The Guy Warning You to Not Diagnose Needs to Chillax

medical Jul 17, 2020

written by Robert Truax, DO

Client: “So, what's wrong with me?”

You want to answer but you have “massage therapists shouldn’t diagnose!” running through your mind and you hesitate.

When I, as a physician, am casually talking to a massage therapist about how they handled an issue with a client, sooner or later, they feel compelled to add the pesky clarification, “but I didn't diagnose.”

This is apparently hammered into you as students, haunting you throughout your career either through instructors reminding you, or fellow massage therapists wagging their finger at you.

Let’s get real . . .

You Diagnose All the Time

The truth is . . . you diagnose all the time.

In school, your instructors taught you to notice tissue texture differences, recognize a tight muscle, and then relax the muscle.

Basically, you diagnosed and treated.

Then, they tell you not to diagnose.

This mixed messaging can hinder you from optimizing your value as a massage therapist because you don't know where the line is, and you fear crossing this mysterious line.

It's not healthy fear when you don't even know where the line is.

I don’t want that for you.

Good news, though. You aren’t alone. Nurses, physical therapists, occupational therapists, athletic trainers all have to navigate this.

So let’s get some clarity . . .

The Meaning of Diagnosis in the Medical Setting

On one level, a diagnosis is merely a definition of a particular condition, a disease name.

This understanding of diagnosis is when you find a disease name in a medical dictionary or textbook: very clear, very concise, and very non-personal.

Even the client can read a definition of the disease and accurately diagnose themselves by naming the correct disease. However, that's not truly a diagnosis in the medical sense.

In the medical setting, a diagnosis is the process of . . .

taking a history,
conducting a comprehensive physical exam,
ordering further testing, coming to a conclusion in light of the testing, giving a name to the person’s condition, then
making a definitive plan as to what or who will care for the issue (meds, surgery, therapy . . .).

Which of the above can massage therapists do?

Take a history.
Do a very limited physical exam with your hands, but no other diagnostic tools are available to you.

The rest of this list requires a massage therapist to have training and even tools they don’t have.

You can’t . . .

order further testing,
come to a conclusion in light of those tests,
give a name as a result, and then
make a definitive plan like ordering meds, surgery, physical therapy.

As you can see, training and tools already limit massage therapists. The professional license is self-limiting.

The caution for massage therapists to NOT diagnose is often overkill, because the system safeguards massage therapists from engaging too far into the process of diagnosis.

So, the teachers and colleagues who need you to know to not diagnose might be overstating this concern and causing more fear and confusion than actually helping.

Easier to Instill Fear than Equip

Why the finger wagging?

It could be a number of reasons.

Some massage therapists do recommend pain relief drugs and one of my patients said that her massage therapist said she couldn't feel a lumbar disc hernia.

You don't palpate hernias. It requires an MRI (Magnet Resonance Imaging).

These warnings not to diagnose may be warranted due to instances like these, and there are various manifestations of this.

I'm not sure it explains the full picture though.

My uncertainty is due, in part, to what I've seen in massage education offerings.

They often fail to give proper context and perspective of how decisions are made within the medical field because the instructors themselves don't have higher level training or experience in the medical field.

Perhaps the finger wagging is a compensation for an inability to teach massage therapists how to properly carry out excellent medical massage therapy in the context of a medical team.

It's no one's fault.

How can they equip if they don't know?

Teaching massage therapists to be confident in their role on a medical team requires instructors with experience in both the medical field and manual therapy.

No shaming intended. The education simply needs to change.

We're changing it in the Massage Medical Collective.

What Massage Therapists Should Not Do

So to be clear: The diagnosing that massage therapists shouldn't be doing is asserting you have fully identified the disease and you'll be managing their treatment.

Broken down, you shouldn't . . .

imply to your clients that you've done a complete exam (system safeguard: you can’t order or read tests),
have a definitive diagnosis for your client (system safeguard: you don’t know because you weren’t able to read or order tests or been taught the full array of differential diagnoses),
claim to be able to manage their condition (system safeguard: you don’t have the capability of managing a disease because you can’t order meds, therapy, or surgery).

I suspect you aren't surprised by this and will now have to radically change how you practice massage.

Further Clarification

If a person makes an appointment with you for a relaxation massage, and

they have no acute complaints,
you come across some tight muscles in the upper trapezius,
you spend some time relaxing those muscles,
they relax quite a bit, and
then you recommend another massage in a week to continue working those traps . . .

you've actually done the process of diagnosis!

You . . .

took a history (“no complaints”),
physical exam (“hypertonic regions of the upper trapezius”),
conclusion (trapezius muscle tightness - which is a diagnosis),
plan (massage now and in one week).

Did you just work outside of your scope of practice?

No, you didn't.

That's what your medical license (in Ohio, massage therapists are under a medical license) allows you to do. That's what you spent hours learning how to do.

This is where the phrase “with respect to what” is useful.

You diagnosed with respect to soft tissue which is what your medical license allows.

Three Scenarios

A client presents for a relaxation massage and during the massage session, you come across some bumps in their neck and they don't seem to be tightness in the muscles.

As you palpate, you consider these might be enlarged lymph nodes – which is a formal diagnosis that's outside of your scope. So, what do you do?

Your options are:

Verbalize “I feel something in your neck and it feels like enlarged lymph nodes and I would like you to see your primary care doctor before I see you next time.”
Fear vocalizing anything that might sound like a diagnosis of disease and hope they go away when you see them next week (because you did reschedule them).
Be hesitant and say “I feel something in your neck and it might be good to see your doctor about it.”

Which would you choose?

I would advise Option 1. You are stating what you palpated, which makes your concerns clear leaving no room for the client to wonder what to do next.

What makes this fine is that you're not implying that you've done a thorough examination or that you will manage the condition.

In fact, you've said that you can’t manage it. The patient will go to their primary care doctor who will then take definitive action, based upon your vocalized concerns.

Remember, the patient has no symptoms so the patient and physician rely, in part, upon an accurate description from you as part of the healthcare team.

Do you believe that a physician in your network would want to know what you discovered in the extended time you massaged the person?

Yes. The answer is yes.

Physicians already networking with you will likely consider you part of their team.

If you're not willing to help the physician, you're undermining your role within the healthcare team. That helps no one.

Our dermatologist said that he has had many referrals from massage therapists and is very appreciative of the special role they play in alerting people to questionable moles.

Assume the physician and patient respects your input, and give it.

Why Not the Other Options?

Option 2: Sure, you met the standard by the state licensing board by not giving a diagnosis; but you're managing the issue in a way that is beyond your scope of practice.

If they have cancer, then you were the first to identify its manifestation but you're assuming care of enlarged lymph nodes (by only recommending they follow-up with you) even if you didn't vocalize a diagnosis.

Option 3: Giving a vague, non-specific concern doesn't give real direction to the patient. They may take your limited information as “it must not be that important” and not make an appointment with their physician.

Or, they'll make an appointment but convey a non-specific concern to their doctor.

Remember, you were feeling those lymph nodes for 10-15 minutes and the doctor has only a few minutes to feel the neck. The more informed the patient is of your concern, the more precise they will be when they communicate with their physician.

So, while Option 2 and 3 comply with State Board restrictions on “not giving a diagnosis,” good medical care would have you do Option 1.

Good medical care IS legal care.

Because the medical-legal term of diagnosis is more than merely vocalizing the name of a disease, Option 2 and 3 are more in violation of the intention of the Licensing Board than Option 1.

So, to reinforce: it's beneficial to vocalize a name of a disease you suspect to a client.

As long as you're not implying that you're certain or that you will be fully managing the condition, merely letting the words “rotator cuff tendonitis” or “iliotibial band syndrome” roll off your tongue isn't problematic.

It means you suspect something in particular, but that the patient should see their physician for a more definitive diagnosis.

Touchpoints

Massage therapists diagnose and manage soft-tissue related dysfunctions and should confidently carry out that scope of practice.
Massage therapists should not directly, indirectly or through marketing, claim they can diagnose and/or assume management of a disease.
As long as this is not done, vocalizing a disease that you consider possible could be appropriate.
In fact, your willingness to vocalize something specific might urge the client to seek a more definitive diagnosis further up the medical team line sooner than later.
Ignore finger waggers and discipline yourself to remain in scope so others don't have to.
Go through your marketing and support materials. Are you reflecting this distinction? Do you recommend pain relief drugs or claim you can palpate herniated disks? Are you within scope with regard to counseling clients? Are you within scope with regard to nutritional and fitness recommendations?