We Have Zippers

http://www.writeopinions.com/mennonite

     "So Mrs. Zopp" I pose to my Mennonite patient as I lift and twist her by the arms to mobilize the lower back, "what's the difference between your church and the one you split off from in Pennsylvania?"

"We have zippers" she replies after a pause to let her work induced muscle strain relax, "and they only have buttons."

__________

     After some initial surprise at the apparent banality of her response, I soon realized that it was not just her snappy answer to my stupid question. Having done a rotation at a homeopathic clinic in Amish country during residency in Philadelphia, I already knew that the so-called plain people preferred so-called natural health care. Any treatment that promised avoidance of prescriptions, surgery, or hospitals was a good treatment, and spinal mobilizations were high on the Mennonite nice list. I also knew they were a pacifist Christian group with strong communal values, thank you very much Mr. Harrison Ford. What was harder to decipher from clinical interactions with members of three different sects in three different practice locations were their spiritual differences.

__________

     "Well that probably makes it easier to make your own clothes" I eventually respond, crossing her arms and leaning over them to mobilize the upper back.

"You'd be surprised" she laughs with a big exhalation after the thoracic spine pops. "It's the little things that make living on the land uplifting."

She Has What I Have

https://www.hbo.com/sharp-objects

    "Could it be contagious?" greets the 30-year-old mother of my 15-year-old patient lying on the table as I walk into the treatment room of my Pennsylvania practice.

"Hello there sweetie" I greet the wan young woman while sitting down on a stool beside her and touching her shoulder. "What seems to be bothering you?"

She flinches at my hand and furtively looks to her mother who answers "she has what I have - pain all over, tired all the time, not sleeping or eating."

"Has she been evaluated somewhere else?" I ask, sliding my stool away from the fearful girl and engaging her Mom.

"Her pediatrician, my gynecologist, urgent care, the ER" she spouts. "They all do the same tests and tell us nothing's wrong."

"Well something's certainly wrong" I console, acknowledging her concerns. "Why did you come in for osteopathic treatment?"

"You helped my neighbor's back and neck pain" explains the mother. "She said something might be out of place in my daughter."

__________

     This brief beginning interaction raised several red flags for there being a significant psychosocial component to this young woman's problem. Sleep changes, appetite loss, and withdrawal from activities all point to there being a potential mental health issue. Her flinching to my attempt at consoling touch suggested post-traumatic stress from some injury or abuse, and her absolute deferral to her mother hinted at a some sort of relationship issue between them.
     Even more disturbing were the identical symptoms in mother and daughter. Questions about water source, pets, and chemicals didn't yield any potential toxic exposures in the home, raising the possibility that the mother was projecting her own distress onto the child. While this disorder, called Munchausen syndrome by proxy, is rare, it did cross my mind while taking the history of the present illness. Still, it's better to reserve judgment about diagnosis or treatment until after the physical examination.

__________

   "Well young lady" I conclude after a head-to-toe examination, "there don't seem to be any major postural or structural problems."

"I knew it" she whispers in her first words of the encounter. "She wanted me to come in."

"This doesn't mean you don't have a real problem" I continue. "A psychologist might have the tools to help you deal with the insomnia, pain, and lack of appetite."

"It's not in her head" spits the mother. "Can't you just help us find the right vitamins and herbs?"

"Sorry I can't help with treatment or prescriptions" I apologize. "Would you like a referral to a counselor?"

"We're sorry too" the Mom replies, helping her daughter to the door. "I think we'll just go to my Naturopath in Baltimore."

What Else Could It Be?

from https://www.123rf.com/photo_39828288_doctor-showing-xray-to-his-patient-in-medical-office.html

     "So what might it be?" asks the older man in my Kirksville academic practice when I show him the shoulder x-ray taken after his Friday afternoon treatment.

"Why don't we wait for the radiologist's reading on Monday" I assert, having never seen such a circular calcification in a glenohumeral joint.

"Come on Doc" he pleads, "I'll worry all weekend if you leave me hanging."

"That marble in your joint is probably related to osteoarthritis."

"What else could it be?"

"It's better not to speculate when I don't really know" I persist.

"I've worked in health services administration my whole life" he continues, shifting to a more formal tone. "I can handle anything you can throw at me."

"Dealing with medical billing and collections is a lot different from misuse of differential diagnosis" I counter, resorting to my own jargon to stave him off.

"My wife's a nurse" he reasons. "She can help me process anything that could be wrong."

"I still don't think it's a good idea" I concede, "but, since you insist on knowing now, that  nodule could also be a bone spur from an old injury, a granuloma from a previous infection, or a calcification from a systemic problem like gout, amyloidosis, or Paget's disease."

"Couldn't it also be a tumor?"

"That would be lower down on the list, but, yes, primary or metatastatic cancer is a less likely cause of a joint calcification."

"Thanks for letting me know" he breathes, sounding relieved. "You'll call with the radiology report?"

"Yes if they think it's anything other than arthritis."

__________

     The system used by medical practitioners to determine if any tests are needed and to arrive at a presumptive diagnosis is called differential diagnosis. The possible causes are ranked from most to least likely, and any serious causes higher up on the list are considered for lab or x-ray testing. This thought process allows a doctor, nurse practitioner, or physician's assistant to arrive at the most likely and rule out the more life threatening causes for a set of symptoms. While infinitely useful for the diagnostic process, the details of differential diagnosis are potentially harmful for the person with the problem to know about (and obsess over).
     For my part, I probably should have known that it's not unusual to see calcified nodules in x-rays of aging joints. Failing to have seen one in radiology rotations as a student and intern or in patients as a resident, I was overly reliant on the radiology interpretation at this early stage of my career. And recognizing this man's anxiety about mortality might have provided a better pathway to helping him through touch and treatment. Experiencing and processing each interaction makes one a more proficient practitioner.

__________

     "Can I have a word with you Dr. Beatty?" calls the school president poking his head into my office.

"Sure, I just finished up with patients" I answer, sliding my chair out and waving him in. "What's up?"

"Do you remember a nursing home administrator you saw a couple weeks ago?" he starts, plopping a patient chart onto the desk beside me.

"Oh yeah, that's the guy I let talk me into divulging too much about his shoulder x-ray before the radiology reading."

"Well, we got this angry letter" he continues, reaching it across to me. "You apparently ruined his vacation and caused him to have high blood pressure, insomnia, headaches, and a few other more litigious problems."

"Ha, I knew I shouldn't have caved" I exclaim. "I'll apologize in a letter a for sharing too much and not calling him. I'll also remind him that he repeatedly asked for more possible causes despite my objections."

"That should be fine" he sighs, standing up to leave before calling back "as long as I don't hear another word about it."

You're The Doctor

(image from Beatty DR et al. The Pocket Manual of OMT:
Osteopathic Manipulative Treatment For Physicians 2nd Ed.
 Lippincott Williams & Wilkins, Baltimore 2011)

    "Well Mr. Honaker, what do you need treatment for?" I asked the older man standing beside the treatment table.

"You tell me" he sneers as he sits on the side of the table, "you're the doctor."

__________

     Manual therapy can be applied in a general manner for the total body or a problem-focused way for specific issues. Massage therapists and other non-physician practitioners tend to use the former approach, chiropractors and osteopaths the latter in order to develop a working diagnosis upon which to base treatment. Only licensed medical practitioners are sanctioned to make a diagnosis, so other manual therapists can be prosecuted for practicing medicine without a license if they do so, even if it's in the best interest of the person being treated.

     I've never liked the term "chief complaint" that's used in medicine for the problem that a person presents with. Afterall, I'm there to try to help that person, and I need to hear their expression of it to better understand what's wrong. The newer term "history of the present illness" is a better description of the process and doesn't label the person providing it as a complainer. Still, change comes slow in apprentice-based training programs so you'll still hear the archaic term used by many physicians as well as seeing it your electronic health record.

_________

     "Ok then Mr. Honaker" I forge on while helping him to lay back. "I'll start at your feet and work my way up, treating as we go."

"That's the way I like it" he finally smiles, relaxing back onto the double pillow.

"Uh-huh, uh-huh" I semi-sing, checking the internal and external rotation of his legs.

The Heels Are Non-Negotiabile

https://www.missguidedus.com/black-stiletto-heel-pointed-ankle-boots-10063250

     "There you go" I quip to the tall and elegant middle-aged woman after completing her head-to-toe treatment, "ready for another round of working and dancing."

"Thanks" she exclaims with a big breath, "I feel so much better."

"I'm glad" I continue while pulling up a stool in front of her, "but there's one more thing before you go."

"Oh no you don't" she asserts while reaching down to zip on her stilettos, "the heels are non-negotiable."

__________

     Part of the job as a manual practitioner is to identify and help correct postural problems that might be contributing to tension and pain. Fallen foot arches, a shorter leg, an arthritic and immobile knee joint, weak abdominal muscles, and abnormal spinal curves are just some of the problems that can cause asymmetry and predispose to overuse. Failure to identify and treat these issues will doom the person with them to chronic pain or limitations in activity.
     My usual practice is to ease a person with chronic musculoskeletal pain into postural exercises by starting with one or two key stretches that might make an impact on day-to-day functioning. For instance, someone with lower back pain from anterior weight bearing due to abdominal weakness might initially benefit from twice a day pelvic tilts and lumbar extensor stretches. Once the back pain is improving, they could add postural strengthening to start reversing the cause for the problem.
     Failure to address the underlying cause might be good for my long term income, but it certainly isn't the best for the person with the problem. And one of the causes for lumbar strain from anterior weight bearing is frequent wearing of high-heeled shoes.

__________

    "Well in that case" I counter while suppressing a smile, "I'll see you in about once a month."

"If not sooner" she adds with a wink, standing a good four inches taller than me and sashaying out as though in the most comfortable shoes in the world.

Done Got A Touch A That Old-Timers

http://www.alanainsworthphotography.com/blog/2014/10/o-winston-link---more-than-a-railway-photographer

     "How long has your hip been hurting?" I ask the thin older man sitting on the treatment table in my West Virginia office.

"Don't rightly know, Doc" he replies while glancing side-to-side in bewilderment. "Done got a touch a that old-timers."

__________

     People from some of the more remote areas in the central Appalachians use creative disease names. You might hear someone say "the sugar" for diabetes or "flea bites" for phlebitis.  A newborn or a drunk might have the yaller jaundice. Consumption and dropsy are still occurring in the deep hollows where tuberculosis and congestive heart failure haven't yet reached. An elderly person will tell you about "my good friend Arthur", but they won't utter the word dementia.
     Many of these isolated places have also clung to an older way of caring for aging family members. Close proximity of large extended families along with an absence of long term care facilities means that Alzheimer's and other forms of mental decline are managed in the home. Moving Granny into a hospital bed in a downstairs bedroom or rotating Papaw among his children's homes are still common practices in many rural mountain areas.

___________

     "Let's have a look at that hip joint" I say, offering a hand to help him lie back onto a couple of pillows to prop up an arthritic neck. "It oughta tell us how long it's been stiff and sore."

"S'long as it might could keep me walking" he agrees, bending his leg up for me do motion testing of the hip. "Don't wanna rely on those young'uns."

Aren't You A Bone Doctor?

http://www.ortopediaytraumatologiamexico.com.mx/fracturadeclavicula.html

     "Whatya recommend for this, Doc?" asks a giant of a man pulling down his argyle sweater collar to reveal a large lump protruding from the front of his collarbone.

"It's a bone mass" I observe, palpating a baseball-sized growth firmly attached to his clavicle. "Did you have an injury there?"

"Oh yeah, mighta broke it against Colorado senior year" recalls the former offensive guard for the University of Missouri and Kansas City Chiefs. "Never told anyone cause the draft was coming up."

"Have you shown it to any other doctor?" I ask, shocked at the size and swelling around an obvious tumor.

"Yeah, my GP had it biopsied" he answers. "Osteo-something-or-other. She said to see a bone specialist."

"It's probably a benign osteochondroma" I add with relief, "but why did you come to me for treatment?"

"Aren't you a bone doctor?"

__________

     Latin interpretation of the term osteopathy has led to confusion since it was coined in 1874 by the founder of the profession, Andrew Taylor Still, MD. Searching for better understanding of disease after losing a wife and three children to meningitis, Dr. Still observed that the musculoskeletal system was dysfunctional with many illnesses. He posited that manual treatment of this somatic dysfunction would help the person to recover by restoring both musculoskeletal and related organ function.
     In the one-hundred-and-fifty years since then, manual therapy has proven helpful for a myriad of musculoskeletal problems and a handful of internal diseases, mainly functional disorders of the respiratory and gastrointestinal systems. Sinusitis, otitis media, pneumonia, influenza, constipation, irritable bowel syndrome, paralytic ileus (cessation of bowel contractility), and gastroesophageal reflux have responded favorably to manipulation as part of treatment in case series, bench research, or clinical trials. But neither early osteopaths nor clinical experience have seen successful application of manipulative treatment for bone tumors.

__________

     "That is what osteopathy means" I tell my literal football player "but the founder of the profession used the term more loosely to describe the relationship between the musculoskeletal system and diseases."

"You mean you can't remove this osteo-whatever?"

"No, but I can recommend an orthopedic surgeon who'll fix you right up" I sum up, "and no charge for that advice."