A child is not a little adult—and a general orthopedist isn’t a pediatric sports medicine specialist. But Dr. Mininder Kocher, Associate Professor of Orthopedic Surgery at Harvard Medical School, is.
Born in Rochester, New York, there was no getting around science in this family. “My parents, originally from India, came to the U.S. in the 1950s to pursue their education. My dad, a professor of thermodynamics, and my mom, an elementary school teacher, pushed hard in terms of education and were especially interested in seeing me pursue the sciences. I spent time in my dad’s lab when they were doing early computing work. We ended up designing a Pinewood Derby car on the computer, building it with his lab guys, and even testing it in their wind tunnel. I’m proud to say there was not a right angle on that thing.”
Instead of thermodynamics, however, a young Minider Kocher approached the sciences from a different angle. “It almost seems de rigeur for orthopedists to have suffered an injury in their youth. In keeping with this, yes, I tore my meniscus in high school, which led to my first exposure to medicine. The famed Dr. Ken DeHaven at the University of Rochester performed my surgery and stoked my interest in orthopedics. I thought it was amazing that a patient could injure something and lose something so important to them—in my case, basketball—and then have a competent person do an exam, determine what’s going on, and then just fix it. They make it possible for you to regain what you lost.”
Finding His Groove in Medical School
After regaining the ability to play basketball and then attending Dartmouth as an undergrad in the same fraternity as Ken DeHaven, Mininder Kocher then headed to Duke University. “Not only did I revel in the OR, but under the guidance of Dr. John Feagin, I became amazed by the form and function of the knee. Dr. Feagin arranged for me to do a rotation in Jackson Hole, Wyoming, where he was running a ski clinic. It was thrilling to see the knee injuries right as they came off the mountain, and then learn from Dr. Feagin exactly how to do a thorough physical exam.”
And what was the primary takeaway from Dr. Feagin? How to take down the walls. “To this day I use Dr. Feagin’s suggestions about how to put patients at ease. It really helps to distract them by talking about something that matters to them…that way their body/knee/shoulder relaxes and you can do a better exam. He also rightly stressed the importance of the pivot shift exam in measuring rotational instability.”
For all of the science floating around him, selecting a specialty was anything but scientific. It had to do with jumping…for joy, that is. “After finishing medical school in 1993, I headed to the Harvard Combined Orthopaedic Residency Program, where I rotated through Massachusetts General, Brigham and Women’s, Beth Israel and Children’s Hospitals. My main sports medicine interest was the knee—until I rotated at Children’s with Dr. John Hall. I was in awe of taking care of children, and my wife confirmed my enthusiasm when she said, ‘Have you noticed that you jump out of bed in the mornings when it’s time to go to Children’s Hospital?’”
But knees made him jump as well. “I was in a quandary because I liked pediatric orthopedics and sports medicine. It was Drs. Jim Kasser and Lyle Micheli, both of Children’s Hospital Boston, who made me realize I could do both. So I stayed at Harvard for an extra year, became chief resident, and did a fellowship in pediatric orthopedics. The fellowship gave me a solid understanding of pediatric orthopedics, as well as growth and development. It was becoming clear that if I wanted to do pediatric sports medicine I needed to have credentials within both disciplines.”
And what better place to acquire the sports medicine credentials than Vail’s Steadman-Hawkins Clinic? Dr. Kocher: “During my time at Steadman-Hawkins I developed arthroscopic skills and gained great insight into how to interact with patients. That experience cemented my interest in pediatrics and adolescent sports, and I was very excited to take emerging technologies and bring them to kids and adolescents.”
Leading the Field
Given the trends in youth athletics, he might even be using that emerging technology on a seven year old. “In prior years we thought that children didn’t get major injuries, but that is changing. I do 675 operations a year, most of which are pediatric and adolescent patients. Youth sports have really changed as children are now playing with greater intensity and are physically bigger. Another shift is that kids are focusing on a single sport now, sometimes by middle school. They play one sport all four seasons, which has meant a skyrocketing injury rate…it’s actually three times higher at games than at practices. While the old paradigm was a Michael Jordan who crosstrained in three sports, we now have a Tiger Woods paradigm where you take a three year old and have him or her focus on one thing.”
Go ahead, Johnny…you can do it.
Yes, ” says Dr. Kocher, “much of this solo sport issue is parent driven. He jokes, “I see about 120 patients a week and 119 of those are ‘elite’ athletes. I say to these parents, ‘Look, I care about your child getting back to play, but we need to think about what he or she is going to be like five years from now.’ Usually I can get parents to get on board with longer term thinking.
Backing him up in these and other conversations is his extensive knowledge of epidemiology. “While in residency, Dr. Matt Liang, a rheumatologist-researcher at Harvard, got me interested in clinical research methods that weren’t being used in orthopedics, namely prospective cohort studies, decision analysis and survivorship analysis. I began to take classes toward a masters degree at the Harvard School of Public Health, and focused on developing a prediction rule for the irritable hip in children to differentiate between septic arthritis and transient synovitis. Not only did this work get me hooked on clinical research, but it was published in the Journal of Bone and Joint Surgery and won the Kappa Delta award.”
Toe, tap, or tackles, Dr. Kocher is ready. “I am happy to have participated in the growth of our sports medicine division. This, the first pediatric sports medicine program in the US, was established by my partner, Lyle Micheli in 1974. We now have five orthopedic surgeons, 10 primary care sports medicine doctors, two sports podiatrists, a sports nutritionist, a sports psychiatrist, and three physician assistants. We manage to cover 50 high schools in the Boston area, several colleges, and organizations like the Boston ballet and USA Track and Field. In part we are able to do this because of our three fellows. They are part of our one year, combined sports medicine program that is focused on pediatric sports medicine. It is approved by the Accreditation Council for Graduate Medical Education and each year receives approximately 100 applications.”
Advice for Aspiring Physicians
For those interested in emulating such a path, Dr. Kocher advises, “It is vital to get the message out that young athletes are different than adult athletes. To do this you should be prepared to give ongoing presentations to other medical professionals, as well as parents. As for the structure, it is important to have the service be not just sports trauma surgery, but to be multidisciplinary within sports medicine. For example, we have a concussion clinic, a bone clinic, and a young adult female clinic, among other offerings. Orthopedic sports medicine groups tend to focus on surgery, but some are starting to have primary care doctors—a good thing because they are integral to things like patellofemoral pain and overuse injuries.”
“Some of my other work involves looking at outcome instruments that are used in adults and adolescents, but not validated in adolescents. Interestingly, we have found that kids often don’t understand the questions (the terms catching or locking, for example). I’m doing this work through the International Knee Documentation Committee of the American Orthopaedic Society for Sports Medicine (AOSSM); we will present our findings at AAOS this year.”
There are advocates for slow food and slow living…Dr. Kocher champions slow orthopedics.
“My team and I are involved in randomized trials of supracondylar elbow techniques, i.e., casting versus pinning. In addition to the cost challenges, it is hard to get patients to participate because they are not interested in being randomized. Another major issue is time…in this field we are adopting new technologies at a faster rate than we can document their effectiveness. In the middle of our randomized femur fracture trial there suddenly appeared new ways of fixing femur fractures. It is hard to keep up…and not necessarily good for patients either.”
On the society front, Dr. Kocher serves on the board of the American Orthopaedic Society for Sports Medicine and the Pediatric Orthopaedic Society of North America, and was elected as a member of the Herodicus Society. “Herodicus is a unique sports medicine think tank. So many meetings we attend involve presenting things, but this organization allows us space to discuss a concept or a problem. For example, now double bundle ACL reconstructions are a hot topic…six years ago the Herodicus members were talking about it in conceptual form.”
And while his family is a hub of sustenance, it’s not a source of repose. “My wife Mich and I met on a Dartmouth biology study program in Costa Rica in which we lived in tents for four months. Our adventures only continued from there, as she went to Duke and obtained a masters in civil engineering and we went on to have five children: an 11 year old girl, a 10 year old girl, a 7 year old boy, a 5 year old girl, and a 9 month old boy. In the winter ‘team Kocher’ goes to the slopes where my wife, a former ski racer, engages in her passion. We also love taking the kids kayaking, hiking and camping.”
“My activities are a bit more limited nowadays as I tore my achilles tendon two years ago and suffered a shoulder injury last year. These injuries meant that I had to stop playing adult league basketball; I do coach now, however.”
