Quiet dissent: a lovely phrase to start off a research paper, and an elegant description of the passive resistance demonstrated by some osteopaths towards guidelines.
In this interesting study, which has come out of the ESO’s fruitful research department, 12 people were interviewed – a mix of students and tutors – about why they reject LBP guidelines. It threw up some illuminating opinions. Guidelines for LBP treatment have been in place in about 13 different countries since 2013, and with the brand new NICE guidelines due to be approved any day now it’s a topical issue. We didn’t have official guidelines when I was a student, and to be honest I would have liked them. How to treat someone osteopathically seems sometimes so nebulously difficult. On what level do you approach them? Should you tackle their obvious issues with their dad, the tight muscle in their neck, the years of postural compensation for that fall on the ice 20 years ago or the lack of exercise and 20 kilos they need to lose? Do you use classical, biodynamic, talking, needling, magnesium oil, functional, chanting? Or maybe just click them and give a bit of a rub to the sore spot. I think osteopaths generally end up doing what they are good at, and the sort of treatment they like to have themselves, but a few incontrovertible ground rules might help. In the proposed new NICE guidelines there are some definite rules: amongst other things, certain medications are recommended, some are not, there is a policy on Xrays and MRIs, acupuncture is not recommended and so on. In a world of uncertainty, I like that, and I like to be able tell patients those things, feeling that I speak with authority. It’s not just what I think.
Do osteopaths have to follow the guidelines?
The first new thing I discovered in this paper is that the authors emphasized that we are, actually, meant to follow these guidelines. I have always been a bit unclear about this. Firstly, how compulsory are these particular LBP guidelines for any doctor or physio anyway? And secondly, aren’t they more an NHS thing that doesn’t apply to the army of therapists treating low back pain out in the field? Well, according to Joanna Figg-Latham, as the current GOsC practice standard stipulates that we should “use the best available research and evidence to guide professional development and patient management” this means that we “should” manage non-specific LBP in accordance with the guidelines. “Should” doesn’t quite equal “must” in my book; it sounds more an aspiration than a rule. At my local soft play centre there are signs up saying “Parents should supervise children”, which sounds almost more a hope than an expectation. It carries within it an implicit acknowledgement that some parents won’t do this, maybe even that it’s an unrealistic expectation to be able to meet 100% of the time. It will be interesting to see exact wording about this in the new Practice Standards.
Why might people not follow guidelines
They boil this down to
- not knowing about them
- not agreeing with them
- not adopting them
- not sticking to them
Why did these 12 osteopaths not follow guidelines?
I love a research study with a load of interview quotes. Here in this paper is a kind of vox pop of osteopathy. No surprises, but fascinating to survey. I think these osteopaths probably fitted into category 2 above. There seems to be quite a lot of superiority expressed, looking down on research and science, a bit of anti-authority sentiment going on, and maybe even a bit of denial. I think my favourite quote of the whole piece was this one
We are different to other practitioners and we don’t have to be told what to do
If they just inserted “and better than” after the word different, this just about summed up the general mood shown by the comments overall. The authors label this all-pervading attitude a belief in the “precedence of osteopathy”. Osteopaths have a feeling of uniqueness, but this goes hand in hand with a feeling of isolation and being unconnected from healthcare in general. They think that because they have this unique philosophy, and also because they distrust science as being quickly out-of-date, skewed, inappropriate for osteopathy and full of vested interests (“you can’t treat with algorithms”) , that the guidelines don’t really apply to them. In fact they seem somewhat “affronted by research”. They also place expert opinion at the top of the evidence pyramid, rejecting both Michael Gove’s recent pronouncement and received current scientific wisdom that systematic reviews represent the gold standard of evidence. This leads to the neatly named “eminence-based” rather than “evidence-based” practice.
Osteopaths in denial
The authors point out that although osteopaths display a paternalistic style of management, this sits rather oddly with their beliefs that they are holistic. A similar buffer seems to exist between their view of their practice as creative, intuitive, diverse and individual and their strong biomedical view of the body.
I’m not sure how representative these are of the whole profession. These were osteopaths who explicitly stated that they do not follow the guidelines, but we don’t know if they are the majority or minority, and additionally the authors do stress that the sample was very small and all subjects were at the ESO and in an educational environment. However in my experience I would say most osteopaths are only dimly aware of the guidelines, and don’t really think they apply very strongly to them.
Another blog is already in the pipeline: Do osteopaths have self-esteem issues?
Poem attached below, which was a favourite of mine as a child – summing up the silent resistance to authority. It came to mind when I read the study, in only a loosely related way, I stress, but here it is for those of you who’ve never come across it:
Dumb Insolence, by Adrian Mitchell
I’m big for ten years old
Maybe that’s why they get at me
Teachers, parents, cops
Always getting at me
When they get at me
I don’t hit ‘em
They can do you for that
I don’t swear at em
They can do you for that
I stick my hands in my pockets
And stare at them
And while I stare at them
I think about sick
They call it dumb insolence
They don’t like it
But they can’t do you for it
I’ve been done before
They say if I get done again
They’ll put me in a home
So I do dumb insolence