The MT's FEAR of diagnosing

[douglowesplace]

Many states now require a massage therapist to have many hours of anatomy and pathology education before ever applying for state certification. Massage therapists should know quite a bit more about the signs and symptoms of many common pathologies. Unfortunately, I have found many massage therapist don’t feel comfortable using this knowledge or didn’t acquire a level of competence in these areas during school.
Some MT’s seem to be reluctant or downright militant about not discussing health issues with their clients. These folks also seem hesitant to call a physician’s, chiropractor or physical therapists office to discuss a shared clients treatment. In both cases the common comment is “if I say or do X I would be out of scope of practice and/or diagnosing”
So why the hours of training in pathologies…? Few of them affect or require changes to the performance of a simple Swedish relaxation massage. How does knowing about the endocrine system, reproductive system or urinary system actually affect the job of doing massage? Many MT’s and students of massage therapy ask the exact same question. If the job simply entails asking if the client is allergic to nuts or oils, what kind of music they like and then performing a general relaxation massage, followed by recommending they drink water and sending the client on their way…there is no need for such education.
I call chiropractors, P.T.s and physicians offices regularly. I have found other healthcare providers in the allopathic medical system more than willing to work as a team for the betterment of our shared client. Often I have a lot more time with the client and gather more information that other healthcare providers do not get a chance to hear about in their shorter appointment time. I forward the information either directly or through the client to the other healthcare providers who may then ignore or investigate the information further.
Massage therapy increase relaxation, reduces pain and can make the symptoms of an underlying pathology more tolerable, which may in turn cause the client not to seek other more appropriate medical treatment because the symptoms are reduced by the massage treatment.
Let’s consider the following case (several versions of which have occurred in my practice) the client comes in because they have aches and pains in their arms and feet sometimes their back. The Client also states that they need “deep tissue” especially on their lower legs because many massage therapists don’t “go hard enough” for them to notice. Their health history reveals they have had several urinary infections over the past few years. The client is obviously overweight and during the massage the therapist notices some cracking of the skin near the heels and a sore on one of the clients elbow. The client’s lower legs also have obvious edema.

So what do you do…?
Do the massage, which they love, telling you they feel much better and will be back next week. Suggest they drink some water. To which they reply, “oh I drink tons of water”



Do you ask if they have a family history of diabetes and ask if they have had their blood sugar checked? What do you do if they have a family history of diabetes and haven’t had their blood sugar checked?

Do you explain that the client has several signs and symptoms that may indicate they could have an underlying health concern that should be assessed by a physician? To which every single client will ask “what symptoms and what possible health concern” Do you tell them that for example reoccurring urinary infection, the reduced sensation and excess fluid in the legs and the skin abrasions/sores can all be signs of diabetes or possibly some other pathology. Do you tell them that only a physician can determine/diagnose such conditions for sure and that they can do it quickly with a simple blood sugar test? Do you tell them that it is very important to go to a doctor to check this out because the sooner conditions are identified the more effective the treatments are?

If the client does have undiagnosed type II diabetes but delays getting it checked because the massage reduces the aches, pains fatigue and stress of the disorder has the massage therapist acted in the best interest of the client? The MT may get a lot more money because that person comes infrequently. The MT’s ego may get built up because the client tells them how wonderfully relaxing the massage is. The big question is what is in the best interest of the client.

I’ve had this occur and when asking doctors about my scope of practice and whether I was diagnosing.their response has always been no …actually not just no but “hell no” I’ve been told that referring a client WITH CAUSE when ANY healthcare professional notices possible signs and symptoms of a serious pathology is EXACTLY the job of EVERY health care professional…by the way “with cause” means you explain why you are referring out…the signs and symptoms and suspected pathology….

Now if you still think this is crossing a legal boundary don’t take my word or the word of any other massage therapist. Talk to a malpractice lawyer. The ones that sue people for malpractice…I have…and been told that I’m more likely to get sued if I chart all those symptoms but never mention their possible importance and never refer them out…


If we want to be accepted and taken seriously by the healthcare system we must take it and our responsibilities with in it seriously…


Just something to think about

 

[debb]

i have no problem with giving an evaluation, with the disclaimer that one should see their doctor, chiro, acupuncturist, because i am not a doctor.
i will not diagnose. i know it's semantics, to a certain degree, but let's give a big HELL no for me. let's not play with the all-seeing-eyes of my state board, or the AMA, i say.

for example, if the client has, what i suspect is a lipoma, and they say, "hey, what's that lumpy thing back there?"
i'll say, "it is most likely a lipoma (with definition). i've had many a client with these, and i understand they can be excised, but they may grow back. if you're concerned, you should speak to your doctor or dermatologist." i then may go on to discuss the effectiveness of massage on lipomas, and ask them if there is any pain or discomfort (which might indicate that there is something else going on here)."

i'm also known to say, "my hands feel 'this'. and that could be an indication of 'that'. you could talk to your doctor/acupuncturist/etc blah blah blah."

diagnose. no thanks.

 

[Osaka_L.A._Connect]

Semantics

I agree it's all about communication..I think that it is critically important to refer out with as much information as posible...

Like moogie..said refering out when you have a suspected rotator cuff tear indicated by a a palpable gap in the tissue inflammation a recent trauma etc is very important...

There are only a few pathologies that require some minor adjustments to relaxation massage..sever typeII diabetes for example only requires lighter pressure if neuropathy is present...pretty minor...

Now if you are a massage therapist who uses proprioneurofaciliatated stretching techniques (PNF) myofascial trigger point therpay techniques, heat/cold/cotnrast therapy, deep transverse friction etc...
specific modifications for individual pathologies are substantial..

My orginal point is simply that I have run into many massage therapists who do not do technical work...which is fine the more massage the better...But some of the these massage therapist say that ANY communication about specific assessment and symptoms is out of scope and daignosis....this causes alot of communication problems for new massage therapists and clients...

I would simply prefer they say that they do not do the technical work and and they do not feel knowledgable enough to discuss these issues....
and stop telling clients and new massage therapsits that these conversations are "diagnosing"...

Thanks for the post moogie

 

[Rare]

Semantics

and stop telling clients and new massage therapsits that these conversations are "diagnosing"...

Nope, what we{the collective we} witness here , on other boards, and in day to day life comes WAY TOO CLOSE to diagnosing which is clearly outside our scope.

Newbies(and oldbies), just don't do it.
It is also OK to tell your client that you DO NOT KNOW....and to suggest further investigation on their part.
If a client is seeing your for anything other than "relaxation" massage then they are playing a larger part in their own health care{afterall, they sought you out} and most likely will research appropriately.

Telling MT's to not tread near diagnosing isn't frivolous, it's good practice.
If anyone wants to argue the point, go ahead, I like (friendly) debate. I suggest you do it in an Ethics class though....

Robyn

 

[fish man]

A few years ago, I did a 300 hour Symptomatology and Diagnosis subject (I thought I wanted to be a naturopath)

I still do not diagnose, just assess and refer if appropriate.

Diagnosis is not easy, even for a doctor with all the tools available to him including bood tests, Xrays, ultrasound etc. All we have available are signs, symptoms and palpation.

If someone comes to me with a sprained ankle, I dont send them off for a diagnosis (unless there are indications of fracture or complete tear), I asess pain and function and treat the area affectsed appropriately.
There are the occasional clients, I send away to their doctor without more than palpation

 

[Tamry]

The longer I am in practice the more wary I am of naming a "suspected pathology." Unless it's strictly a soft-tissue situation (which I can assess and address), I feel most comfortable saying that a set of reviewed symptoms (together with observed signs) are good things to consult a doc (chiro/PT/etc) about. "Just to make sure there's no underlying problem."

But who's going to be satisfied with that? I know I wouldn't if I were on the receiving end. So when pressed, I do try to say something like "A few different health concerns have the XYZ symptoms you're showing, and I know enough to point it out to you but not enough to guess whether there's a problem." And I force myself not to guess aloud what those might be. Sometimes I have silently guessed the same as a doc; sometimes I have been WAY off.

Of course then there are the clients who won't have anything to do w/AMA medicine and sort of hope we will try to dx because they trust us . . . fortunately I haven't had one of those whose massage would have required a different approach depending on diagnosis, but I know that day will eventually come.

I agree w/Robyn - I don't think we have to second-guess our assess-&-address skills for soft-tissue situations, but I know too many MTs who sound way more free and easy with the pathology opinions than I feel comfortable doing.

 

[SARCO]

A couple of points

As I said my opinion comes from speaking with MD's, two surgeons, several PT's and chiropractors...

and most importantly a lawyer specializing in medical malpractice...

As long as your charting and communication with the client are clear..that the condition is "suspected" followed by a referal to the appropriate medical profesional who is qualified to "diagnosis" there is no danger of diagnosis....

But not refering out or refering out but not telling your client exactly what signs, symptoms are concerning and why..could get you into trouble....

To be honest there are very few lawsuits involving massage therapists unless there is extreme gross negligence...

there is a literature review of cases of massage therapy malpractice over 10 or 15 years...I think I have the abstract on my website...I've got the full text somewhere on my office computer...

I will track down the tittle of it ...it's very interesting reading..
All of the cases involve some pretty ridiculous behavior on the part of the massage therapist...

Like one rolfer doing deep transeverse friction and applying heat to a clients neck the day after a whiplash injury before she had seen a physcian....

My goal is to notice the things I can notice and get my clients to the right medical professional with as much information as possible...they can then make a decision with that MD etc as to a course of action..(i.e. informed consent)...

As to discussing this on an ethics thread..I have clear guidence from a leagal professional who has decades of experience in the field of medical malpractice..the line is pretty clear leagally...

I think the ethics conversation would come into play... for those who have not looked for a clear leagal distinction...

I have yet to encounter a problem with a client , or doctor etc...
just other MT's...

Dale

 

[ADEE]

Well, to each their own. I'm not acting out of "FEAR" in this situation as your thread title shouts; I've just come to a different conclusion than you about how I will phrase things. This hardly ever comes up for me when I really stay focused on the soft-tissue work anyway.

 

[Christian T]

FEAR OF DIAGNOSING

Hi i agree with you in a way where i think massage therapist should take all out anatomy knowlege to "REFER" client to the doctor in case where our knowlegde indicates our client may have a medical condition...

i agree on all that...but i think we still cannot be diagnosing people . we may know what it is that they have but we can just tell them for sure that they have certain medical condition thats md's job....

however very good point i guess we should be afraid od diagnosing people becasue we are not md's..but we shouldn;t be afraid of refering people to the adequate health care provider