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Don’t Mess With TCOM

Plans to add allopathic education to a top D.O. school raise concerns over the fate of osteopathic identity

The New Physician January-February 2010

TCOMIn mid-August 2009, my wife, a Texas College of Osteopathic Medicine (TCOM) alumna, dragged me along to a dinner hosted by a wealthy TCOM booster. The dinner was a stuffy affair, and much of the first hour of conversation was filled with pleasantries and well-intentioned anecdotes. Up until that point, the dinner party’s most interesting offering was the tortilla soup. But while we were enjoying our main course of enchiladas, Scott B. Ransom, D.O., president of the University of North Texas Health Science Center (UNTHSC), including TCOM and other health science schools, dropped a bombshell: UNTHSC would wholeheartedly pursue the establishment of an allopathic medical school to complement its college of osteopathic medicine.

Over the past year, the issue has galvanized regional and national medical communities, including the Fort Worth community, the Texas Osteopathic Medical Association (TOMA) and the American Osteopathic Association (AOA).

In recent years, the distinction between osteopathic and allopathic physicians has been eroding, and many tensions that did exist have become relics of the past. Currently, most health care leaders are much more concerned with a current dearth of primary care physicians, which will only be worsened by projected physician shortages. UNTHSC’s plans to build an allopathic medical school to complement TCOM is the most recent and significant development of a waning distinction between allopathic and osteopathic physicians, and aims to create a blended health care environment to service the health care needs of Fort Worth and Texas. But at its core, osteopathic medicine is ideologically different than allopathic medicine, and many osteopathic physicians still celebrate this difference, the osteopathic identity.

Osteopathic medicine is distinctly American. In 1874, Andrew T. Still, M.D., D.O., dissatisfied with allopathic medicine, founded osteopathy. Still’s efforts were born of his frustration with allopathy’s concentration on drugs and surgery. Still believed that physiological disturbances in the body could be traced back to abnormalities in the musculoskeletal system, which physicians could heal using hands-on therapy. He believed that such therapy could enhance the body’s natural tendency for health and self-healing. This hands-on intervention is the forebear of modern-day osteopathic manipulative medicine (OMM).

For many years, allopathic physicians debunked osteopathy and considered it a “cult.” The American Medical Association (AMA) went so far as declaring it unethical for allopathic physicians to practice alongside osteopathic physicians. But by the mid-20th century, tensions between the two groups eased, in large part due to osteopathic medicine’s progressive stance and incorporation of allopathic principles and practices. By the 1970s, osteopathic physicians were allowed to join the ranks of the AMA. By 1973, osteopathic physicians were finally licensed in all 50 states after Mississippi granted them the right to practice.

But with increased acceptance came concerns that the osteopathic identity is being lost. Today, a minority of osteopathic physicians practice OMM. In addition, though an appreciation of primary care is central to osteopathic culture, a smaller percentage of D.O. graduates are choosing to pursue primary care, and a growing number prefer to train at allopathic residencies. Consequently, some experts contend that the greatest threat to osteopathic medicine comes from within the field itself.

Students from MSU’s colleges of Human Medicine and Osteopathic Medicine study together in the Radiology Building. Radiology is one of several medical departments administered jointly by both colleges. MSU Students

UNTHSC: big plans for a bigger problem

Opening up a medical school is a daunting endeavor. UNTHSC initiated the process of considering a new medical school in November 2008. Over the past year, UNTHSC has been busy hosting study groups, eliciting opinions of proponents, opponents and third parties, and contracting with expert consulting firm PricewaterhouseCoopers to draw up provisional business and academic plans. On Nov. 20, 2009, the UNT Board of Regents unanimously approved taking the next steps necessary for the addition of an M.D.-degree granting medical school at UNTHSC—an important step forward.

Over this next year, Ransom and UNTHSC aim to develop a more detailed plan, ensure clinical cooperation from regional hospitals and medical centers such as Texas Health Harris Methodist, Plaza Medical Center, JPS Health Network, Baylor All Saints Medical Center and Cook Children’s Medical Center, and raise the $21.5 million necessary to cover start-up costs from the community. Most importantly, Ransom says, he wants to “make sure the heritage and traditions of TCOM and other UNTHSC programs are strong and continue permanently.”

Eventually, after final approval by the UNT system’s Board of Regents, the proposed allopathic addition will need to be approved by the Liaison Committee on Medical Education (LCME). Also, the Texas Higher Education Coordinating Board needs to agree with the plan, and a state statute precluding UNTHSC from granting allopathic degrees needs to be repealed. Ransom says it could be three years before an allopathic medical school is opened at UNTHSC and 10 years before this first class of allopathic physicians completes residency training.

Ransom sees the addition of an allopathic institution and expansion of the osteopathic class size as critical to the health of the local and regional Texas communities. “This M.D.-granting medical school,” Ransom says, “the rapidly growing D.O. medical school, and expanding our other programs are important ingredients to support the health care needs of our very rapidly growing region.”

Ransom stresses that opening an allopathic school and rapid expansion of the osteopathic class size is crucial because UNT needs more undergraduate and graduate medical education opportunities for all of its students—a problem exacerbated by the closing of all osteopathic hospitals in Texas. Ransom says that many of the hospitals and health care organizations currently poised to develop and provide such opportunities “are very interested in partnering with an LCME-accredited M.D.-granting medical school” while expanding their clinical education opportunities with TCOM. “If we choose not to develop an M.D.-granting school,” Ransom warns, “they will likely seek another partner.”

According to Ransom, other anticipated benefits include more research money and the fact that the most effective contemporary medical systems are blended and involve both allopathic and osteopathic physicians.

Ransom says that most of the infrastructure for an allopathic addition—faculty, staff, student affairs, classrooms, laboratories, library and other resources—already exists. He also cites plans to use many existing resources more efficiently to keep costs down, although he maintains the allopathic medical school will be separate from TCOM and maintain a distinct cash flow. For example, both osteopathic and allopathic medical students could use the gross anatomy lab and the clinical skills and simulation lab, but at different times.

There is opposition to UNTHSC’s plans to develop an M.D.-granting medical school on a state level by TOMA and on a national level by the AOA. “The leadership of TOMA and the leadership of the AOA are pretty unique groups that are more focused on osteopathy as a concept and osteopathy as a profession,” Ransom says. “All of us agree that we must protect the growth and excellence of TCOM. We all must also stay focused on the health care and other needs of Fort Worth, our region and our state.” Ransom believes that the “vast majority” of both osteopathic and allopathic physicians and all key members of the local, civic, philanthropic, business, hospital and medical community support the creation of an allopathic medical school at UNTHSC.

Opponents of the proposed creation of an allopathic medical school at UNTHSC have concerns that date back to the project’s official proposal in November 2008. Monte E. Troutman, D.O., a TCOM faculty member, former TOMA president and a Texas delegate to the AOA House of Delegates, says “the administration at UNTHSC did a poor job at the way they started it out. They did not anticipate where the people with the biggest concerns would be…and come and try to straighten it out before they started down this path.”

George M. Cole, D.O., the president of TOMA, feels that Ransom has never been clear on the benefits of the proposed creation. “The goal posts have changed a number of times during the president’s presentation of this issue,” Cole says. “It is now pretty well-centered that the…predominantly allopathic physician base of Fort Worth wants to have M.D.-training programs in their hospitals.”

Cole is disappointed by this sentiment, which he sees as “a terrific slap in the face” to the osteopathic students at TCOM. Troutman echoes this concern claiming that it insults not only the students but also the greater osteopathic community. “Because we are not an LCME school,” Troutman says, “[others believe] we don’t have the same qualifications; we don’t have the same abilities.”

Troutman echoes TOMA and the AOA when he says the top concern is to maintain the integrity of TCOM. He stresses that an allopathic school could drain monetary and nonmonetary resources like faculty and classroom space.

Finally, Troutman wonders, “How are you going to guarantee that these students, if they’re going to be locally [trained], are still going to have osteopathic physician educators in a hospital that…is over 95 percent allopathic?”

Mark A. Baker, D.O., a member of the AOA’s board of trustees and past TOMA president, questions why an allopathic school needs to be established at UNTHSC simply to draw research funding. “The AOA understands the [UNTHSC’s] desire to continue to be a quality institution and build on its reputation as a research leader,” Baker says. “But we don’t agree that adding an M.D. degree is the best way to achieve that goal. It’s unrealistic, and it’s almost discriminatory to believe that TCOM can’t become a quality research institution because it’s an osteopathic medical school, and that’s one of the things that Dr. Ransom implies.”

Recently, the AOA and other osteopathic organizations expressed their dissatisfaction with UNTHSC’s proposed plans by withdrawing nearly $200,000 in infrastructure funding to the Osteopathic Research Center—an institution devoted to evidence-based research on OMM and housed at TCOM.

Cole sees the creation of an allopathic medical school under the proposed business plan as an impossibility that will end up affecting TCOM’s bottom line. “We would be opposed to any additional degree program that came into the Health Science Center that took resources away from TCOM,” Cole says, “and this [plan], guaranteed, will take resources away from TCOM.” He also notes that at other medical schools that educate both M.D.s and D.O.s, there are huge cost discrepancies due to high LCME-associated costs. For example, it costs significantly more to educate allopathic students at Michigan State University. Cole says the extra cost of training allopathic physicians won’t be covered by state capitation, private donors, the UNT educational system or tuition—it will have to come from TCOM.

Cole points out that many hospitals that have proposed graduate medical education and associated undergraduate medical education opportunities in exchange for the establishment of an allopathic medical school won’t be able to afford the residency programs. For example, Texas Health Fort Worth, Cole says, “can’t bleed off $10 million a year to put into residency programs.” Secondly, the Higher Education Coordinating Board must approve the school, which may prove difficult because other existing health science centers won’t want to compete for financing.

Opponents like Cole see better options to meet the paucity of primary physicians, such as increasing the TCOM class sizes well past the 230 students planned by UNTHSC within the next two years. “Everybody says what you need is primary care and that’s what we do,” Cole says, referring to TCOM. “I think we ought to increase the class size to 500 students.” Cole goes on to say that a $50 million boost to TCOM itself would be far more beneficial than creating an M.D.-granting medical school.

Finally, another roadblock could limit the viability of the proposed creation of an allopathic school at UNT: The Texas state legislature must repeal a law that precludes the granting of an M.D. degree at UNTHSC. As Cole says, “We’re just 6,000 country docs, but we’ve got a lot of friends. We’ve been taking care of these legislators for 40 years.”

The Lone Example

Michigan State University (MSU) is the only university that has both allopathic and osteopathic medical schools based on the same campus. Both medical schools were established in response to concerns of a projected physician shortage in the 1960s. In 1964, the allopathic medical school was established, and in 1969 MSU incorporated a nearby private osteopathic medical college, making it the first state-supported osteopathic medical school. Although both sides of the debate in Texas are hesitant to draw too many analogies with the University of North Texas Health Science Center’s (UNTHSC) plans, MSU can serve as a harbinger of sorts. James Randolph “Randy” Hillard, M.D., associate provost for human health affairs at MSU, member of the American Osteopathic Association and the American Medical Association, is the only allopathic physician administering an osteopathic school.

“Having both schools on the same campus works perfectly well,” he says. “There is some ongoing competition—mostly healthy competition.” Because some of the basic medical science classes are shared between both colleges, Hillard explains that there is some “economy of scale.” But when asked about his feelings concerning UNTHSC’s proposal, he’s cautious: “If I already had one college, I think I would expand it rather than having another college of a different type.” That being said, he’s pleased with the success of both colleges at Michigan State. Both the osteopathic and allopathic medical schools at MSU are rapidly expanding, highly successful institutions committed to humanism and primary care.

Dr. Naveed Saleh is a journalist, editor, and a science and technology journalism graduate student at Texas A&M University.