Background: Osteopathic Medicine

On the nomenclature of medicine in the United States

The United States is impressive in its ability to make things complicated.  Instead of having just one type of physician like everywhere else, we have two – Doctors of Medicine (MD) and Doctors of Osteopathic Medicine (DO).  MDs and DOs have, after completion of the national boards, an unlimited medical license and the ability to treat the entire body both medically and surgically, and are thus equal in the eyes of US law.

MD’s and DO’s have their own medical schools – which I will refer to henceforth as MD Schools and DO Schools, just to keep things simple.  Many use the term “allopathic” to describe MD Schools and “osteopathic” to describe DO Schools.  I refuse to do this, because “allopathic” schools teach the modern western medicine that we all know and expect, and are acreditted by the Liaison Committee on Medical Education (LCME) to grant the standard MD degree (note that British systems which use the MBBS degree).  Furthermore, “Allopathic” is a term that was coined by the ultimate quack – Samuel Hahnemann, the founder of Homeopathy – to describe conventional  medicine and to contrast it to his invention.  Now, I shouldn’t be too hard on old Hahnemann, because conventional medicine at the time was pretty whack – Galenic medicine (based on Humors) was just going out of style and things like leeches and bleeding were considered conventional therapy.  But homeopathy has been widely disproved and its principles should be immediately found ridiculous by anyone who has taken a high school chemistry class.

Nowadays, “allopathic” medicine can safely be referred to as just “medicine.”

“Osteopathic medicine” should also be referred to as just “medicine.”

Back in the day, Osteopathy – or the search for disease through the bones, was a separate system of medicine.  A.T. Still, the founder of Osteopathic Medicine, was an MD who was disturbed by the outcomes of conventional medicine, which were often poor.  He decided to develop his own system in Missouri, where he founded the first Osteopathic Medical School in Kirksville.  From there, schools and Osteopathic Hospitals spread throughout the United States, enjoying some modicum of success in the medical boom of the late post civil war period and early 20th century.  Many osteopathic schools closed in the aftermath of the Flexner Report – a disparaging treatise on medical education published in 1910 that lead to wide reform.  Nevertheless, Osteopathic Hospitals and Medical Schools continued to exist throughout the United States (I was born in one) and these hospitals were staffed by doctors educated in the osteopathic tradition.  DO’s were trained almost universally in Osteopathic residencies, and were subject to widely divergent laws governing practice rights.  DO’s were somewhat common in the Midwest and Appalachia and had the same practice rights as MD’s, but rare on the coasts and in the South where  practice rights were limited.

For much of the early to mid 20th century, the American Medical Association (AMA) committed itself to eradicating Osteopathic Medicine, Chiropractic, and Homeopathy.  It published studies, articles in major newspapers about bad outcomes in Osteopathic Hospitals, and used its enormous lobbying power in Washington and in state legislatures to limit DO practice rights.  It ultimately failed to destroy the profession, but the AMA was successful in one way –  the American Osteopathic Association decided to largely follow the LCME guidlines on education at their schools, and started producing graduates trained in the same subjects as their MD counterparts.  Modern DO schools follow the same curriculum as MD schools, with an additional 200 hours of Osteopathic Manipulative Medicine (OMM). The bread and butter of A.T. Still’s philosophy is now limited to a few hours a week of study during the first two years of medical school.

The LCME then allowed DO graduates to take the MD board examinations (USMLE) and compete for spots in ACGME (Accreditation Committee on Graduate Medical Education – read MD/AMA) residencies (formally called GME – Graduate Medical Education).  Today, DO students routinely take the USMLE along with their own board examination (COMLEX) and enter ACGME residencies instead of those sponsored by the AOA.  In fact, only 49% of all AOA residency slots were filled in 2008 and the number of DO’s matching into ACGME residencies is increasing by about 15% every year.  60% of graduating students now match into ACGME residencies and train alongside with and under the supervision of MD’s.  Additionally, most of the Osteopathic Hospitals have either closed or merged into larger hospital systems – where before they worked in separate professional environments, DO’s and MD’s now work side by side throughout their careers.  Comments pop up all the time on SDN by DO students saying that OMM is a waste of time and irrelevant in modern medicine, and studies have shown that few practicing DO’s actually use the treatment modality.

One Treatment Modality does not make a difference

So what is the difference, why do we still have two separate degrees for medical education?  As you can probably surmise, I don’t think we should.  There is really no practical difference, I believe that the DO degree will be gone within 20 years, based on both the trends in GME  and the change in philosophy of students entering and graduating DO schools.

That all being said, my or any medical student’s opinion on the matter does not change the fact that older DO’s, who run the AOA and the medical schools, believe themselves to be fundamentally different from MD’s.  Spend a few minutes reading DO-online, and you will see that there is a “culture shock” going on within the community.   Older DO’s have a us vs. them bunker mentality bred from years of defending themselves and their profession against assault by the AMA.

This quote, in the context of a debate on admitting MD students into AOA residencies, by the Dean of the Michigan State University College of Osteopathic Medicine:

“Manual medicine is not osteopathic medicine,” he argued. “Osteopathic medicine is a distinct philosophy, a distinct profession, and it always will be. We need to continue to act like we believe this. If we allow the perception to gain ground that the only difference between DO and MD is manual medicine, we will lose this game.” (Bolded by me)

How is osteopathic medicine different?  Is it really a distinct profession?  And if so, why do Osteopathic Medical schools let any of their students enter ACGME residencies? Take a look at this article from the Journal of the American Osteopathic Association, in which the principles of osteopathic medicine are officially laid out. There are four, and here they are:

1. A person is the product of dynamic interaction between body, mind, and spirit.

2. An inherent property of this dynamic interaction is the capacity of the individual for the maintenance of health and recovery from disease.

3. Many forces, both intrinsic and extrinsic to the person, can challenge this inherent capacity and contribute to the onset of illness.

4. The musculoskeletal system significantly influences the individual’s ability to restore this inherent capacity and therefore to resist disease processes.

No one is going to disagree with the first three principles, but the fourth gets a little sticky.  Modern medicine is not limited by the belief that the musculoskeletal system is a significant influence in the overall physiology of every disease process, as is set forth in the linked article and in these principles – it might be, but it doesn’t have to be. So why limit ourselves by insisting that it is?  Why limit ourselves to principles at all? Rigorous and timely research can lead medicine towards new treatment modalities that haven’t yet been conceived, and thorough medical education can educate us to use treatments that have scientific basis and long established success in a clinical setting.

A recent study published in the JAOA found that a lack of training in or a disbelief in the efficacy of (the author is not clear) OMM that is disconnecting young DO’s from their profession and increasing calls for a full merger into the MD degree and AMA/LCME/ACGME system.

So going back to the dean’s quote above, we have an obvious issue – he says that manual medicine isn’t the only difference between MD’s and DO’s, but the study in JAOA says that a lack of training in OMM (the only real difference between the DO and MD education) is the reason that there is increased student pressure to merge the DO degree with the MD degree.  Moreover, it seems that a glance at the AOA’s osteopathic principles would lead to the conclusion that the only thing really different about the profession is that questionable principle 4, considering that the AOA lets its doctors complete their training under the tutelage of MD’s at ACGME residencies.

Conclusions

My reason for writing this article is to both set up future articles and to give a background to an important decision the old pre med must make – DO or MD.  While it is my opinion that there is no practical difference between the DO and MD degree in the United States*, I do believe that there is a difference in the quality of education – both in the classroom and clinically – between the majority of MD schools and DO schools.  I will talk about this more in later posts, but my advice is to thoroughly research the lecture and clinical curriculum of any school (MD or DO) that you plan to apply to or attend.

That being said, there are some interesting things happening in “DO World.”  While there are new MD schools opening, there has been explosive growth in the number of new DO schools.  The AOA has allowed a for-profit medical school to open in Colorado – something not seen since the days before the Flexner report.  Recently, the president of a large osteopathic school was fired for suggesting that the school attempt to gain LCME accreditation.  As alluded to above, some in the DO community are pushing for MD’s to be allowed into AOA residencies to save them from being defunded due to chronically low attendance.  Finally, OMM – the reason for the difference between degrees – is understudied at best, at worst its efficacy is questionable.  Younger DO’s are embarrassed by the older and die hard’s continued belief in things like cranial osteopathy – a treatment that flies against basic anatomical knowledge and is considered quackery at the level of homeopathy by most.

There is an impression among the pre med community that DO schools are more friendly to non-traditional applicants than are MD schools.  This has not been the case for me – MD schools were very friendly, and their are many schools that specifically state that they are looking for people coming from other careers.  However, there is anecdotal evidence along with some numbers backing up this assertion – the average age of matriculants to DO schools is higher than that of MD schools – although anyone who has taken a basic statistics course could  punch a thousand holes in that stat.

Nevertheless, the DO vs. MD debate is more important for us, as old people, than it is for traditional 22 year old pre meds.  Due to our age, we are looking at something they might not care about – expediency.  We want to get out there and practice, we have families,  spouses to keep happy, and all of life’s little mistakes already piled up on our back – an anchor that the young do not have to carry. If a DO school lets you get there easier, it might look like a tempting option. But then again, maybe not.  Either way, it is worth some deep thought.

* While international medical authorities universally accept the MD degree, this is not the case with the DO degree where recognition is spotty.  This won’t be an issue unless you want to practice in specific countries.  Major organizations, like the Red Cross and Doctors without Borders, universally recognize the DO degree.

References:

1. Gervitz, Norman. The DO’s – Osteopathic Education in America.  Baltimore: John’s Hopkins University Press. 2004.

2. Schierhorn C. “Slumping Osteopathic Graduate Medical Education piques educators at summit“. The D.O. magazine. American Osteopathic Association. Feb 2008. p.22-28

3.  Rogers FJ, D’Alonzo GE Jr, Glover JC, Korr IM, Osborn GG, Patterson MM, et al. Proposed tenets of osteopathic medicine and principles for patient care. J Am Osteopath Assoc. 2002;102:63-65. Available at:http://www.jaoa.org/cgi/reprint/102/2/63.

4.  Shannon SC, Teitelbaum HS. The status and future of osteopathic medical education in the United States. Acad Med. 2009 Jun;84(6):707-11.

5. Bates BR, Mazer JP, Ledbetter AM, Norander S.  The DO difference: an analysis of causal relationships affecting the degree-change debate. J Am Osteopath Assoc. 2009 Jul;109(7):359-69.