The Best Doctors You’ve Never Heard Of
While DOs are often indistinguishable from MDs (they are fully licensed, and can prescribe drugs and perform surgery like an MD), their medical education is rooted in a distinctive philosophy. Like all integrative doctors, osteopathic physicians are taught to encourage the body back toward health using the least invasive measures first. What differentiates their training is this: It focuses on how the structures of our bodies are deeply linked with how healthy we are. The field was founded upon manual manipulation, a therapy designed to improve the flow of air and blood, lymphatic, and other fluids in the body to maximize self-healing mechanisms and improve the function of our brain, organs, and joints. Doctors who practice manipulation, like Shadoan, say they can help a body return to health by adjusting tissues and bones just so. Sounds like a long shot, but there may be increasingly good reason to believe in this touch-centered medical approach.
For one thing, DOs are fast becoming a pillar of American health care. As we barrel toward an unprecedented physician shortage, they are stepping up to fill the widening gap. One in four medical students in the US are enrolled in a DO program, and this number is rising rapidly. In 1970 there were 14,000 Dos in the US; that number is expected to be more than 100,000 by 2016.
Next time you visit your oncologist, psychiatrist, or even your primary care doctor, eyeball their credentials; you might be seeing a DO without even realizing it. Today’s osteopathic doctors can be found in all medical specialties; out of 100 DOs, fewer than five specialize in manual manipulation, the way Shadoan does. But the other 95 have been trained in it and are likely to use their hands: to diagnose you, to soothe you, to convey warmth and connection, says Boyd Buser, dean of the University of Pikeville–Kentucky College of Osteopathic Medicine. Studies from the past couple of decades show associations between touch and faster wound healing, stronger immunity, and reduced pain, suggesting that doctors who touch their patients may be able to offer more effective medical care.
Manipulation exemplifies the traditional osteopathic approach to medical care. There is also evidence that it can help relieve lower-back pain, which is why I’m standing sock-footed in Shadoan’s office, listening to classical music and concentrating on my breathing.
Shadoan asks me to lie faceup on the exam table. He rolls his stool to my right side and slides his hands under my back, palms up. There are multiple manipulation approaches, and he specializes in one known as cranial osteopathy, a sometimes controversial practice focused on the cranial bones and the tissues surrounding the brain and spinal cord. DOs like Shadoan are particularly concerned with increasing the flow of cerebrospinal fluid, which provides nutrients, cushions the brain inside the skull, and circulates rhythmically through the brain—between the membranes that surround it and up and down the spinal column.
As Shadoan sets to work using his fingers to investigate each vertebra in my spine, he explains the DO philosophy: “Many drugs address the symptoms, not the cause. You’re not sleeping, here’s something to make you sleep; you’re nauseated, here’s something that will block your nausea response.” He has intense brown eyes and a cropped beard—more East Coast intellectual than New Age spiritualist. “Medicine that treats the patient,” he says, “seeks to understand why the problem is there and resolve the conditions that create that problem.” When medication is necessary, Shadoan uses it. “Drugs and surgery are often a less efficient, less healthy way to deal with things,” he says. “But sometimes they’re necessary.” If a patient needs a knee replacement or radiation therapy for cancer, Shadoan refers them to a specialist and suggests manual manipulation as a complementary treatment.
His fingers work down my spine and into my right hip, then slowly down my right leg all the way to my ankle. He’s checking the “movement and quality of tissues,” he says, explaining that the texture and flexibility of bones, joints, muscles, ligaments, fasciae, and organs beneath his fingertips tell him a lot about my health, and what adjustments might improve it. He repositions himself to stand at the end of the table, facing my feet. He gently presses his fingertips between the tendons on the top of my right foot, and I feel an unpleasant tenderness. When he tests the same spot on the left foot, eyebrows raised at me in question, I tell him it doesn’t hurt at all. He nods.
Taking my less sensitive foot in his hands, Shadoan pushes his palm flat against my sole and gently rotates the foot outward. “Does this hurt?” he asks. No. He repeats the position on my right foot. “Ow!” I yelp, recoiling slightly. Pain has just gone shooting up my right leg, through my hip, and into my lower back. It wasn’t excruciating, but it was completely unexpected. “I thought that might be it,” Shadoan nods. It’s a little unsettling that he seems to know things about my body that I don’t.
“‘I thought that might be it,’ Shadoan nods. It’s a little unsettling that he seems to know things about my body that I don’t.”
That ankle got injured awhile back, and Shadoan suggests that to ease the pain in my still-unhealed ankle, it’s possible I’d unconsciously begun to favor that foot when I walk. This would have alleviated the discomfort in my ankle, but also would have changed how my weight was distributed throughout my body, causing my hip to twist and putting stress on my lower back, an imbalance that could strain muscles and put pressure on nerves. I have no way to test this theory, of course, but it’s intriguing.
A massage therapist might have helpfully kneaded tight muscles near my spine; an MD might have prescribed a painkiller. Shadoan did something that felt more like a gentle untangling, what he would describe as resetting the alignment of tissues and bones so that I would bear my weight more evenly and so blood and other healing fluids could flow unimpeded through my system again.
Although osteopathic manipulation is most commonly used to treat musculoskeletal conditions like back, joint, and neck pain, its practitioners say it offers relief from a range of medical problems, from asthma to migraines to Parkinson’s symptoms. Some research bears this out. There is evidence, for example, that using manipulation to treat elderly patients with pneumonia results in shorter hospital stays and less use of medication. Other studies have suggested a link between manipulation and activity in the endocannabinoid system, the same system affected by the pain-relieving cannabis in marijuana.
But the results of studies are mixed overall, and there have been few reliable trials. This may be partly because, like treatments such asacupuncture, manipulation doesn’t fit neatly into the scientific model of clinical testing. The gold standard is the double-blind, placebo-controlled study, in which neither practitioner nor patient knows if the person is receiving the treatment or a placebo. These studies are incredibly difficult to do on manipulation, because you have to do “sham” treatments. At best, the patient won’t know if they’re getting the treatment, but the practitioner will. Another reason may be cultural: The MD track has historically been better at training doctors to do research, and MDs have not been hugely motivated to do clinical trials on manipulation. Only a slim percentage of doctors practice manual manipulation, and some look on the therapy with skepticism. In recent years, there has been a push for more rigorous testing, which should eventually shed light on how and for what conditions this therapy is most effective.
Shadoan scoots his stool back, stands, and takes hold of my right arm. He rotates my shoulder joint, then my elbow, kneading tender points until they are no longer tender. In this, the treatment is reminiscent of a session of physical therapy, in which a therapist might find points of tension, where muscles are contracting, and press into them until the muscles release. Finding a particularly sore spot on the outside of my elbow, Shadoan moves my arm into a slightly elevated and inward-twisted position, which relieves the pain in my elbow and makes my head ache at the same time. He lowers my now-floppy arm onto the table and begins to press his fingers into my abdomen, near my belly button, while explaining how he takes all the information he’s getting and “puts it into a framework of the entire body being a tensegrity system.” I’m getting pleasantly woozy, which makes it hard to concentrate on what he’s saying. As he pushes the heel of his palm rather forcefully into my rib cage, I breathe out, hard, then ask what he means by “tensegrity system.”
“Tensegrity is a term coined by the architect Buckminster Fuller,” Shadoan says, “referring to tension and integrity. In architecture, you find tensegrity in domes, where you have a latticework of interconnected joints and supporting material stretched across them that puts tension into it to hold it, transmitting force throughout the whole thing.” Early civilizations built massive pyramids and ziggurats that were simply stacked: no tensegrity. Once we mastered the concept, it allowed us to build suspension bridges and skyscrapers—buildings where the height is much bigger than the footprint.
“Like skyscrapers, humans have small feet and relatively big torsos and heads,” he goes on. “Our brain monitors where the parts of the body are relative to each other and decides, OK, we need a little more tension here, a little less tension there. The brain is doing that all the time, whether we’re sitting, standing, running, throwing. The number of unconscious calculations is unbelievable. An osteopathic treatment works to help the body to be more efficient in how it distributes weight and force.”
Shadoan has his fingers tucked into my torso and is pulling on my rib cage. My whole body is vibrating like a plucked string.
“It’s why when we treat somebody, we treat them from head to toe, whether they have a head injury or a broken ankle,” he explains. “The body is trying to distribute all of our weight and keep us in balance on our tiny feet.” When you’re injured, suddenly other areas near the injury may have to carry more than their share, ultimately leading to problems distant from the injury. “If you twist your ankle, it’s going to affect your knee, your hip, your back, your shoulder; you may get headaches. Go to an osteopath who specializes in manipulation and they’ll treat the whole system.” Tensegrity has been used to create and test models in fields like cell biology, but like a lot in medical care, the concept amounts to unproven theory. Nonetheless, it makes intuitive sense: Because the musculoskeletal system is intimately interconnected with the nervous system, which controls the function of all our internal organs, the theory says that adjusting structure can affect a staggering range of processes in the human body—including disease.
My mind is a rowboat unmoored. The oars have slipped from their locks into the water below. But I try to remember this: The human body is more like a skyscraper than a pyramid, which is why if you have a sprained ankle you can end up with headaches.
There’s been much enthusiasm of late for preventive medicine, both from the government (as a feature of the Affordable Care Act) and from patients, who have been turning to integrative care in droves. This may be why so many doctors-in-training are being drawn to the growing number of osteopathic colleges—for the hands-on approach and emphasis on preventive care. Because DO schools have historically been easier to get into than conventional medical schools, however, some see them as a back door to a medical degree. But applicants’ scores have been rising steadily over the past decade, and competition for spots in osteopathic colleges is intensifying. Last year, 17,944 hopefuls applied for just over 6,200 spots.
“When I float out of Shadoan’s office, I’m breathing more deeply than I have in months.”
While many MDs gravitate toward high-paying and more prestigious specialties such as cardiology and surgery (in part because they have more student debt to pay off), 60% of DOs are primary care physicians. Inspired by the social mission imparted in osteopathic med school, more than one in five practice in underserved communities, both rural and urban. And according to the American Osteopathic Association, graduating DOs are largely continuing this trend. This may be good news for a country in which the number of MDs going into primary care is plummeting, and the anticipated physician shortage will hit underserved communities hardest.
At the same time the number of DOs is rising, the already hazy lines between DO and MD are getting blurred further. Last year, the Accreditation Council for Graduate Medical Education announced a plan to merge the historically separate DO and MD residency programs into a single system. This means that by 2020 all doctors in the US, whether MD or DO, will finish their medical training under one umbrella. In a press release, Stephen Shannon, the president of the American Association of Colleges of Osteopathic Medicine, said that this approach “not only streamlines but strengthens the postdoctoral process, enhancing the ability of all physicians to learn the unique characteristics of osteopathic medical practice.” Whether this plays out in practice remains to be seen.
When I float out of Shadoan’s office, it feels as if I’m breathing more deeply than I have in months. The pain in my back has subsided, my arms swing loose at my sides, and my skull seems perched more squarely atop my spine. I’ll feel mildly euphoric and absentminded, my whole body humming, for hours. After the initial pleasant effects, I’ll be deeply sore for at least a day.
In the short term, my back pain was relieved, an effect that has also been reported in clinical trials indicating that manipulation can lower rates of pain relapse, the use of pain medications, and missed days at work. The long-term effects of a single treatment are harder to quantify. Manual manipulation is designed to support the body’s own healing mechanisms, so that you recover faster and stay healthier over time. I can’t say how much faster I healed with this one treatment than I might have healed without it. Or how fast I might have healed with more regular treatments. Sometimes my back still hurts, but I also sit hunched at a computer all day. This is why controlled studies like the one with pneumonia patients are crucial to understanding manipulation; they track a group of patients over time.