Investigating the Underpinnings of Diagnostic Delay in An Adolescent Hip Disorder: Lacey Smith Joins the COMET T-32 Program

Lacey Smith’s enthusiasm for taking a multifaceted approach to understanding interconnected systems started in college as an Anatomy & Physiology Teaching Assistant. After a lifechanging fellowship in Thomassique, Haiti, Smith was inspired to pursue medicine with a focus on health equity. Now a T-32 pre-doctoral fellow at OrACORe, Smith is redefining what it means to pursue a career in orthopaedic surgery by conducting research that combines medicine and health equity. In this blog post, Smith recounts the experiences that led to her current investigation of the socioeconomic underpinnings of diagnostic delay in a bone disorder prevalent in adolescents.

The Road to OrACORe

Lacey Smith relocated to Haiti in 2016 with a strong interest in public health and medicine. As a global health fellow engaging in both public health programming and the day-to-day patient care in a rural health clinic, the through-lines between patient advocacy and healthcare led Smith to envision a future in medicine. “The universal need for health—treatment of any and everyone, and the ability to look at everyone and see their humanity—is what excited me about a career in medicine,” said Smith.

“The universal need for health—treatment of any and everyone, and the ability to look at everyone and see their humanity—is what excited me about a career in medicine”

Lacey Smith

In 2018, after 13 months in Haiti and another year spent obtaining her master’s degree as a Mitchell Scholar in Maynooth, Ireland, Smith matriculated to Harvard Medical school (HMS). “I arrived with the goal of becoming a primary care physician because I wanted long-term engagement with my patients, a working relationship where they knew I would be with them through moments of pain and discomfort.” For the first 2 years of medical school, Smith recounts being certain of a path toward primary care. However, during the tail end of her clinical year, she found herself intrigued by a completely different field. During an emergency department shift, Smith encountered a case of a Nursemaid’s elbow, a joint displacement in the elbow, in a young child. “I remember how uncomfortable [she] was, and how worried her parents were,” Smith recounts. Fortunately, a Nursemaid’s elbow can be rectified non-operatively, and Smith’s attending was confident that she could reset the displaced elbow. “Reducing the elbow that day was a pivotal moment for me because it provided the encouragement I needed to explore a specialty that focused on musculoskeletal disorders,” she recounts.

As Smith continued to delve into Orthopaedics, she discovered how self-sustaining the operating room (OR) was. “Spending time in the OR wasn’t something I imagined doing before, but the more time I spent working with my hands, the more I realized I could not envision a career without it. In clinic I simultaneously realized that I could still continue to walk alongside patients in the same way I initially set out to do with primary care.”

A Bridging of Interests

Once settled on Orthopaedics, Smith set her sights on immersing herself in orthopaedics research. She connected with Dr. George Dyer, an orthopaedic surgeon as well as the Program Director of the Harvard Combined Orthopaedic Residency Program, who encouraged her to apply for the T-32 fellowship where she would be under the mentorship of Drs. Katz and Losina. Upon her entrance as a pre-doctoral fellow, Smith began her research on the socioeconomic factors associated with diagnostic delay in slipped capital femoral epiphysis or SCFE (pronounced “skiffy”). SCFE, a bone disorder commonly found in children and adolescents, occurs when the femur shifts in relation to the femoral head, resulting in progressive deformity, a reduction in mobility, and pain. The disorder can be destabilizing, both physically and emotionally for young people and can have long-term consequences such as premature osteoarthritis of the hip. SCFE holds specific importance to Smith because of an experience she had while working in a clinic. “SCFE is often a missed diagnosis, and my team and I missed the opportunity to both pursue imaging and diagnosis discomfort in a timely manner,” said Smith. Although this missed opportunity was disappointing, it prompted her to investigate the underlying features associated with diagnostic delay in SCFE. Now, Smith studies diagnostic delay in SCFE with a close lens on communities vulnerable to inequitable care where disparities in the diagnoses of disease may exist. “Structural drivers of inequity continue to impact the health of communities, and the health of children. It’s important to me to have my research grounded in pursuing health justice and thereby racial justice” she said.

On the topic of mentorship, Smith points to the invaluable mentorship she’s received from Drs. Katz, Losina, and Dyer throughout the research process. “They [Drs. Katz, Losina, and Dyer] were pivotal in helping me frame my question, and I cannot overstate how generous they’ve been in lending me their knowledge and encouragement.” As Smith puts it, the T-32 fellowship has transformed how she sees herself as a current medical student. “The T-32 has challenged to be intellectually creative, in a way I haven’t been in some time. In medicine you don’t want to lean heavily on the idea that pre-established problems have pre-established solutions, but it can be easy to fall into that routinized mindset. Doing independent research strengthened my ability to carefully evaluate complex scenarios and to consider innovative approaches. What I’m learning about research through this fellowship is shaping the way I see myself practicing medicine.”

“The T-32 has challenged to be intellectually creative… doing independent research strengthened my ability to carefully evaluate complex scenarios and to consider innovative approaches. What I’m learning about research through this fellowship is shaping the way I see myself practicing medicine.

Lacey Smith

A Path Forward

After completing her research year as a T-32 trainee, Smith will return to her fourth year of medical school and will continue to shadow Dr. Dyer in the operating room. She plans to also continue participating in away rotations in orthopaedics and looks forward to coordinating the Haitian Annual Assembly of Orthopaedic Trauma conference in 2022.

After her final year of medical school, Smith will apply for residencies in orthopaedic surgery. She pictures three components to her future career: A focus on health care justice, global health, and her clinical practice. Smith’s strong interest in incorporating global health into her career is a direct result   from her experience in Haiti. “I care deeply about the communities of Haiti, both there and in the United States, and I hope to continue to be involved throughout my career in a sustainable way. Whether that looks like advocating in support of orthoapedic surgeons in Haiti or propelling the voices of Haitians forward, I’m looking forward to being a part of that work.”

For those interested in a career in medicine or research, Smith offers some salient advice— “While you’re working toward your career goal, make sure that your life is also centered on the multitude of things you’re passionate about. I love medicine. I also love my friends, baking bread, being outdoors, and learning languages. I would have never thought I’d be speaking Haitian Kreyòl in the United States, but pursuing that interest is now shaping how I connect with community members and patients here in Boston. Continue to nurture your various interests. The experiences that come from doing so will always add to your career aspirations and satisfaction.”

To learn more about the COMET T-32 program, click here.