Inside osteopathic medicine’s parallel worldThe New Physician
“To find health should be the object of the doctor. Anyone can find disease.” —A. T. Still
Like a well-worn comic book plot, the practice of medicine most Americans are familiar with has an alternate universe—a parallel world with its own history and philosophy. It is a world where physicians train in alternate institutions, belong to alternate professional organizations and sport an alternate degree: D.O. (doctor of osteopathy) rather than M.D.
In actual practice, the variations between the two types of physicians are often so slight as to be unnoticeable to patients, and a day in the life of each can appear indistinguishable. But the differences are there, subtle but deep.
Osteopathic medicine was conceived in 1892 in Kirksville, Missouri, by Andrew Taylor Still, M.D. Disappointed with the limitations of traditional allopathic medicine, he set out to devise an alternative. At that time, just before 20th-century medicine began to blossom with modern pharmacology and surgical techniques, M.D.s could offer few sure-fire treatments for injury and disease, so alternative ideas in healing, like chiropractic and homeopathy, were sprouting up all over.
Still called his therapy “osteopathy”—from the Greek osteo, meaning “bone,” and pathos, meaning disease or suffering. He believed that manipulation of the spine could improve the flow of blood and other fluids throughout the body, and was the best means of treating almost any ailment. And while other nontraditional therapies of the time were ultimately relegated to the sidelines of alternative medicine, osteopathy developed and evolved into osteopathic medicine. One hundred and fifteen years later, more than 50,000 D.O.s practice in the United States, and that number is growing.
What started as a form of practice centering on one therapy has become much more expansive and generalized. Osteopathic physicians are licensed to do everything an M.D. does, although they receive additional training in a modality known as osteopathic manipulative medicine (OMM). Otherwise, the differences in practice between the two can be so subtle that patients commonly don’t realize their family physician is a D.O. rather than an M.D. “Osteopathic medicine used to be radical; it is not so radical anymore,” says Kenneth Veit, D.O., dean of the Philadelphia College of Osteopathic Medicine.
Marty Knott, a fourth-year at Texas College of Osteopathic Medicine and national president of the Student Osteopathic Medical Association (SOMA), says that the differences are blurred further by the fact that “allopathic physicians are doing more holistic therapy, and osteopathic physicians are getting more into evidence-based medicine. Some merging is going on.”
When describing how their approach does differ from the allopathic, D.O.s are likely to characterize their practice as holistic, people-oriented, and focused on prevention and wellness rather than disease. They will tell you they see body, mind and spirit as a unified structure wherein dysfunction in one area affects the smooth operation of the others. Many M.D.s will take issue with this—not because they disagree with its basic truth, but because they reject the notion that this approach is the purview of osteopathic medicine only.
Yet despite allopathic medicine’s growing embrace of holistic therapies, perceptions persist that it is more focused on illness than on health; more interested in diseases than in people. These are fair claims, says Joel Howell, M.D., who teaches the history of both allopathic and osteopathic medicine at the University of Michigan Medical School. “These criticisms can be true of allopathic medicine.”
Certainly, osteopathic medicine centers on a commitment to treat “the whole person.” Purists believe that the body has a natural tendency toward homeostasis, or balance; that it “wants” to heal; and that if given the right conditions, will heal itself. The osteopathic philosophy is as much about enabling the body’s wellness as curing its ills. “All bodily systems need to function well together at an optimum level to fight off disease, infections and so forth,” explains Kevin D. Treffer, D.O., associate professor of family medicine at Kansas City University of Medicine and Biosciences College of Osteopathic Medicine. “This is what we call health.”
Still’s primary innovation, OMM, uses physical manipulation of the musculoskeletal system to restore the body to its natural homeostasis. As one might expect, it’s most commonly used for musculoskeletal complaints such as low-back pain. But it can also be used for lymphatic drainage to reduce congestion, asthma and labor pains, and even induce or speed up labor, explains Jay Bhatt, president of the American Medical Student Association (AMSA) and its first osteopathic student to fill that role.
Separate But Equal
Osteopathic medicine is taught in a network of osteopathic medical schools on 23 campuses around the country. These schools are independent and distinct from allopathic medical schools, and are accredited by the Bureau of Professional Education of the American Osteopathic Association (AOA), which in turn is recognized by the Department of Education and the Council on Postsecondary Education. To be admitted to an osteopathic medical school, applicants submit transcripts, recommendations and MCAT scores. For the academic year 2005-2006, 13,406 students were enrolled in U.S. osteopathic medical schools.
The osteopathic curriculum is much like the allopathic: two years of basic sciences and two years of clinical study. Courses cover the same material as allopathic schools and often use the same textbooks. Graduation is followed by a one-year rotating internship and then a residency. Primary care is heavily emphasized during a D.O.’s training, and 60 percent choose to specialize in family practice, internal medicine, OB-Gyn or pediatrics. However, all specialties and subspecialties are open to D.O.s. AOA certification programs are available in 18 specialties, including anesthesiology, neurology and pathology.
D.O.s can also apply to programs certified by the Accreditation Council for Graduate Medical Education (ACGME). According to Veit, orthopedics and physiatry are particularly attractive to D.O.s, and their musculoskeletal training makes them particularly well suited to these specialties.
Just like M.D.s, D.O.s must pass state boards in order to practice. Each state has its own licensing requirements; some states administer the same tests to M.D.s and D.O.s, while others have separate exams for each. Passing the boards certifies D.O.s as full physicians, trained and licensed to provide all the care that M.D.s provide. They can prescribe medicine, perform surgery, make and accept referrals, and battle with insurance companies, Medicare and all the rest of the red tape.
That Healing Feeling
The distinguishing feature of osteopathic study—OMM—is threaded through almost every lesson and clinical rotation. Training begins on the first day of medical school, and can amount to, over four years, 400 to 500 extra hours of course work. “OMM training is important, even if a student enters a specialty where OMM is not a dominant part of the practice,” explains Veit. The knowledge and skills learned in the OMM curriculum will make a person “a slightly different physician for the rest of his or her life.”
This difference includes a thorough understanding of the musculoskeletal system, as well as the knowledge that “it is OK to use your hands; OK to touch people,” says Veit. “Manipulative medicine gives the patient a sense of satisfaction. Something magical happens in OMM.”
Something magical happens to the student as well, it seems. Veit points out that while it takes a long time to become good at OMM, some level of proficiency can be achieved very quickly. “Early in their training, students learn techniques that they can try out on their boyfriends or girlfriends, friends and family. Right away, students can gain the feeling that they are healers.” This is a feeling that allopathic students may have to wait years to know.
But like so many great ideas that launched movements, OMM may wield more influence as a theory and a unifying principle than a practical tool. It is often misunderstood—even occasionally reviled. A perusal of Internet medical forums discussing the practice reveal that in some quarters, manipulative medicine is held in the same regard as chelation therapy and colonic irrigation. The more charitable of skeptics class it with acupuncture or massage.
The bias even extends, on occasion, to D.O.s themselves. One patient who asked his D.O. to use manipulative therapy to treat a musculoskeletal problem was referred to a chiropractor. Surveys of osteopathic physicians indicate that use of OMM is declining, especially among D.O.s who did their residencies in ACGME-accredited programs. And as more D.O.s are choosing specialties other than primary care and completing ACGME-accredited residencies, some worry that the therapy may slip even further out of mainstream osteopathic practice.
The decline in OMM use is not due to a loss of faith in the procedure, however: Lack of opportunity, equipment and time, plus problems with reimbursement, are the most common reasons cited in surveys.
Those who do use OMM find it soundly beneficial, even if just as a framework for thinking about patient care. “When I see patients after surgery, and they complain of aches and pains,” says Knott, who currently is applying to surgical residency programs, “I think about how they are positioned and how that may be affecting their comfort. Even if you don’t use OMM, you think about it every day.”
The move toward evidence-based care has also been a problem for OMM. “We don’t teach that by treating a patient with OMM you can cure diabetes,” explains Treffer.
No, but what claims do D.O.s make for it, and how well supported are those claims?
“Currently we are trying to validate with research and clinical trials what is largely anecdotal and observational evidence,” says Knott. Much research has been funded from within the profession by the AOA and the Osteopathic Heritage Center. But lately, more grants are coming from the National Institutes of Health and the National Center for Complementary and Alternative Medicine (NCCAM).
“NCCAM has been really good at funding research,” says Knott, who himself has been involved with the center, researching the mechanisms of OMM. Using manipulative medicine to treat ear infections in children, pneumonia in adults and, of course, for back pain, has shown promise in studies. “If we can demonstrate that there is a scientific method [to OMM], and if it is shown to be better and safer than traditional medications, then it will become the standard of care,” says Knott.
Meanwhile, those who do use it keep at it because their patients say it works. “[They] keep coming back. The important thing is helping patients,” says Treffer, whose practice is “99 percent OMM.”
According to Bhatt, osteopathic medicine tends to appeal to those with a sense of social responsibility; its emphasis on primary care attracts those with a community focus.
Lauren Sachs, a third-year at the Kansas City University of Medicine and Biosciences College of Osteopathic Medicine, had never even heard of osteopathic medicine until she went to college in Kirksville, the birthplace of the field. “As soon as I learned about [it], I knew that the overall osteopathic philosophy was exactly in line with the kind of medicine I wanted to practice.”
For Sachs, OMM is “a tool I have in my tool belt that I will use when appropriate,” but it was not the main reason she chose an osteopathic school—although she does enjoy OMM, and her family is always eager for her to practice on them when she comes home for a visit.
The past few years have seen a substantial increase in osteopathic education. In 2005, 8,255 students applied to osteopathic schools, up from 6,324 in 2002. One reason for the jump is that several osteopathic schools have opened branch campuses to accommodate more enrollees. According to the American Medical Association’s American Medical News, forecasters are expecting an additional 2,000 to 2,500 osteopathic students to enroll over the next decade.
Much of this increase has been stimulated by calls for academic medicine to produce more primary care physicians. But like M.D.s, D.O.s often choose other specialties for economic reasons—educational debt and the perception of low pay in primary care. Still, says Stephen Shannon, D.O., president of the American Association of Colleges of Osteopathic Medicine, family practice offers many benefits that appeal to today’s osteopathic students: the sense of having more control over their lives, closer relationships with patients and the option of working part time. The latter is a significant benefit to women who want to balance family and career; half of all osteopathic medical students are female.
Significantly, osteopathic students tend to be older than allopathic students and have more life experience, says. Shannon. The attraction works both ways: Osteopathic schools seek out a certain type of student, he says. “We look for mature individuals who are sure what their path in life will be. Many…are coming to medicine as a career change. They are often former high-school teachers or people with previous experience in the health professions—EMTs, physician’s assistants, former military medics.”
Many become members of AMSA, which embraces allopathic and osteopathic students equally. “Osteopathic students have always been a big part of AMSA,” says Bhatt. “Other professional organizations don’t give such a warm welcome.” Currently, AMSA is launching an osteopathic medicine awareness campaign that will feature education in the community, visits to undergraduate schools by osteopathic deans and AMSA and SOMA members, and a lot of bridge-building between the two worlds of medicine. Recently, a group of AMSA members were invited to present to the AOA board in closed session, an almost unheard-of honor. “AMSA and the AOA believe in a lot of the same things,” says Bhatt.
Unfortunately, the perception lingers that many people attend osteopathic schools because they were unable to get into allopathic schools. In fact, the entrance requirements are fairly similar. Osteopathic schools do place less emphasis on numbers (MCAT scores and GPAs) than allopathic schools, says Shannon, but they place more emphasis on personal characteristics and other attributes.
For some people, it may actually be harder to get into an osteopathic medical school. “That it is easier to get in
is a common slam [on osteopathic schools], but the data don’t really support that,” says medical historian and M.D. Howell.
In any case, the differences in this respect are as minor as any between the two worlds. The two types of education really are, says Knott, just different paths to a common end: practicing medicine. And despite occasional cracks about the shortage of evidence for manipulative medicine, or insinuations about the lack of patient focus in allopathic medicine, there is really not much acrimony between the two worlds. And there seems to be less and less as time goes on.
As allopathic medicine, urged on by groups such as AMSA, takes a more holistic and socially responsible approach to health care, and as osteopathic medicine puts more time and energy into research to support its approaches, the few differences between the worlds will continue to dissolve.
[Editor's note: The online version of this story has been corrected to clarify some of the uses of osteopathic manipulative medicine.]
Avery Hurt is a freelance writer based in Birmingham, Alabama.