Passing on the Tradition
Steven Sanet, DO

[Editor's Note: The AAO continues the series conducted by Charlotte H. Greene, PhD, with editorial assistance provided by Donald R. Eaton, Jr. Dr. Greene conceived this project–an ongoing series of interviews–to convey some of the rewards and challenges encountered during a career in osteopathic medicine, to highlight the role and contributions of mentors and to provide accounts that might otherwise be lost.]

I discovered the world of osteopathy by accident. I was a karate guy with two studios and really enjoyed what I was doing. I'd never had a thought of becoming a doctor, nor had any burning interest in medicine, despite having two uncles who were MDs. Then I got married, had kids right away and poverty set in. So, I went into medicine for very altruistic reasons–to provide for my family and to make money so we could move out of my parents' house before we died or my wife killed me.

I was 10 credits short of graduation at the end of my second undergraduate year but instead of waiting another year for my degree, decided to try to make a deal with one of the medical schools I had been in touch with. They were just starting to have fast-track programs where they shaved off time for the medical degree, but I was aggressive and had taken my own approach of sending them my report cards at the end of every semester. I had a perfect grade record and asked why couldn't I be admitted.
I am sure they all thought I was a little nuts, but I had made up my mind that I was going to one of those schools, and that is how I came to attend Philadelphia College of Osteopathic Medicine (PCOM). They had a policy that enabled me to begin my medical career without having a bachelor's degree upon admission, since my undergraduate college was willing to credit course work that I would complete at PCOM. Thus, I completed my undergraduate education in two years and graduated summa cum laude while working full time.

The inspiration that prompted my commitment to osteopathic manipulative medicine occurred during my sophomore year in 1992.1 had just transferred from PCOM into the fellowship program at Southeastern College of Osteopathic Medicine at Nova Southeastern University in Florida, and received a generous stipend that enabled me to travel to a Convocation of the American Academy of Osteopathy in Colorado Springs. It was there that I heard Dr. Robert Fulford speak. He described specific problems using terms like "energy" and "spirituality," yet he had an extraordinary command of the physiology and anatomy of the body. At the Evening with the Stars program, I observed him doing things that I could not explain. It was obvious to me that he had his feet on the ground with regard to the fundamental science. In an eye blink, Dr. Fulford inspired me to practice osteopathic medicine as I do now.

I met the late William E. Wyatt, DO, FAAO, during that same Convocation. In his omnipresent red shoes, shirt and pants, he described himself as "A Big Old Tomato," and wouldn't always describe things with their proper terminology. For example, when asked, "What's wrong with this patient?" he would simply say, "She's got a twist." Whatever it was, it was a "twist"' and he was going to untwist it. If you watched him work, though, it was like watching Van Gogh paint. I tell students that if they want to know how to help people and make them well, they have to talk to these older physicians, who have both the technical skills and the experience.

After graduation, I returned Northeast to Riverside Hospital in Delaware to embrace an internship that fed my highly motivated, highly sleep-deprived state. I treated practically everyone in the hospital, from janitors to patients to nurses and house staff, without question. By the time I completed my internship, I already had a patient base of people who knew me and wanted me to treat and care for them. All told, I practiced in Pennsylvania for eight years, and for six years in Delaware, then settled back in Pennsylvania where I am from.

Part of my practice is Amish and part is "English," (the word the Amish use when referring to anyone who is not Amish. Be you black, white or Chinese, you are still called "English"). Half the problems I see in my "English" practice are back, neck or head pain–things you commonly think of as being treated with manipulation. The other problems, and those of some Amish, are not. I see a lot of autistic children, a lot of severely neurologically compromised kids and bizarre genetic conditions. People show up at my door after having run out of other options and expect that I can help. I always tell them that if we see some improvement after a few treatments, then I will continue. Otherwise, I will not. Very often, I find it is possible to do something to improve their lives.

I do not try to sell osteopathy, nor get into long speeches of why it should work. It isn't relevant whether they believe in my philosophy or principles—it's about whether I am going to do something beneficial or not. If you can get results when other physicians have not, you don't have to look very far to get patients. The Amish are a perfect example. They don't fully understand what I do and call me a chiropractor. It is useless to explain the difference to them, but they pay for what gets results. If you fix the problem, then they open their wallet, pay you and come back with a gazillion family members. They don't care what you say or what is hanging on the wall. However, if their shoulder is bothering them, and you don't fix it, they are not coming back.

I never hang my diplomas on the wall. I hang little toys, drawings, my art work, Star Trek figures, and things that amuse me. (The only one that this bottlers is my mother, who said, "I spent a lot of money getting those certificates and diplomas framed, and now your treatment room walls look like your bedroom when you were 5 years old!") No one knows what an osteopath is. They show up at my door because someone said that I had either helped them or a member of their family.

Once in awhile, I get an older person who asks, "You are a doctor aren't you"?! smile and respond, "As far as you know. Now, either I am a little crazy or I am just a hit confident that I can help you." But I never lie and never say that I can guarantee that I will fix a problem. Instead, I ask, "Why are you here?" Most times it was because they had been to many other physicians, and, so far, no one could help them. So, I say, "Then, how about you give me a chance"? I find that this is the best way to overcome fears—i.e., a little logic tinged with a little humor.

In the "English" world, people want to see a lot of substantiation. That is a big difficulty for young doctors just graduating, joining a practice, working for other people, and having to deal with insurance issues, third parties or lawyers. Those kind of confusions come between doctor and patient. However, patients are becoming more resourceful. They are coming in looking for someone to help them after looking at a bunch of information (both good and bad) on the Internet. In my parents' day, they just went to the doctor and whatever the doctor said, that was it—no questions, no arguments.

We need to remember that the osteopathic profession began with a guy that was an upstart. He didn't do what he did to get rewards or accolades. Consider that Andrew Still lived in an era where children were dying of meningitis, and all the medicines that existed were essentially snake oils, which incidentally are immensely popular today, they have just changed form.

Advertising dollars drive a lot of medicine. For example, various media influence patients to ask their doctor about this med or that one. So, the patient goes in and asks the overworked, understaffed, hurried doctor about it. It is likely, unless the request is for Oxycontin or heroin rather than an allergy medicine, "like their Aunt Jane takes," that they will get it. Sadly, in my observation, most of the errors I have seen physicians make were not made because they were dumb or because they didn't care, but because they were in a Ininy-. A smart person in a hurry will make mistakes.

The National Health Service in England is creating a pathway for patients to phone in and discuss their symptoms with a doctor before coming in as a way to try to short-circuit some of the face-to-face time because they are imploding from the burdens of socialized medicine. I disagree with the concept of socialized medicine because those doctors have even less time to spend with their patients, and. thus, the potential for more mistakes.

When I was on call in the hospital, and at 3:00 in the morning a nurse requested Maalox for a patient with a upset stomach, I would get up and go look at the patient. I am not talking about a cardiac patient, but one that might have been there for an orthopedic problem. I still got up and went to look at them. It is not below the standard of care for a house physician to order Maalox on the word of a nurse, but there was always the possibility that a half-hour later, I would be pumping on the chest of the same patient then having a heart attack. The truth is that when I am actually looking at a patient telling me he has a 3:00 a.m. stomachache, there is other information that comes to me. It is hard to specify, but it makes me think that it may be something else. That is what I get from contact time, from interaction with the patient.

A caring physician should get up at 3:00 in the morning to look. It is fundamental to the osteopathic profession that we look at the whole patient. That is absolutely the right method. However, medicine has become so specialized, that I fear it will be lost as the physician's view continues to narrow. My license says general practice, but! have caught a lot of serious medical pathology, only because my contact time is at least a half hour. With the Amish patient, it is talking to them while they are taking off their hairpins and apron. With the "English" patient, I talk with them the entire time I am doing the assessment.

There is a certain amount of information obtained from testing and a lot of information you get from talking. We make jokes in medicine about the "by the way." A patient comes in complaining his back hurts, but as they are leaving they say, "by the way," and ask for a prescription for Viagra—the real reason they came in. The truth is there will be a lot fewer "by the ways" if you talk to the patient. They will tell you about the real problem. I look at this as my whole job—the physical and the psychological aspects of the problem that is bothering them. That requires an ear and some time.

When I was a student in Florida, I spent a lot of time giving manipulative treatments in a very large clinic. I became friendly with an MD from Ecuador who had passed the USMLE equivalent and was redoing his residency. He would tease me that manipulation was 'real' medicine, and I would tease him back. One day, he came in all bent over, unable to stand straight and asked me to take a look at his back. I laid him down on the table and proceeded to fix him, and he never forgot it.

Sometime later, he came to a program, and I taught him how to do manipulation with one cautionary, "You are starting at a disadvantage after years and years of practicing as an MD, and you have to be aware that when you start putting your hands on your patients, they are not going to forget. You are not going to be able to go backwards." Prophetically, it was so true—his patients are crazy about him and they will not leave him alone.

When osteopathic physicians who have never incorporated manipulation into their practice ask me to teach them techniques, I always start with the simplest ones. The reason being that, if they use them and get a positive result, it is the greatest revelation for them and they will use them again. If! show them something complicated, they become unsure and probably will not try it. Or if they get a bad result, they probably will never do manipulation again. The danger with that is they may become either anti-manipulation, or indifferent to it, and do not become fans.

If there really is an osteopathic difference, this is how! conceptualize it: If a person has a backache for a day or two, they will most likely shake it off, but when a person has been in chronic pain for a while, it starts to change their life. I do not do anything matter-of-factly. I have a bizarre sense of humor, which I use to allay patients' concerns, but if someone comes in crying because their child died, I make sure I sit and listen to see if there is some concern I can answer, and as an osteopathic physician, there is always something that I can put my hands on. There is a deep bond established through your hands. If you are a doctor that listens, and puts hands on your troubled patient, you have done a great thing for them. Maybe the best you can do for a person is to hold their hand when they or a loved one dies.

I had a fellow come to me who had a Stage 4 cancer the size of half my fist in the root of his mouth. He said he had a few months left to live, so I asked him why he came to me. He said, "I have a post nasal drip that is keeping me awake at night." You could step out from that situation and pose the question, "Why are we trying to do anything? In a few months he will be dead." But it was his two months! I treated him, and, at a follow-up visit, he said his post-nasal drip was better, thanked me and left. People like him are written off all the time, and, as the health care situation keeps proceeding as it is, this type of need just keeps on growing.

Around the world, osteopathy is huge and uses a non-medical model—no prescribing, no surgeries and can even be shamanistic. People in third-world countries can't afford allopathic medicine. IIowever, if they go to an osteopathic physician, they know they are going to get manipulated. The whole world touches except in the Western world, so when you use your hands to treat, people can readily relate.

Unfortunately, students see osteopathy as an all-or-nothing approach. They think they are not going to become a manual medicine physician, not do the type of evaluations that their teachers taught in school and not do any type of treatments. I understand the need to teach the students everything, as they must thoroughly understand the science to avoid doing something wrong. But there is also the need to bring it all back into perspective. If they become a family physician, there will be a waiting room full of people, and maybe the best they can do is a bit of something to treat each patient. That bit of treatment is very important. The reality, though, is that most family doctors are not going to become specialists in manipulation.

My message to students is very simple: No matter your specialty, find a few minutes to put your hands on your patients and try some simple techniques. You will find that touching translates to care. It is not a placebo, it tells the patient that you really care about them. The funny thing is that once you do treat a patient, you start to care about them and become vested in their care. It will translate to your personal and professional success and satisfaction. It will enhance your practice, and though you, as we all do, are going to make mistakes, patients can sense your intent.