Commentary

Finding a way forward after the Larry Nassar case

A past president of the American Osteopathic Academy of Sports Medicine shares his perspective on healing in the aftermath.

The collateral damage from Larry Nassar’s crimes reaches far and wide.

The search to uncover Nassar’s enablers exposed institutional barriers that have kept sexual abuse out of public view. Litigation will continue for years. Communities will take as long to heal.

The effect on physicians is less publicized, but also concerning. Some people have conflated his crimes with traditional osteopathic training, which has rightfully angered many DOs. Others worry about the sanctity of the doctor-patient relationship. What is not considered is the direct impact on some physicians, especially those trained or mentored by him.

Steve Karageanes, DO

Many of us are struggling to process our reactions. Anyone associated with Nassar likely feels embarrassment, anger and betrayal. The scope of his harm comes into focus when you consider the vast network of physicians, therapists, trainers, and coaches who sent athletes to him for over 25 years.

I have worked hard to combat my impulses of guilt and shame, anger and depression. We shared the same mentor in medical school, worked on state concussion legislation, filmed osteopathic manipulative treatment (OMT) video projects, worked OMT workshops at national conferences, yet I never heard or saw evidence of his vile assaults against children. I asked myself for months, did I miss something? Was it always there?

Reconciling our emotions

After the assistant attorney general read my victim statement at the sentencing, I resolved my conflicts through three realizations.

First, Nassar did not use OMT to abuse his patients. The survivors’ statements all described something entirely different from legitimate medical treatment:

  • High number of “treatments” (some “treated” hundreds of times)
  • No gloves
  • No lubrication
  • No chaperone (including medical students or residents)
  • No explicit consent
  • No explanation

In September 2016, Nassar initially defended himself by saying, “I do not use gloves because I am not penetrating into any orifice,” a statement debunked by over 160 women. He lied because any physician would know his actions weren’t legitimate.

Second, Nassar’s confession made me realize how aggressively he groomed his environment. Consider his status with USA Gymnastics, the numerous lectures across the country, famous Olympians’ pictures plastered on his walls, years of community outreach, his autism charity foundation and his prolific social media presence. This calculated image kept the referrals coming.

Finally, I learned how pervasive sexual abuse is. Since Nassar was first charged, national scandals have erupted across politics, media and the entertainment industry, only scratching the surface of the issue. The national statistics are staggering, according to RAINN’s (Rape, Abuse & Incest National Network) website:

  • Every 98 seconds, someone is sexually assaulted.
  • Every 8 minutes, that assault victim is a child.
  • Only 6 out of 1,000 perpetrators go to prison.
  • 1 out of every 6 American women has experienced an attempted or completed rape.
  • About 3% of American men have experienced an attempted or completed rape.
  • From 2009-2013, Child Protective Services agencies substantiated or found strong evidence that 63,000 children a year were victims of sexual abuse.
  • Of victims under 18 years old: 34% of victims of sexual assault/rape are under age 12, 66% are age 12-17.

Resolve to get involved

DOs are needed to help heal our communities. We cannot allow this issue to fade into the night. Here are a few ways to move forward:

  1. Sexual assault claims must be taken seriously: If authorities had taken action against Nassar in 1997, hundreds of survivors would have been spared. Women and men often decline to press charges because they fear retribution if they aren’t believed. Watch any victim statement and see if any single one seems insincere.
  2. See something, say something: A common thread through the numerous high-profile sexual abuse cases was how many people told victims “Oh, that’s just Harvey (Weinstein) being Harvey”, “that’s just Charlie (Rose) being Charlie”, “that’s just what Dr. Larry does” to explain the behavior. If you witness borderline unethical behavior, call it out.
  3. Ask about sexual abuse: Make sure your intake forms have questions about sexual assault. Do not forget about follow-up inquiries with established patients.
  4. Learn your state: Each state has different statutes of limitation, legal definitions of rape, and age of consent. Visit RAINN’s guide to get information specific to your state.
  5. Build your network: Get the right professionals in your referral network (psychiatrists, psychologists, counselors and social workers) to facilitate treatment for patients. The quicker you can get your patient in, the more likely they are to get help.

Let healing begin

Allow yourself to feel the pain. Avoid denying your feelings, particularly if your reaction is strong. The pain fades with time, but denial makes it linger.

We owe the survivors our effort to confront sexual abuse. We are osteopathic physicians, and our dedication goes far beyond “do no harm.”

As our osteopathic oath articulates, “I will be ever vigilant in aiding in the general welfare of the community, sustaining its laws and institutions, not engaging in those practices which will in any way bring shame or discredit upon myself or my profession.”

Nassar broke our oath. We will pick up the pieces and move forward, so this never happens again.

 

25 comments

  1. This is the appropriate response to the @LATIMES OpEd editorial of the last week. This tells the country we as Osteopathic physicians are NOT that monster.

  2. I agree with Dr. Robinson. Also, his (Nassar’s) abhorrent behavior does not define almost all physicians, regardless of Osteopathic or allopathic orientation. Why elevate this man by giving him media attention? Let him serve his time and may he fade away gracelessly. At the same time, why not educate our youth about what IS a proper relationship with a health care professional?

  3. Unfortunately, this man’s actions were performed under the guise of osteopathic manipulation. How was it that there was no oversight from the Michigan State OMM department? There were too many warning signs for such oversight not to happen, and one is left with the impression that the MSU OMM department may have actually facilitated this man’s activity.

    1. That is quite an accusation. Regardless of the fact that Dr. Nassar was not part of the MSU OMM department, I don’t see how anyone else can be blamed for crimes that took place while parents were in the room. Furthermore, people without last names should not point fingers.

  4. I am glad to see that not much has been focused on nationally regarding the “Osteopathic” perspective on this sad case of abuse. It could have easily become a national focus that would have been an embarrassment to the profession and the few of us who still treat in the traditional Osteopathic way.

    I hope, though, that leaders in the Osteopathic profession do not react in what has sometimes become a predictable way and back off further in teaching young and motivated Osteopathic students the proper use of traditional Osteopathic manipulation. A. T. Still emphasized learning anatomy and physiology of the wonderful self-healing human body that God created and treating patients from that foundation. He didn’t teach techniques that we are so fond of focusing on today. Let us find ways to strengthen His vision and encourage getting back to our roots in treating patients with appropriate safe guards in place to build our reputations, not tear them down.

    But, we live in a different time than A. T. Still did and have to work in an office environment that is not always friendly to the traditional ways.

    It can be done but we must want to do what is in our patients’ best interests and find strong and honest people to bring into the profession.

    Good luck moving on from this ordeal we have witnessed. I’m sure the Old Doctor is rolling in his grave over this development.

  5. Dr. Karageanes, thank you for your profound candor in describing your own emotions and reactions to having worked with Larry Nassar and how you have moved forward. Thank you for offering us all critical actions to take as we respond to this tragedy. I hope there will be more discussions like this. I also hope the AOA will take the lead in guiding DOs with regards to how to educate and treat patients osteopathically in a manner which will leave no doubt about the intentions of the healing encounter. Questions such as how does the physician prepare the patient for the very physicality of a legitimate osteopathic treatment, and should the physician now employ a chaperone at every treatment require attention. These are unfortunate but necessary conversations we must have when practicing in the “post-Nassar” era.

  6. MSU-COM, my Alma-Mater, needs to make a statement ASAP! We need to hear about their tribunal of physicians that reviewed LN’s ‘tx’ and deemed it ‘appropiate’ therapy during the initial investigation, and why he was allowed to continue these practices in their clinical setting. This is a burning concern that will not go away and will need to be explained!

  7. I agree with Dr Karageanes points in the article.
    I for one was astounded by the frequency of sexual abuse. I knew it was pervasive but not to that extent. I know that questions about are part of the history-taking but those need more priority and as much a part of a visit screen as asking about chest pain or depression.
    I am sadden, frustrated and angry. As an MSUCOM grad the Nassar story hurts me to my core. I have so many questions that are unanswered. I have heard little from COM about it’s investigations, the steps COM took to perform significant oversight. I can’t imagine performing an exam or treatment on a female patient involving a sensitive area without a chaperone. After all of those years and exams didn’t one person–peer, medical assistant, administrator–ever question his methods. I find that unbelievable. I was taught that chaperones are present for all sensitive exams. I have been involved in medical education for 25 years. That is something we always teach and stress. What went wrong? Before we can heal we need to make sure the process that led to this is fixed immediately. At all Spartan events the announcement is if you see something say something. Why didn’t they? To COM where is the Spartan Will. When will we get explanations, answers and actions from COM? Until then, the Spartan Will from COM are just words.

  8. Do we know what technique Nassar was using. My thoughts went immediately to the technique of “pyriformis massage” as taught in 1970’s, which involves transrectal or transvaginal massage of the pyriformis muscle. I actually used this once in about 1975 on a male veteran with chronic back pain. I could see selling this to a very competitive group of athletes with enormous musculoskeletal stresses. It is certainly no excuse for repeated molestation of young women but perhaps that could be where he started.

  9. I am very sorry for your pain, and the shadow that this has cast on Osteopathic Manipulation and sports medicine. My heart aches for all those children and young women repeatedly assaulted under the guise of medical treatment. Larry was in my class in medical school. I would describe him as humble, a little dorky, and not remotely flirty or machismo. It was these characteristics that allowed him to get away with this for so long. This is different than Weinstein and others who flaunted their power and privilege and thought they were above the law. Larry was much more devious. He is much more comparable to Bernie Madoff, who scammed smart people out of billions for years. I understand the wish of our colleagues to let him fade from view and move on. However, we have a duty as DOs to study him thoroughly and make sure this never happens again. We need to understand his process and what the warning signs were early on so that no one can ever get this far again. What struck me as particularly poignant is how he got away with not using gloves. When I heard this, I immediately knew this was abuse and nothing more. There was no further defense of a legitimate medical procedure. This would be a place to start and make sure that our youth understands this, and that these procedures should always be chaperoned without any exceptions.

  10. Thank you, Steve. Well said with timely reaction and advice for our profession as well as sincere sympathy for the victims. As you stated, we owe it to the survivors to confront sexual abuse, all sexual abuse. “Let healing begin.”

  11. Yes Nasser broke our oath but the rest of our profession did not. We are stronger than that. We can no longer allow sex abuse tone swept under the rug no matter who the abuser is, even top leadership of this country. NO ONE IS ABOVE THE LAW!!!

  12. Regarding Larry Uhrig’s statement above:
    “He didn’t teach techniques that we are so fond of focusing on today”, I hope that does not include any vaginal or rectal techniques. I learned none of these in my training at MSU COM in the late 1970s, and had no idea that any were being used in any fashion now.
    If they are taught now, anywhere, and endorsed by the AOA or any other osteopathic organization, I hope that stops now. Let’s not risk having another DO claim that he or she is using that to “treat” anything — as in this day and age, accusations of abuse will likely be more common than ever. I’m sure we all hope and pray that there are not other sexual predators out there with DO degrees. There are plenty of external osteopathic techniques effective in treating pelvic and back problems. Our reputation IS at stake. More importantly, let’s protect our patients. Let this be one of the first steps in “doing no harm”.

    1. Other than teaching proper approach to performing vaginal deliveries, A.T. Still did not teach any internal vaginal techniques as far as I know from memory, having read many of his writings.

      My comment was to refer to the well-known historic fact that Dr. Still taught anatomy, anatomy and anatomy and expected the student to learn from his knowledge of anatomy to reason how to treat any problem he or she may face in treating a patient from an Osteopathic perspective. He did NOT teach techniques in the rote manner that we do so today. “Position the limb in this manner and hold for x seconds.” “Move the joint in this way and hold until it releases.” Still did not teach or test techniques. He corrected students who treated patients in this manner. We do virtually nothing of this approach today.

      That was the crux of my comment.

  13. Dr. Karageanes , thank you for this thought out and well written commentary that has no doubt been very heavy on the hearts of both osteopathic and allopathic physicians alike.

  14. “Many of us are struggling to process our reactions. Anyone associated with Nassar likely feels embarrassment, anger and betrayal… I asked myself for months, did I miss something? Was it always there?”

    Thank you for this article, Dr. Karageanes. Larry Nassar was a mentor for me in the sports medicine club at MSU COM, often offering for us to come to Twistars and his clinic to watch him work. I felt guilty at the time that I didn’t find the time to do this. Now I wonder, could I have saved one of these girls had a been there? Could I have been the whistle blower? Would I have had the courage to stand up for what is right as a medical student versus a respected physician? I wonder how I could have missed such evil in a mentor. I am ashamed. I am scared that I could miss this again. I have watched many of the victim’s statements in hopes that I can learn how this went on for so long, how so many blindly respected Nassar, and how the school that I love failed so many girls. I want to hear their voices because so many did not over the years. I feel stuck in a rut of guilt over a crime that was not mine. This article helps me to focus on how to move forward.

  15. Thank you Dr. Karageanes and Baker for your article, emails, and this commentary. The horror of Nassar’s abuse of his patients and betrayal of our profession has kept me up nights. I can’t wrap my brain around it because it hurts my heart. I can’t even imagine how his victims and close colleagues are feeling. Reading these comments has been comforting. I don’t feel alone in my reaction anymore. Thank you.

  16. First, I am not a DO. Yet I have been the CEO of several Osteopathic Hospitals and a hospital accreditation surveyor for the AOA for over forty years. So in that vein, I will offer several comments.

    I, too, was chagrinned to hear Nassar was a DO. Like most of you, I am sickened that he used to perpetrate his crimes, the very thing that defines you most: your profession. That gives rise to a whole new level of disgust to mind because he dirtied your identity. A travesty. I will also say that to the others of us that work with you proudly under the osteopathic umbrella, we’re hurt too. So many of us share your views and feelings.

    But my second and more salient point is that the DO population is not immune, statistically from having one of its own do such things. Maybe percentage-wise the DO population fares better that the balance of professional categories in humanity but the “takeaway” is we need to be more perceptive and insist that no one gets a pass or variance from the highest standards in such sensitive and potentially litigious situations – like having another person in the room.

    You’re still the best in my book. Don’t beat yourselves up because you didn’t know or have reason to suspect Nassar of anything. Monsters that prey on victims in their particular arena or professional environment are experts at shrouding their deeds and remaining above suspicion. They act out their esteemed, above reproach professional role perfectly.

    All of us. Every one, wishes we could somehow undo what he did to those children but of course we cannot so I suggest this should serve to strengthen our resolve to make sure it won’t happen again. It’s not terribly unlike the “Me Too” revolution of late which swept business, Hollywood and sports.

    I would like to see the AOA formulate some initiatives to address what it can both with a.) affiliated organizations and b.) by itself to do what is reasonable to implement meaningful steps to seriously reduce the likelihood for future similar issues.

    Sincerely,

    1. Thanks for your insights, Bruce. We definitely need initiatives to prevent this again. There will be a 4-hour session at the OMED meeting this fall dealing with sexual assault and abuse. Hopefully more is forthcoming.

  17. I was heartened to read Dr. Karageanes’ list of critical precautions exercised by osteopathic physicians who provide true osteopathic manipulative treatment. That has been missing from all the other coverage I have read about Dr. Nassar and his crimes.

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