Listening to patients with our eyes [PODCAST]

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“Patients communicate immense amounts of information through body language. The primary understood, universal body language is choking. Anywhere in the world you go, if someone is choking, they use both hands to grab their throats. No matter what country you are in or what language is spoken, you can recognize someone choking and provide aid if trained. Body language is also understood to convey various subconscious emotions – crossed arms can be used by someone who is angry, frustrated, or scared, or shutting down in a conversation; open arms and uncrossed legs can be used by individuals who are open to new ideas, and willing to communicate with those they are talking to.”

Jennifer Ribar is an osteopathic physician.

She shares her story and discusses her KevinMD article, “Listening to patients with our eyes.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Jennifer Ribar. She’s an osteopathic physician, and she wrote the KevinMD article “Listening to patients with our eyes.” Jennifer, welcome to the show.

Jennifer Ribar: Thank you for having me. It’s good to be here.

Kevin Pho: We’ll get into your article in a little bit, but first off, can you share your story and journey to where you are today?

Jennifer Ribar: Yeah, so I was born and raised in Fairbanks, Alaska, and I knew from a young age I wanted to be a physician. I always thought I wanted to be an OB/GYN, so when I got into medical school, that was my initial thought path. But like many people that go into medicine, the path changed a couple of times, and as cliche as it sounds, but true, my path chose me. I specialize in osteopathic manipulative medicine. Throughout my career, I’ve had a few mentors that have led me to the type of techniques that I use, and specifically why I wrote this article.

So I currently practice in Fairbanks, Alaska, and at the practice that I work at, many of us specifically work with the fascial distortion model. It’s a very intriguing methodology. I was taught it initially in my medical school career, and I am currently an instructor, one of eight instructors in the United States that teach it.

One of the things that I really enjoy about teaching it is seeing people that have been in medicine for decades, who are burned out, tired, not necessarily happy in their practice, and they come to the classes that we teach, and they leave and they just suddenly have this vigor and excitement to go back and practice again. I personally love going to work every day, and I know not everybody can say that. It’s what I do on a day-to-day basis, the patients that I see. It’s an extremely rewarding job, and I feel very grateful that it found me, essentially.

Kevin Pho: So we’re going to talk about the fascial distortion model as part of your KevinMD article, but before I get into that, I think you’re the first physician I’ve had from Alaska on this podcast, and I’ve done almost 600 episodes. What’s it like to practice medicine in Alaska?

Jennifer Ribar: It’s unique, I think. I mean, it’s similar to the rest of the United States, but it’s unique, for sure. We have a very independent mindset in the people that come here. So particularly in my practice, where I treat pain, you have people that are coming in with chronic pain, but they’re still out chopping wood and dog sledding and hunting, and have very bizarre injuries for how their pain starts. But it’s great. I love the people here. I love working here. I love living here. Like I said, I grew up here.

Another interesting aspect of it is we get a lot of people from what we call the bush, so it’s the villages in Alaska, the rural parts of Alaska, and their journeys to find health care are unique in and of themselves.

Kevin Pho: So tell me some of the unique challenges that both you and patients face living in Alaska.

Jennifer Ribar: Yeah, so part of being in Alaska is that there’s only a few large areas, and otherwise everyone else is very rural, as I said. And so many patients have to fly to find a health care provider of any sort, and so that’s a unique challenge for many people I service. My patients come from rural villages, but also come from really a couple-hundred-mile radius and drive multiple hours to see us in our clinic.

Another interesting aspect of practice in Alaska is there’s not a lot of specialties. So Fairbanks, where I practice, for instance, currently doesn’t have a rheumatologist, so patients might have to go to Anchorage, Alaska, or fly out of state to see that kind of specialist. That definitely affects my patient population, with people with a lot of chronic pain and a lot of autoimmune disorders. And so that creates an extra element of collaboration with providers that aren’t necessarily in my community, to try to provide the best patient care.

Kevin Pho: All right, now let’s transition into the KevinMD article that you wrote. It’s titled “Listening to patients with our eyes.” Now, for those who didn’t get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

Jennifer Ribar: Absolutely. So the premise of the article is basically sort of an introduction to a different way to look at your patients. We are trained as medical providers to listen to our patients, and I think there’s more of an emphasis on that in the last few years, decade or so, to try to listen more. Physicians on average interrupt patients after 15, 18 seconds. What’s the next thing? We have to keep going, keep going. And so we ask a lot of questions and listen with our ears, and we ask particular questions, but our patients give us a lot of information in how they move their bodies, particularly when it comes to pain.

In the fascial distortion model, we call it a universal body language, essentially. So we all know the universal body language of choking. Anywhere you go in the world, if someone’s doing this, you know that they’re choking. But there are other gestures, body languages, how patients move their hands to touch themselves and indicate where their pain is, that can give us a lot of information. There’s actually some research being done in Europe right now to validate these universal body languages that we teach in the classes about the fascial distortion model.

And if people can be trained in this model, people don’t have to do manual medicine. You don’t even have to be in a specialty that touches your patients. But if you can visualize your patients differently, and how they’re moving in space, we can actually gather a lot more information about how to effectively treat them and give them more pain relief.

Kevin Pho: So I’m going to ask you more details in terms of what exactly you do, but first off, just because I actually don’t know, what exactly is the fascial distortion model?

Jennifer Ribar: So it’s an anatomical perspective on analyzing and treating the body, essentially. This model was developed by Dr. Stephen Typaldos. He was a DO, and he specifically did ER medicine for his career. He passed away about 16 years ago now, but he spent 20 years developing this model based on the patient being the expert.

That’s the interesting paradigm of this compared to other types of medical modalities, where we have all these years of training, this degree behind our name, and yes, we’re very intelligent people and have a lot of skills. But the patient lives in their body every single day, and knows how they feel, knows how they move, and they can communicate that really subconsciously, on their level, and communicate things and show us how their body is, how their body hurts.

This model not only teaches how to interpret those body languages, body gestures, but the other core premise of this model is actually manipulations and how to treat the fascia. It’s basically looking at the body through the fascia, and how the fascia is integrated in our musculoskeletal system and really is a contributing factor to a lot of pain that people have.

Kevin Pho: So take us into your exam room, and if you could, give us perhaps a case study of how you would use this model on a typical patient that you see.

Jennifer Ribar: Absolutely. So for a new patient coming in, for instance, I had a woman recently come in, 82, I believe, a couple of days ago, having shoulder pain. She’s been seen by orthopedists and has a lot of arthritis and some chronic tearing in her shoulders, in her rotator cuff, and she is not really a great surgical candidate. So she basically has to try to figure out how to function in her day-to-day life, and so she was sent to my office to see if we could help just with pain management. Somebody in their 80s is not commonly a great surgical candidate, and we also don’t want to be putting them on a lot of narcotics or really strong medications that can put them at risk for other health issues and morbidities.

So we basically talk about her history, and then on my examination, from the second she comes in my door, I’m already watching how she moves and how she shows me her pain. My core question that I ask every single patient, whether they’re new or I’ve seen them for a long period of time, is, “Show me where it hurts.” And basically they will touch, move, sweep, all different types of gestures, and there’s different gestures that indicate to me different fascial distortions. It’s called the fascial distortion model, so we call them distortions, and then I can treat.

So one of the key things is doing some range of motion before and after, and it’s really fun, because when you see someone that comes in and they can only raise their arm this high, and it hurts in a certain spot, and you treat them for about five to 10 minutes, maybe sometimes longer, sometimes a little bit shorter, but usually five to 10 minutes, at least at the first visit, and suddenly they’ve got 20, 30 more degrees, or suddenly their hands are above their head. For her, she gained probably about 20 degrees after the first visit. So that’s always really exciting, and they’re like, “Whoa, I haven’t done that in years.”

And so that’s part of what’s really fun about my practice. It seems like voodoo or witchcraft to the patient sometimes, but there’s a fundamental understanding of how we’re addressing the body, and that’s fun.

Kevin Pho: Are you talking about the osteopathic manipulation that all the DOs get in their training, or is it something different?

Jennifer Ribar: It is a part of that, but this is not taught at DO medical schools right now. It’s a newer modality, and so it’s not as widespread. There’s a few schools that we teach at. I’m going to be teaching some weekend courses in the spring at a couple of medical schools, but it’s not in the core curriculum right now. Our national organization is working on trying to help develop some curriculum content, so that schools that are interested can integrate it into their classrooms.

Kevin Pho: You said earlier that this modality has decreased your burnout. You come to your practice with a certain amount of joy every day. So go more into that. Why is that?

Jennifer Ribar: It’s great to be able to have a patient leave feeling better than when they came in, and that’s not something that we can do in every specialty. And it does happen, and that’s part of medicine. But for my practice, in my day, not everybody walks out feeling better, but a significant majority do. And so it’s just really rewarding to have someone come in, they’ve tried everything, they’ve seen every specialist, and “I don’t know what you’re going to be able to do for me,” and to be able to make them feel better physically, but also mentally and emotionally too.

Because when you incorporate the listening with your eyes, and validating that, “Yes, you’re pointing here, and I’m also feeling something when I touch there,” the patients just change their demeanor, their mental state. Really, watching people that come in completely closed off on the first visit, and after a few visits they’re sharing more with me than they’ve shared with other providers, it’s just so fulfilling to be able to empower patients, really, to say, “I’m listening to you.” It’s just really powerful.

Kevin Pho: We’re talking to Jennifer Ribar. She’s an osteopathic physician, and she wrote the KevinMD article “Listening to patients with our eyes.” Jennifer, I’m a primary care internal medicine physician, and for those other doctors who are also in primary care, what are some tips that you could give them so they could incorporate maybe just a little bit of those techniques in their exam rooms?

Jennifer Ribar: Always, my recommendation is that taking an actual course or module is a good starting place. We are actually offering an online four-hour introduction to sort of get a taste of what this is. But once you understand the terminology and see what the body language is, you can incorporate it immediately into your practice, even as a primary care physician. You don’t even have to add to your physical exam or add to the time of your visit at all, and you don’t even have to do the manipulations. If you can just see what the body language of the patient is showing you, then you can reach out and find somebody near you, hopefully, that does this model.

But the beauty of this model, compared to many other types of manual manipulations, is anybody can do it: MD, DO, nurse practitioners, PAs, physical therapists. And it doesn’t add much time to your practice. One patient pointing to one spot, that one spot takes actually about five to 10 seconds to treat, and then you can elaborate more on that if you want to. But really, primary care providers can integrate this into their practice extremely easily. The best way to learn more about it is to either take a full course with myself or one of my colleagues, or at least get an online introduction, which gives you a good understanding of what these gestures look like.

Kevin Pho: And where can people find these resources?

Jennifer Ribar: So the American Fascial Distortion Model Association, or AFDMA, is our main national website, so www.afdma.com. And I teach through the FDM Academy, so that would be fdmacademy.com. So those are two great resources, and you can find us also on Facebook and Instagram.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Jennifer Ribar: I think, find the things that can help you find that spark again. Whether it’s something like this, or basically find something that gives you that spark in medicine again. I know we’re all really burned out because of the pandemic, and this is a great way to help you find that connection to why you wanted to go into medicine in the first place, and why and how we can help people.

Kevin Pho: Jennifer, thank you so much for sharing your time and insight, and thanks again for being on the show.

Jennifer Ribar: Thank you.

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