Thursday, June 27, 2013

185 Orthopaedists Walk Into a Bar...

I have a friend who does improv in New York City, and she told me about the traditional “walk into the bar…” joke or as they call them “185 jokes”.  The jokes are always along the lines of 185 something or other walking into a bar and being refused service.  The punchline, fast and furious, is generally groan-inducing.  A recent contribution from her goes like this:

185 Scoliscore tests (gene test for scoliosis) walk into a bar.  The bartender says “We don’t serve your kind here.”

              The Scoliscore tests respond, “Well, that sure threw us a curve!”

This month, June, has been Scoliosis Awareness month as always.  I have had the experience of giving four talks, writing three papers and two articles and being interviewed twice on media, always about scoliosis and mostly about Scoliscore, which I am championing.  Earlier articles in my blog have discussed the test which can determine the prognosis of a mild to moderate scoliosis with up to 99% accuracy, making it one of the most effective prognostic markers currently available in clinical medicine.

One of the reasons I have had this luxury is my self-imposed (and hopefully temporary) sabbatical from clinical care.  In three months, I have not seen a single patient (which has been unquestionably painful) and have not done a single surgical operation, which has been surprisingly refreshing.  Being out of the OR has allowed me to reflect on medical care from an entirely different perspective than my previous busy surgical practice allowed.

Doctors are an interesting lot.  We tend to define ourselves very strongly in terms of the composition of our practice.  We place ourselves by geography (“urban” vs. “rural”), by referral pattern (“primary” vs. “tertiary”), by complexity of the patient we see.  Surgeons, that most superstitious of groups, tend to define ourselves by surgical parameters – how busy are we, what is our caseload, what types of surgery are we comfortable with and what will we refer out?

The old adage from residency days is “a chance to cut is a chance to cure.”  But being outside of the surgical sphere made me realize that surgeries actually define a failure of a kind; the failure of non-operative treatment.  And in the bustle of being a busy surgeon, we run the risk of losing sight of the patient attached to the surgery.  No surgeon defines him or herself by the number of clinic patients seen, or the number of times that operative care was not invoked.

Humans also tend to define themselves in broad categories.  When it comes to medical care, they will often group themselves by their diagnosis, and will often carry the stigmata that go along with that diagnosis.  In adolescents and children, that is a particular issue, since placing yourself in a “diseased” category makes you somehow “other” or “different”.  Scoliosis is particularly pernicious in this regards.

Thinking, writing and speaking about Scoliscore through the eyes of a non-surgeon as much as I have over the past several months has led me to see the strengths of the test differently.  To be sure, a high score is very helpful.  It can define referrals and govern treatment plans.  It can give the doctor and patient a chance to explore more aggressive treatment options up to and including surgical intervention.  There is that surgical angle again (no scoliosis pun intended).

But the low score is inarguably most important to the patient.  With a 99% negative predictive value (only 1% or less of kids with the low scores will progress to need treatment) it will remove the fear and the stigma of having the diagnosis.  A child with a low score does not need to define herself as having “scoliosis” at all, since it so unlikely that there will be any consequence.  She can go on to other more congenial definitions like “preppy” vs. “Goth” or “athlete” vs. “artist”, and fit in more readily into the difficult vagaries of adolescent society.

 So, 185 low-risk Scoliscore tests walk into a bar.  The bartender says, “We don’t serve your kind here.”

The tests say, proudly, “We are not a kind.  We are as individual as anyone else in this bar. Serve up the drinks!”
That little effort would surely get me booed off the improv stage, but for a child with the diagnosis of scoliosis, it is surely a punchline to be cheered!


  1. Do you have contact information you can provide? We were about to schedule our daughter's surgery with you before you left active practice. We are looking for a recommendation for someone else you would highly recommend. Any help would be GREATLY appreciated.

  2. Thanks for all you did for my daughter Ashley. You treated her from 2005 till 2010 after an auto accident. Due to multiple injuries she needed several surgeries. She was better after each surgery and we never regretted a single one. As a recent graduate with a degree in special education, she will be applying this winter for acceptance into an occupational therapy program. Ashley desires to work in a hospital with pediatric patients after surgery. Again, thanks for the care you gave her and so many others.

  3. Dr. Mankin, A friend of mine referred me to your practice and I am so sad to see that you are no longer practicing. From the blog contents – it seems you are exactly the type of physician we would want for our 16 year old daughter, Erin. Erin was diagnosed with Tuberous Sclerosis (TSC) 3 years ago at the age of 13. She had a couple large subenpendymal giant cell astrocytomas (SEGAs) that required immediate surgery and then we learned that she was born with a genetic disease, TSC. Since then we have learned that she has kidney tumors (angiomyolipomas) and a whole host of other symptoms including severe anxiety. Just two days ago we were told that the “lumps” on her back were caused by scoliosis and were part of the TSC as well. Since brain surgery in April 2010 at age 13, Erin’s body shape has changed. Her shoulders seem to droop or slope, her right shoulder blade is noticeably raised, and she seems to have a lump at the base of her neck. Her back often hurts. Erin says, “her spine feels like it cracks.” Additionally she has gained significant weight. At every doctors visit I would ask about the physical changes and her back pain/cracking – but no one ever mentioned that it was scoliosis until two days ago. Now we are told Erin will likely have to wear a brace for an extended period of time or have surgery on her spine. My question to you is: Have you ever heard of a connection between TSC and Scoliosis? Or, is there a connection between major brain surgery and the development of severe scoliosis? Prior to brain surgery Erin was thin, tall for her age and continuing to grow, she had level shoulders and her back did not have anything that appeared to be abnormal, even though she had been diagnosed with a very mild case of scoliosis around age 10. (I also have a very mild case of scoliosis – and I have never seen what I knew to be a more severe case of all this time I thought the physical body change was endocrine related as opposed to spinal curve.) If there is any advice you have, suggestion of Raleigh area physicians who may be aware of TSC and Scoliosis – your help would be greatly appreciated. Again, after reading your blogs, I wish you were still in practice and thank you for sharing…it’s a wonderful ministry. – Sincerely, Jessica Graber, Wake Forest

  4. Glad to hear you're enjoying your sabbatical, but look forward to having you re-enter clinical practice. Having a 13 yr old athlete in the family means we have an ongoing need for a good orthopaedist. Most recently we are dealing with an AIIS avulsion fracture. Hope you see your new practice announcement soon!

  5. Celeste (13) had an upper scoliosis curve of 50 degree and lower of 45 degrees last January. We started doing schroth method exercises in May. Her last xray showed that the upper curve went down to 40 degrees and the lower to 35 degrees. She does go to PT twice a week at Advance Physical Therapy in Chapel Hill as they have 2 wonderful certified schroth method PT s there. We felt that surgery should be a last resort. Can you do any research during your sabbatical on this type of exercise to strengthen certain muscles to derotate the spine and lessen the curve? It also helps to alleviate any back pain she was having. We had seen you last Jan for that xray and surgery was recommended. We can be reached at home listed ph number with our last name Sedito. Thanks for your open ear and mind.

  6. I'm so happy to "find" you here! We (Maddie) enjoyed being your patient and we certainly have not filled your void yet. Thanks for all of your encouragement and support over the last year, and hopefully we will find you again soon!
    Chandler Francis


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