor of osteopathic medicine. I was unfamiliar with the discipline but open to anything.

I made an appointment with her and finally found the systems thinker I was seeking. After examining me, she explained the concept of the kinetic chain (created by a mechanical engineer!), which describes how interrelated groups of body segments, connecting joints, and muscles work together to perform particular movements. She blew my mind when she said a tight hip can cause dysfunction in the opposite shoulder: both my hips are tight but my left is tighter, which explains why my right shoulder required surgery 4 years before my left. I knew it! Everything is connected.

But why? X-rays revealed mild scoliosis in each section of my spine and two partially fused vertebrae, a condition I was born with and what the radiologist had confused for a neck injury. The scoliosis caused muscle imbalances throughout my body, resulting in bad movement patterns that have gotten more problematic as I’ve gotten older. It explains both my chronic pain and why I was so injury-prone, particularly during sports.

An x-ray of my neck 4 years before I was diagnosed with mild scoliosis. I hear spines are supposed to be straight…?

It’s possible the “why” goes even deeper: the fused vertebrae in my neck may be due to a rare congenital spinal disorder. The genetic test would cost $1200 out of pocket, however. I’m curious, given the prevalence of the Frank back in my family, but not enough to justify $1200. Furthermore, the result wouldn’t affect the recommended treatment of physical therapy.

Following the scoliosis diagnosis, I was able to find a wonderful physical therapist who also embodies systems thinking in medicine. Over the past six months, she’s been identifying problems in my movement and showing me how to correct them through stretches and strengthening exercises. I’ve also started doing yoga at home (shoutout to this Yoga with Adrienne video), which has helped increase flexibility in muscles that have been tight my whole life. Yesterday I went on a hike, and I was elated to experience only normal soreness and not stabbing knee pain on downhill sections, an experience to which I’d become accustomed.

Where modern medicine falls short

I have easily seen over a dozen different health care providers related to issues that I now know can be traced back to scoliosis. The first orthopedic surgeon never wondered how my shoulder pain could be related to my foot surgery or abnormal neck x-ray; the second surgeon never contemplated why a 32-year-old with chronic back pain was on her third orthopedic surgery in 10 years. It was only through my stubborn self-advocacy that I finally met a doctor who would look at my constellation of issues as being connected rather than a series of unfortunate but unrelated events.

I think I know why. Doing root cause analysis requires time and deep thought, which is not possible in 15-minute appointments, especially when it takes me that long just to explain my health history. I have felt on numerous occasions that a doctor I was seeing wanted to treat my symptoms as quickly as possible (preferably through a prescription) and get me on my way. Through encouraging ever-shorter appointments, our healthcare system incentivizes quick solutions to symptoms.

Furthermore, I suspect that in modern medicine, there is just so much information to know that specialists are becoming increasingly hyper-specialized, created compartmentalized sub-disciplines. In any field, it is difficult to be a specialist and a generalist at the same time; I certainly see that in my profession. Modern medicine is doing an insufficient job at developing systems-level generalists who communicate with each other. Primary care providers are supposed to provide that “glue”, but I’ve yet to meet one who could advocate for me better than I can advocate for myself.

In short, medical professionals could learn a thing or two from spacecraft systems engineers. The wonderful experience I had with the spinal doctor, with her training as a D.O. rather than an M.D., suggests an answer in the osteopathic whole-body approach to treatment. As with spacecraft engineering, compartmentalizing medical knowledge into ever-smaller disciplines without mechanisms of communication between them is a recipe for pain.