DO doing manip in an allopathic residency?

[sophiejane]

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I'm starting residency in July (FM) at an allopathic program, which I love, but there have been few DOs there in the past. Faculty seem generally receptive to it, with one or two exceptions. Almost half of my class are DOs this year (!!) so I imagine change is coming in this area, in one form or another.

My questions:

1. Are we allowed to do OMT on patients if there is not a supervising DO on staff? Any medico-legal issues around this that anyone knows about?

2. How do you introduce OMT-naieve patients to their options? What's a good "opening line" for a patient that you feel will benefit from manip but who knows nothing about it?

Thanks in advance...

 

[McDoctor]

I'm starting residency in July (FM) at an allopathic program, which I love, but there have been few DOs there in the past. Faculty seem generally receptive to it, with one or two exceptions. Almost half of my class are DOs this year (!!) so I imagine change is coming in this area, in one form or another.

My questions:

1. Are we allowed to do OMT on patients if there is not a supervising DO on staff? Any medico-legal issues around this that anyone knows about?

2. How do you introduce OMT-naieve patients to their options? What's a good "opening line" for a patient that you feel will benefit from manip but who knows nothing about it?

Thanks in advance...

1. OMT is considered a medical procedure, at least as far as billing goes. One could argue that you shouldn't be doing any medical procedures as an intern without adequate, qualified supervision. Perhaps that's being overly technical, but it is a potential medico-legal pitfall.

2. I only use it for musculoskeletal pain. I don't get technical, or start spouting osteopathic holistic mumbo jumbo. I simply ask patients if they want me to adjust their back, sort of like a chiropractor might do. It gives them a frame of reference.

 

[mlw03]

1. OMT is considered a medical procedure, at least as far as billing goes. One could argue that you shouldn't be doing any medical procedures as an intern without adequate, qualified supervision. Perhaps that's being overly technical, but it is a potential medico-legal pitfall.

2. I only use it for musculoskeletal pain. I don't get technical, or start spouting osteopathic holistic mumbo jumbo. I simply ask patients if they want me to adjust their back, sort of like a chiropractor might do. It gives them a frame of reference.

i'm allopath trained, so i know nada about osteopathic manipulation. i comment here from a patient's perspective. if my doctor (and i'd have no problem going to a DO for my personal PCP) said they wanted to "adjust my back" like "a chiropractor might do" i would definately NOT be interested. there are a lot of educated people who think chiropractors are quacks (personally, i'm undecided - i figure some are, most aren't) and don't want to hear that stuff from their PCP.

from the legal perspective, i would agree with this post that doing a procedure without attending-level supervision is a risky move. if something goes bad, that's gonna be tough to defend in court. if a DO wants to continue manipulation therapy during residency, from a legal viewpoint it might be safest to do it in the construct of a DO residency program.

 

[sophiejane]

if a DO wants to continue manipulation therapy during residency, from a legal viewpoint it might be safest to do it in the construct of a DO residency program.

Is this the law or your opinion?

I'm really more interested in the law, since everyone has different opinions.

There is an allopathic FM program in my state whose PD is a DO and they do plenty of OMT there.

I'm just wondering if you have to have a supervising DO on staff, as a technicality. I know how to do manip, I don't need someone overseeing me for that. It's actually very simple and very safe.

 

[sophiejane]

there are a lot of educated people who think chiropractors are quacks (personally, i'm undecided - i figure some are, most aren't) and don't want to hear that stuff from their PCP.

So...that's kind of a big generalization. You'd be surprised how many highly educated backs, necks, wrists, and hips I've treated, and how many of those folks specifically see a DO because they can do manip.

 

[mlw03]

Is this the law or your opinion?

I'm really more interested in the law, since everyone has different opinions.

There is an allopathic FM program in my state whose PD is a DO and they do plenty of OMT there.

I'm just wondering if you have to have a supervising DO on staff, as a technicality. I know how to do manip, I don't need someone overseeing me for that. It's actually very simple and very safe.

i'm not a lawyer, so it's just my opinion. laws of course also vary state to state. however i think it's intuitive that doing any procedure without trained supervision is a liability. just because you know how to do something and have been trained on it in med school doesn't mean it'd hold up in court. again, it seems intuitive to me that if this kind of thing were to go to court, the training of the person doing the procedure and that of the person supervising the procedure, would come under review. then it's up to the judge and/or jury to decide if things were done in a responsible manner.

 

[sequela]

i think your best bet is to talk w your program and affiliated hospitals/clinics regarding their own policies, state laws and beyond. sometimes it's a lot more complicated then what the "law" says. if this is the case at your particular program, you don't want to find out when it's too late...even if nothing bad happened, you don't want to get in trouble for doing something you're not allowed to do and then have to deal w the office of so-and-so while your running around trying to care for patients.

i just finished doing my hospital's online hippa training and i was rather impressed by all the rules, polices, forms, requests, offices, blah blah blah involved or potentially involved in every move you make. i haven't even started and i already feel "regulated"

 

[mlw03]

So...that's kind of a big generalization. You'd be surprised how many highly educated backs, necks, wrists, and hips I've treated, and how many of those folks specifically see a DO because they can do manip.

of course this is true - that's the beauty of the free market. you have a unique service that you can market. however my point was that some people think that stuff is total voo doo and when they hear the words "chiropractic manipulation" they're gonna say no thank you and never return. that also is part of the beauty of the free market. as a practitioner you can decide how you want to market your services in a way that best suits your needs as both a physician and as a person who wants to make money.

 

[McDoctor]

i'm allopath trained, so i know nada about osteopathic manipulation. i comment here from a patient's perspective. if my doctor (and i'd have no problem going to a DO for my personal PCP) said they wanted to "adjust my back" like "a chiropractor might do" i would definately NOT be interested. there are a lot of educated people who think chiropractors are quacks (personally, i'm undecided - i figure some are, most aren't) and don't want to hear that stuff from their PCP.

from the legal perspective, i would agree with this post that doing a procedure without attending-level supervision is a risky move. if something goes bad, that's gonna be tough to defend in court. if a DO wants to continue manipulation therapy during residency, from a legal viewpoint it might be safest to do it in the construct of a DO residency program.

In my residency clinic, most (if not all) of my patients do not possess a high level of education. Many have not completed secondary school. If I tell them I'd like to mobilize their lymphatics, maybe free up some areas of fascial restriction, and then attempt to realign areas of asymmetry within their lumbar spine using a High Velocity Low Amplitude technique, they are likely to stare at me blankly with a glassy look in their eyes as they attempt to process what I just said. So I just tell them I'm going to crack their back. I don't do alot of OMT anyway.

Obviously, you tailor your approach to the person standing in front of you. I would approach an educated patient differently, and use different terminology. When I enter the real world next month, there probably will be some growing pains for me dealing with a more suburban, upscale patient base.

I agree with you that if you want to incorporate OMT into your practice, then do an AOA accredited residency. They set minimum standards for training. The AOBFP has a practical component incorporated into their board certification process, and your board certification states Board Certified in Family Medicine and Osteopathic Manipulative Treatment. You have a leg to stand on if you have a bad outcome.

 

[McDoctor]

Is this the law or your opinion?

I'm really more interested in the law, since everyone has different opinions.

There is an allopathic FM program in my state whose PD is a DO and they do plenty of OMT there.

I'm just wondering if you have to have a supervising DO on staff, as a technicality. I know how to do manip, I don't need someone overseeing me for that. It's actually very simple and very safe.

If you are billing for it, then you probably need to be supervised by someone who can verify that you are doing it correctly.

On a minor level, I disagree with the notion that every fresh DO intern is 100% fully competent using OMT safely and effectively. Even though this is the approach I see pretty much every osteopathic training institution take, I think it sort of devalues OMT and makes it harder to defend its legitimacy. I think, in order to be taken seriously, training institutions should stop paying it lip service and treat it like they would any other procedure. Train interns how to do it, even if its redundant to what they got in med school, and restrict them from using it solo until they display satisfactory competence.

Just my 2 cents on the issue of OMT and osteopathic education. Again, I don't have a huge dog in this fight, since I don't use it much.

 

[sophiejane]

On a minor level, I disagree with the notion that every fresh DO intern is 100% fully competent using OMT safely and effectively. Even though this is the approach I see pretty much every osteopathic training institution take, I think it sort of devalues OMT and makes it harder to defend its legitimacy. I think, in order to be taken seriously, training institutions should stop paying it lip service and treat it like they would any other procedure. Train interns how to do it, even if its redundant to what they got in med school, and restrict them from using it solo until they display satisfactory competence.

I agree with you there. I wasn't saying every new DO is 100% fully competent, nor that I am, but I only do those techniques I am good at and have used a lot over the past 4 years. In fact, I do very little HVLA.

I don't feel like I need hand-holding to do indirect, cranial, and muscle energy techniques, or the few thoracic and lumbar HVLA techniques that I use regularly. I would love to have the opportunity to learn more from an OMT specialist, but that would be only possible at an AOA program, as you mentioned.

I weighed the pros and cons, and it made more sense for me to go to the allopathic program. Of course I will talk to my PD to get the official line from my program, I just wanted to see what others were doing.

 

[AmoryBlaine]

On the flip side what do you guys think about MDs who do a little OMT? When I was on Ambulatory one the DO attendings was teaching the MD residents how to do some osteopathy. A few of them were saying they liked learning it b/c they could bill for it when they had their own practices.

Seems a bit strange to me, since if DO is a big difference in philosophy and OMT is a difficult and precise art one would not expect allopaths to master any of it in a few afternoon sessions. I mean I went through the paces with them, I certainly could not appreciate any of the misalignments that the attending was feeling...

 

[mlw03]

On the flip side what do you guys think about MDs who do a little OMT? When I was on Ambulatory one the DO attendings was teaching the MD residents how to do some osteopathy. A few of them were saying they liked learning it b/c they could bill for it when they had their own practices.

Seems a bit strange to me, since if DO is a big difference in philosophy and OMT is a difficult and precise art one would not expect allopaths to master any of it in a few afternoon sessions. I mean I went through the paces with them, I certainly could not appreciate any of the misalignments that the attending was feeling...

interesting thought - as an MD student, i would never try to do manipulation in practice, for the same reason i talked about above: liability. i hate having to think like this, but i always imagine how things would come across in a courtroom. i imagine a lawyer asking, "and what part of the curriculum at USF taught you how to do this procedure that ended up causing my client significant harm?" sure, billing for procedures can be profitable, but i don't think the risk of a truly un-defendable lawsuit is worth the benefit you may get from billing for the additional procedure.

 

[sophiejane]

Seems a bit strange to me, since if DO is a big difference in philosophy and OMT is a difficult and precise art one would not expect allopaths to master any of it in a few afternoon sessions. I mean I went through the paces with them, I certainly could not appreciate any of the misalignments that the attending was feeling...

Exactly. It's not the techniques, it's the diagnosis that is the art. We spend 4 years (some of us less, if we don't use it on 3rd and 4th year rotations) learning how to palpate and diagnose structural problems.

In an afternoon, I can teach you how treat a patient's lumbar and thoracic spine, but you won't be able to localize your treatment because you won't be able to diagnose the vertebral level of the dysfunction. They can say "my lower back hurts", and you can do a few techniques, but you aren't practicing OMT--you are doing the structural equivalent of shooting antibiotics at a bug you aren't really sure is there and certainly don't know what it is.

Spending an afternoon showing MD's "techniques" is not the best approach, in my opinion, and it dilutes and misrepresents osteopathy.

 

[NotAProgDirector]

I think the answer to your question is very straightforward.

1. As a medical resident, you will likely be practicing medicine with a training license (most states have some sort of a training license for residents).

2. Using your training license, you practice supervisied by your faculty. They are ultimately responsible for all of the care you deliver.

3. Allopathic faculty are not trained in OMT, and hence cannot supervise you doing it.

Hence, performing OMT is outside the scope of most/all allopathic residency programs, and would be outside the scope of your license to practice medicine.

The only exception I could see would be if one of your faculty was comfortable with OMT, then you could perform it under their supervision.

 

[Winged Scapula]

aProgDirector's post was my experience. I had a few DO colleagues in my surgical residency and when one mentioned doing OMT on a patient we all were told (even the MDs) not to do procedures without adequate supervision and given that none of the faculty were DOs, they could not supervise and would be considered negligent if something were to go wrong.

Your program may differ but this made complete sense to me.