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Tuesday Mar 13, 2018

Dismissing Osteopathic Manipulation Rubs Me the Wrong Way

I was drawn to osteopathy by the basic tenet of treating the whole person rather than a collection of symptoms. I then learned another osteopathic principle in medical school, that "structure and function are interrelated."

[osteopathic physician performs structural exam]

A simple example: When someone breaks their leg (structure), it doesn't work as well (function). During my training, I learned how we, as physicians, could influence structures and functions of the body with osteopathic manipulation, as well as with medications, surgery and advice about nutrition and exercise. I chose family medicine, as many osteopaths do, because it aligned with the holistic, hands-on care I was trained to provide, enabling me to care for the whole patient and their families.

Steven Salzberg, M.S., Ph.D., recently wrote a scathing piece for Forbes(www.forbes.com) titled "Medicare Data Reveal $564 Million Wasted On Chiropractors and Osteopathic Manipulation."

What is infuriating about Salzberg's article is his apparent lack of knowledge about osteopathy and his assumption that the "high-quality evidence" that physicians rely on significantly improves the lives of patients more than the manipulations he dismisses as "pseudoscientific."

In his cursory dismissal of osteopathic treatments, wherein he combined chiropractic (which seems to be responsible for the majority of the money "wasted" in the CMS data he used(www.cms.gov)) with osteopathy, Salzberg revealed his poor understanding of osteopathy.

As an osteopath, I provide integrated and patient-centered medical care for my patients. I use evidence-based medicine to guide my discussions and treatment recommendations. I tell patients that often, less is more (antibiotics can't treat viral infections), that food is medicine (eat more plants and less sugar and processed foods) and that they need to move their bodies every day (stop sitting for eight hours straight). When patients ask for all their labs to be checked, I take time to explain that we often can't provide what they're ultimately looking for -- reassurance that nothing bad will happen to them. There is a fallacy that by monitoring blood work and imaging, and by prescribing certain medications, we can always intervene early and make a significant difference in all our patients' lives. Sometimes we can. But not nearly as often as people have been led to believe.

But perhaps even more upsetting is Salzberg's disservice to patients and the medical world when he fails to balance his opinion with the positive impact of osteopaths in our medical care system. Historically, osteopathic physicians have chosen primary care fields rather than subspecialty care. In 2015, for example -- the same year as the CMS data Salzburg cites -- 54 percent of osteopathic students who participated in the American Osteopathic Association Intern/Resident Registration Program matched to primary care residencies. This year, that figure rose to 62 percent.

If Salzberg wants to discuss the cost of providing medical care in this country, he should acknowledge the growing need for primary care physicians that is being addressed by the increasing number of osteopaths each year and the amount of health care dollars that are wasted when patients go to the ER or a subspecialist for care because they do not have access to a primary care physician.

It's also worth questioning the high-quality, evidence-based medicine that Salzberg thinks is worth the cost. Don't get me wrong -- I am a strong believer in the importance of practicing evidence-based medicine. But I don't pretend that medicine has all the answers, or that we have perfected scientific research.

John Ioannidis, M.D., D.Sc., professor of medicine and health research, policy and statistics at Stanford University, challenges us to question the majority of the evidence we rely on in his influential 2005 article published in PLOS Medicine, "Why Most Published Research Findings Are False."(journals.plos.org) He asserts that "claimed research findings may often be simply accurate measures of the prevailing bias."

That said, it's worth noting that a literature review published in December in the Journal of Family Practice pointed to meta analyses that found "decreased pain and improved function in patients who received osteopathic manipulative treatment for low back pain."(www.mdedge.com)  And this month, a study(jaoa.org) and an accompanying editorial(jaoa.org) in the Journal of the American Osteopathic Association indicated that the incidence of adverse events associated with osteopathic manipulative treatment is far less than previous estimates.

Ultimately, what matters most to me is how my patients feel and whether they're able to maximize their quality of life whenever possible. They are more than a collection of lab values that I can adjust to meet the current evidence-based goals. Moreover, in practicing medicine, we must humbly admit that we often don't have the answer.

If my patient leaves my office feeling better because I spent time listening to their concerns, placing a hand on the area that hurt and offering words of encouragement, do I care if it was a "placebo" that made them feel better? It's certainly better than spending less time with them when they are in pain and inappropriately prescribing an opiate that may contribute to the current public health epidemic.

Margaux Lazarin, D.O., M.P.H., provides comprehensive family health services at community health centers in the San Francisco Bay Area, with a focus on providing evidenced-based care for underserved communities.

Posted at 01:03PM Mar 13, 2018 by Margaux Lazarin, D.O., M.P.H.

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