Leaving aside the first 3 paragraphs, which lay out the aims of the document, the first part of the document (up to and including paragraph 11) is OK, good or very good.
Paragraphs 12-19 are also generally OK, despite the fact that I find the whole concept of “Typical experience” objectionable. My problems with this are two-fold:
I do not believe there is a typical experience, even for my own patients. The way I work – from history-taking through examination to treatment is individual to that specific patient and what I do and say can vary enormously. So I think it is misleading to the public to imply that there is some sort of typical or standard experience.
It is a fundamental principle of Osteopathy that we are patient-centred and aim to tailor everything we do to the individual patient; there shouldn’t be such a thing as a typical experience.
Paragraph 20 is where I start to have real problems. An orthodox “diagnosis” may well be a useful shorthand for communicating with other healthcare professions, but osteopaths will always “strive to achieve a more comprehensive understanding and provide a detailed explanation of the factors involved…” – that is one of the distinguishing features of Osteopathy. However, in real life we do not always reach a “diagnosis” on the basis of which a treatment plan will be devised. That is simply far too idealised. In practice it is not uncommon to start treating what you find while you are still examining: the tissue response is part of both assessment and treatment, and the changes created in other structures then give more clues as to the underlying factors. To explain in detail exactly what I am going to do and why at each stage would grind the treatment to a near halt.
Paragraph 23: What it is appropriate to treat osteopathically depends principally on the skills of the individual osteopath. In practice this is certainly true for me, but I can think of people who would disagree with this statement in principle.
Paragraphs 24 and 25 raise the thorny issue of consent. It is, in practice, impossible to prove that a patient has understood. If we have any suspicion that they haven’t, then, of course, we make more effort. But is isn’t those patients that bring osteopaths before PCCs; it is the patient who I am confident has understood, but, in fact, who subsequently decides that they hadn’t. The osteopath has no possible protection against that, and thus the consent law fails to work. I don’t know what the way around this is, since it is a failure of the law. But as things stand there is no point any healthcare practitioner obtaining “consent” because it is meaningless in court.
Paragraph 26 uses the term ‘manipulation’. To medics and physios this is normally synonymous with HVT. It should be avoided. The reference to ‘visceral structures’ reflects something that we believe but for which we lack “scientific” evidence. This is a red rag to the “quackwatchers” and should be removed.
Paragraphs 27 – 30 are OK.
I could not disagree more with paragraph 31. To attempt to categorise osteopathic practice in terms of type of treatment technique, type of ‘condition’ treated or the type of patient group, completely misses the point of Osteopathy. The characteristics of Osteopathy are that it is, in principle, independent of treatment modality, that it addresses the patient rather than the condition and that the only patient the osteopath cannot treat is the dead one. Those are principles of Osteopathy.
The patient only knows the osteopath(s) they have encountered. It is not helpful to the patient to know how ‘commonly’ those particular methods may be. The only things that matter to the patient are:
Is it safe?
Does it work?
I agree that the use of manual techniques for assessment and treatment is a characteristic of Osteopathy, but I think it is very misleading to patients to categorise treatment techniques as typical. If I choose not to use a ‘typical’ technique that may be because the patient isn’t ‘typical’.
Paragraph 32 refers to “the types of presenting problems that osteopaths may treat”. We should never use this language – for 2 reasons:
It isn’t true. We don’t treat conditions, we treat patients. That is the point of Osteopathy;
We have no evidence to support this. Professor Ernst would be on our backs in an instant complaining that we are advertising treatments for which there is not a jot of evidence. All we can say is: “Patients with the following problems tell us that osteopathic treatment has helped them.”
Paragraph 33 states: ‘This lies with the clinical judgement of the osteopath.’ This is precisely the point – and obviates the need for much of this document!
I disagree with paragraphs 35 and 36 so complketely and so fundamentally that no more needs saying.
Paragraph 37 hits the nail on the head and states clearly why much of this document is not needed.
Paragraph 38 isn’t needed, but it does allow for Osteopathy to develop, which is good.
For obvious reasons I think paragraphs 39-41 are not helpful or relevant. Para 39 uses ‘manipulation’ again. Paragraph 40 states that osteopaths using cranial techniques ‘will explain them fully to patients so they can understand them”. I would love to see that! No-one has yet been able to explain cranial techniques to me in any way that is physiologically remotely plausible, let alone ‘fully’ – and I use cranial techniques myself. Not because I understand them fully but because I observe changes in my patients when I use them. Mind you, no-one has a proven model for the way HVT works either…
As far as I can see the purpose of all this is that we have to able to demonstrate that we are competent to use the methods we do. If those were taught at undergraduate level, then they were part of a GOsC-approved course and the GOsC can legitimately assume our competence unless there is evidence to the contrary. But all the osteopaths I know continue to learn and develop throughout their career. I graduated a mere 6 years ago, but most of the techniques I use now were not formally taught at the BSO. If we are using methods we have learned post-graduation the GOsC has no way of knowing whether we are competent in them. That puts the onus back onto us to demonstrate that we really have gained the knowledge and skills to work in that way (or with those patients). To mind that is part of being a responsible competent professional, and rightly lies within the scope of our professional judgement.
Paragraph 43 is the consent problem again, only this time with a twist: the more rarefied your practice, the more careful you need to be about getting consent. I disagree, and if you put it the other way round, you can see why: the more mainstream your practice, the less fussy you have to be about getting consent.
The PCC does not see it that way! We are required to be meticulous about gaining consent under absolutely all circumstances regardless. Full stop.
And, actually, if consent were worth gaining, then that is how it ought to be. It is just a shame that the consent isn’t worth anything anyway. This paragraph again requires us to ‘ensure the patient understands’, which is not really possible.
Paragraph 44 states that ‘Although it is essential that osteopathic practice should be grounded in plausible and reasonable evidence, it may sometimes involve the use of techniques that are based on clinical judgement and experience and where evidence for their use is yet to be fully developed.’ To the best of my knowledge, that includes, if not all, then the vast majority of what we do, as far as EBM is concerned.
Paragraph 45 makes a good point. Osteopathy has fuzzy edges, yet I firmly believe there is a recognisably “osteopathic” approach to healthcare. But also bear in mind that you could practice entirely within the ‘Typically encountered osteopathic practice’ defined in this document and be a Physio or Sports Massage Therapist.
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