In Your Words  |   May 2013
Seeing With Native Eyes
Author Affiliations & Notes
  • Charles R. Perakis, DO
    Dr Perakis is a retired family physican who lives in Scarborough, Maine
  • Address correspondence to Charles R. Perakis, 38 Jones Creek Dr, Scarborough, ME 04074-9229. E-mail:  
Article Information
Imaging / Neuromusculoskeletal Disorders / Pain Management/Palliative Care / Being a DO / In Your Words
In Your Words   |   May 2013
Seeing With Native Eyes
The Journal of the American Osteopathic Association, May 2013, Vol. 113, 434-435. doi:
The Journal of the American Osteopathic Association, May 2013, Vol. 113, 434-435. doi:
Contemporary physicians have lost their native skills. They have come to rely on tools other than those they are able to carry with them. Although modern devices can open new ways of seeing, these novel instruments have blinded physicians to the richness of their own senses. 
Every day, physicians care for patients who present with subjective concerns, such as fatigue, pain, or dizziness. These symptoms may herald serious underlying organic disorders. So contemporary physicians first seek to rule out these disorders. 
The patient is sent for blood tests and imaging procedures. The patient is immediately told that if the symptoms are severe enough, it is worth spending money, time, and potential injury to track down the cause. When the test results are normal, the physician and patient are back where they began. If the results are equivocal, the physician may repeat the tests or order new, confirmatory tests. “What if I miss something?” the physician thinks, picturing the attorneys in the wings. “How much uncertainty is reasonable?” 
The spots on the magnetic resonance image might represent multiple sclerosis. Disk protrusions might signal nerve compression. The patient, on hearing the diagnosis from the physician, may attach the wrong label or diagnosis to these findings. Once attached, this label can be removed only with difficulty and leaves messy remains. 
The physician who uses native skills follows a different trail. He or she begins by observing the patient's nonverbal and verbal communication. Listening to the patient's story, the physician encourages the tale, suggesting paths, looking for signs, or searching for familiar footsteps. What is there? What is not there? What tracks and signs have the patient left, and what do these tell us? 
Some patients are better storytellers than others. The physician who uses native skills recognizes this discrepancy and helps all patients develop their stories. Crucial details must not be left out. The physician is willing to put an ear to the ground or bend over and look closely. This physician, like the native tracker, switches back and forth between the high-power and the low-power lens. 
What odors are in the air: tobacco, alcohol, coffee, or ketones? Does something smell fishy? Does something stink? Physicians using native skills are aware of the importance of examining bodily fluids and discharges. Using just their senses. Animals leave characteristic scat. Scat tells many tales. 
How often today do physicians hear the patient say, “The doctor never even touched me”? The physician using native skills appreciates the value of touch. It is diagnostic and therapeutic. How can an examination be complete if a patient is not touched? The physician must hone this sense. How does a patient react to touch? What is the texture of the skin? What is the tension of the muscles? 
By the time the physician with native skills has concluded his or her first encounter with a patient, the physician has heard the story, has matched it with other stories, and has generated some hypotheses. Before ordering blood work or imaging procedures, however, this physician explores with the patient what the symptoms and signs might indicate. 
Or, to put it another way: 
Interpreting the Trail
It is all about
negotiating the meaning.
First be present.
When you are still,
you are mindful; you are attending.
Senses fully engaged;
open and curious.
The story unfolds.
The unexpected appears.
Observing closely and often,
Senses sharpen with practice.
As you couple yourself to experience,
you breed expertise.
Both animals and patients
leave trails
telling stories.
Both leave private bits of sign.
Who passed?
What happened?
It is more than tracks.
It is more than symptoms.
As tracks appear differently,
depending on substrate;
Symptoms appear differently
depending on
who is presenting them.
Let the big picture provide context.
What is the evidence?
Sometimes subtle, indistinct.
If noticed, illuminating.
Through practice; “dirt -time”
Patterns emerge; search images develop.
Observing, analyzing, reflecting
helps distill them.
Those who work daily in this territory;
The local tracker,
the family doctor
know the terrain.
Both have had previous conversations
with the landscape,
with patients.
They know normal.
Both use hypotheses and deductions.
Testing for proof.
Some make bold conjectures,
formed from empathetic connections.
They ask questions, others don't dare ask,
Sometimes seeming to leap from
vague observations to complex suggestions.
Learning to interpret the trail
is not taught.
It is something you do.
You teach yourself.
Seeing patients,
Being in the woods,
Letting time elapse,
Trusting the process;
More of the truth reveals itself.
Both trackers and healers,
filled with gratitude;
appreciate the beauty
in the story of the trail.
Gratitude breeds happiness.
   Financial Disclosures: None reported.