OMT's effectiveness already proven [letter]

              262 • JAOA • Vol 103 • No 6 • June 2003 Letters
LETTERS
OMT’s Effectiveness
Already Proven
To the Editor:
I have read the Journal of the American Osteo-pathic
Association with interest since 1934. I
graduated from Kirksville College of Osteo-pathic
Medicine, Kirksville, Mo, in 1935 and
established a practice in Springfield, Min-nesota,
in 1935.
I believe I had the most extensive osteo-pathic
medical practice in Minnesota, which
operated for more than 53 years. In addition,
from 1940 to 1971, I directed the only osteo-pathic
medical hospital in Minnesota—then
or since. In those early days, the practice of
osteopathic medicine was greatly limited
in most states, though not as limited in Min-nesota,
Iowa, Missouri, and Michigan.
Students at Kirksville College of Osteo-pathic
Medicine were there because they
had had an experience with osteopathic
medicine. Some had a relative who was an
osteopathic physician, but most had per-sonal
experience with the osteopathic struc-tural
examination and osteopathic manip-ulative
treatment (OMT).
After graduation, most students opened
private practices but were limited to pro-viding
only OMT to patients. In Minnesota,
however, osteopathic physicians could also
perform minor surgery and provide
obstetric and gynecologic services.
For years, we worked hard to improve
our practices, wondering all the while if
our profession was coming to an end.
I decided to become an osteopathic
physician because OMT saved my maternal
grandmother’s life and stopped my having
convulsions during childhood fevers. Of
greatest impact, however, was my experi-ence
with a segmental dysfunction, which
I still like to call an osteopathic lesion.
During my busiest practice years, I pro-vided
care to between 45 and 55 patients
daily and then made as many as nine house
calls in the evening. Approximately 80% of
my patients were given OMT, and I had
patients coming from 100 miles and further
to receive the care I provided.
In my earliest years of practice, I pro-vided
30 minutes of OMT to each patient
but learned to perform structural diagnosis
and provide treatment more quickly after
hearing a chief surgeon from Kansas City
describe the extensive structural work that
could be achieved in 5 minutes.
I almost always included soft tissue
treatment in my manipulative care for diag-nosis,
movement of venous blood and lym-phatic
systems, and mobilization of the
articulations. The osteopathic physician of
my childhood, E.C. Dymond, DO, had
studied under A. T. Still, DO, MD, and
always included soft tissue treatment,
which I assumed he had learned from Dr
Still.
On three occasions, Kirksville College
of Osteopathic Medicine contacted me
about joining the staff of one of their satel-lite
clinics, but I was so entrenched in Min-nesota
that I did not go. I am soon to
become 89 years old. Were it not for my
age, I would be glad to teach OMT.
I do not know the answer to the
problem of osteopathic physicians aban-doning
OMT. I believe some of the causes
include the desire to become a physician,
regardless of which type, and teaching that
was questionable, dealing only with the
correction of a segmental dysfunction; and
failing to teach the value of treatment in
general diseases. Osteopathic medical stu-dents
today are overeducated and, yet, may
not receive needed training in OMT in their
years of internship or residency.
It is hard for me to understand why we
continue to talk about proving the value of
the structural examination and OMT. All
of us old-timers know its value.
These days, it seems that many in the
osteopathic medical profession prefer to
build financial resources and contribute to
stores of research and clinical experience,
while ignoring the single, most important
feature of our profession. I hope we can
redirect our energies—perhaps beginning in
colleges of osteopathic medicine—to whole-heartedly
embracing and reprioritizing the
role of OMT as the core mode of therapy
provided by osteopathic physicians.
Robert M. Tessien, DO
Springfield, Minnesota
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JAOA • Vol 103 • No 6 • June 2003 • 263
LETTERS
Letters
Rein in Runaway Costs
Associated With
Malpractice Insurance
To the Editor:
When I completed my residency in obstet-rics
and gynecology in 1961 and entered
practice, a moderately priced home cost
approximately $20,000, a new Chevrolet
automobile cost approximately $2000, and
a stamp cost 3 cents. At that time, my annual
malpractice premium cost $150. Today, a
moderately priced home costs approxi-mately
$200,000, a new Chevrolet costs
approximately $20,000, and a stamp costs 37
cents. Malpractice insurance in my specialty
has risen to approximately $150,000 per year
in some states and more in others.
I may just be a country doctor from the
Pine Barrens of New Jersey, but I have
learned some basic math through the years.
Although there has only been a tenfold
increase in the cost of many staple items in
the United States, the cost of medical mal-practice
insurance has multiplied a thou-sandfold.
Am I missing information that
would help explain why malpractice insur-ance
rates are completely out of line with the
rest of our economy?
When an attorney prepares a will, he or
she typically charges a fee for time, expertise,
and paperwork. He does not strike a deal
that allows him to receive one third or one
half of your estate, nor does he prepare the
will on a contingency basis. Let us hold the
reality of that financial arrangement—fee
for services rendered—as we discuss con-tingency
fee and pro bono arrangements in
the legal profession and their application in
the medical profession.
The legal profession maintains that con-tingency
fees in medical malpractice cases
allow people who otherwise could not
obtain legal counsel to do so. Attorneys also
pride themselves on offering pro bono pro-grams
to the public, guaranteeing legal rep-resentation.
How many in the medical profession
have been called to the emergency depart-ments
of our hospitals to tend to an auto-mobile
accident victim, a woman with an
incomplete abortion, or a woman having a
ruptured ectopic pregnancy? How many in
the medical profession have refused to
render care to those patients because of their
inability to pay? How many in the medical
profession have conducted clinics for the
needy in our communities without renu-meration
or have waived fees for patients in
our offices when they had fallen on hard
times? If attorneys offered their pro bono
and contingency fee programs to alleged
victims of malpractice who cannot afford
services and, on successful settlement, then
collected a fee for hourly services and
expenses, that would be a fair and equitable
system and would ultimately result in lower
malpractice insurance rates. I would call
that pro bono plus.
Another way to bring down the number
of expensive medical malpractice lawsuits
involves a time-honored system to deal with
injury in the workplace. It is called com-pulsory
arbitration. The injured employee
has his or her case reviewed by an arbitra-tion
board, usually consisting of a union
representative, a physician who is an expert
in the area of practice, an attorney, and a
lay member. Responsibility is assigned, con-tributory
negligence is determined, and the
board recommends a dollar amount as
award. The employee has the option of
accepting the decision or taking the issue
further with a lawsuit. If the case makes it to
trial, the jury may be informed that the
plaintiff turned down an award recom-mended
by the arbitrators.
This system has operated successfully
in industry for many years. It helps deter
costly lawsuits with fees that may include
discovery costs, expert witness charges, and
court costs. Compulsory arbitration could be
as effective in medical malpractice cases,
helping to drive down costs appreciably.
Realistically, however, it is unlikely that
attorneys would kill the goose laying all of
those golden eggs.
There is a move afoot at both the state
and federal levels to put a cap on awards for
noneconomic damage (ie, pain and suf-fering).
Arguments abound on both sides
of the issue, but I have no doubt that limiting
awards to reasonable amounts would help
to drive down the cost of malpractice insur-ance.
Once again, however, we face the
obstacle of attorney-dominated legislatures.
Attorneys have another gimmick to
unnerve and harass the medical profession
and generate even larger legal fees: puni-tive
damages. A physician being sued has to
seek private counsel to defend against puni-tive
damage, as that aspect is not covered in
a malpractice policy. The threat of the ques-tion
of liability may force many physicians
to rush to settlement. This aspect of the law
should be handled the same as for noneco-nomic
damages discussed earlier to rein in
the runaway costs of malpractice insurance.
It has been estimated that approximately
6% of physicians account for 100% of med-ical
malpractice cases. If this is true, we, as
a profession, had better police ourselves
more effectively and act quickly when indi-cated.
There are several ways to deal with
chronic offenders. A supervisor could be
assigned to oversee patient care provided by
a physician with a history of malpractice
lawsuits. A similar program could be insti-tuted
in a private practice. Finally, physi-cian
retraining programs could be initiated
by hospitals and medical schools. The physi-cian
in question should be held responsible
for all costs associated with his or her reha-bilitation
program. The state boards of med-ical
examiners have to become more
involved in the process, suspending or
revoking the licenses of chronic offenders
who defy rehabilitation.
Will true reform ever take place in the
arena of medical malpractice? I think that it
had better—and soon. Our brightest people
are being forced to leave specialty areas
with particularly high malpractice insur-ance
rates, leaving academic environments
for more rural areas of the country with
lower medical malpractice insurance rates.
What a sad loss for our academic institu-tions.
Will young scientific minds continue to
be attracted to the medical profession? I fear
that most will find other ways to pursue
careers in the sciences. Although the cost
of malpractice insurance continues to rise
and the fixed costs of running an office are
also increasing, the revenues in physicians’
practices continue to decline in an inverse
ratio as the result of decreased managed
care reimbursements. Let us hope that the
crisis that we currently face will be resolved
by clear- and forward-thinking people in
government and that the future of medicine
will once again be promising and desirable.
Daniel H. Belsky, DO, MSc
Boca Raton, Florida
264 • JAOA • Vol 103 • No 6 • June 2003
LETTERS
Letters
Osteopathic Physicians
Provide Quality Care—
With or Without OMT
To the Editor:
Although the article by Donald G. Spaeth,
DO, PhD, and Alfred M. Pheley, PhD, “Use
of Osteopathic Manipulative Treatment by
Ohio Osteopathic Physicians in Various
Specialities” (J Am Osteopath Assoc. 2003;
103:16-26), is interesting, I disagree with
some of the authors’ conclusions. The
article points out the complete lack of use of
osteopathic manipulative treatment (OMT)
by 17 specialties and the rare or occasional
use of OMT by many other specialties. The
authors conclude that clinical and specialty
programs need to improve instruction in
the use of OMT. I submit that were these
programs to improve OMT training, the
results would be the same due to the dif-ference
in OMT use that occurs in clinical
training programs and in practice.
As an internist, I have had to manage
more complicated, chronically ill patients
because of the changing landscape of
medicine over the past 25 years, leaving no
time to provide OMT. This does not reflect
less regard for osteopathic principles and
practice, but rather the reality of the needs
of my patients and the impact of external
forces in the practice of medicine today.
That specialists report using no OMT
reflects the fact that OMT is not what they
are trained to do and is not expected in
these specialties.
The authors note “a disturbing trend” in
the low use of OMT for patients with
chronic obstructive pulmonary disease
(COPD) and asthma by nearly all osteo-pathic
specialists in Ohio. It is noteworthy
that the number of critical care and pul-monary
physicians in Ohio who have
increased their use of OMT since starting
practice is zero. I believe this statistic would
likely apply nationally and suggest that the
reason for this is that there is no scientific
evidence OMT makes a meaningful differ-ence
in either condition. The reference cited
by the authors that “dysfunctions in the
thoracic area are reported to benefit from
OMT” is vague, anecdotal, and more than
half a century old.
Truthfully, no colleagues that I know
of believe that OMT has any impact—pos-itive
or negative—on either COPD or
asthma, other than perhaps the psycholog-ical
benefit derived from a laying on of
hands. I believe it would take randomized,
prospective studies to prove or disprove
whether OMT could alter any of the fol-lowing:
excessive bronchial mucous secre-tion
seen in both COPD and asthma; the
role of cytokines from tissue mast cells,
eosinophils, T lymphocytes, macrophages,
and other mediators of subacute inflam-mation
seen in asthma; or improvement in
lung elasticity and alveolar function due to
alveolar wall destruction in emphysema.
If such studies showed convincing evidence
of a positive effect from the use of OMT, I
believe most osteopathic physicians would
be glad to add this mode of therapy to their
armamentarium for these conditions.
The authors suggest that it is the respon-sibility
of clinical and specialty programs to
emphasize OMT as well as to determine
its effectiveness. Although specialty col-leges
can track the use of OMT, it is more
logical that the American Osteopathic Asso-ciation
and affiliated academic research
institutions bear the standard for deter-mining
effectiveness of OMT in any par-ticular
disease entity that clinical and spe-cialty
programs can then confidently teach.
In their summary, Drs Spaeth and
Pheley appear to admonish the entire pro-fession
by pointing out “room to increase
the use of OMT” and that “each osteopathic
physician must work to improve the use
of OMT and other aspects of osteopathic
principles and practice.” The authors note
that OMT is only a part of osteopathic prin-ciples
and practice, yet suggest that the lack
of use of OMT implies lack of belief in the
“mandate for distinctiveness of the osteo-pathic
medical profession.” Nothing could
be further from the truth. To reiterate, OMT
is not used by many specialists because it is
not indicated, nor has it been proven to be
of benefit. In other instances, OMT is not
used because of time constraints. These
realities are not mutually exclusive of spe-cialists’
belief in osteopathic principles and
practice. Most osteopathic physicians are
proud of their osteopathic medical heritage
and are grateful for the opportunity to pro-vide
treatment for their patients as osteo-pathic
physicians. The unique distinctive-ness
in the care provided by our profession
is not lost on our patients who receive good
medical care—with or without OMT.
Ronald M. Crow, DO
Little Rock, Arkansas
Response
We appreciate Dr Crow’s comments about
our article. His concern about maintaining
our “osteopathic difference” is one that is
shared by many in the osteopathic medical
profession. Dr Crow’s statement, “That spe-cialists
report using no OMT reflects the fact
that OMT is not what they are trained to
do and is not expected in these specialties,”
is precisely what we hope to bring to the
attention of osteopathic physicians.
Our profession is being required to sup-port
its claims of being different and better
than the allopathic medical profession. We
quote “vague, anecdotal, and more than
half a century old” references relating to
pulmonary diseases because that is all there
is to quote. Osteopathic manipulative treat-ment
[OMT] has long been reputed to be
of benefit to patients with pulmonary dis-eases,
but where are the studies that support
or disprove these claims? Hopefully, fur-ther
research will be stimulated so our pro-fession
will have the support needed to pro-mote
our distinctiveness, or at least
discontinue implying inaccurate claims.
We agree with Dr Crow that the Amer-ican
Osteopathic Association and the spe-cialty
colleges need to determine the effec-tiveness
of OMT in various disease entities.
Specialty colleges need to supply the lead-ership
in establishing the applicability of
OMT to their specialties, as they know best
the pathophysiology and details of diseases
with which their members deal. For spe-cialty
colleges to remain passive and leave
the initiation of such research to others is
shirking responsibility and limiting poten-tial
contributions to the osteopathic med-ical
profession. Indeed, researchers outside
of the specialty may not see themselves as
qualified to understand the issues most in
need of empirical support. Lack of specialty
involvement in OMT research is a missed
opportunity to make the greatest impact on
our profession.
JAOA • Vol 103 • No 6 • June 2003 • 265
LETTERS
Letters
In acknowledging our use of outdated
references, we challenge Dr Crow and others
to identify current references in the literature
that continue this dialogue. Osteopathic
physicians and other individuals who work
to promote the future of the osteopathic
medical profession must consciously move
beyond the usual “vague, anecdotal” state-ments
our profession promulgates. Unfor-tunately,
the overall tone of Dr Crow’s com-ments
are typical of the profession’s current
leanings; unless each of us stops relegating
our understanding of OMT to others, the
osteopathic profession is headed for its
demise.
Donald G. Spaeth, DO, PhD
Director of Medical Education
Highlands Regional Medical Center
Prestonsburg, Kentucky
Alfred M. Pheley, PhD
Professor and Chair, Community and Rural
Medicine
Assistant Dean for Clinical Research
Edward Via Virginia College of Osteopathic
Medicine
Blacksburg, Virginia
Evidence-based Epidural
Mnemonic Provides Quick
Referral
To the Editor:
Labor pain and methods to relieve it are of
major concern to childbearing women
around the world. In developed countries,
most women use epidural anesthesia for
labor analgesia.1
Epidural analgesia carries with it a set of
complications derived from randomized
studies. These complications can be difficult
to remember by nurses, medical students,
midwives, and residents when they are
faced with questions or concerns from the
patient.
To contribute to the completeness of the
process of obtaining informed consent by
general practitioners, family physicians,
anesthesiologists, and obstetrician-gyne-cologists
regarding epidural analgesia, or
while teaching, we composed a mnemonic—
which is also an acrostic, as the first letter of
each sentence read vertically forms the term
epidural (see box). It is important to note
that each of the mnemonic phrases is based
on level-1 evidence (randomized controlled
trials) as defined by the United States Pre-ventive
Services Task Force.
As most of our colleagues have found
this mnemonic to be valuable for teaching
and during practice, we decided to share it
with all osteopathic physicians. We believe
this tool promotes excellence in the clinical
practice of evidence-based obstetrics.
Gary Ventolini, MD
Director
Associate professor
Elton Kerr, MD
Assistant professor
General Obstetrics/Gynecology Division
Wright State University
Dayton, Ohio
Reference
1. Hawkins JL, Gibbs CP, Orleans M, Martin-Salvaj
G, Beaty B. Obstetric anesthesia work force survey,
1981 versus 1992. Anesthesiology. 1997;87:135-
143.
Response
Although this mnemonic is a useful tool
for students, residents, and physicians to
help remember the risks and benefits of
epidural analgesia for women in labor, we
must make sure that the mnemonic does
not replace a true discussion.
We must present these risks within the
context of absolute risk versus relative risk.
What is the clinical significance of women
in labor being more likely to receive pitocin,
as complications of pitocin use are rare and
pain relief is almost universal?
Some of these suggestions are contro-versial.
For example, the randomized, con-trolled
trial referenced by the authors actu-ally
concludes that nulliparas do not have
an increased incidence of cesarean section
for dystocia when using epidural analgesial.
Finally, no mnemonic is exhaustive. This
one does not mention sequelae of inadver-tent
spinal tap. A mnemonic cannot replace
discussion. Analgesia should be taught in
prenatal classes. And remember, conver-sations
about pain relief are best held in
our office, not in the labor room.  
Paul M. Krueger, DO
Assistant dean for education and curriculum
University of Medicine and Dentistry of New Jersey
School of Osteopathic Medicine
Reference
1. Bofill JA, Vincent RD, Ross EL, Martin RW,
Norman PF, Werhan CF, et al. Nulliparous active
labor, epidural analgesia, and cesarean delivery for
dystocia. Am J Obstet Gynecol. 1997;177:1465-
1470.
Excellent analgesia
Prolongs labor
Increases instrumental deliveries
Debate: Increases or decreases cesarean delivery
Uses more oxytocin
Reports of associated severe perineal trauma
Augments temperature
Lowers blood pressure