To refer or not to refer?

When is something not normal?  When do you concern and inconvenience your patient by asking them to go to see their GP?  Do you risk making yourself look a fool?

Much of the training to be an osteopath is about conditions we don't treat.  Why is that?  Well, many systemic conditions present with symptoms that mimic musculoskeletal problems.   Fibroids that refer to the low back, deep vein thrombosis which the patient thinks is a torn calf muscle, prostate cancer metastasised to the low back and causing back ache there.   That's why we ask so many questions to try and differentiate between something which is probably musculokeletal in nature from something that may have a systemic and possibly sinister origin and requires further investigation.

We have a duty to maintain our continuous professional development through a mix of self-study, talks and courses and recently I have been on a couple that were specifically about spotting people who needed to be referred.  The first was a course on neurological and intracranial anatomy and pathology.  This was part lecture, part looking at preserved specimens of intracranial pathologies and part handling of dissected human neurological and intracranial anatomy.  It was fascinating and a little daunting and I am very grateful to the people who expressed a wish that their mortal remains should be used in this way...I didn't just do it so I had something interesting to write about here, by seeing and handling the structures in 3D and as near to their natural state as possible it is much easier to picture, to understand how, for example, different types of intracranial bleed progress and how they effect the patient.  A more common pathology I am likely to spot is skin cancer.  I attended a talk on skin cancer and the strongest message I took home from it was that they aren't always easy to spot.  Skin cancers can look benign and equally there are many benign lesions  which often show features associated with skin cancers.  I suggest everyone brush up on their ABCDE of Melanomas but remember that it's only a guide...the only one of the 5 criteria that is a very strong warning is E - evolving.  Anything that looks like a melanoma and is changing faster than anything else on the back, needs urgent investigation.  I only attended the course 3 weeks ago and have already referred one patient on for further investigation, her GP has made an appointment to use a dermatoscope to look further into it (pun intended) - so that probably gives you the answer to the questions I posed at the beginning.
When is something not normal? - Most of the time I am unsure
When do you concern and inconvenience your patient by asking them to go to see their GP? - When something may not be normal and leaving it may be deleterious to their health
Do you risk making yourself look a fool? - Every time there is anything above the lowest suspicion of something not being musculoskeletal, better to look a fool than risk a patient's health - but bear in mind I have trained for 4 years, kept up to date on courses and asked the patient a lot of questions so it is required less than you'd think 

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