CHAPTER THREE

HOW “TYPICAL” DOCTORS EXAMINE. THE PRICE YOU PAY

     What Makes a Great Physician?

          I would answer that he is a great physician who, above other men, understands diagnosis. It is not he who promises to cure all maladies, who has a remedy ready for every symptom, or one remedy for all symptoms; who boasts that success never fails him, when his daily history gives the lie to such assertion.  It is rather he, who, with just discrimination, looks at a case in all its difficulties; who to habits of correct reasoning, adds the acquirements obtained from study and observation; who is trustworthy in common things for his common sense, and in professional things for his judgment, learning and experience; who forms his opinion positive or approximative, according to the evidence; who looks at the necessary results of inevitable causes; who promptly does what man may do of good, and carefully avoids what he may do of evil.

                                                                                                                                                      Dr. Jacob Bigelow

                                                                                                                                                      Nature in Disease, 1852

The origins of trust in your doctor

Who the doctors are

The significance of symptoms and signs

The usual allopathic examination – the essence of the problem

its possible costs to you

The problems with x-rays

The misuse of psychological tests for pain

How you can begin to resolve the Pain Pandemic

In high academia, the definition of pain fills a long paragraph, but pain is its own definition.  Pain is what hurts.  Its essential purpose is to preserve well being, life itself, by warning that something is wrong.  If we cannot feel pain, we perish.  Pain is what drives most people to seek help, and, in a reasonable world, they would readily understand which practitioner might best provide it.  My main purpose is to help you resolve that question.  Today, the market place is in disarray, and you need to be reasonably perceptive.

     Please do not misconstrue my intent.  An authentic doctor-patient relationship is priceless and must be preserved.  The doctor you trust from experience is your best counselor.  I have often been told that I must make a choice:direct this book primarily to you - the patient - or to the members of the healing professions, my M.D. colleagues particularly.  For good reason, I resisted and am striving for both, because the failure of knowledge is pervasive.  Still, to be consistent to my purpose, I’m writing this first for you because you most need it.  You are medicine’s purpose.  My primary obligation is to you.  Only from overwhelming social awareness will reform be driven.  

     As vitally important, believing in the person you trust for your care can become a near-religiously intense dedication that may not be fruitful.  When you are in need, you are vulnerable and exploitable.  Stories of ineffectively treated sufferers returning indefinitely for the same repetitively unsuccessful ritual (called treatment) are legion.

     While most professionals try to do their best, the dilemma is still compounded by the contradictory methods their different training produces and imposes on their thinking.  Though they are licensed professionals, they are historically antagonistic to each other, and in the best of circumstances, with good people involved, I have seen blind ritualism prevail over common sense because doctors are only human.  It seems a paradox that people allegedly dedicated to healing could be so hostile among themselves.

     The primary participants and competitors are allopaths, osteopaths and chiropractors.  Allopaths, as I have described, usually practice traditional medicine.  They have an "M.D." (Doctor of Medicine) appended to their names.  They are by far the largest and most powerful, and have most influenced society's values.  Osteopaths have a "D.O." (Doctor of Osteopathy) appended to theirs, and chiropractors have a "D.C." (Doctor of Chiropractic).

     None of the professions are homogeneous or necessarily harmonious, and there are continuing shifts within them.  There are no pure "gold standards" for comparison.  Each offers remedies which are theoretically regulated by limits of licensure.

     Ideally, an examination by a member of those professions begins with the thoughtful taking of the history and an appropriate physical examination.  When I heard that admonition repeatedly in medical school, I began to be appalled that such a self-evident statement had to become almost a nauseating mantra, but it wasn’t long before I learned that it cannot be repeated often enough.  

     The examination has a special vocabulary.  Symptoms are what clinicians hear patients say concerning their complaints.  They are called subjective because they are thoughts.  Signs are the physical findings that clinicians observe from actual examination.  They are called objective, which implies that they can be measured in some way and that other professionals, who are similarly skilled, can/will/ should find them also.

     Patients likely begin to give their histories the same way to whomever they consult, but the thought patterns those words would generate in each professional’s mind could be quite different.  How skillfully your complaints are investigated by further questioning, how they are sieved and interpreted, will almost certainly be different.  At the same time, the precision of the inquiry is the benchmark of the clinician's intent either to find an accurate answer or to exploit you and dispose of you as expeditiously as possible.

     Allopaths, osteopaths and chiropractors still don’t even have a common vocabulary. In critical issues, they often are not understandable to each other.  So a few questions have to be asked: How can contradictory concepts and methodologies rationally, even reasonably, coexist? Is it reasonable that findings that have meaning to one profession can be categorically denied by another?  And is it reasonable that such disparities should raise serious questions?  Yes, at least that is reasonable.

     The taking of the medical history and the physical examination work in tandem.  Between the two, the professional’s pursuit of the history is usually considered relatively more important because it suggests the direction of the investigation, and hopefully is evidence for the clinician’s understanding of your problem.  Then, the examination, with the opportunity to discover relevant signs, largely determines the success of the hunt.  

     Ancillary tests-- for instance, blood test, x-ray - when, – even performed before your examination - how many, of what, in addition to, or instead of, may powerfully influence what the clinician will decide to do, for better or worse.  Tests are either thoughtful adjuncts to answer reasoned questions or just "shots in the dark prayers.”  Ideally, from those approaches - your history, your physical examination, your response to therapy, and subsequent testing, your diagnosis will likely be established.

     What is the usual experience patients have with allopaths?  Suspicion of the Fundamental Flaw’s presence usually arises early.  Reflect on what happened when you sought care for a pain somewhere.  Consider your attitudes and those of others who you know concerning, as example, the use of x-rays (or x-ray like procedures - MRI or CAT Scan).  Their influence is so pervasive that, in four decades of practice, I have yet to hear a patient first tell me about a physical examination or treatment that had been performed.  Too frequently, they first tell me that x-rays were taken.  One young lady memorably felt compelled to declare it in the first sentence about an incidental old accident not related to why she was seeing me, "A car rear-ended me ten years ago - and I had x-rays!" X-ray, in effect, bestows the "Good Doctoring Seal of Approval."  It happens almost every day, “everywhere” in some way.  We have been exposed to its propaganda as thoroughly and nearly as dangerously as the radiation itself because we are encouraged to welcome more of it.

     If anything at all shows on them, there is even some degree of relief!  Because, for lack of a precise physical examination, any resulting ambiguity about the cause of a complaint has allegedly been alleviated.  The black and white of it appears to be a diagnosis or, at least, support one.  Something is there.  You can almost hear the angels sing.  It implies that you are validated in an important way.  There need be no concern that your pain is "imaginary."  X-rays proved your condition, didn't they?  And the doctor’s reasonable need for having provided a professional service may be satisfied, as well.  Whether such conclusions are truly valid is what this is about.

     Is there any denial of the most common after-medical-visit conversation?  

     "What did the doctor do?" "He took an (x-ray), and he told me...."

     The Los Angeles Times, March 29, 1993, Jack Smith's article:

          "Because of a severe back injury, I have spent the past week close to my bed, screaming every time I make an imprudent move.  My wife learned to ignore my cries, even though they must sound mortal.

          She has made ice packs for me, virtually spoon-fed me and even driven me to Dr. --; the exertions required for that outing were extremely painful, but an X-ray showed no broken bones, and the doctor said the pain would subside in six or eight weeks...."

     Such common events well illustrate the considerable problems with the status and the interpretation of x-rays.  The temptation is enormous to order such tests too casually and too soon.  Too often, they are substitutes - ordered in place of an examination that may dispense with their need.  That isn’t really very "scientific."  X-rays need to be a directed extension of a considered clinical question! That is when they are realistically valuable.

     At the same time, there is a mitigating "other hand," and it is also powerful.  Defensive medicine refers to any action, or inaction, whose primary purpose is to insulate the doctor from a potential lawsuit.  It includes the use of diagnostic tests that reinforce against a possible accusation of being "incomplete."  The conspiracy has become a stable part of our societal insanity.

     Suppose a physician elected not to take an x-ray - or perform any other procedure that, in fact, had no reason other than to cover "tail feathers," and a complication occurs.  An adventurous attorney would be grateful for such an "omission."  What might a jury be persuaded to believe?  What do doctors do when x-rays have become so accepted as standards of care?  That's how stinky thick the soup is.  The absence of an x-ray, necessary or not, has settled many, many lawsuits against doctors.  

     Without equivocation, I have never yielded to that “need” because I have felt confident I could beat any such accusation.  I have done it several times when testifying as an expert witness by showing the attorney I could not be intimidated, that I know my medicine, and, from my manipulative perspective, easily convinced the jury that I only take x-rays responsibly.  But in the scheme of things, from all those circumstances, and more, the habit for x-rays is so ingrained, and the public has learned to be so expectant, that all sides are culpable of this very seriously draining problem.

      Now let’s focus on some real prices beyond their immediate financial cost.  Let’s consider life-threatening conditions first.  You never shed the radiation you receive.  They go with you to the grave, which may be sooner because of them.  Studies now seriously suggest that one of the common causes of breast cancer is too much “diagnostic” x-radiation.  The casual misuse of x-ray is among the most influential causes of the Fundamental Flaw because it has contributed so heavily to the loss of hands-on skills in almost all specialties, not only in orthopedics.

     Overheard in an emergency room:  “Doctor, the child in the next cubicle has a fever and is coughing.  Do you think he might have pneumonia?”  Send him to x-ray and let’s see what the film shows.”  What happened to palpation of the chest?  To percussion?  To auscultation – the use of the stethoscope?

     Whatever the musculoskeletal complaint - "Doctor, my wrist hurts."  "Doctor, my shoulder hurts." - The reflex response is now our folklore: "Let's take an x-ray to see if something is wrong."  Or even worse, “…and see what it tells us.”  A sheet of film is not an oracle.  It doesn’t have vocal chords.  It can absolutely be relied on to say absolutely nothing.  Nothing automatically jumps off the film.  Everything is only an image.  Images have to be correlated.  Images may, or may not, be relevant.  The presence of something on an image cannot just be presumed to apply to a particular case.  The absence of something from an image does not necessarily mean pathology does not exist!  But if the doctor doesn't - ("But the doctor didn't even take an x-ray.")  (“So if I have to take an x-ray, why don't I just get it over with?”)  ("But doctor, how could the x-ray not show something?  I hurt.  Something's got to be there!")    on      and on    and so on....

     On the other hand, when the scribbling of an order only a few decades ago could easily costs a few hundred dollars, today, the same minimal effort costs ten-fold and far more.  

     I have treated patients who brought x-rays and related studies costing thousands of dollars with them.  Possibly to their initial dismay, I did not look at them.  I may examine them after my examination, but I have a particular reason for not doing so first:  I don’t want to chance that they will influence my formative thinking.  Sometimes those patients left my office pain free.  I hadn’t needed the studies.  They hadn’t been necessary at all.  They could never answer the relevant questions that the clinical presentation posed but that an appropriate physical examination did.

     While imaging procedures were just specifically indicted, the problem is generic, so a general statement is necessary:  Instrumentation is supposed to make diagnostics easier by providing or enhancing the acquisition of information that is not otherwise available.  But it cannot deliver what it is not designed to!  Technology never relieves the responsibility to appropriately investigate, regardless how seductively its data may tempt.

     The wise clinician decides what is valuable and whether the limitations, expense, and inconvenience of interposing a machine is worthwhile.  But under no circumstance may the conclusion be entertained that if a machine does not produce some result, that "NO objective signs" are present that may be discovered with appropriate physical examination.

      Instrumented tests are sinister in another way:  they may seem to support the rationalization that an adequate diagnostic effort was, after all, performed. Technology is fire; it is fireworks, sometimes spectacular, but potentially dangerous in the minds of those whose thinking is Fundamentally Flawed because it so easily interferes with reflection.  In this, I am not a lone voice crying in the wilderness.  This complaint regarding technology is well recognized.

     The very same cry appears in a JAMA (Journal of the American Medical Association) article published decades ago:

     "In the name of objective science, we have become integrated into the machine rather than the machine integrated into patient care. Although machines are defined as slaves, they have a way of becoming masters of clinical judgement through dependency, diffusion, distraction and most importantly, through fixation, experiencing the machine as an extension of self...Physicians appear blind as to how much the machine interferes between the patient and the doctor, crowds into their psychological space while profoundly complicating physician's ethical behavior.... We need an expanded Hippocratic tradition in all hospitals that deals constructively with the implicit counterproductive costs of pain and arrogance in all medical technology. The medical profession needs to turn again to the bedside to learn about a new disease, in this case, the syndrome of the technical fix.... With each technology, old and new, we need to be witness to our purpose as physicians who value life as a quality, not blindly worship life as a quantity.... Primum non nocere machinae (Let us do no harm with our machines)."

     A typical musculoskeletal examination that does not involve manipulative reasoning will demonstrate why the practitioner early on is desperate for help from wherever it seems to be available.  Sometime during the exam, the painful area is touched to see if it is tender;  the patient may be asked to move the involved part;  perhaps the gross range will be measured or estimated;  the body part may be passively ranged, as well (the clinician moves it some distance along its normal course), and a question will likely be asked if and when pain is experienced.

     Tests to elicit pain are among the most telling about a clinician's sensitive knowledge of the issues and skills that may relieve.  The ability to carefully identify tender structures is consequential, especially in those related areas that are unsuspected by the patient.  Of critical importance is that only sufficient force must be used to elicit the response.  To crudely provoke pain is to blunder.  

     Among the most potentially barbaric excuses for a "test" is the commonly performed gross compression of the symptomatic neck by the examiner pushing down on the top of the head, especially with the neck in extension.  If it is done at all, it must be done with extreme caution, but you must never allow it!  The experienced examiner has other means to study the problem.  For the little information it may add, it can also seriously compound your injury.  

     Your muscle power may be tested.  Tendons may be tapped with a percussion hammer.  Some circumferential measurements of the limbs may be taken.  Sensation is tested, too often by the rolling of a wheel with sharp points along the patient’s skin.  In my opinion, the wheel’s very presence in the doctor’s office is reason for some suspicion, especially if it is rolled too rapidly.  The sensory examination will be more fully discussed later, but its essential is: it is totally subjective!  The response is totally dependent on what the patient reports.  What the patient says, is!  Time must be spent to develop a language of clear communication so that the examination becomes a considered diagnostic procedure instead of just a blind ritual.

     Except for special tests to specific structures, those procedures are the usual limits of the clinical examination for musculoskeletal pain - what is traditionally considered a complete general type examination - along with the x-rays, of course.

     The patient’s treatment may include a prescription for medication, likely pain medications, anti-inflammatory medications and/or one of the notoriously popular "muscle relaxants," especially if spasm was identified.  Quite possibly, an injection is administered, and treatments might be provided which may consist of hot packs, maybe cold, electrical stimulation devices, and massage.  Those are the most common.

     If the patient’s neck is injured, a form of cervical (neck) traction may be provided in the office or for home use: a device hanging from a door with a halter pulling exclusively on the head, likely impacting the jaw.  While it may help, the odds are substantial that it will hurt and even complicate the injury.  Such devices are frequently discarded and for good reasons.  I will relate more about that later.

     Hopefully, the pain condition was relieved, but it may not have been as time passes without improvement.  If the injury occurred at work, special meaning may be insinuated.  If litigation is in involved, the patients problem may deteriorate even more drastically.  As symptoms progress, other parts of the patient’s world are affected.  Ability to perform is increasingly impaired.  The family suffers.  Work deteriorates, and sleep, appetite, and sex drive are dragged into the impairment.  Time irrevocably continues to pass, and life’s quality slips towards the abyss.

     More special studies may be ordered.  More costs.  The ante goes up.  Studies may show something, in which case, the question arises whether it is relevant.  But the clinical examination still doesn't help because of the Fundamental Flaw.  More time.  More costs.  More loss.  Anguish.  Despair.  More medication.  More examinations with larger reports.  Conflicting reports from self interested parties.  Chronicity.... it doesn’t end.  It might never end, even under better circumstances, until, finally, the patient’s life ends.

     Among my bitterest memories is when it happened to a woman who had been my patient, - one of the sweetest, most gentle women I have ever known. The insurance company refused her further care.  Late one night, in final anguish, she went miserably to the side of her swimming pool, tied a heavily weighted rope around her waist and pushed it in.  Her name was Robertta (“Two t’s please.”).  Her picture is on my wall now, in frustrated, affectionate memory to her.

     Suppose doing everything traditional shows nothing.  All investigation, all studies are fruitless.  The patient is authoritatively informed that there are no objective findings, nothing that can be seen or measured or touched.  That might not necessarily have been true, but the traditionally accepted criteria for objectivity support it.

     "No objective findings" more than implies that there is nothing physically wrong.  “Mental gymnastics” by the patient is implied.  Either the patient is accused of consciously lying -malingering-  or the patient is imagining, or just plain “nuts.”     And the system defends itself that everything “scientific” and appropriate was done, and that reasonably, nothing essential was left out.  That may be the case, or it may not.  Regardless, the patient has become a real "pain in the neck,” or elsewhere in the anatomy, to people who just want to get on with their lives and who resent that they are being seriously inconvenienced.  

     With time, there may, or may not be, improvement.  If not, the final sentence "Learn to live with it..."  only adds to the patient’s anguish and increasingly deep resentment, which is a very reasonable cause for depression, which they then crucify the sufferer with as “proof” that he was a mental case in the first place.

     The psychologist-dominated “Pain Clinic 80s” was one of my decades of special battle.  The MMPI reigned.  A number of personality indexes were graphically reported.  The so-called “W” pattern was considered classical for depression.  Many people with long-term pain had it, and the psychologists basked in their domination: the emotional basis for a large segment of the population’s pain was “proven!”  No, it was not!  Most often, it only proved the inanity of the system that would hysterically leap off the edge to such insanity.  But influential professionals said it, and the traditional medical establishment had nothing to fend it off with–Fundamental Flaw.

     The patients who entered most pain clinics missed the most crucial intake event: an appropriate physical examination.  Most often, it was presumed that the multiplicity of examinations before they reached that place certainly would have found physical injury - Fundamental Flaw.

     Again and again, I would almost scream, “I never found the patient who preferred to learn to live with a rock in his shoe if the rock could be taken out of the shoe.”  I was not one of the establishment’s favorite people.  That’s all part of another story.

     Another unfathomed problem is that the patient’s symptoms may have spontaneously diminished over time as a dysfunction might only have “accommodated” - become dormant - awaiting its repeat performance again and again - indefinitely and progressively.  These are the issues that medicine, now dominated by managed care needs to concern itself with because they are an ongoing drain whose early-on resolution would save astronomic sums.  Managed care, which is now virtually synonymous with the insurance companies, have lots of money for many reasons, but they have no budget, no thinking, for studying the fundamentals of what this is all about.

     Imagine being asked the most important medical question today concerning overall improvement in efficiency: what is fundamentally lacking in the initial traditional medical examination?  And consider that you now have the answer: The restoration of biomechanical (manipulative) reasoning.

     Imagine that you have the opportunity to participate in the most important foundational undertaking for the medical benefit of humankind for the amelioration of common causes of pain and for improved conceptual harmony in the healing arts - so that the most reasonable combinations of therapy will be applied.  That is what assisting in the correction of the Fundamental Flaw offers to you.

     No matter how big the system, eventually, health care must focus on providing service to one individual at a time:  To you!  (Or from you!) Assert your new knowledge!  By attending to your needs, whoever you are, by expressing yourself where you receive care, or where you give it, you can be among those who will cause the great change to happen.

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Chapter Three

Chapter Two

Chapter One