Hearing the Call of Osteopathy

By Steve Paulus, DO

Each Osteopath, who practices within the tradition of Andrew Taylor Still, has a unique story of how they crossed the threshold into this healing art. Answering the call to become an Osteopath requires a different category of discipline and a special brand of attention. Osteopathy did not call my name in a clear voice containing the authority to mobilize potential into action. I heard frequent whispers into a somnolent consciousness and required an act of Nature to force me to accept my destiny. While I was waiting, in between the singular episodes of my life, the whispers grew louder and more articulate. Finally, I could no longer ignore the call of Osteopathy and transformation occurred.

As an Osteopathic medical student, I had a natural and intense interest in Osteopathic principles and practice. During my first two years of medical school I dove deep into the study of Osteopathic philosophy, became the President of the local chapter of the Undergraduate American Academy of Osteopathy (UAAO), became a second year teaching assistant in the Osteopathic Manipulation labs, took every available elective course in Osteopathic Principles & Practice, brought in teachers from all over the country to augment the meager basic Osteopathic teachings at my school, and mentored with a gifted local Osteopathic teacher.

The most important action I took to develop my skills in Osteopathic diagnosis and treatment was to establish my own “clinic” for fellow students. Starting in the second half of my first year I began to treat my colleagues during lunch breaks, in between classes, and after school. I gave 3-6 treatments per day for 15 months. People scheduled appointments with me and I literally practiced every new Osteopathic procedure on willing, stressed, and exhausted medical students. By the end of my second year of school I had given over a thousand Osteopathic treatments and developed a sensitivity based upon experience rather that theory.

Even as a freshman Osteopathic medical student, I felt an intellectual drive to become an old fashioned Osteopathic family doctor linking the practice of family medicine with the principles and practice of Osteopathy. From the beginning of medical school in 1981, I carefully organized my formal and informal educational curriculum to fulfill the specific goals I outlined for success. My third and fourth years of medical school, internship, and residency were a near absolute immersion into the allopathic world of medicine, to the exclusion of Osteopathy—a necessity I was reluctantly willing to accept. I felt strongly that I would be much more effective as an Osteopathic family physician if I experienced the intricacies and intensities of the orthodox western allopathic medical perspective. I felt the need to see and treat a wide variety of illnesses and have a practical working knowledge of human pathology.

For five years, from the beginning of my third year of Osteopathic medical school until the end of my residency, I seldom utilized Osteopathic Manipulation. During this institutionalized apprenticeship I trained primarily in hospitals, but was also educated in outpatient offices. I would often make myself available to Osteopathically treat fellow students, nurses, and even the teaching physicians. However, I rarely was able to care for patients using Osteopathic manipulation. The Osteopathic hospital where I did my internship expressly forbade any house staff (interns or students) from ever treating patients using Osteopathic manipulation. We were threatened with disciplinary action if it was discovered that we used our Osteopathic hands-on skills to help a patient. I still cringe at the irony and tragedy of being an Osteopath in an Osteopathic hospital forbidden to utilize Osteopathy.

Unfortunately during the intensities of the medical training process there were very few open moments to treat using Osteopathic manipulation. Often the work schedule demanded 90-100 hour workweeks with an on-call schedule from every other to every third night. Even if I had an open moment to offer a patient Osteopathic manipulation, I was so exhausted that I was unable to gather the energy to direct my full attention to provide a proper treatment. It was, and still is, easy for me to intellectually function in states of sleep deprivation and extreme stress. However, it was and still is, nearly impossible for me to offer my undivided attention, to give a quality Osteopathic treatment during states of extreme fatigue or pensive preoccupation.

I halfheartedly accepted the need to place my Osteopathic skills on hold during the institutionalized training process. My personal goal was to integrate Osteopathic and allopathic practice and I recognized the need to learn medicine, surgery, and the proper use of drug therapy. I was willing to pass the time until I was in private practice, where I could “do whatever I wanted.” I patiently waited for the opportunity to implement my well-organized ideas, plans, and manifest my goals.

After completing an allopathic Family Medicine residency at the University of Nevada in Reno, I was recruited to work in a small farming community in central California. I was taken in by an experienced MD family physician who had been in practice for ten years and desperately needed a young associate to lighten his patient load. I had no formal financial guarantee from the local community hospital, but I was virtually promised a busy practice by my new colleague. I took out a small business loan to purchase basic equipment, hire a nurse, and begin practice as a small town Osteopathic family physician in Watsonville, California.

Upon entering private family practice I was unprepared for the immediate busyness of my schedule. I thought I would have time to transition and to pragmatically re-develop my Osteopathic skills. I was overwhelmed immediately with a busy office and hospital based practice. I attempted to reserve a percentage of my day for scheduled appointments devoted exclusively to Osteopathic Manipulation, but I rarely had the space in my schedule to make it work. I was not only overwhelmed with a very busy office, I could not figure out how to integrate Osteopathy into a medical practice. I was seeing 6-8 patients an hour and only had enough time to take a brief history, perform a focused exam, and swiftly write out a prescription for a medication.

In addition, I rapidly realized that my skills in Osteopathic manipulation had atrophied. I lost the sensitivity of touch that I so carefully cultivated during my first two years of Osteopathic medical school. With a sense of urgency I began to take post-graduate, continuing medical education (CME) courses in Osteopathic manipulation. Frustrated but not discouraged, I developed a rapid method of treating patients in a busy office based family practice setting. My results were good enough to satisfy my patients and sufficient to keep me, temporarily, from becoming disheartened.

I found my groove in the medical community of Watsonville. I was respected, had a thriving office and hospital practice, and my understanding of Osteopathy was expanding. I began to have some successes in treating, what I thought were, unusual problems using Osteopathic manipulation. Patients with hypertension began to “mysteriously” require lower doses of medication. I was sometimes able to take people completely off anti-hypertensive agents, reduce their dosage, or decrease the number of different drugs they were taking. This unexpected Osteopathic success only created for me an internal, philosophic dissonance. I was becoming dissatisfied with the intense and rapid pace of a busy family practice. It was difficult to truly establish a close relationship with patients during a rushed 5-10 minute appointment. I was beginning to long for the luxury of seeing only 2-3 patients per hour, so I could give them my full attention. My groove was feeling more like a rut.

From the paradox of success mixed with dissatisfaction came a natural disaster that permanently changed my life. The 1989 Loma Prieta earthquake devastated the central coast of California (particularly Watsonville) and rocked the foundation of my preconceptions and goals for professional life. I was in my office seeing patients and the building literally fell off its foundation three feet, slid down the hill, and the structure cracked in half. Thank God none of the 7 people on this geologic roller coaster were injured.

The earthquake proved to be metaphorical. The resulting emotional aftershocks rocked my life for the next 7 years. The earthquake set into motion a chain of events that freed me from a misguided sense of duty. I believed I had an obligation to practice family medicine in a small town. I told the fixed story of my professional goals so many times that I was inflexible to emerge from the trap I self-created.

I was forced to close my family practice. My associate moved to Arkansas. I was devastated. I had lost everything. Left without a job (so to speak) I began to work at a local urgent care center owned by the emergency room physicians at Watsonville Community Hospital. Ironically, I could now pay off the small business loan for a medical practice that no longer existed. My old office building was razed and it became an empty lot.

Working in the sterile, regulated, and impersonal world of urgent care medicine proved to have its advantages. For the first time in seven years I was able to sleep through the night, uninterrupted by phone calls from patients or hospital admissions. I felt that my personality was changing—for the better. The edge of cynicism and anger (dependent upon sleep deprivation) began to finally wear down and round out so that these toxic emotions could roll away from my life.

Over the next year, I began to Osteopathically treat the nurses, administrators, and other doctors at the clinic. That year I took six advanced post-graduate Osteopathic Medicine courses. My Osteopathic skills, repertoire, and clinical sophistication dramatically increased. The administrator and medical staff were impressed. Remarkably, I was offered an Osteopathic specialty clinic in the urgent care environment. I saw scheduled patients and consulted with any of the practitioners in need of a musculoskeletal second opinion. I rapidly expanded to three full days of specialty clinic and two days of traditional urgent care. My goal of integrating Osteopathy and allopathic medicine was evolving in a direction I hardly imagined possible.

The satisfaction of a successful Osteopathic specialty clinic lulled me into a false sense of security. The more I practiced Osteopathy, the further I attempted to integrate the principles of this unique healing art to other aspects of my work. I was no longer satisfied with dividing the expression of Osteopathic principles and only including it in my specialty clinic. I began to incorporate the integration of Osteopathic philosophy into my work as an urgent care physician. Sometimes I would offer a quick Osteopathy treatment, but more often I would educate and include the basic Osteopathic orientation into the urgent care medical practice. For example, rather than just give an antibiotic for a patient with a one-day history of a mild viral upper respiratory infection, I taught the differences between viruses and bacteria and encouraged people to trust their natural abilities to heal themselves. I discussed the toxic side effect of antibiotics, promoted rest, and offered a wholistic approach to the care of infectious diseases.

I began to refer hypertensive patients to my specialty clinic. I taught people exercises they could do at home to prevent injuries. I sent people to stress reduction classes instead of giving them anti-anxiety drugs. Most of all I began to spend more time listening with my full attention. My sense of hearing the “unsaid” became more acute. The sensitivity and receptivity of my touch dramatically elevated. All my senses became more acute. I could increasingly feel a problem with some unusual inner perception that bypassed my sensory nervous system.

My euphoria at discovering and developing my inner senses was devastated by another foundation shattering event. This time it was a man made event that challenged my limited and innocent worldview. I was called in to the clinic administrator’s office for a meeting. This bureaucrat was a businessman, a manager with an MBA who ran the day-to-day operations of two large urgent care clinics. He told me that customers had submitted complaints about my work in the urgent care clinic. I was taken aback and surprised. He told me that several patients had directly called him to express their dissatisfaction when I did not give them antibiotics for their cold or flu. I kept quiet, waiting in surprise and impatient anticipation of what might be said next. He then said that I should prescribe more antibiotics, especially if the customer wants this product.

I was furious. This was an individual with no medical training telling me to give drugs when they were not indicated. With barely disguised indignation I told him to never again tell me how to practice medicine. I went into a long educational discourse on the differences between viruses and bacteria, the proper standard of care, and the list of potential side effects of inappropriate antibiotic use.

I did not leave his office feeling triumphant. I sensed the rumbling of another earthquake approaching my life. Two weeks later I was called in to the medical director’s office for what he termed a “friendly chat.” The medical director was an MD emergency room physician who was the senior partner in the urgent care clinic. He told me that the clinic administrator had briefed him on our discussion. He pulled up a chair next to me, absent mindedly put his hand on my arm, and in a soft contrived voice “suggested” that I should just give patients whatever they want. He said, “If you don’t give them the drug someone else will. We can’t afford to lose their business.” I was shocked! He then continued, “Steve, just give them erythromycin, it’s an innocuous drug and it has no side effects.”

I was literally speechless. I did not know whether to be angry or to cry. My heart sank to my toes. He took my lack of response badly. Abruptly he removed his hand from my arm, sat up and moved to his chair behind an oversized desk. Leaning back he waited. I just looked at him and just as I was about to express myself he said, “I am disappointed in you Steve. I thought you would see the errors of your ways and play by the rules.” He continued, “I see other problems with the way you practice. The average length of visit for the doctor/patient encounter at this clinic is 5 minutes and 17 seconds; your average is 8 minutes and 29 seconds. We cannot allow customers to wait, I suggest you talk less and see more patients.” He added, “The clinic average per patient charge is $79. Your average is $59. You can easily bring your average up by ordering more chest x-rays for people with bronchitis. We all know that the insurance companies will pay for any imaging test you determine to be medically necessary. Or you can order a strep screen on every patient with a sore throat. At $18 per test this would rapidly bring your charges up to everyone else’s average.”

He was not finished, but I was. Time slowed to an imperceptible crawl and I was no longer angry. I felt an odd sense of calm emerging into stillness. I felt a deep sense of relief and inner peace. I noticed the manifestation of a feeling of freedom. I stood up and finally said my first words, “Thank you, this was educational and helpful.”

I walked out, drove home, and immediately called Fritz Smith a local Osteopath who had practiced in Watsonville for more than 30 years. Ironically, over the past several months he had frequently called, beseeching me to take-over his practice so he could retire. I finally told him I was ready. In this rarefied state of awareness I knew I was ready to fulfill my destiny: to follow in the footsteps of Andrew Taylor Still and become a true Osteopath.

Sometimes, life just doesn’t work out how we have planned—thank God!