The Journal of the American Osteopathic Association
March 1998 volume 98:3 pages 164-167
COMMUNICATION FOR OSTEOPATHIC MANIPULATIVE TREATMENT: THE LANGUAGE OF LIVED-EXPERIENCE IN OMT PEDAGOGY
Elliot Gaines, Ph.D.
Anthony Chila, D.O.
This article address problems in teaching osteopathic manipulation that are considered inseparable from questions about the scientific merits of OMT. A communication strategy is proposed based on the philosophy of osteopathy as it is correlated with phenomenology--a philosophy and methodology that brings experience and perception into spoken language.
This article addresses two recurrent problems in osteopathic medical pedagogy. Questions about the scientific merits of osteopathic manipulative treatment and the search for consistent, effective teaching methods for OMT have been persistent in the discourse of osteopathic medical curriculum. While grounded on scientific principles, the philosophy of osteopathy in the words of A.T. Still, William G. Sutherland, and other prominent osteopathic scholars, advance concepts in metaphorical language that may seem obscure and dated to many of today's students. Evidence in the literature of osteopathic medicine supports the congruence of phenomenology with the philosophy and methods used to teach OMT. The philosophy of phenomenology offers an alternative paradigm to address questions of scientific merit, and could provide a consistent language to a rigorous, scientific approach to communication for OMT pedagogy. A solution is proposed for the tactical adaptation of a communication strategy based on an interpretion of osteopathic methodology and the philosophy of phenomenology.
INTRODUCTION: COMMUNICATION FOR TEACHING OMT
Since the profession was founded by Andrew Taylor Still in the late 19th Century, osteopathy has been distinguished by a particular philosophy of medicine, a focus on primary care and prevention, and osteopathic manipulative treatment or OMT. Two articles in the July 1993 issue of THE DO; "Teaching OMT: Osteopathic Medical Schools Seek to Improve Methods," and "Practicing OMT: As Demand Rises, Reasons Against Using OMT Fade," bring up important questions concerning the medical practice of osteopathic manipulative treatment and the training of students in the use of those techniques. Manipulative treatment and a belief in the interrelated nature of the human being as a unified whole are central to the philosophy of osteopathic medicine as conceived by A. T. Still. A communication strategy based on a philosophy of phenomenology may provide solutions to the problems suggested by both of these articles in teaching the special skills and knowledge required to perform OMT.
According to Rollin E. Becker, D.O., the science of osteopathy as envisioned by its founder, Dr. Andrew Taylor Still "includes a knowledge of philosophy, anatomy, and physiology for the whole body, together with their clinical application in both diagnosis and treatment." Osteopathic physicians are trained to use palpation as a way to feel with an informed sense of touch integrating all of the senses. With this diagnostic tool, a system of signs can be perceived and interpreted as the unique human condition embodied by the patient. This is an interpretive process that osteopaths have learned to apply in practice, but one that remains particularly difficult to communicate for the purpose of teaching.
The philosophy of phenomenology regards communication as a self-reflexive process that moves consciousness to speech. The specialized language of phenomenology is appropriate to speaking about the phenomena of the human body perceived through the palpatory skills of the osteopathic physician. Phenomenology is defined in this project as a descriptive process that seeks to express the essence of being or "lived experience" through speech communication. Osteopathic pedagogy can look to phenomenology for descriptive terminology that seeks to expose presuppositions and discard the obvious in order to illuminate the essential nature of perceptual experience.
This project examines the experience and perception of osteopathic practice through an analysis and interpretation of certain osteopathic texts. By interpreting a limited selection of literature from traditional osteopathic teaching, this article will explicate the lived experience of sense perception in OMT expressed within those texts. The purpose of this paper is to bring theory into practice by exploring the problematic nature of communication in osteopathic pedagogy and its relationship to phenomenology as a philosophy that explains experience. In the first section, the problems of teaching within the tradition of osteopathic discipline are defined along with the issues of interpretation of perceptual experience. The second part views the problem of osteopathic teaching methods in context with the a priori philosophy of science that does not openly deal in the interpretive properties of medical practice. The next section elaborates on the correlation between the language of phenomenology and literature of osteopathic pedagogy. Finally, a stategy is proposed for the adaptation of a phenomenology for OMT.
THE PROBLEMS DEFINED
The central issues that I will address from the articles mentioned are: (1) understanding the scientific basis of the discipline of osteopathic manipulation, and (2) transferring classroom knowledge to the clinical practice of OMT. These two propositions are problematic and inseparable because the conventional view of scienctific empiricism ignores the importance of interpretation in medical practice. The ideal science of the clasrroom becomes a dynamic interactive process of interpretation in the clinical setting. Teaching must than avoid any impression of subjectivity in the interpretive process. Though not generally acknowledged, interpretation is integral to all medical practice and overcomes negative assumptions of subjectivism through the application of rigorous method.
While heavily grounded in anatomy and physiology, osteopathic students are obliged to develop palpation skills that rely on sense perceptions to assess the medical condition of a patient. Throughout this paper, discussion is limited to palpation skills rather than speaking to more complex issues and the diversity of manipulation techniques. William A. Kuchera, D.O., FAAO observes:
First, the students have to get used to feeling things. If they feel something, they have to believe it. Then they have to learn what normal tissue feels like so that later they can tell what abnormal tissue feels like.
What this indicates is that perception must name or catagorize a phenomenon in order to create a language or semantic field of differentiation . Phenomenology recognizes that consciousness must be consciousness of something as differentiated from something else. Thus, the student must have some previous knowledge of anatomy in order to begin to descriminate structures in a living body. Kuchera posits a hermeneutic circle--an interpretive back-and-forth play to understand an immediate perception based on past knowledge--in this case, a move from the ideal anatomical form to a recognition of signs as "normal" and "abnormal" in the living body. This is difficult for the new medical student since, as John M. Jones III D.O. suggests, students are generally selected for cognitive skills and consequently, learning OMT seems ambiguous and demanding a different dimension of ability. The tacit assumption here is that students must learn to interpret a system of signs that reduce the ideal forms of textbook anatomy to that of signifiers manifest in living body tissues.
The living conditions of sense perception imply interpretation, yet this contradicts most assumptions about scientific method. Considering that semiotics--a systematic analysis of linguistic, aesthetic, or material interactive codes of communication--is not a conscious part of the medical ciriculum, it is nonetheless a conventional tool for interpretation in medicine. For example, Foucault explains that a symptom becomes a sign when the physician, through interpretation, organizes consciousness to describe the significance of the sign in terms of the semantic field of medical discourse. Having been trained to accept as knowledge only what lays claim to scientific verification, students may doubt their own experience until they understand that applied anatomy conforms to the specificity of the living patient.
The "applied anatomy" of William G. Sutherland, D.O. contains what he refers to as "The Breath of Life," which can only be learned through experience with a living being, not in a book or from a cadaver. The tradition of osteopathic philosophy embodied in the physician's use of palpatory skills as a diagnostic tool, affirms the notion of a philosophy of science beyond the limitations of conventional empiricism to include lived experience as knowledge. Phenomenology, as a philosophy adapted to a rigorous, systematic methodology and based on a radical empiricism that privileges conscious experience rather than hypothetical constructs as data, is consistently implied in osteopathic literature. Phenomenologists like Maurice Merleau-Ponty have had a long-standing interest in perception and the body as the location of knowledge, not as ideal knowledge, but as an immediate relationship with the world. The highly specialized language of phenomenology uses terms like intentionality to explicate the embodied perspective of consciousness as a condition of being in the world. As a philosophy of science, phenomenology recognizes interpretaion of experience as a way of knowing.
Knowledge and Perception
Epistemology addresses issues of knowledge and asks how people know what they claim to know. The way in which physicians and scholars believe knowledge originates determines their methods of inquiry and the nature of the theories they construct. Ideas about the origins of truth and knowledge come from many perspectives, particularly concerning " . . . the relation between the visible and the invisible--which is necessary to all concrete knowledge . . . ." Similarly, the philosophy of A.T. Still states: "Each truth or division as we see it, can only be made known to us by the self evident fact, which this truth is able to demonstrate by its actions." Knowledge begins with lived experience, the pre-reflective perception of the world as it exists before names, catagories, or science.
The teaching of osteopathic manipulation is thoroughly grounded in anatomy and physiology. Traditional osteopathic literature from Still and Sutherland, however, is rich in 19th century metaphorical language that seems soft and unscientific while implying a non visible, but perceptible potency in life. Their words suggest a need to understand ontology, or the nature and experience of being alive, which is an essential aspect of the osteopathic healing art. According to physicians like Becker, Sutherland, and Still, one must "try to read between the lines to find a practical fulfillment of these basic principles" of osteopathic medicine expressed in words like "Spiritual Fulcrum . . . Highest Known Element . . . Potency . . . Tide . . . Breath of Life". These words are vague and possibly misleading, but the methods of phenomenology lead toward a precise language that aims to clearly express the explicit qualities of perception and "lived experience." Phenomenology could provide the linguistic referent necessary to read between the lines and help the student make the clinical transition.
The merit of scientific knowledge is generally based on empirical evidence; observation and experience subject to verification. Such discourse is a continuous activity within each discipline requiring special knowledge and language to follow the logic of new developments. Clearly, A. T. Still affirms a merger of science and perceptual experience as he maintains: "That which you can see, feel, hear, smell or taste is a fact, and the knowledge of the ability of any one fact to accomplish any one thing, how it accomplishes it and for what purpose, is a truth sought for in philosophy". The scientific discourse of osteopathic manipulation is grounded in the experiential perception of applied anatomy and palpation.
Raymond J. Hruby, D.O., F.A.A.O., notes that one of the reasons some D.O.s do not use OMT is that "scientific evidence is weak." The discourse of OMT depends on the ability to perceive and identify data presented in the physical evaluation of the patient indicating osteopathic principles. According to Anthony G. Chila, D.O., F.A.A.O. of Ohio University College of Osteopathic Medicine: "The clinical decision to employ manipulative interventions is contingent upon proper diagnosis, differential diagnosis, and experience in the use of manipulation." Again, the hermeneutic circle is implied as a reflective process bringing past knowledge into play with the current phenomenon. Charges against the scientific merits of OMT by some osteopaths may indicate a failure to master the high level of technique necessary to experience and understand the essential nature of osteopathic discourse. As stated by Dr. Becker:
To learn to feel function, to think function, and to know function within anatomical physiology is not an easy art and skill for the physician to develop. It takes hours, days, weeks, and years to bring this training into the hands, ears, and mind of the physician. And yet, it is fundamental to the total understanding of the science of osteopathy as taught by Andrew Taylor Still.
Osteopathic medicine employs a radical empiricism consistent with phenomenology that affirms the interpretation of experience and perception as valid scientific knowledge. The words "art" and "skill" imply a sense of play or a creative process that is the existential reality of the hermeneutic circle. Thus, the understanding of the scientific basis of osteopathic manipulation first requires special knowledge and experience with the bio-mechanical nature of the body and the medical processes manifest through the techniques of OMT.
TOWARD A LANGUAGE OF LIVED EXPERIENCE OF OMT
Though not intended as an in-depth discussion of phenomenology, this project is a proposal for the adaptation of phenomenology as a method where it is appropriate to help develop better communication of sense perception in OMT. The language and philosophy of phenomenology would provide an element of consistency to OMT teaching programs that are currently very diverse. Following are just a few examples from osteopathic literature to demonstrate that a phenomenological method is already in place in OMT.
The process of transferring cognitive classroom anatomy to the lived experience of sensing through palpation and administering osteopathic manipulation exhibits a clear correlation with the language, philosophy and methodology of phenomenology. William G. Sutherland, D.O., expresses this process in the following:
When palpating let your fingers light gently on the skull, on the abdomen, or anywhere on the patients body. Let your hands be like a bird lighting on the branch of a tree, quietly touching and then settling down over the area. While your fingers are there feeling, seeing, thinking and knowing, they can tell you more in one minute than a firm grasp can gain in an hour's observation. You will train them to observe without interfering.
As an example of osteopathic pedagogy, this first step toward interpretation of perception demonstrates phenomenological description that seeks to "let things speak for themselves." The condition of the patient's body must emerge on its own, isolated without preconception, before the phenomenon can be interpreted from an informed position.
After extensive training in textbook anatomy, the introduction to a lived experience such as the applied anatomy of palpation is expressed by Viola Frymann, D.O., FAAO, as " . . . like the first visit to a foreign country." Key elements of phenomenological method: the procedures of description, reduction , and interpretation, correlate with Dr. Frymann's workshop on palpation: "The first step then, in the process of palpation is detection, the second step is amplification, and the third step must therefore be interpretation". Detection suggests locating and describing the anatomical phenomena. Amplification implies bracketing--a phenomenological term for putting aside the obvious--in order to bring forward or illuminate signifiers of abnormality. Interpretation moves to identify abnormality as a sign of dysfunction. While these examples suggests a relationship between osteopathic and phenomenological method, the terms and procedures should not be taken as self evident. The space of this article cannot provide the thorough explication necessary for a meaningful understanding in the proper context. However, a method of applied phenomenology should not be conceived of as a rigid system, but an adaptation of the philosophical process to the specific phenomena.
Dr. Frymann's three step process assumes an ability to use the phenomenological epoche, or "bracketing" that calls for the suspension of knowledge or presuppositions concerning a phenomenon to help facilitate the observation of the essential character being studied. As a spiraling, abductive process, bracketing is also suggested by Dr. Becker's "three problems" that occur every time a patient enters the physician's office:
There are the patient's ideas and beliefs of what he considers his problem to be; there is the physician's concept of what he considers the patient's problem to be; and, finally, there is the problem of what the anatomical-physiological wholeness of the patient's body knows the problem to be . . . .the patient's body knows the problem and is outpicturing it in the tissues .
This examplifies bracketing in that all presuppositions must be placed in the back of the mind, or out of consciousness, in order to access the pure essence of the phenomenon (see illustration). As Dr. Chila expresses the same idea, "the physician must learn to get out of his/her own way" in order to perceive the patient's body.
PROPOSAL FOR PHENOMENOLOGY FOR OMT PEDAGOGY
There is great potential for appropriating the language of phenomenology to establish a more consistent pedagogy for osteopathic manipulation. Terms such as lived experience, bracketing, description, reduction, interpretation, and many others not included in this article apply to specific concepts and procedures existing in osteopathy. The radical empiricism of phenomenology may also contribute methodological procedures to the scientific research demands of OMT. This is not, however, a proposal for osteopathy to accept a predetermined approach. According to Jenny Nelson, Ph.D.:
The phenomenological procedures performed in one study cannot be replicated in another, precisely because the phenomenological method is grounded in, and dependent upon, adhering to the specificity of the experience/ phenomenon under investigation.
The task is for osteopathic pedagogy to adapt a phenomenology informed by osteopathic principles. Evidence of the compatability of the two disciplines is strong. Through a national colloquium, a more consistent approach for teaching OMT could be developed by teachers from the OMT departments of all sixteen colleges of osteopathic medicine, Fellows of the American Academy of Osteopathy, and the American Osteopathic Association. Osteopathic physicians in collaboration with communication scholars skilled in phenomenolgy and familiar with osteopathic principles and practice could produce a method of clear communication in rigorous scientific terms. The ultimate goal of this project is to help improve osteopathic teaching, and to advance and perpetuate the distinctive healing art of osteopathic manipulative treatment.
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