Dr. Christopher Bono

While many high school seniors are worrying about the prom, Dr. Christopher Bono, Chief of the Orthopedic Spine Service at Brigham and Women’s Hospital in Boston, was preparing for a career in medicine. This native Brooklyn boy was accepted into medical school in his senior year of high school. Of his early family life, Dr. Bono says, “My dad was born in the U.S., but my mom was born in Sicily. Our roots here in the States are in a densely Italian American neighborhood where street festivals and celebrating saints’ days were the norm.”

The Bono household frowned on an excess of merriment, however. There were other, more academic, matters at hand. “My dad taught high school math and my mom was a secretary; both emphasized education. But it was my grandfather whose life really influenced me in that regard. In Italy he had been an air traffic controller, but once he came to the U.S. the only job he could find that paid well was that of a longshoreman. It was quite an adjustment for him…at the age of 36 he had never done manual labor. He was tireless in his efforts to convince me that I needed to excel in school, something that wasn’t very common in my neighborhood. I listened to him, and decided to pursue my interest in science and math.”

The measuring, cutting, and hammering that ran in the family veins would also help. “Many of my dad’s family members were carpetlayers and my paternal uncle was a master carpenter. One day when I was 15 I was watching PBS when a show on knee replacement came on. ‘I can do that. We have the tools in our garage, ’ I said a bit arrogantly. My future flashed before me and I began to think seriously about medicine as a career. I was a babe in the medical woods, though, because at that time I didn’t even know there were different kinds of surgeons.”

Now about that early, early acceptance into medical school. “I got the chance to participate in a special New York City initiative, the ‘Brooklyn College Downstate Seven Year program.’ It consisted of three years of college, followed by four years of medical school at Downstate. After entering medical school I came to find that I wasn’t a good candidate because of my grades. I persisted, however, and turned to Dr. Paul Tornetta, then a first year attending at Downstate. A few seconds of his time—and his belief in me—would alter the course of my life. In desperation I meekly went into his office one day and said, ‘Do you think I can get into an orthopedic residency?’ His reply was short, but confident: ‘Do a research project with me and work hard on your rotations and you will get in.’ Thank you, Dr. Tornetta.”

Full of zeal for orthopedics, Christopher Bono began working with his new mentor and set about applying to residency programs.

Things clicked at the University of Medicine and Dentistry of New Jersey [UMDNJ] and I began there in 1996. I had an absolutely great time in orthopedics and was really pleased to find that the surgeries felt very natural. I can honestly say that from an early point I felt as comfortable doing an operation as I was doing almost anything else in life. While I had struggled through the first two years of medical school—in part because I was not interested in electrolytes and the like—I couldn’t stop reading about orthopedics.

“Dr. Fred Behrens, the Chair at the time, was my most significant mentor. He was a rock of a man, and inspired me to be a thorough researcher, a dedicated orthopedic surgeon, and a balanced person. When he saw me working so hard as a resident and taking my vacations in the lab, he cautioned me to ‘smell the roses.’ My research during this time ended up being one of the most significant of my career, namely, a meta analysis of lumbar fusion outcomes. Despite meta analyses being unpopular at the time, along with the fact that I had no statistical training, the work was well received by several societies.”

Then a prior meeting opened a door that was nearly closed. “I had met Dr. Steve Garfin in my second year of residency, at which time he asked me to call him when I was ready to look for fellowships. When I finished UMDNJ in 2001 in fact he had stopped taking fellows into his program. He took me anyway; the year was nonstop work, as modeled by the incredibly energetic Dr. Garfin. He absolutely loves spine surgery and is a supremely compassionate human being. In the middle of the fellowship I was vacillating about spine surgery; 9/11 had hit that year and I was worried about my family. I told Dr. Garfin that I needed a week off, something unheard of. He allowed me to take this break; I spent time with my family and then came back refreshed and ready to fully dedicate myself to spine.”

Then Dr. Bono found out that confidence, a good team, and perhaps a textbook in the OR can take you a long way. “Drs. Paul Tornetta and Tom Einhorn, both at Boston University (BU), convinced me to join their team. While I wouldn’t trade the experience for anything, in retrospect it was a difficult place to start a career. I was a young spine surgeon without any other fellowship trained spine surgeons on staff. I took an outrageous amount of call, something necessary in part because BU was an indigent hospital and was the ‘last stop’ for many patients. While I was well prepared from my fellowship, it was still challenging to figure out how to handle the complications and indications, especially if it was a type of case that I had not done before.”

“For example, we had a patient with a tumor, something I hadn’t encountered much in my fellowship. There was a resident and an approach surgeon, the latter of whom was unsure about how to do a thoracic exposure for spine. He was actually reading an approach textbook in the OR before the operation. It all comes down to having confidence but not overconfidence; you should always ask yourself, ‘Am I seeing what I think I’m seeing?’”

Wanting more company and less call, Dr. Bono left Boston University in 2006. “Brigham and Women’s Hospital had been recruiting me, and I was really pleased because at BU there was little room for spine collaboration. I was an island. At Brigham I was made Chief just four years out of fellowship, and had a research coordinator and a physician’s assistant. I also had the opportunity to collaborate with Massachusetts General researchers on spine projects and a spine fellowship.”

While he makes no claims to be a psychiatrist, Dr. Bono is savvy enough to realize that knowing what’s going on inside a patient’s head affects what he does—or doesn’t do—in the office and in the OR. “I am very proud of my current project, which involves looking at the influence of pain on patients’ decision making with regard to spine surgery. We surveyed 150 patients who had no previous spine surgeries and tried to determine the threshold of how much pain they had versus what compromises they would be willing to accept. We found that those in more pain accepted more risk and less favorable outcomes. Interestingly, higher educated women are less risk tolerant compared to higher educated men. Also, whites were found to be more risk tolerant than nonwhites. Going forward we will look at whether this new survey instrument was predictive of a patient’s decision to have surgery or not.”

Dr. Bono, known as a critical reviewer of the literature, is the Deputy Editor for orthopedics for The Spine Journal. Dr. Bono: “Another interesting study I have done is a meta analysis looking at 20 years of lumbar fusion outcomes. We compared instrumented to noninstrumented fusion and without knowing it, found things that were predictive of what was going to happen. The outcomes of lumbar fusion in the literature are actually not improving, despite all of our new gadgets and hardware. Also, we found that the degenerative diagnosis influenced outcomes. There are prospective studies showing that if there is a lumbar fusion done for degenerative stenosis versus lower back pain then the outcomes are different. Based on our study, as well as others, the government has picked up on different diagnoses resulting in different outcomes. They have in fact used this information to help guide what procedures will continue to be covered and which may potentially not be covered in the future.”

Dr. Bono knows that the best use of data is to get it off the pages and into action. As a board member of the North American Spine Society (NASS), and Chair of its Committee on Professional, Economics and Regulatory Affairs, Dr. Bono is a direct liaison between insurers and NASS.

We review policy changes from insurers, something made easier now by the fact that the insurers are listening to us more. In the last five years NASS has gained a significant amount of credibility; in the past, if a payor asked about a procedure the NASS response was always, ‘Pay more.’ Outcomes were never mentioned. Now, when we respond to policies, we use the best available evidence to support a reasonable rationale.

He may just take the same approach on the home front. “I often like to take my wife and three children to society meetings. Of course, the children want me to lay out for them the activities that are available beyond dad’s lecture and cadaver events. When not roaming to conferences, we see my parents, who live in New Jersey. Just spending time together as a family is fantastic…and I squeeze in time at the gym when I can.”

Dr. Christopher Bono…fusing science and the art of life.