Osteopathic Psychiatry, the Forest, and the Trees

You remember the 1998 film, The Horse Whisperer, don't you? Robert Redford riding the range of Montana. Kristin Scott Thomas the intense New York magazine editor. Her daughter, Scarlett Johansson, reeling in the aftermath of an accident involving her, her horse, and an 18 wheeler. Music by Thomas Newman, recalling redemption at Shawshank Prison, sets the tone (no one scores redemption like Newman).

Kristen Scott wants Redford to fix her daughter's horse. It's pretty simple, she says, do whatever it is you do, take my money, and I'll be on my way. I'm busy, my life is full, I don't have time for distractions. He's an animal, not a person, fix him, like my car. You live on a ranch, you fix things, fix this.

But Redford can't and neither can anyone else. Not with a snap of the fingers, anyway. Some things take time, he replies, and your horse is one of them. You should also know, I don't treat symptoms in isolation. Your daughter will be involved and very likely, so will you, before all is said and done. The forest is as important as the tree.

Osteopathic Psychiatry is like that, or it ought to be. 

When I published Osteopathic Psychiatry: Time to Smell the Roses, I had no idea it would become as popular as it has, suggesting other people are as interested in the subject as I am. Curiously, that particular post was inspired by a problem I had researching osteopathic psychiatry. Apart from chapters in the seminal osteopathic textbooks and scattered journal articles, there wasn't much out there. Google "psychiatry" and you'll be busy reading til the next millennium. But a body of literature, devoted specifically to the theory and practice of osteopathic psychiatry, eluded me. I was reminded how unexplored territories are labeled on old maps. No roads or rivers, just the phrase, "Beware, there be dragons here."

Sometimes I wonder if this "empty book shelf syndrome" stems from uncertainty about whether there is such a thing as a peculiarly "osteopathic" psychiatry? What if psychiatry is nothing more than a purely allopathic endeavor that osteopathic physicians practice in imitation of their M.D. colleagues? If that were truly the case, we could stop right here. End of discussion. 

On the other hand, what if the diagnosis and treatment of mental distress and disease, its biophysical underpinnings, and behavioral expression, is a sub-field of medicine, independent of theoretical orientation or professional degree? I believe this is precisely how we should think about psychiatry, much as we do with the other forms of practice that make up the fabric of medicine as a whole. 

Now we're in the position to ask, is there any justification for an osteopathic approach to psychiatry? Are there identifying marks rendering it unique? Suggesting clinical activity is "osteopathic by association," i.e. osteopathic by virtue of being practiced by a DO, doesn't work as well as it sounds. That's too much like saying a wedding ceremony is Baptist (or Jewish or anything else) because a Baptist minister performed it. You can take my word for it, I've performed enough weddings to know, the minister's denominational affiliation means very little. The character of the rite itself must reflect the tradition the minister represents. 

Taking a clue from DOs who practice physical medicine, one of at least two key elements in the "rites" of osteopathic psychiatry should be the insistence upon a person-centered framework for diagnosis and treatment. In my experience, MD physicians almost universally describe DOs as whole-person oriented in contrast to their own problem-based focus. Put simply, and perhaps too simply, MDs are trained to evaluate the tree; DOs to evaluate the tree and the forest as a single entity. Superior is not how I'd describe the difference; complimentary is far more accurate. Our medical house is big enough for each of us to have our own room and share the common spaces without feeling cramped.

A second key element, which could actually turn out to be the defining feature of osteopathic psychiatry, is the way it attends to the mind-body interface. We're physicians, not psychologists. We learn how to perform physical examinations, treat physical illness, and use Osteopathic Manipulative Medicine (OMM) in patient care. Whether we do these in the clinical setting or not, the training and experience are still there. At the core of osteopathic medical training is the explicit understanding there is no artificial distinction -- no disunity -- between mind and body. If the triad of mind-brain-behavior represents the tree, the body, at bare minimum, represents the forest. Mind-body integration lies at the heart of everything we do. How this will work out in terms of philosophy and psychiatric practice guidelines is the direction I think we're moving.
 
The way we're accustomed to thinking about medical practice is changing rapidly. Integrative care, involving psychiatrists who function as consultants within primary care settings, may become increasingly common. A new generation of osteopathic psychiatrists has begun applying OMM to alleviate the somatic dysfunction accompanying, compounding, or in some cases, even leading to symptoms associated with psychiatric illness. DO and MD psychiatrists alike may find themselves monitoring medical conditions their instructors customarily referred to the Internist. Our generation of psychiatrists -- particularly osteopathic psychiatrists -- may eventually be known as the one that took the stethoscope out of the desk drawer and placed it back round our necks, where it belongs.

(Creative commons image by takomabibelot via Flikr)

Medical School Without a Doubt

"Regrets, Eric, that you're not down there with them?"

"Yeah...no doubts, though."

These words pass between coach Sandy McGrath and runner Eric Liddell in the film Chariots of Fire (1981).  Sitting in the stands, they're watching the 1924 Olympics event in which Liddel refused to participate because it was held on Sunday. 

As you may recall, Liddell was firm in his religious convictions, including keeping Sunday as the Lord's day. Adherence to his beliefs brought him into conflict with the Olympic Committee whose members found it incredible anyone would place God above King and Country. Seeing his teammates run without him, he wishes he was among them -- even with strong convictions, he's still human -- but it's a wish unaccompanied by doubt. In his final race, a competitor says of him, "He has something to prove. Something personal. Something guys like (our) coach would never understand in a million years."

Probably the second most common question I get about attending medical school at my age relates to whether I have any regrets about my decision. "Now that you're here, has medical school lived up to your expectations? Would you do it again, knowing what you know now? Is the pursuit and presumed attainment of a dream everything it's cracked up to be?"

Truthfully, it depends on the dreamer. For me, it certainly has been, and continues to be, as fulfilling as I hoped it would be, and in ways I couldn't have imagined what seems like a lifetime ago. In part, this is because I haven't been aiming at achieving a distant goal nearly as much as I've been engaged in a daily process of achievement. 

Life is a terminal illness for everyone and waiting to live is folly. Sure, like the rest of my classmates, I can hardly wait for the day I get my first paycheck as an attending physician, but delaying enjoyment of what I'm doing until then is like carrying a dream around in a bucket that has a hole in it. You wake up one morning to find your dream has dribbled away when you weren't looking.

This is why I try to take every day as another chance to work at being a doctor, even one in training, though may I forget, as we all do. Distracted by a mistake or worried about my performance, I stumble over my own frailty, and then a nurse asks me what she should do next or a patient smiles after we've discussed her upcoming procedure and I remember. Doctor is who we are on the inside, long before our names are punctuated by the initials D.O. or M.D. on our white coats.

Would I do it over again, knowing what I know now? I've probably answered that one already, but let's just say a person can arrive at the point where living authentically is more important than playing it safe. You bet I'd do it again, though, with the virtue of hindsight, there are a few things I'd do differently along the way. For instance, I'd make the acquaintance of Francis Ihejirika, MD, much sooner. Francis is the founder of the PASS Program in Champaign, Ill., and even more than successfully preparing me for board exams, he taught me how to think as a medical clinician. Eight weeks of being challenged, encouraged, patted on the back and kicked in the pants were life changing. "Thank you" is scarcely enough.

I'd also be less afraid, if that's possible and maybe it isn't when you're trying to swim against fifty-foot waves that drown the biggest ships as though they were the tiniest toys. But that's what medical school can seem like. We start out feeling vulnerable -- much like we do in those crazy dreams where we're naked and everyone else isn't. You've had those, too, huh? Funny how I never manage to have Daniel Craig's physique (Casino Royale, 2006), despite what Freud said about dreams representing wish fulfillment. Anyway, we end up finding out the individuals we thought were the smartest, the most gifted, and presumably, the most invulnerable, have have been battered by the waves, too. 

Medical school is a huge undertaking; it's the hugest thing most of us have ever attempted. I can't stress this enough. Honesty forbids me from coloring this truth in anything but black and white. Nothing I know of can adequately prepare a person for the volume of material they're going to face, the hurricane force at which it strikes, or the feelings of aloneness that surface in the wee hours before exams. It's something you have to experience to know. But looking back, I can see how I've grown in the confidence surviving brings and without a doubt, I'm braver because of it.

(Creative Commons image of Eric Liddell via Wikipedia)