Welcome And Guest Introduction

Dr Andrew Greenland 0:00

Welcome to another episode of the Voices in Health and Wellness Podcast, where we have honest conversations with clinicians, founders, and innovators who are rethinking how healthcare is delivered and experienced. Today I'm joined by Dr. Scott Werden, a physician who has dedicated a significant part of his work to understanding and diagnosing thoracic outlet syndrome, a condition that was first described as early as 1818, yet still remains widely misunderstood and often missed in modern medicine. Scott works with Vanguard Speciality Imaging in San Francisco and has helped build a national community of physicians and patients focused on improving awareness, diagnostic accuracy, and treatment for thoracic outlet syndrome. So with that, Scott, I'd like to welcome you to the show and thank you very much for joining me today.

From Internal Medicine To TOS Imaging

Dr Scott Werden 0:42

Thank you, Andrew. Really appreciate the opportunity to share with your audience.

Dr Andrew Greenland 0:46

Wonderful. Perhaps we could start at the top. Could you give us a little bit of background and your kind of career path and how you've ended up doing the work that you currently do?

Dr Scott Werden 0:55

Well, uh, I'll just start out by saying this, and I tell my kids this all the time. Whatever I planned didn't work out the way I expected. So roll with the punches. I started out actually after medical school. I did an internal medicine uh internship and residency, and then I did the our big board certification examination. And right afterwards, I was saying, this is not what I want to do. And I went back and did another residency and fellowship in diagnostic radiology. I was very fortunate because radiology has benefited from all the advances in technology, ultrasound machines, CAT scans, MRIs. And I was busy working as a radiologist. I was running an imaging center. Um, but a few years before, let's say uh about the year 2000, I was in a group in San Francisco, and a drug rep came in and said, we have a couple speakers tonight up in Marin. It's a really nice little seaside community north of San Francisco. And I wasn't that interested. I didn't pay attention until he said free dinner. So I went and I watched a talk by a Dr. Tracy Newkirk. He's a man, a neurologist, who has spent over 40 years of his career working on Therascalet syndrome. And I was fascinated by both the material and his enthusiasm for it. I knew very little about the disease. Nothing had been covered in medical school that I can remember, or in two internships and two residencies. And there's also another speaker with him, uh Dr. Jim Collins, who has since passed away, who was very enthusiastic as well, about his technique for doing MRI of thoracic outlet syndrome. And uh I went up after the talk and I spoke to the two docs, and it was very interesting. I tried to institute this kind of imaging and work something up myself at my group at the time, but they just really thought it was interfering with making money and getting the work done. About two years later, I got a big packet in the mail. I was running an imaging center, and it was a legal case that Dr. Newkirk, the neurologist, had been involved in. And the defense had hired a doctor who said that thoracic outlet syndrome, TOS, didn't even exist. And the judge said, I can't make head nor tails of this. Let's get a third party. And nobody could think of a third party, except Dr. Newkirk to his credit, remembered me chatting with him after dinner two years prior. So I got the case, I helped with a case, and then I said, you know, we've got this great tool, MRI, that can show everything if you know how to use it. And I said, I'm gonna apply myself, I'm gonna figure out a way to image this disease. And that was an inflection point in my life because a huge chunk of my life is now occupied with the disease.

What Thoracic Outlet Syndrome Really Is

Dr Andrew Greenland 3:46

Thank you. Really, really interesting background. So, Scott, tell um when somebody finally reaches you with thoracic outlet syndrome, what have they usually been through already? And actually, you probably got to talk a little bit about what thoracic outlet syndrome is for those who are uninitiated.

Dr Scott Werden 4:00

Great. Uh, thoracic outlet syndrome is a nerve entrapment syndrome, very simply. But the nerves that it involves are the brachial plexus. This is uh on each side of your neck, you have this cluster of five nerves that comes out from the spine. It forms a branching network with all these little branches coming off and big branches forming, called a plexus. It's the second largest plexus in the human body. And it goes through a very complicated transition from the neck over the chest, down the armpit, the medial side of the arm, and along the way, it has to pass through several tunnels, along with a large artery and a large vein. Those tunnels can be narrowed for any number of reasons. But what's worse is that the arm motion, and we the arm is the most mobile joint in the human body, causes narrowing of those tunnels in unpredictable ways. So what happens is the three types of TOS depend on which structure is being involved. I'll get to that. But the most common type and the difficult type to diagnose is the neurogenic type, where the brachial plexus, the nerves, are either compressed or stretched by arm motion. So diagnosing it, uh, you have to understand very complex anatomy where the neck joins the chest, joins the shoulder, and then you have to understand the motion, what happens when patients move their arms. And then you better be prepared because there's a huge amount of anatomic variation between people at this spot. So thoracic outlet syndrome is simply compression or tension of those nerve roots. Okay, now rarely, I'll just add in the artery can be compressed or the vein can be compressed, but those are 5% or less of cases, and they're easy to diagnose. We don't do that. We take the difficult cases. How do patients get to us? It's a great question because a lot of patients have been through a lot of different doctors before they get a diagnosis. When I first started this, Andrew, uh, 25 years ago, I don't want to date myself. I have to look for some gray hair soon. Um, patients would go through eight or ten doctors before they'd happen to find us by luck. And they were miserable because after they'd see their first three or four doctors, as you can imagine, the next doc would say, Well, yeah, it's patients seeking drugs for their pain, or there's some other secondary cause, or they have depression or a psychiatric disease, because there was no test that showed the disease, and very few doctors knew much about it, honestly. So I used to say that my job is to diagnose a disease that doesn't exist because a lot of doctors would just tell the patients it doesn't exist. You can't have it. Now, since then, we have been like not as to a great a degree as you, but we've worked hard on raising awareness for this disease that we believe in. And fortunately, uh the field has grown tremendously over the past 25 years. There are clinics at the best hospitals in the country. We know some great specialists scattered around the country. And when patients come to us now, we try to get them to one of these specialists and let the specialist make the best guess whether the patient has TOS and then consider our advanced imaging.

Dr Andrew Greenland 7:24

Thank you. So you talked a look about the diagnosis and being able to get that diagnosis. What happens next for the patient that you find with the condition?

Dr Scott Werden 7:36

So this depends on what's wrong inside. Because of the anatomic variation, there are different causes of compression of this brachial plexus. Some patients have an extra muscle, or their brachial plexus takes an unusual course through a muscle instead of around the muscle, or the rib and the collarbone get too close together. There are a number of things that can go on. And depending on the treating doc, there are a number of different approaches. Docs, when they see these patients, they do specialized provocative tests by moving the arms and neck into certain positions. It's not part of a standard neurologic examination, which explains why docs in the past may have said, I don't see TOS. Standard neurologic exam doesn't show it. But if you do these specialized provocative tests, you can start to ferret this out. None of those clinical tests of moving the arms and having the patient do maneuvers is great by itself. When you combine them, they're a little bit better. None of them shows you what the anatomic cause is. So we work together with the clinicians once we figure out what the anatomic cause is. Now, during that process, something that's become more used over the past 10 years or so are these selective injections. Some docs will inject a numbing medicine, lidocaine, into specific muscles of the neck or the chest. And if you do that, some patients have a significant decrease in their pain, numbness, tingling, all their symptoms. In the 70s, when this was first done in LA, uh, it was done kind of crudely using um electromyographic needle. And they didn't observe it under ultrasound as is commonly done today. And so the fluid could leak out. Uh, and if it went around the brachial plexus, it would just numb up the nerves. It wouldn't accomplish anything because any nerve will go numb if you put lidocaine around it. But they decided at the time that the patients that responded to that injection would go to surgery, and they had what is now known as a typical success rate. I can discuss those numbers in a bit. Um, unfortunately, the it wasn't a controlled study. They didn't compare patients with a negative lock that didn't respond and went to surgery. But to this day, people have experimented quite a bit using anesthetics, steroids, Botox for a longer acting effect, injecting these various muscles and trying to find the muscle or the muscles that contribute to this pain condition. So we're still learning about that. Some docs will do electrophysiologic studies and EMG and nerve conduction velocity as part of the diagnosis. And these tests, I think to almost every experienced TOS doc I speak with, these tests are irrelevant. They don't become abnormal till late in the course of the disease. And by that point, you have motor nerve involvement, and nobody wants to wait for that because that's much harder to recover from. So uh I would say the clinical tests are enough for some doctors. The doctors who just rely on clinical tests without imaging tend to use those selective muscle blocks. There are other docs who feel that the imaging is important so that they know what they're going to see before they go in, and maybe my hope is to triage patients to different kinds of treatment. I'll give you an example. We see uh fairly often as one of the causes of compression of the brachial plexus, that the rib, the first rib stays in place when you raise your arms, and the collarbone comes down very close to the first rib, and it narrows that space between two bones and compresses the brachial plexus. Now, in that case, removal of part or all of the first rib is kind of the accepted treatment, and that's understandable. If I show on my MRI there's compression, you remove that floor, the first rib, there's now space when the collarbone moves. But there's been a recent uh movement of some progressive surgeons to just remove some of the muscles, the scaling muscles, and to leave that first rib alone. And the thought is that it would be an easier surgical procedure, less time in the operating theater, less time in hospital, faster recovery with less pain. Of course, you haven't removed this point of obstruction theoretically. And what's happened is the research is showing that clearly shorter surgery, shorter time in-house, similar, maybe slightly better results, uh shorter time away from work, just overall, it's worked really well. Now, from my point of view, and I'm obviously biased, I think we should do imaging on many patients. We don't know if those patients had compression between those two bones. It's possible that they had different causes of TLS. Nonetheless, it's really cool to see people so progressive and trying these new things. And I think we're getting into a golden age of TLS where people are working together more. I think thanks in part to us, because we try to connect people, and um, realizing that multiple specialists should be involved with a patient with TLS.

Dr Andrew Greenland 12:59

Thank you. Now, obviously, you're very specialized in this area, and you've talked about awareness has improved. But what's something about this condition, thoracic outlet syndrome, that most doctors are still getting wrong, in your opinion?

Dr Scott Werden 13:12

Okay. I want to be careful and not step on toes. Um, and I have my opinions and I have some facts, but all the facts are not in for sure. So there's a lot we don't know about the disease, and from my point of view, that means we need a rigorous set of standards to move ahead to break some of those log jams. The diagnosis of thoracic outlet syndrome, there's no gold standard yet. The clinical tests don't do it. The MRI, I think, is great, but by itself it doesn't do it. And until we establish that, it's hard to read outcome studies when you have a group of patients that entered the study and they probably have neurogenic TOS, but you're not sure. Now, that doesn't directly answer your question. For doctors, I'm going to share a little bit of history. I actually want to read you a quote. It's one of my favorite quotes to keep me grounded. Uh, Robert Heinlein, a famous science fiction writer, he said, expertise in one field does not carry over into other fields. Experts often think so. The narrower their field of knowledge, the more likely they are to think so. So we get a lot of docs who don't know anything about imaging who will ignore what I do. They don't need it, even though they don't know it. And it's a valuable tool. MRI, there's no radiation, shows tremendous amounts of data. And we know that this area is full of complexity. But there are docs who are just dead fast against it because, whatever reason, they have their dogma. Um, there are docs who still say it doesn't exist or it's disputed. In the late 1980s, I love reading about medical history. Um, there was a guy at the Cleveland Clinic, a neurologist who is very well respected, named Asa Wilborn, and he specialized in doing these EMG nerve conduction velocity tests. As I mentioned briefly before, those tests are often negative in TOS. They're not helpful really in any way. If they confirm it, you probably already have other data. And if they're negative, you probably still think the patient has TOS. But Dr. Wilburne uh said that instead of three types of TOS, arterial, venous, and neurogenic, I'm finding a lot of the neurogenic patients have complaints that are too many territories, and there's nothing I can measure specifically. And the EMG that I do is negative, and they don't have muscle atrophy in their hands. So I'm gonna create a category for those people, which is most of people with TLS. I'm gonna call it disputed neurogenic TLS. Now that's a pejorative word. That's like, yeah, yeah, you're trying to force this on me. It's not an objective word in science, it's not EMG negative neurogenic TLS, it's disputed. Like there's an argument about it created by one man. At the same time, a surgeon in Colorado in Denver named David Roos was doing very well and was being successful with patients with this disease, and he was finding a series of anatomic bands and variation at the junction between the neck and the chest, and he would remove those. And his patients did well. Well, the two of them got into a really interesting argument in the literature. There was one article by David Roos saying neurogenic TOS is underdiagnosed, and in the same article, same journal, there was an article by Dr. Wilburne saying TOS is overdiagnosed, and they argued back and forth. And um, you know, it wasn't scientific really, and it wasn't it didn't open the door for further discussion or consideration. So for many years that I've been in this, neurologists in particular would say, oh my god, TOS, like it was uh what's the QAnon? That's how they would would label it. And that does not allow them to view a patient objectively, in my opinion. Besides the fact it ignores tons of data. There's medical literature out there, as you pointed out, since 1818, Sir Astley Cooper wrote that first paper, but there's tons of literature. I have in my collection like 2,500 papers, which I'm still trying to digest and read through, many of them. And there's no argument that this disease exists. We don't fully understand it. That doesn't make a whit of difference to the disease process. It goes on the way it goes on, whether we understand it or not. So our job is to understand it. So there are docs who um excuse me, they will turn patients away from the idea or turn patients away from their practice. And part of our goal has been to raise awareness. You know, I love what you do. We have a live stream uh we do every few weeks, and we try to bring on guests who are like you, educated and open-minded and progressive. And partly we want people just to know the term. Fortunately, what's happened recently is a lot of major athletes have been diagnosed with thoracic outlet syndrome. So forget science, you know, basketball, baseball, football, those are the important things to people. So Victor Wembanyama, an amazing young basketball player, was diagnosed. Uh, before him, Markel Fultz. Um, there have been several baseball pitchers that can run through names, but one in particular was Steven Strasberg. He was a phenomenon, he was a once-in-a-decade pitcher, World Series MVP. And he had a sad and unfortunate course of potentially TOS. So, um, what we do is when we read about these people being diagnosed, we will write about them and try to help people understand why it's important for the athlete, what the causes are. And it's really helped, I think, raise awareness in general.

Dr Andrew Greenland 19:14

Thank you. Perhaps an obvious question, but with all this sort of conject conjecture and disagreements and argument, what are the bottom line consequences for patients?

Dr Scott Werden 19:24

Yeah, and that's really that boils it down to how do we help patients get over this, get through this. I think patients now with TOS, as I think about your question, I think they're very lucky now. I know it's hard to say that for someone who has a disease that really affects their lifestyle, but there are now young doctors coming out of training, seeing a little bit more, or maybe a moderate amount more, of TOS than they ever did. I don't know about you. Did you learn about TOS in medical school?

Dr Andrew Greenland 19:56

Probably for about five minutes. Okay.

Dr Scott Werden 19:59

I've spent 25 years, so you're faster than me. Um yeah, I think there are surgeons coming out with more experience now. I don't see more neurologists. Maybe that'll change later. Let me read you another quote that I pulled out. Excuse me. Um, I'm really into paradigms. You know, the same set of facts viewed by two different people uh can have two different outcomes. Uh Thomas Kuhn wrote the paradigm shift. And I remember I was in a coffee shop once chatting with someone next to me, I didn't know about that. And a third guy piped in and he said, you know, you don't change anybody's mind. They just retire or they die, and that's when the paradigm shifts. And and I just found this quote recently by um Max Planck, famous physicist. He said, Science advances one funeral at a time, which I think is so true. Some of these people hold this dogma so tight. Um, there's a surgeon I know, vastly experienced surgeon in TOS, really nice man, cares about his patients. Perfect. He and I were on a steering committee of a nationwide research protocol uh that was being submitted to the NIH. And we're trying to figure out how to set this up to include all the possible tools that could diagnose TOS. And nobody wanted imaging outside of an X-ray. Now, it was all surgeons and one radiologist. And so, of course, my one vote didn't carry any weight. But this really nice man, this surgeon would argue with me on the phone in front of everybody else. And I would bring up things like, look, you're a surgeon, you're altering or removing tissue. Are you telling me there is magical tissue that we can't see on MRI that you can see at surgery? And if you tell me what it is, I'll find a way to see it and view it. And it devolved to the point where he just said, You know what, Scott, you just don't you don't understand. Which he can't even give up his dogma and discuss it because clearly there is no magic tissue.

Dr Andrew Greenland 21:59

I've

Dr Scott Werden 22:00

Changed my protocol many times because I learn from the surgeons. I go observe surgeries when I can. I try to pick people's brains because there's so much we don't know, and because I believe that we will find the answer together, multi-specialty. So, yeah, so it so it's interesting that the human side of science, that people have decided what the science is. They'll use the facts that support their viewpoint and they'll put their fingers in their ears when they get facts that dispute their viewpoints. I find it fascinating. And this is why there are plenty of examples in medicine. You you probably know about uh Robin Wharton, the guy in Australia who thought that uh Helicobacter caused gastric ulcers. Okay, for decades, no one would buy it. And um he published papers, no one believed it. And then he had his assistant, Barry Marshall, another physician, actually swill down some Helicobacter, develop an ulcer, and then the ulcer went away when he received antibiotics only. And they eventually, in 2005, won the Nobel Prize for that. But something as simple as that, why couldn't doctors keep their minds open to say, well, it sounds far-fetched, but okay, let me look at the data. So, same thing with TOS. So the human side of science is fascinating to me. For patients, uh, as I said, I think it's a golden age. I think we get a lot of patients who reach out to us because we've changed our protocol. We don't reach out to doctors nearly as much as now we reach out to patients because it seems like our goal and our place in the universe is to do that, to raise awareness, to educate people, and then to get them to the right place. And now every year there's a few more TOS specialists coming out, and we can refer patients to them in different parts of the country. So for patients, uh the biggest hurdle in their way is not having heard the term thoracic outlet syndrome. Once they have, then they can move forward.

Dr Andrew Greenland 23:58

Amazing. So I guess your role is primarily as a diagnostician in this space, but how does it work? Um, how does your consultative role work in terms of sort of liaising with other clinicians and physicians in practice? How does that all kind of work out?

Dr Scott Werden 24:13

Thank you. That's that's a really good question. We try to position ourselves as being a consultant. We advise patients on TOS and educate them in consultation phone calls with me, but we don't step in the way of the clinician who's obviously intimately associated with the patient, has examined them, is the quarterback. That's what we tell a lot of patients. Get one doc who is your quarterback. They'll take our imaging findings, our suggestions, they'll take the orthopedic suggestions, the pain management doc might have done a scalene block, one of those muscle injections. And that quarterback in the middle needs to incorporate all of that. I'm always open to speak to patients' doctors, uh, to tell them what I see on the MRI and share what little knowledge I have. And I think that once the patients get the get their little team together, they make a lot of progress. There's physical therapy that's involved too, which may preclude surgery and often does. And some surgeons are finding physical therapy quite helpful after surgery if the patient does go. I will add in a couple of points here. The success rate of the surgery is usually measured like with a visual analog scale or similar pain scale for patients. Um, at about six months after surgery, about 85% of patients feel good to very good. But at two years, it's about 70%. So there's 30% of patients that don't get better. 30%, and we can definitely do better than that, partly through earlier diagnosis, which is now being shown. Shorter time between diagnosis and surgery has a better outcome. Um, but also in the past, they've always written down that only 10% of patients go to surgery. I haven't seen any new data in a while, and I think it's higher than that. I think more patients are going to surgery than 10%. I think we can do better at um getting that number down if we find better conservative measures, muscle blocks, maybe minimal surgery. Um, some people are doing uh robotic surgery, some people are doing endoscopic surgery, this whole host of things. But my job is I feel in the center. I know a lot about TOS, and I'm glad to talk with patients doctors. I advocate for patients, I advocate for the docs. You know, I just think it's one big kumbaya. We can accomplish a lot if we work together.

Dr Andrew Greenland 26:37

Do you think healthcare needs more of this kind of deep subspeciality collaboration, thinking more widely?

Dr Scott Werden 26:43

Well, I'm in a tiny corner of the world, Andrew. I mean, my my corner of the world is just this tiny little disease. And because I'm partly OCD, um it brings me satisfaction to learn more about it. I've loved anything since medical school, since I was a kid. I had one of those, they called it the visible human. It had a clear outer shell and it had all the bones and the organs inside that you could take out. So TOS is an ananimous dream. There's so many variations, so many complicated structures that I'm always learning. So that's for me. Um, I think the the role of the primary care doc is critical. I was just mentioning a quarterback for a TOS patient. Well, you know, my primary care doc, which I saw a couple days ago, is my quarterback. If I have this report from this study and I'm taking this medication and might need to be changed because of my blood test from this source, you know, that's the guy or the gal. Uh, I'm a doctor, and you know, I don't know what he knows. He's got this broad overall picture. My personal opinion would be there's always going to be a place for these hyper-specialists for those challenging diseases, but we should be working within the milieu of uh, you know, people who see the broad landscape. You know, human beings are complex.

Dr Andrew Greenland 28:01

So thinking about um your practice and your more of a uh the business side of things in terms of what you do, what does a typical day look like for you right now? And I guess there's no such thing as a typical day in this space, but I'm just trying to get some sense of how things pan out for you.

Dr Scott Werden 28:15

Well, if I'm lucky, I get to do a podcast, you know, spreading the word. Uh and thank you for that opportunity. It's really, I'll just remind people your podcast is great. Listen to some episodes, you do a great job interviewing people. Thank you for that opportunity to be a part. Um usually, boy, my days are pretty um typical day. Typical day is my dog hearing mailman outside. Okay. Uh typical day, you know, I spend a lot of time trying to make sure I've got the latest papers that I can and download them. And I'm trying to build this relational database using uh Obsidian and some other software to take notes from these PDFs, and I'm trying to learn more in all these different areas. Uh, I spend time on the phone with patients. I spend time with my admin person. It's just two of us, really, and we have to juggle a lot. Um, when I have studies to read, and I don't read that many studies, it's you know a couple a week, but those take me a couple hours to read through each one, generate a report, get it back to the doctor. Um I think the best parts of my job are interviewing patients. We get lots of follow-up from patients. We have one guy, really nice guy, is a minor league, high minor league pitcher trying to get into the big leagues and been through a lot. And he constantly sends notes. This is my progress, this is happening, but now this is happening. And so I feel like number one, it's great that we're making progress with a guy with a challenging condition. Number two, I'm learning some more from hearing what his other doctors have done. And number three, I've got to solve some problems myself, so I have to research. Um, so I'd say it's a mix between reading studies, doing uh some of our awareness things like our live streams or social media, which I'm still learning about, um, talking with docs, talking with patients, and uh trying to move some research forward. I've got too many ideas and not enough time to write them.

Dr Andrew Greenland 30:09

Got it. So, which which are the challenges or bottlenecks that are most impactful right now? I mean, I think you've alluded to a few things, but what are the things that really get in the way for you?

Dr Scott Werden 30:21

I don't have enough man hours to handle like emails and admin stuff. I wish I could spend 100% of my time uh putting these papers together, digesting them, and starting to write on the data that we have. I can I think I've got a lot of data that I want to get out to the world. You know, in an academic setting, you get paid if you get grants and you're paid for your time to do that, and I'm not. So keeping the business afloat is harder than I thought. And um, it's just it's labor love instead of buying a sailboat, I guess, to put my money into this, uh, which brings me more pleasure. Um, yeah, I need more time, I need a longer day. I I love doing what I'm doing, I could spend 25 hours a day doing it. Um bottleneck, yeah. We we've got plenty of tools nowadays with computers and stuff, so we can do amazing things. It's really time and man hours.

Dr Andrew Greenland 31:16

So thinking about the next sort of six to 12 months, what are your plans for what you do over the next year or so? Is anything on the cards?

Dr Scott Werden 31:25

I didn't expect that kind of question. Let's see. You know, because I'm busy day to day with never a typical day, I don't think that far ahead. We are trying to plan a couple of things I don't really want to go into detail about spreading our word more using social media and uh getting my face out there. Um we are trying to get in closer with some high-level athletes. You know, it's a very closed community. Um, one of the people who came to me, who's a professional athlete, uh, said he had two choices of surgeons, and um he didn't like either one. I said, Well, I've got tons of other surgeons I can refer you to. You can check their website, talk to them, they have different approaches. Said, no, in my field, all the athletes are expected to go to one of these two surgeons. And so that that political part is difficult. We'd like to get more involved with some of the sports because we think we can help. And we think that these players are unique, they're so highly skilled, they're so finely tuned, they should have the best. You know, my MRI doesn't cost that much, and I've been doing this 25 years, my friend. It's you know, I can see things that should be seen. Um, and I can help at very, very, very low cost and risk to the this these athletes. So I'd like to be more involved in the athlete in the athletic world. We work with college athletes now, uh, but the pros, it's harder to get to. And then I'd like to write papers with some of my my colleagues around the country, some people who I think know so much and they're such nice people, they care. Almost every TOS specialist cares so much about people because this is a challenging disease. So I'd like to be able to share some of my data and write some papers with those people. That would be a good plan for the next six to twelve months. Wonderful.

Dr Andrew Greenland 33:20

So if all this um publicity and awareness works really, really well and you have a sudden influx of new patients, what would happen? There's only one of you from what you're saying. Um what would happen? And my kids are grateful for that. And hopefully nothing will break, and that includes you. So, what would happen?

Dr Scott Werden 33:39

Well, I can definitely spend more time. I have a second job where I work full-time as a radiologist, and I can take more time away from that. Um what I'm trying to do, you know, business-wise, which I'm not trained at all, is to balance the revenue with the people that we hire to help us out. And if I had more uh revenue, I know this sounds terrible, but you know, with more revenue, I can hire more people and get those man hours to handle the stuff that's not necessary for me. My business operations guy, Herb, has been with me forever. He's such an evangelist. He just thinks we're doing something really good in the world, and he thinks that's really good for our soul. And so he works endlessly for me. And I've only got one of him. But he's always telling me he's got to protect my time. I have to do the critical stuff, and we're not there yet. So I can read more studies, I could write papers. Um, I think that just if we progressed, if we had an influx of people, business-wise, I'd be able to get more help to allow that. I know that sounds kind of dry, but welcome to the world today.

Dr Andrew Greenland 34:44

And you've had a very interesting career path and journey, and I'm really impressed by your level of specialization and knowledge in this area. But if you were starting your career again tomorrow, would you do anything differently?

Dr Scott Werden 34:59

You know, internal medicine training was valuable because the clinical skills to understand the physical exam and how you work up a patient was valuable. But I probably would have done it one year instead of the full three years. I also, believe it or not, I was I was a dropout in school after high school. I dropped out and I spent several years away. So I would go back, wish I could get those years back and start some things earlier. The TOS thing, if I could, I'd just start it earlier. It's fascinating to me. I love doing it despite the little business challenges and patients who have a huge emotional burden because they're in a lot of pain and they need help. Um, it's just it's just really rewarding. It's it's great to be able to help somebody regain their life. That's a wonderful feeling. So I would put more time into that earlier if I could redo things.

Dr Andrew Greenland 35:50

And the final question I would ask you about the next year, but thinking even further into the future, which is always impossible to do, what do you think real progress would look like for patients with TOS over the next five to 10 years?

Dr Scott Werden 36:02

I would say to just increase the rate at which we're progressing, there are some really great progressive people coming out now from training. There are some older folks who are really progressive who have been in the field 10 or 20 years. If we stay the course and increase the rate of getting these people together, having the specialists meet each other, having the specialists work together on patients, getting some real data, like a solid diagnostic criterion for this patient has it and this patient doesn't, I think we'll do great for patients. We'll understand the disease so much better. I think it's already happening. I think some of the people that I get to work with are amazingly bright, amazingly dedicated. That's another part of my life that I'm you know thankful for, besides helping patients. They get stimulated all the time by these great people. So the final part would be raising awareness that more people know about TOS and they don't have to go through four or five doctors before somebody suggests the diagnosis. So um raising awareness, uh maybe through sports and athletes, but just spreading the word so patients get diagnosed earlier, they get treated earlier, they get treated better with more progressive things that we're learning about different types of treatment, different types of surgery, different types of physical therapy. And that would be um if I am on my deathbed and I look back, my number one thing would be my family, but my number two thing would be have we helped enough patients, you know, with TOS and change the world a little bit.

Dr Andrew Greenland 37:30

Scott, thank you. This has been such a fascinating conversation. I mean, one of the reasons I started this podcast was actually to build a global network of specialists, people doing exactly what you're doing, so that when patients need the kind of help that falls outside my expertise, as an example, I know exactly who to connect them with. So I think your work is a great example of how powerful that kind of collaboration can be. And I'd like to thank you so much for joining me and sharing this conversation today.

Dr Scott Werden 37:53

I really thank you for your time and for inviting me. Thank you, Andrew.