Does Panda Bear love the DOs?

[HarveyCushing]

Dain Tasker, D.O. "...In order to be truly scientific we must love truth better than we love our preconceived ideas of what truth is" (Gevitz 65).

One of my favorite quotes in the book. I don't know if I can say of all time, but at least it is a top 10 quote.

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[Mung]

Although Rolfing uses MFR, it actually has a pretty specific intention which is significantly different than the way most PTs, DOs or LMTs use MFR.

I will agree with that, similar techniques different intentions, applied in different ways. Although I would say that Rolfers may believe that they are creating structural alignment in the gravitational field, and this may help reduce pain and improve function, I may be wrong but I do not believe they promote themselves as practicing rehab.

(Thanks for the Hx lesson!)

 

[Mung]

Ida Rolf disguised much of what she does as "myofascial therapy" and tried to group it under the umbrella of manual therapy in order to gain credibility.

Technically all massage, therapeutic or otherwise, is "myofascial" as you are working the fascia and muscle. So calling it "myofascial" doesnt add any credibility nor is it a good descriptor.

Thats like saying a medication is "biochemical." No $hit.

True. What's in a name? that which we call a rose
By any other name would smell as sweet;

 

[Dr JPH]

True. What's in a name? that which we call a rose
By any other name would smell as sweet;

"When you lose an argument, turn to cheesy quotes."

JPHazelton c.2007

 

[8744]

Thank you for what you do.

So diabetes only matters when its time for the amputations?

Impossible for everyone put obtainable for many, is not the ideal for the doctor to strive to keep people well?

Unless you are independently wealthy, you will not have time to keep people well. Sorry. What many people need is a "life coach" more than a doctor and you will not be qualified for that job. Even if you were, you will not have an hour per visit to encourage, cajole, and comiserate.

After you diagnose 'em, treat 'em, and prescribe 'em, you're done and the proverbial ball is now in their court.

 

[Dr JPH]

After you diagnose 'em, treat 'em, and prescribe 'em, you're done and the proverbial ball is now in their court.

And most patients drop it.

 

[Mung]

So if I piss in a cup, give it to my patients as a cure for their COPD, and only charge $3, that's cool? What if I dress it up in fancy theories about "electrolytic solutions promoting healing in highly vascular areas"? I mean, is that a potential treatment that may provide psychosomatic relief, or is it just five bucks for piss in a cup?

reductio ad absurdem

 

[Mung]

Unless you are independently wealthy, you will not have time to keep people well. Sorry. What many people need is a "life coach" more than a doctor and you will not be qualified for that job. Even if you were, you will not have an hour per visit to encourage, cajole, and comiserate.

After you diagnose 'em, treat 'em, and prescribe 'em, you're done and the proverbial ball is now in their court.

You do not have the time understood. But are you not part of managing the patients care with other providers-could this not be delegated to someone with more time? If there is no one why not? Paying them would certainly be cheaper than paying for the consequences down the road.

 

[8744]

Obviously, there will always be the train wreck patients, but that doesn't change the fact that the goal of medicine should be to intervene before the patient is seriously ill, indeed, before the patient even shows a symptom of illness. Subjective feeling is a valuable, but imperfect measure of the state of one's health, tools like nutrigenomics will open up many more possibilities. The idea that prevention is not "real medicine" is part of what is bankrupting our health system and creating dissatisified patients who are flocking to see anyone but doctors with their health problems.

I repeat, did I say I was agin' primary care and preventative medicine? I don't think I did. But a weekly high colonic is not preventative medicine and neither is the majority of the bunk and snake oil that we call CAM.

Don't blame doctors for people's health problems. Patients are dissatisfied because they don't like what they hear. "Lose weight." "Stop doing drugs." "Stop drinking." "You are getting old and will die one day." Easier to find some quack who will align their qi and tell 'em what they want to hear.

 

[8744]

From what I have seen, most physicians view preventive medicine as synonymous with "early disease detection". From this extremely limited perspective I understand your point that wellbeing doesn't matter. Unfortunately, this view fails to integrate the mounting evidence that suggests that disease risk can be modulated by interventions to lifestyle and diet.

No! You don't say! I need a million dollars worth of research to tell me that most of my ICU patients are fat, smoking, sedentary people?

Good Lord. Stop the presses.

 

[spicedmanna]

Easier to find some quack who will align their qi and tell 'em what they want to hear.

I have yet to meet a decent and credible therapist, of any tradition, tell a patient what they want to hear, knowing that it isn't the root of their health problems. Doing so would most definitely constitute quakery. If the problem is smoking, then I think just about any therapist worth their salt would cite that. Perhaps, though, they would address that problem differently and from different angles. But I think they would suggest that one stop exacerbating the problem in addition to all else. Maybe I'm giving too much credit to these supposed practitioners. Who knows. We are being hypothetical.

 

[Dr JPH]

I had my shakras aligned once.

In the morning when I woke up my wallet was gone and my junk was itchy.

She was one helluva healer.

 

[8744]

...Oh well, you are delightfully bitter....

I am not bitter in the slightest. I'm just telling you how it is. You guys really buy into the medical school propaganda about how special we are but it ain't really like that. People are going to smoke crack, drink, eat doughnuts, and sit on their lard asses watching TV despite your best efforts.

 

[Dr JPH]

I am not bitter in the slightest. I'm just telling you how it is. You guys really buy into the medical school propagnada about how special we are but it ain't really like that. People are going to smoke crack, drink, eat doughnuts, and sit on their lard asses watching TV despite your best efforts.

I agree with this.

 

[spicedmanna]

People are going to smoke crack, drink, eat doughnuts, and sit on their lard asses watching TV despite your best efforts.

The sad thing is, you are probably right.

 

[Dr JPH]

The sad thing is, you are probably right.

No, in this case he IS right. Its a daily struggle.

Hell...even WE arent compliant with our own doctors! (to Dr Andrews...I didnt ice my ankle 3 times a day like you had said...and my cholesterol is still >200)

 

[spicedmanna]

No, in this case he IS right. Its a daily struggle.

Hell...even WE arent compliant with our own doctors!

I cannot argue with that.

 

[Mung]

So JP did OMT not work until the research you believe in was published?

Who funds the research? And who conducts the research? Double blind?

 

[Dustbunny]

And most patients drop it.

And lots of providers, too, when they're the patient... (I am so non-compliant sometimes I embarrass myself.)

I had my shakras aligned once.

In the morning when I woke up my wallet was gone and my junk was itchy.

She was one helluva healer.

People are going to smoke crack, drink, eat doughnuts, and sit on their lard asses watching TV despite your best efforts.

Arr matey.

 

[Krazykritter]

As someone who is about to enter clinical rotations I think this is a very interesting discussion for a number of reasons but this gets me every time:

The dichotomy that exists between the premeds & those in practice (whether as residents or rotations) is absolutely stereotypical. The vast majority of premeds (excluding DropKickMurphy, of course) are so idealistic & believe that they can truely make a difference to everyone they come across.

Those of us who have been throughly disillusioned by the studies & research shown to us about patient compliance & what we have to do to cover our own asses, are willing to do just do our best knowing that it is as much as we can do hence the comment by JP, Tired, & Panda about 150 pack yrs & such.

I can't wait to get into the clinics & see diseases instead of read about them, but if you are going to be the type of physician who takes it personally that your diabetic patients will just not maintain an A1C level below 7, you are going be very unhappy.

 

[spicedmanna]

I can't wait to get into the clinics & see diseases instead of read about them, but if you are going to be the type of physician who takes it personally that your diabetic patients will just not maintain an A1C level below 7, you are going be very unhappy.

I agree with you, Krazykritter, thoroughly. Although, at the end, I don't think what I am saying is any more than, "I'm going to do what I can despite the problems with compliancy, etc." Also, I don't think caring about a patient is the same as taking it personally or being codependent with one. I think I can care about my patient and also let go of the outcome, particularly if I've done the best I could do, to no avail. After all, it's their life, and I don't really have any control over it; they are free to do with it as they please. I don't have any illusions about that. I plan on doing my best, however, to be their advocate. Will I lose more than win? Yes, it is likely. I hope I continue trying nevertheless.

 

[DragonWell]

The dichotomy that exists between the premeds & those in practice (whether as residents or rotations) is absolutely stereotypical. The vast majority of premeds (excluding DropKickMurphy, of course) are so idealistic & believe that they can truely make a difference to everyone they come across.

It's interesting to note that depression increases during 3rd and 4th year, when the rubber hits the road so to speak, and the pre-med ideals you're talking about actually get tested.

"Students may become depressed at any point in medical school, but Gartrell has found that the period of greatest distress occurs during the third and fourth years, when students rotate through the hospitals and clinics. ...

The Harvard medical student mentioned above recalls that her mood took a downturn during her third year. The pressures of school were building, and medicine was not turning out to be what she had expected. She began to think, "Man, this life isn't exactly what I imagined it would be, and now I'm stuck and have all these debts. I don't like what I'm seeing in the hospital; that's not how I want to practice medicine." She found herself disillusioned by the long hours, the competition among students and doctors, and the lack of time for really caring about, and not just for, patients."

-emphasis mine
-White Coat, Mood Indigo — Depression in Medical School
-NEJM Volume 353:1085-1088 September 15, 2005

 

[Mung]

I am not "reducing" anything. I am asking, in round-about fasion, the substantive difference between an unproven "holistic" treatment, and piss in a cup. You're misusing the phrase.

From your example no, no difference. Is reducing all "holistic" care to your piss in a cup an absurdity, why most surely, or is it Shirley?

 

[Dustbunny]

Those of us who have been throughly disillusioned by the studies & research shown to us about patient compliance & what we have to do to cover our own asses, are willing to do just do our best knowing that it is as much as we can do hence the comment by JP, Tired, & Panda about 150 pack yrs & such.

Those are all the reasons I resisted going into medicine for years. (I read too many doctors' blogs for my own good.) Pharmacy is a lot "cleaner" in many ways, including this one. But it's also less satisfying...

That begs the question -- do I have an advantage over the average MS1 because I'm already jaded before I even begin med school?

 

[spicedmanna]

That begs the question -- do I have an advantage over the average MS1 because I'm already jaded before I even begin med school?

Maybe. There are a lot of RN's, PA's, NP's, paramedics, etc., career healthcare workers, that eventually go on to medical school. I think there is some edge that comes from knowing the realities of the healthcare system. However, I also think there are definitely new heights of becoming jaded.

Just don't become so jaded that you become blinded to what's true. Any preconceived notion, whether happy-campy, or darky dark, has the potential to mask the truth and take you away from the present, thus impeding your ability to be effective.

 

[docbill]

WOW this is a great thread... Panda you were too kind, I think!

I get the impression that some DOs are still trying to find their next messiah!!
OMM I can see how that works.. but that is still borderline for me. Other stuff.. hmmm... if one more DO or pre-DO mentions prevention or whole body medicine.. I will get even crazier.

Too bad some schools are still run by the OPP department. I personally don't think that is the best approach.. but then again.. who cares what I think.

Everyone who posts please put if you are pre-DO (pre-MD) or actually in DO (MD) school.. just so we can start isolating ideas of, and what things are really like. I know the usual suspects.. like panda, Jp, Jack...

 

[DragonWell]

Those are all the reasons I resisted going into medicine for years. (I read too many doctors' blogs for my own good.) Pharmacy is a lot "cleaner" in many ways, including this one. But it's also less satisfying...

That begs the question -- do I have an advantage over the average MS1 because I'm already jaded before I even begin med school?

Actually, I did talk about my experience working as a nursing assistant in long term care in my PS, and the theme was basically ideals vs. reality. I was a also a massage therapist at the time and worked with a lot of geriatric patients, and when I started the CNA job, I had the bright idea of incorporating massage therapy into the job.

Then I realized when you have 12+ patients with various end stage diseases depending on you for all their bodily functions, you are happy if everybody gets some nourishment into their body and is clean and dry more than they are wet and messy. Talk about train wreck patients and a depressing environment, (not to mention all the ass wiping ) - but in some way I can't explain, it was still one of the best jobs I've ever had. It wasn't anything like what I thought it would be, and the hours and pay sucked, but it was meaningful in a way no other jobs in my life have been.

I expect medicine to have far bigger challenges and conflicts, and I hope even more meaningful rewards.

MS-1 (DO)

 

[JayneCobb]

Where is your contribution to research?

At the click of a button I can find 500 papers on OMT.

And as someone who works with Kuchera on a daily basis I can tell you that the research is being built up every day, and the legs its standing on arent as shaky as peopel think.

If you must know. The head of our OMM department quit suddenly between my first and second year which put a hamper on our research that summer, which is why I ended up annotating the other professors books and adding in references. I spent a good amount of time on OstMed looking for papers. And the vast majority of what I found at that time was not quality research. There is good data for some aspects, but the evidence for cranial, and even myofascial OMM is weak and does not fit with the grandiosely claims they make for these techniques.

Keep in mind that I do feel that HVLA and muscle energy do have decent data behind them. Counterstrain's data is weak, along with the other mentioned techniques.

 

[Krazykritter]

-emphasis mine
-White Coat, Mood Indigo — Depression in Medical School
-NEJM Volume 353:1085-1088 September 15, 2005

Wow...you got me. I'm really depressed. For future reference the way you diagnose or would suspect depression in someone is not by some ridiculous quote from a single article, but according the the DSM IV critiria of 5+ signs of SIGECAPS (look it up if you don't know them) lasting for greater than 2 weeks.

You're definitely right though. I'm finishing my M2 year, happily married, about to go start living what I dreamt of doing as a kid so I guess I must be depressed. There's a huge difference btwn being an idealist & a realist especially when it comes to patient care. I was using the term disillusioned loosely. Good diagnosis though...

 

[DragonWell]

Wow...you got me. I'm really depressed. For future reference the way you diagnose or would suspect depression in someone is not by some ridiculous quote from a single article, but according the the DSM IV critiria of 4+ signs of SIGECAPS (look it up if you don't know them) lasting for greater than 2 weeks.

You're definitely right though. I'm finishing my M2 year, happily married, about to go start living what I dreamt of doing as a kid so I guess I must be depressed. There's a huge difference btwn being an idealist & a realist especially when it comes to patient care. I was using the term disillusioned loosely. Good diagnosis though...

Lighten up, dude. I posted that quote 'cause it related to what you said about the idealism of premeds, not to accuse you of being depressed. I went back and edited my post to clarify. Okay?

 

[Krazykritter]

Seriously, if you're going to use DSM in a sarcastic comeback, you ought to at least look inside it to make sure you're giving the right criteria. I'm thinking you ought to look this stuff up before you take your boards.

Sorry, Tired. I fixed the info above to represent the real criteria. You can't tell me though that you would hold back an SSRI for only 4 of the criteria present for greater than 2 weeks.

Psych & Behavioral med were my absolute lowest priority for review, but I guess maybe they should get bumped up a bit.

 

[Orthodoc40]

but if you are going to be the type of physician who takes it personally that your diabetic patients will just not maintain an A1C level below 7, you are going be very unhappy.

Bummer. That sounds like depression just waiting to hit me in 2 years....

 

[EastWestN2grt]

The irony that the system is set up to reimburse a doc for dialysis and amputations but not for spending time educating a diabetic about how to eat and manage their meds .

 

[DragonWell]

Upon further reflection, I think that my comment above is an oversimplification. It is easy to blame the system, but until I am in the trenches myself, I will defer to those who have actual experience with reimbursement and who seem to agree that patient compliance is a larger hurdle than reimbursement.

 

[spicedmanna]

. . .I will defer to those who have actual experience with reimbursement and who seem to agree that patient compliance is a larger hurdle than reimbursement.

Along the same vein, I wish to express that I've been largely out of line with my comments about patient care.

The other problem I had with your analysis was that, in the majority of institutions I have worked in, diabetic education is a priority. Patients are offered diabetic education classes, counseling by certifed diabetic educators, trips to clinical nutritionists, pamphlets, resources. It was a central theme on my FP rotation, and I routinely get sent information on classes from my own HMO (although I'm not diabetic). And all the people involved in this, obviously, are getting paid. For the life of me, I don't know how much more we can do, short of breaking into people's homes, and passing laws banning diabetics from McDonalds.

Good to know.

 

[Dr JPH]

Why are you agreeing? His statement was wrong.

Premeds...

 

[Dr JPH]

So JP did OMT not work until the research you believe in was published?

Who funds the research? And who conducts the research? Double blind?

Of course the OMT worked before it was published. Its been working for over 100 years.

But I wouldnt be doing it not for the scientific validity. I wouldnt be treating patients if what I was doing was sham, fake or fraud.

OMT research that I am involved with is being funded by NIH, DoD and private donors.

Conducted by DOs and DO students with a few masters students as well.

Double blind? How can you double blind a study when one of the physicians must actively participate in the treatment of the patient? For some of the studies, however there is double blinding when the study is looking at non-clinical outcome patterns (eNos, lymphatic flow, etc).

 

[Dr JPH]

I don't understand why people don't get this. Washing hands between deliveries "worked" before we understood infectious diseases. And mercury didn't work before we understood the physiology of metal poisoning.

The duration that a treatment has been around does not speak to its efficacy or safety. True, we have treatment that survived the age of scientific scrutiny, but we have many more that did not. Just because a treatment existed before the science to evalute it was around, does not mean that it is somehow "exempt" from inquiry now.

Absolutely.

And they lasted so long because a) they didnt have anything else and b) what they were doing wasnt killing people.

Well, when people began to ask questions about these treatments then they began investigating their efficacy.

I could care less if people want to drink magical tinctures, rub crystals on their bodies or chew on dirt to cure their epilepsy.

But for me to do something there needs to be the following behind it:
- Anatomy - knowing the anatomy of what you are doing
- Physiology - knowing the physiologic responses
- Biochemistry (if applicable)
- Biomechanics (if applicable)

When I perform OMT a few things happen. Muscle tightness decreases, range of motion increases, pain decreases, blood flow increases. I know this because I can see it first hand in my patient. But not only that, my knowledge of anatomy and physiology can account for every single response that I see in my patient.

Playing with energy fields might not hurt a patient and it sure wont cure them...but its fraud to market these types of things as a medical modality that will be used to treat or cure a patient of a disease.

Show me the research that says that water molecules have a "memory" and thus homeopathy is valid.

Show me how cranial is moving bones which we know (from research) are fused.

You cant.

 

[Krazykritter]

Show me how cranial is moving bones which we know (from research) are fused.

You cant.

BLASPHEMER!!!!

I happen to agree w/ you 110% about Cranial. I just hadn't been able to call anyone a blasphemer in awhile....

 

[Dr JPH]

BLASPHEMER!!!!

I happen to agree w/ you 110% about Cranial. I just hadn't been able to call anyone a blasphemer in awhile....

IMO cranial should not be considered part of OMM. I think it should be its own separate entity. Let the cranialites continue to do their thing but take it off boards and out of the DO curriculum.

The only reason its part of our world is because a DO came up with the idea. I see no parallels between the pure musculoskeletal treatments (ST, MFR, ME, HVLA) and cranial. The only factor in common is that all were first described by DOs.

The biggest proponents of cranial are not the DOs. Theyre the people coming out of the Upledger training schools. Massage therapists and PTs doing "craniosacral".

Calling cranial "OMT" is like calling NASCAR a sport. Makes no sense, but saying it out loud pisses SOMEONE off.

 

[DragonWell]

The other problem I had with your analysis was that, in the majority of institutions I have worked in, diabetic education is a priority. Patients are offered diabetic education classes, counseling by certifed diabetic educators, trips to clinical nutritionists, pamphlets, resources. It was a central theme on my FP rotation, and I routinely get sent information on classes from my own HMO (although I'm not diabetic). And all the people involved in this, obviously, are getting paid. For the life of me, I don't know how much more we can do, short of breaking into people's homes, and passing laws banning diabetics from McDonalds.

Thanks for the info.
I guess it's easier to look for a simple external solution (ie the way payment is set up) than to confront the messy reality of the situation. What can I say, I'm an old hippy from Washington State - sometimes I regress and start blaming the system, man. I guess I needed a cold shot of reality. Thanks for snapping me out of it.

 

[Mung]

I also will add that I got carried away with some of my comments esp. re: diabetes care. It seems much is being done, maybe some places are doing much better than others. But I speak from way outside left field and knee jerked.

I will also say I am sorry to Panda Bear, you know and have experienced more than I can comprehend. And that if you are able to everyday provide top level care and service to people that are suffering because of their chosen lifestyle and not be bitter -you the Doc! Last night I was thinking well why don't you just shoot them sons of beyatches and git it over with-and there I realized truly what great things you do.

Seems to me this country is one of addicts: addicted to junk food, over eating, drinking, smoking, drugs, oil, TV, (and online forums.)

Perhaps this is the crux. And if the country doesn't go thru rehab and stay on the wagon then we as a country are in trouble. I do not know what needs to happen, just that what is happening now does not seem to be working.

To HP and Panda
And as for my thoughts on CAM, again I will suplicate forgiveness. The burden is not upon doctors to provide the proof that an alternative type of treatment works. I do not know how to conduct or properly evaluate research, or the costs involved. I will say that I have seen both people and animals respond to different types of CAM and so I know there is some gold in them thar hills and I also know that much of it might as well be Tired's piss in a cup.

I hope you all got a few laughs out of this deep fried p-nut butter 'nanner sandwich eatin' king of the porcelain throne. Hopefully I start to think and study more and type less.


PS HP Hope you were at least able to get some temporary subjective relief and forget about that cholesterol for a while while the chakras were being aligned. and BTW if you haven't found anything to cure that itch I hear rhus tox 30c might be good ; ).

 

[Mung]

Of course the OMT worked before it was published. Its been working for over 100 years.

But I wouldnt be doing it not for the scientific validity. I wouldnt be treating patients if what I was doing was sham, fake or fraud.

That was my point that there are treatments that are working. But have not been yet validated.

So if you know OMT worked because of experience would you still not use it unless you also had research that you feel backed it up, even if you knew that it may provide relief and no harm to a patient that is not being relieved otherwise?

PS

I tried to edit the cost, and double blind stuff out of previous quote and I would have gotten away with it if it weren't for those danged meddling kids!

 

[Dr JPH]

So if you know OMT worked because of experience would you still not use it unless you also had research that you feel backed it up, even if you knew that it may provide relief and no harm to a patient that is not being relieved otherwise?

As I said above, even if there were an absence of research I could still rely on the anatomy and physiology of what was happening. The same cannot be said for most forms of alternative medicine.

And I disagree...the burden IS on the doctors to provide proof that these things work. We owe it to our patients to not only rely on our experience and instinct, but to explore every scientific aspect that we possibly can in order to provide optimum healthcare.

Simply continuing to perform a particular treatment without the slightest bit of data supporting it or without at least a comprehension of the biochemical and biomechanical workings is innapropriate.

 

[Mung]

And I disagree...the burden IS on the doctors to provide proof that these things work. We owe it to our patients to not only rely on our experience and instinct, but to explore every scientific aspect that we possibly can in order to provide optimum healthcare.

I want to make sure we are understanding each other.

When I said it was not the burden of the doctor to prove a CAM therapy worked, I did not mean to imply that the doctor was using an unproven therapy.

I was meaning someone says this works for X, the doctor says prove it and then we will talk.

Is this what you understood in your reply?