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Letters to the Editor  |   August 2013
Relighting the Fire in Our Bellies
Author Affiliations
  • Robert A. Cain, DO
    Department of Medical Education, Grandview Medical Center, Dayton, Ohio
Article Information
Disaster Medicine / Gastroenterology / Osteopathic Manipulative Treatment
Letters to the Editor   |   August 2013
Relighting the Fire in Our Bellies
The Journal of the American Osteopathic Association, August 2013, Vol. 113, 598-599. doi:10.7556/jaoa.2013.020
The Journal of the American Osteopathic Association, August 2013, Vol. 113, 598-599. doi:10.7556/jaoa.2013.020
To the Editor: 
If you are reading this letter, you are most likely an osteopathic physician (ie, DO) or osteopathic medical student. As such, you are witnesses to the struggle of patients to overcome illness, and you understand first-hand the challenges they can face. 
Think for a moment about the last time you placed your hands on the abdomen of a patient after a surgical procedure, felt the distention caused by an ileus, then waited for the return of bowel function. 
Think for a moment about the last time you watched a patient with chronic obstructive pulmonary disease (COPD) struggle to walk down a hallway and then wished you could do more. 
In a 2006 letter, Mychaskiw1 wrote that OMT is overemphasized by the American Osteopathic Association (AOA). I continue to hear this sentiment expressed by both DO clinicians and educators. He also noted, “Osteopathic medicine and osteopathic principles do not start and end with OMT.” 
Where has the fire in our bellies gone? 
Does anyone notice when research appears that can feed that fire? A recent retrospective study by Baltazar et al2 concluded that OMT applied after a major gastrointestinal operation is associated with decreased time to flatus and decreased hospital length of stay (LOS). A 2012 pilot study by Zanotti et al3 reported that OMT performed on patients with COPD who underwent pulmonary rehabilitation may improve exercise capacity as determined by a 6-minute walk. 
These studies suggest that low-cost, low-harm4 OMT has a positive impact on otherwise difficult-to-treat conditions. Why does our profession not hunger for more research of this kind? Why do we instead frequently hear comments from osteopathic colleagues that there is little or no place for OMT—save for managing a limited number of complaints (such as neck pain or back pain) in primary care? 
If you are facing, for example, the prospect of a gastrointestinal surgical procedure, would you not opt for treatment that hastens your recovery and shortens your LOS? If the answer is yes, should your patients not also have access to the same level of care? 
As an educator I am intrigued by the way that DOs, particularly those in training, apply evidence in the real world. Confirmation bias seems to run rampant at times, particularly with OMT. It is sometimes said that the absence of evidence to support OMT is a reason not to use it. But who is to blame for that absence? 
Adhering to the osteopathic oath, DOs have pledged to “be ever alert … to develop the principles of osteopathy which were first enunciated by Andrew Taylor Still.”5 In other words, advancing the profession is a task for all of us. 
Ileus is a common postoperative complication and treatment options have not changed substantially over the years. Is the role of OMT in managing ileus unclear after decades of studies since the founding of this profession? Why is the question of performing OMT on patients postoperatively not of interest to every resident in osteopathic general surgery residency approved by the AOA? 
Likewise, COPD is a common disorder. Shouldn't DOs in every residency or fellowship program—whether in family medicine, internal medicine, or pulmonary medicine—discuss the article by Zanotti et al3 and determine how to apply the results to patients in their care or to the design of future, larger-scale studies? 
Instead, we overlook the benefits revealed by decades of observational reports of OMT. We fail to conduct subsequent research that might confirm previous investigators' findings. This lack of initiative erodes the distinct foundation of osteopathic medicine. Why are we still awaiting the definitive prospective study of OMT? Do we think someone else will conduct the study for us? 
Where is the fire to demonstrate that our unique form of care does in fact lead to better outcomes? Perhaps we should ask if such research would even change the opinion of those who see no modern place for osteopathic medicine regarding its practice as 19th century therapy. 
If the practice of osteopathic medicine is to continue its focus on the patient, then the findings about OMT must give fuel to our inner fire. I argue as a board-certified pulmonologist that walking an additional 49 meters in 6 minutes can have a profound meaning for a patient with stage 3 COPD. This is particularly true if it enables that patient to do something of importance, such as walking to the mailbox or bathroom, or crossing a room to meet a grandchild. From an evidence-based practice standpoint, the findings of the study by Zanotti et al3 matter a great deal and can easily be applied to patient-centered practice. 
Is OMT overemphasized by the AOA? Perhaps it is not emphasized enough. 
Our duty as DOs is to help our patients realize their health potential, not simply to manage their diseases. This profession can end the decades-old debate about osteopathic distinctiveness if it will simply decide to follow a path that reminds us that our duty is to provide health care. 
The first step in osteopathic decision making should be to identify and remove all impediments to a patient's full recovery—structural, social, spiritual, nutritional, bacterial, or surgical. Our knowledge and our hands allow us to both clear an obstructed bowel and promote recovery of function in the bowel. Such follow-through helps to define holistic care and to keep us patient centered. 
If we produce superior outcomes through the delivery of truly holistic care—as reflected by the results of the 2 aforementioned studies2,3—we could solidify the role of osteopathic medicine and redefine the US health care system. 
There remain many unanswered questions about human health. Sadly, we seem to balk at the work of determining how to implement osteopathic manipulative medicine for maximum impact. Or we have balked at publishing such effects. Are our principles and practices a myth or reality? Only we can answer such questions, guided by the knowledge gained while earning an osteopathic medical degree. 
Many individuals in the osteopathic medical profession have spent decades working to gain the acceptance of others. In that time, such efforts moved us further from the core beliefs of our profession. I offer that osteopathic concepts have not been proven wrong; they have been neglected in an effort to be more like our allopathic colleagues. 
What if that neglect has failed patients and the health care system by limiting (or, in many specialties, eliminating) a form of treatment that may in fact alter the course of disease and contribute to maintenance of health? 
Think about this neglect the next time you place your hands on a distended abdomen or listen to a patient tell you about his or her struggle to breathe and do nothing to incorporate your osteopathic skills when treatable dysfunction is present. 
We have an opportunity to change the course of this profession. It begins by determining if there is something our form of training and decision making adds to patient care that is not easily replicated by others. 
Some will worry about perception, wondering what patients will think if we perform OMT as part of their treatment plan. Pomykala et al6 found in a survey-based study that 98% of 168 hospitalized patients believed that OMT improved their overall comfort level, 94% felt it was helpful to their recovery, and 98% would recommend it for other hospitalized patients. Similar results were found in a survey-based study4 of patients in the outpatient setting. 
Putting aside for a moment the osteopathic tenets7 and their focus on interrelations of structure-function and mind-body-spirit: who wouldn't want to improve the patient experience in this era of pay for performance and value-based purchasing? A savvy hospital executive might start by asking medical staff why they aren't using OMT to treat patients, particularly in hospitals that sponsor AOA-accredited residency training programs. 
What if, 5 years ago, an influential figure had noticed these positive findings on OMT in 2 of the studies4,6 I mentioned? Imagine the ways in which our profession could have provided leadership as ideas for health care reform were taking shape. 
An old proverb attributed to many cultures states, “The best time to plant a tree was 20 years ago. The second best time is now.” It is not too late for our profession to make a difference in health care reform. The opportunity will pass, however, if we keep debating what it means to be osteopathic and putting off a decision to act on the core competencies described by our tenets.7 
We must relight the fire in our bellies and search for answers that help us carry out our duty as osteopathic physicians. 
References
Mychaskiw GJr. Will the last DO turn off the lights? J Am Osteopath Assoc. 2006;106(5): 252-253,302. [PubMed]
Baltazar GA, Betler MP, Akella K, Khatri R, Asaro R, Chendrsekhar A. Effect of osteopathic manipulative treatment on incidence of postoperative ileus and hospital length of stay in general surgical patients. J Am Osteopath Assoc. 2013;113(3):204-209. [PubMed]
Zanotti E, Berardinelli P, Bizzarri Cet al. Osteopathic manipulative treatment effectiveness in severe chronic obstructive pulmonary disease: a pilot study. Complement Ther Med. 2012;20(1-2):16-22. [CrossRef] [PubMed]
Licciardone J, Gamber R, Cardarelli K. Patient satisfaction and clinical outcomes associated with osteopathic manipulative treatment. J Am Osteopath Assoc. 2002;102(1):13-20. [PubMed]
Osteopathic oath. American Osteopathic Association website. http://www.osteopathic.org/inside-aoa/about/leadership/Pages/osteopathic-oath.aspx. Accessed July 12, 2013.
Pomykala M, McElhinney B, Beck BL, Carreiro JE. Patient perception of osteopathic manipulative treatment in a hospitalized setting: a survey-based study. J Am Osteopath Assoc. 2008;108(11):665-668. [PubMed]
Tenets of osteopathic medicine. American Osteopathic Association website. http://www.osteopathic.org/inside-aoa/about/leadership/Pages/tenets-of-osteopathic-medicine.aspx. Accessed July 12, 2013.