Bones and Me 

Barrett L.Dorko, P.T.
 

I see in the APTA  Journal that the editor, Jules
Rothstein, has an imaginary friend named Immelmann. Coincidentally, so do I 

Not only that, where Jules says that his friend is often like Spock from
Star Trek (the original series), mine is remarkably like Dr. McCoy from the
same show. In fact, that's his name. He's sarcastic, cynical, and quick to
judge. Although well-versed in scientific principles, he lacks a certain
appreciation for the arts and the more subtle aspects of human behavior
He's a prickly conversationalist with a cold smile. Worse yet, he doesn't
wait until I'm alone before he shows up (I understand Immelmann waits), he
often barges into the treatment room while I'm busy. 

Just this morning I was standing along side a patient supine on the plinth
when McCoy snuck up beside me, put his mouth close to my ear and said,
"What are you doing?"

"Well," I said, "I'm not trying to do anything just now. This guy's in a
lot of pain and I think it's a good idea to simply stand here quietly for a
few moments. You know, let him see that I don't move quickly or
thoughtlessly. I'm a big guy and he's scared enough...
"Hold it Dorko," said McCoy, "don't assume that I know anything about
what you're up to with this "therapeutic presence" baloney you're always
peddling. Have you got some evidence to support your behavior? Have you
taken the time to do a study of the outcome when you don't act so nice?"

"Okay, okay," I said, "I'll start doing something if that will keep you
quiet. Do you notice, Bones, that his symptomatic leg is held rigidly in
internal rotation at the hip? Don't you think it would be a good idea to
somehow get him to alter that posture? It would reduce the neural tension
in the region." 

"First of all, you know I don't like it when you call me "Bones." I prefer
"Doctor." And what makes you think that the posture of the hip has any
clinical significance? They didn't teach you that at Ohio State. I know
because I was there even though you slept through most of your classes." 

"I read an article by Alf Breig a few years ago about the biomechanics of
the lower limb with respect to hip rotation and I just put two and two
together. It seemed to me that in the clinic when the patient held..." 

"Stop right there Barry Boy. Do you mean to tell me that without any data,
without compiling any more evidence than your reading of a single article
that you should proceed with treatment? And don't give me that "it works"
argument unless you want a headache. I live in there, you know." 

"I wouldn't dream of it Doctor. It just seems to me that the "correct" way
to treat people depends largely on my interpretation of the literature and
the inferences that I am willing to make when translating clinical science
to clinical practice. I think that we need to abandon the  quest for
absolute truth and look, instead, at clinical research as a way to develop
a reasoned philosophy about patient care. We have to apply research
findings to the patient sitting in front of us. After all, science isn't
about proving things, it's about making sense of things. When I teach,
this is the sum total of what I say, and I never claim that my method
is  more successful than anyone else's, I just show  through the literature
that it makes sense."

"My, my Dorko, that was a nice little speech. But it sounded a little
canned. Where did you get it?"

"Well," I said, looking sheepish, "a lot of it was in Di Fabio's editorial
this month, but I added a little of my own stuff. You know I believe in
keeping my eyes open for any support I can find. Yesterday it really paid
off. You really ought to look at it Bones, it's right up your alley." 

But the Doctor didn't take the bait when I called him Bones. He turned on
his heel to leave when something caught his eye. "What's this book about
intuition doing here? Are you going to become a psychic next? 

"Oh, no. That's a wonderful book about the nature of seeing the
connectedness and wholeness of any observable phenomena. The author details
the distinctions between empathy and other sensations when dealing with
others and...

"Save it," said McCoy. You can run off at the mouth to someone else about
the soft side of practice. I've got a journal to read. Just remember,
you're a therapist, not an astrologer." 

Alone with the patient at last I gently place a hand on his leg. "Here" I
say, "let me show you what it feels like to turn it this way."

 

This essay was written in response to Jules Rothstein's editorial in the
Journal of the American Physical Therapy Association (Volume
79 Number 11 November 1999) It was entitled "Immelmann's Indignation."

 

Other articles and essays referred to in the body of this dialogue include:
"Biomechanical Considerations in the Straight Leg Raising Test" by Alf
Breig, Spine vol. 4 No. 3. 1979 pg, 242-250. 

"The Rest of the Deer: An Intuitive Study of Intuition" by Margaret
Blanchard. Portland, ME: Astart Press 1993

"Myth of Evidence- Based Practice" an editorial by Richard P. Di Fabio,
PhD, PT  Journal of Orthopaedic & Sports Physical Therapy Volume 29 Number
11 November 1999