The nontraditional student [letter; poetry]

              68 • JAOA • Vol 101 • No 2 • February 2001 Letters
Wasn’t A.T. Still an
MD, too?
To the Editor:
Twenty years ago, I was medical director of
the outpatient pediatric clinic at the Uni-versity
of Oklahoma-Tulsa, having finished
pediatric training at Baylor College of
Medicine, become board-certified, and
nominated for a teaching award. After my
second son was born, I left that position to
establish my own practice and be more in
touch with patients. Ten years ago, I took
my first Sutherland Cranial Teaching Foun-dation
basic course in Osteopathic Manip-ulative
Medicine (OMM). That experience
gave the expression “being in touch” a
whole new meaning.
Given what I now know about the typ-ical
progression of training in OMM, it
seems a rather odd place to have started, but
for me it was an excellent introduction.
After another year, another basic course,
and an American Academy of Osteopathy
(AAO) convocation (that emphasized pedi-atrics),
I was swept up by the profession. I
began taking OMM courses, as well as all
examinations, at Oklahoma State Univer-sity-
College of Medicine (OSU-COM) with
first- and second-year students. The more I
learned, the more I incorporated OMM
into my practice. In 3 years, I passed the
competency exam in cranial osteopathy
and was asked to teach in the OMM lab at
OSU-COM.
Five years after that first introduction,
the osteopathic perspective had virtually
taken over my established pediatric practice.
There was no such thing as a “straight”
medical problem. I was constantly looking
for the structural correlate to help explain
and treat an illness. My prescription writ-ing
and subspecialty referrals plummeted,
and allopathic colleagues began to think I
was “out there.” Wanting to justify myself,
as well as improve reimbursement for my
activities, I began doing research on otitis
media, funded by the AAO’s Samuel
Robuck Fund. The American Osteopathic
Association (AOA) later granted me sig-nificant
monies to expand that research to
a multicenter trial using several other sites
across the country. In addition to main-taining
my private practice, I hold a 1/3
faculty position for teaching and research at
OSU-COM. I lecture and table train at
SCTF and Cranial Academy courses. I even
contribute examination questions for the
Osteopathic National Boards (COM-LEX–
USA).
I am a born-again osteopath and am
passionate about the discipline’s possibili-ties.
Here is a profession where elders are
respected for their experience and frequently
remain active in some fashion until death.
How refreshing to go to national meetings
where participants do not just sign in and
go play golf, but stay for lectures and gath-er
outside the hall to talk. I also respect
the deep spiritual foundation of the pro-fession,
as I have always maintained that
the therapeutic relationship should be
approached with reverence. To have that
manifest between my hands is a profound
gift.
Approximately 2000 continuing medi-cal
education (CME) hours and 10,000
osteopathic manipulative treatments later,
I now believe that to overlook the somat-ic
dysfunction in patients is a disservice.
As welcomed as I am made to feel by
my osteopathic colleagues, I have come to
realize that there is a glass ceiling for MDs
in this profession. I am barred from taking
the certifying examination for Neuromus-culoskeletal
Medicine and Osteopathic
Manipulative Medicine (formerly Special
Proficiency in Osteopathic Manipulative
Medicine) that would recognize my hard-earned
proficiency. I am not alone. There
is a growing number of allopathic physi-cians
with substantial osteopathic training
and experience who have dedicated their
lives to the osteopathic profession. We
deserve to be recognized by some level of
certification—even a variant of that con-ferred
on osteopathic physicians—that will
be recognized by third-party payers and
other professionals. I am aware of the
efforts of the AAO and the AOA to cre-dential
this group of professionals; however,
this effort seems to have floundered. I am
concerned that osteopathic physicians are
on the verge of giving away their authori-ty
in this field by hesitating on the brink of
leadership.
I joined the AOA to signify my solidar-ity
with the profession, but the AOA does
not even provide me the courtesy of track-ing
my CME hours, as it does for osteo-pathic
physician members. CME-granting
institutions do not recognize that I have an
AOA membership number. The profession
seems to trust me with its students and its
research money but refuses to validate my
osteopathic education in a way that would
convey to the community-at-large that these
activities have merit. DOs have the right
to enter into MD residencies and can be
certified by allopathic specialty colleges.
However, the favor is not returned to those
who have achieved standards that many
osteopathic physicians do not maintain.
It would surely be possible to measure
whether a physician choosing to learn and
practice osteopathic medicine has grasped
its essence. Certainly one does not grasp
the essentials from a weekend course, but
one does not work intimately in so many
aspects of this profession for 10 years with-out
getting them. I am not suggesting the
AOA blur the distinction between osteo-pathic
medicine and allopathic medicine. I
fully appreciate the historical lessons from
the California merger disaster. I simply do
not see why the profession refuses to set
specific expectations for allopathic physi-cians
wishing to be accredited to practice
osteopathic medicine as a subspecialty.
These credentials need only apply to OMM,
as other specialties are provided by allo-pathic
boards.
Letters
I vacillate between being philosophical
and frustrated over my situation. Perhaps
my predicament is a microcosm of the
identity issues many osteopathic physi-cians
feel in trying to practice osteopathy
in the medical environment today. I am
reminded, however, that in his day,
Andrew Taylor Still did not “fling the ban-ner
of osteopathy” for it to be hidden as a
skeleton in the closet or to be a jealously
guarded secret. He did it to reform and
revolutionize modern medicine. We (yes, I
include myself) still have the opportunity
to take the lead and make this change. I
can not fully join you in this endeavor
unless I am recognized as a proper repre-sentative
of this profession.
Embracing converts can only strength-en
the profession and complete the mission
of its founder. Allopathic physicians who
practice osteopathic medicine are not a
threat to the profession. Allopathic insti-tutions
do not and can not train and cre-dential
for osteopathic competency in the
way that osteopathic institutions can. They
lack long-established teaching programs
and adequately trained faculty. The AOA
must take this opportunity to make room
for and give an identity to qualified MDs.
Early osteopathy was full of MDs who
switched camps with encouragement from
Andrew Taylor Still, who was himself an
MD.
I accept the tremendous challenge that
is before me. I realize that it is more diffi-cult
to get board certification in OMM
than any other specialty—osteopathic or
allopathic. Moreover, it takes dedication,
education, service, research, and years of
hard work to become a Fellow in the
American Academy of Osteopathy
(FAAO). MDs and DOs of other special-ties
become fellows of their boards sim-ply
by paying their dues and putting in
their time after examination. Being an
FAAO is an enormous honor that is under-appreciated
by most MDs. Not this one. I
implore you to remove the glass ceiling,
end this reverse discrimination, and allow
me to join you in carrying the banner of
osteopathy.
Miriam Virginia Mills, MD
Young Peoples’ Clinic
Tulsa, Oklahoma
Article fails to recognize
unequal partners equal
odd coupling
To the Editor:
I am writing regarding the article, “Osteo-pathic
medicine and managed care: A
match made in heaven,” in Managed Care
Practice.1 You have got to be joking!
I refer you to a recent article in Amer-ican
Medical News2 in which an internist
was terminated by one of his health plans
because of a higher-than-acceptable uti-lization
of specialists. One must ask to
whom this was unacceptable. His patients?
No, his insurance company!
I was terminated by a health mainte-nance
organization (HMO) and lost over
500 patients, as well as nearly losing many
dollars per year in capitation payments. I
was further humiliated by being in the
awkward position of having to explain to
those 500 patients that I was not termi-nated
for being an incompetent physician.
The manner in which physicians are
ousted from HMOs follows a pattern. The
first step is a presentation of data dissem-ination
to show you that other physicians,
according to the HMO, conduct practices
that are more cost-effective than yours.
The second step is “friendly persuasion.”
(Read: You are in imminent danger of
being deselected.) The third and final step
is deselection, which you are not allowed
to challenge, only appeal. This process is a
joke and much like the show trials of the
Nazi regime.
Until physicians are allowed to negoti-ate
the terms of managed care contracts to
their satisfaction and until managed care
companies are liable for litigation, I will
continue to believe that osteopathic
medicine and managed care is a match
made in hell.
Miles A. Brumberg, DO
Sewell, New Jersey
References
1. McClellan C. Osteopathic medicine and man-aged
care: A match made in heaven. Managed
Care Practice 2000;7:1,5.
2. Page L. Physician fights plan’s use of profiles.
American Medical News 2000 Dec 18;cover, 1, 4.
On becoming a doctor
To the Editor:
When the old doctor approached the
patient, extended his hand warmly, and
said, “Hello, I’m Dr. S,” he seemed so
comfortable with the title of “doctor.”
This scenario was in stark contrast to
my experiences as a new resident. Although
my patients referred to me as “doctor,” I
felt somewhat awkward with the title. I
began to ponder the question: When does
one actually become a doctor? Did it occur
at graduation from medical school or on
completion of a residency program? Could
it be related to a medical license or board
certification? Although my mind raced
with these thoughts, I knew that becoming
a doctor involved something much less
tangible. What was it that made Dr. S
seem so comfortable with the title of doc-tor?
The question lurked as I concentrat-ed
on surviving internship. I had no idea I
would soon discover the answer to my
enigma.
When I first met Mr. W, I looked at
him with a filtered view. He was just
another patient with multiple medical
problems. I examined Mr. W every morn-ing,
and each time he would ask, “Doctor,
how am I doing?” I always responded
with indifference.
Over the next couple weeks, Mr. W
began to deteriorate. His was a difficult
case to manage because he had severe con-gestive
heart failure with concomitant renal
failure. We were constantly juggling his
medications. He had severe dyspnea, which
caused him to spend all day slumped over
a railing, gasping for air. In spite of his
obvious discomfort, I remained detached
to avoid clouding my medical judgement
with emotions.
One afternoon, I walked past Mr. W’s
room and noticed he was extremely short
of breath. He was slumped over the serv-ing
tray, his chin almost touching his chest.
His breathing was shallow and rapid. The
back of his neck glistened with sweat as he
strained to breathe. As I looked at Mr. W,
I could not help but feel sorry for him.
His distress seemed to unlock my emo-tions
from the isolated cage of clinical
medicine.
I wanted to help him desperately, and
Letters JAOA • Vol 101 • No 2 • February 2001 • 69
my mind raced for an answer. His pulse
oxgenation was 98%, so there was no
indication for intubation. His lungs were
wet with bilateral rales, so my first thought
was to give him a diuretic, but the combi-nation
of hypotension and renal failure
made diuresis contraindicated. I was at
the limit of my medical training.
In my search for an answer, I reached
around to his back and noticed that his
paraspinal muscles at the T1 through T5
levels were in spasm and that his rib cage
was barely moving. At this point, com-passion
forced me to react. I placed the
bed at a 45  angle because the patient
could not tolerate lying flat. I then began
to use paraspinal inhibition and, to my
surprise, the patient started to breathe
slower and deeper. A few minutes later, I
switched to a modified rib-raising tech-nique.
By the time I had treated both sides
at the T1 through T5 levels, the patient
was breathing comfortably and was no
longer in respiratory distress. He then
reached up, touched my face, and said,
“You are a good boy.” That was the first
time he did not call me doctor, and ironi-cally,
it was the first time I felt like one.
As I walked down the hall, I finally
understood what it was that made Dr. S so
comfortable with the title of “doctor.” He
had earned it through numerous experi-ences
with patients. Becoming a doctor
has nothing to do with a medical degree,
board certification, or a medical license. It
happens when our patient interactions
become rooted in compassion and human-ity.
This is something that comes from
within, and each medical school graduate
must find his or her own path. I feel for-tunate
that my path involved osteopathic
medicine, for it not only enabled me to
help my patient—it allowed my to realize
the moment I had become a doctor.
Michael Kelly, DO
North Shore University Hospital
Manhasset, New York
Books
I have Harrison’s on my sofa
Robbins on the floor
Stedman’s on the table
With many many more.
I’m covered up in textbooks
From my toes up to my head
I have to shove them all aside
Just to get into my bed.
Then I close my eyes to sleep
I toss and turn all night
With dreams of Johnson’s Physiology
And Immunology by Stites.
I was getting a little worried
Because you know these books aren’t
really real
Till I found they’re helping me
Perfect my palpatory skill.
You see, I reached into my bag one day
My listening hand was quiet
And scanned the spines of several books:
Moore’s, Wheaters, Gartner and Hiett.
I introduced some gentle motion
And found the one I sought
In the silky slippery spine
Of good ol’ Lippincott.
So now I palpate all my books
I can percuss them just as well
I don’t think I will auscultate
But only time will tell.
Bones and Blood and Guts
Bones and blood and guts inside
Brains and hearts and livers hide
Beneath our genteel frames
Underneath we’re all the same.
Construction worker to beauty queen
Medical student to college dean
And everybody in between
Underneath we’re all the same.
All pleasantries aside
By mortal pieces we are tied
The very things we need to hide
And hiding them seems such a shame
For underneath we’re all the same.
The Nontraditional Student
She stands transfixed
And stares out at a sea of faces
And they all stare back
Sucking in her words
She is terrified
She draws in a breath
And it comes thundering out
Shuddering
The urge to run is strong
She longs for the anonymity of the
pine trees
And the geese and the dogs
And the people who love her
And don’t care what she knows
And yet, she wonders at the
physiology
Of that indrawn breath
But even that is a fleeting thought
Because all her thoughts are fleeting
these days
There are too many of them crammed
inside her head
So that they push and shove each
other
Trying to be heard
The floor of the medical school
comes up
And wraps itself around her legs
And twines down her arms
And droops over her fingertips
Claiming her
You belong to us
You are where you need to be
So, she closes her eyes
And when she opens them again
She is one hundred twenty pounds
Blonde hair streaming down her
shoulders
A fearless nerd-child who knows
everything
And the sea of faces are
Round cheeked, downy haired,
diaper clad
Sucking their thumbs and raising
their arms
Wanting to be held
It was a brief illusion
But it helped
70 • JAOA • Vol 101 • No 2 • February 2001 Letters
Neurology
Neurology’s a bummer
It’s making me uptight
I’m feeling dumb and dumber
Just can’t get those quizzes right.
Dopamine schmopamine
GABA DABA DOO
So serotonin’s 5HT?
I don’t have a clue.
White matter, gray matter
Yeah, we have a brain
But all these little details
Are driving me insane.
I know we need to know it
I think it’s up there in my head
Lost in neurofibrillary tangles
And in neurons that are dead.
—Rita Roberts, MSII
Ohio University College of
Osteopathic Medicine
Athens, Ohio
Letters 71
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