This is an unusual post: it is by an osteopath who sent it to me for publication but insists he does not want to be named because he is still working in the profession. I think he has an interesting story to tell and therefore agreed to publishing his article, even though its author has to remain anonymous.
I graduated with an honours degree in osteopathic medicine in 2000 and remain registered as an osteopath. I am writing to help others avoid the same errant thought patterns that I developed, when assessing osteopathy.
My venture into the world of osteopathy began, as I am aware many have, with the assurance that osteopathy is far better than physiotherapy. There is an established musculoskeletal pathway in this country provided by physiotherapists and to wish to practice a therapy other than this, one must be sure that it is superior to physiotherapy in many aspects: effectiveness, remuneration, job satisfaction etc. And this belief was drummed into me ad nauseam by virtually all the osteopaths that I encountered. Despite hearing this for over 20 years, I have yet to see any evidence that it is the case.
The manipulative therapy at the heart of osteopathy should be a focus of strong suspicion. It is obvious that the cracks and pops elicited from spinal and peripheral joints are nothing more than a placebo party-trick, but it is a key feature of the treatment taught and practised by osteopaths throughout the country. In fact, the evidence appears to contradict the structural/mechanical model that underlies osteopathy. Spinal alignment, muscular and postural imbalances are seemingly not predisposing or maintaining factors for many musculoskeletal conditions, despite what continues to be taught in osteopathic colleges. It is hugely underappreciated that most of the factors deemed by osteopaths to be significant to a patient’s symptoms are prevalent in asymptomatic people.
The reality facing osteopaths is that spinal and musculoskeletal pain in general is so little understood, that you can only be confident in your ability to ‘treat’ it with osteopathic manipulative therapy by ignoring the complexity and opacity of the problem. Chronic low back pain for example, is such an obscure entity that it seems the success of one practitioner over another has little or nothing to do with their technical knowledge or ability, and more, maybe, to do with interpersonal dynamics. This makes for a frustrating and somewhat embarrassing career, given that the technical side of much of the work is a charade. I saw no objective reason to believe that I could do significantly more good for a patient than could be done with some basic exercise and possibly a massage.
When I graduated, there was widespread debate over whether dysfunction of the lumbo-sacral joints or the sacro-iliac joints was the most significant factor in back pain. Some osteopaths focused on one area, others on the other. I didn’t however perceive a difference in results from either group of practitioners, or from me, when switching between the two models. In fact, if I made no attempt to differentiate between the two, still no change. This proved true across the board – little or no change in outcome from a wide variety of approaches to the same issue. This is the nature of osteopathy; it is mostly vacuous as a form of assessment and treatment.
A common remark amongst osteopaths is that if you see ten osteopaths, you will get ten different diagnoses. This has consistently been my experience with my own symptoms, those of friends and family, and clinical observation. Good luck developing your ‘skill’ in that environment. Inter-practitioner repeatability was virtually non-existent when assessing the position and function of most joints of the body, especially the spine. If it is not repeatable (and very little in osteopathy is), then it is not science.
Confirmation bias was a huge factor in my education. ‘Successes’ were celebrated and failures ignored. We enjoyed reports from patients of how much good we had done but had practically no training in how osteopathy relates to scientific evidence. We still don’t have a decent body of research as to how it fares as a therapy compared to other approaches, or how specifically osteopathic treatment outcomes differ from the natural progression of symptoms.
Osteopathy is so far removed from mainstream medicine that it has been possible to build and maintain it on a foundation of anecdotal evidence; born of a vague perception that it must be superior to large institutionalised medicine, which is inherently inept and corrupt. There is an awareness amongst osteopaths that the evidence for osteopathy is pretty much all anecdotal but there is a faith that it will be proven effective once tested properly. Never mind the fact that anecdotal evidence is the worst form of evidence and you should not follow a system of healthcare produced by it. It is worse than no evidence, because when heeded it can lead to believing falsehoods that seem true. In osteopathy, the scientific method has largely been ignored for groupthink and indoctrination.
Osteopaths in private practice (which is most of them) encounter huge financial pressure to over-diagnose and over-treat. Most episodes of musculoskeletal pain should be viewed as a normal part of life. They are self-limiting and do not require any formal intervention. Unfortunately, people’s anxieties are perpetuated by osteopaths who pander to the worried-well, to maintain the core of their income. Best practice for the majority of people seeking help from an osteopath is reassurance and advice to stay positive and active. This doesn’t pay well, so instead patients are given a course of manual therapy and extended ‘maintenance sessions’, both of which are of little to no short-term benefit and absolutely no long-term benefit.
But we all know that osteopaths earn more than physiotherapists right? Again, no clear data. In my experience of working in private multi-disciplinary practices, the flow of work heading the way of physiotherapists is far more consistent, given the long-established referral pathways from within the NHS and private medical insurance. Also, the NHS provides solid financial benefits and security that are not available in the parochial, private environments that osteopaths have to work in. Public and student perception of the likely earnings of an osteopath is remarkably high but there is a large swathe of osteopaths that never make a decent living from it. It is tragic to see otherwise intelligent people plough their money, time and effort into an alternative medicine cult. The same time and money could be spent pursuing a career that offers a net benefit to society and provides significant opportunity for personal development and progress, intellectually and financially.
The exultation of historical leading figures, derision of those questioning the status quo, veneration of tutors, delusions of grandeur and unshakable faith in the veracity of osteopathy are difficult influences to identify and navigate as a young student. Undergraduates need to be taught to think critically, both scientifically and philosophically. And this is especially crucial in the quagmire of alternative medicine; as the world is awash with misinformation about health. We should engender a clarity of thought, appropriate scepticism and strength of character that enables people to call bullshit sooner rather than later, in the face of such patent nonsense.
Numerous times I have been assured that osteopaths receive a similar level of education to doctors (albeit for a shorter duration), however, the serious academic training that occurs in actual medical schools makes this claim risible. Osteopaths mostly seem to think far too highly of their training; which is, in fact, fairly rudimentary. (Speaking as someone who has recently observed for a number of days in a leading teaching clinic in the UK.)
If you wish to study a musculoskeletal therapy, please, for the sake of your mental health, your financial income, your family and the good of the public; study physiotherapy. There is value in helping people deal with physical pain, the use of therapeutic exercise, and certain forms of manual therapy. Osteopathy, however, has nothing uniquely effective to offer and forms one of the most over-rated careers imaginable.