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Osteopathic medicine is a branch of the medical profession in the United States, with recognition outside the US in forty-seven countries, including most Canadian provinces. Physicians and surgeons who graduate from osteopathic medical schools are known as physicians or osteopathic medical physicians and hold a professional doctorate, the Doctor of Osteopathic Medicine (DO), in contrast to the more familiar degree, the Doctor of Medicine, or MD.^[1][2][3]

Frontier physician Andrew Taylor Still founded the profession as a radical rejection of the prevailing system of medical thought of the 19th century. Still's techniques relied heavily on the manipulation of joints and bones to diagnose and treat illness, and he called his practices "osteopathy." By the middle of the 20th century, the profession had moved closer to mainstream medicine, adopting modern public health and biomedical principles. "Osteopaths" became "osteopathic physicians", gradually achieving full practice rights in all 50 states, including serving in the US armed forces as physicians.^[4]

In the 21st century, the training of osteopathic physicians in the United States is very similar to that of their MD counterparts.^[5] Osteopathic physicians attend 4 years of medical school followed by at least 3 years of residency. They use all conventional methods of diagnosis and treatment. Though still trained in Osteopathic Manipulative Medicine (OMM)^[6], the modern derivative of Still's techniques^[7], a minority of osteopathic physicians use it in actual practice.^[8]

Osteopathic medicine is considered by some in the United States to be both a profession and a social movement,^[9][10] especially for its historically greater emphasis on primary care and holistic health. However, any distinction between the MD and the DO professions has eroded steadily; diminishing numbers of DO graduates enter primary care fields^[11], fewer use OMM, holistic patient care models are increasingly taught at MD schools, and increasing numbers of DO graduates choose to train in non-osteopathic residency programs.^[12][13][14]

US osteopathic medical physicians may be licensed in 47 countries, although osteopathic curricula in other countries differ from those in the United States. Osteopathic practitioners educated outside the US are known as "osteopaths" and their scope of practice excludes usual medical therapies and relies more on osteopathic manipulative medicine and other alternative medical modalities.

Discussions about the future of osteopathic medicine frequently debate the utility of maintaining a separate, distinct pathway for educating physicians in the United States.^[14][15] Studies have repeatedly shown that many recent osteopathic medical graduates are either disinterested in or reluctant to embrace an identity distinct from their MD counterparts.^[16] The rapid expansion in the number and size of schools has raised questions as to the quality of education at some osteopathic medical schools. Leaders within the osteopathic community have referred to the present situation as a crisis.^[12][13] Other contentious topics have been for-profit medical education, which osteopathic accreditors permit,^[17] and the status of LGBT osteopathic physicians.^{[18][19][20][21]}

[edit] Demographics

Physicians entering US workforce by education, 2005^[22]

From its inception, the osteopathic profession has been smaller than the older MD profession.^[23] Currently, there are 25 accredited osteopathic medical schools^[24] offering education in 31 locations in the United States and 126 accredited US MD medical schools.^[25]

• In 1960, there were 13,708 physicians who were graduates of the 5 osteopathic medical schools.
• In 2002, there were 49,210 physicians from 19 osteopathic schools.
• Between 1980 and 2005, the number of osteopathic graduates per year increased over 250 percent from about 1,000 to 2,800. This number is expected to approach 5,000 by 2015.^[26]
• In 2007, there were 25 colleges of osteopathic medicine in 31 locations.^[27] One in five medical students in the United States is enrolled in an osteopathic medical school.^[28]
• By 2020, the number of osteopathic physicians will grow to 95,400, say expert predictions, according to the American Medical Association.^[29]

Geographic distribution of osteopathic physicians as a percentage of all physicians, by state. Locations of osteopathic medical schools are shown in red.^[30]
     <3%      3-5%      5-10%      10-15%      15-25%

Osteopathic physicians are unevenly distributed in the United States. The states with the highest concentration are Michigan and Oklahoma where osteopathic physicians comprise over 20% of the total physician workforce. The state with the greatest number of osteopathic physicians is Pennsylvania, with 6,048 DO's in active practice in 2008.^[31] The states with the lowest concentrations of DO's are Louisiana, Massachusetts and Vermont where only 1-2% of physicians have an osteopathic degree.^[30] Public awareness of osteopathic medicine likewise varies widely in different regions.

[edit] Osteopathic principles

A physician demonstrates an OMM technique to medical students at an osteopathic medical school.

In addition to the Hippocratic oath, Osteopathic medical students take an oath to maintain and uphold the "core principles" of osteopathic medical philosophy. Revised in 1953, and again in 2002, the core principles are:

1. The body is a unit, and the person represents a combination of body, mind and spirit.
2. The body is capable of self-regulation, self-healing, and health maintenance.
3. Structure and function are reciprocally interrelated.
4. Rational treatment is based on an understanding of these principles: body unity, self-regulation, and the interrelationship of structure and function.^[32]

[edit] Significance

There are different opinions on the significance of these principles. Some note that the osteopathic philosophy is akin to the tenets of holistic medicine.^[33] They suggest that osteopathic philosophy is a kind of social movement within the field of medicine, one that promotes a more patient-centered, holistic approach to medicine, and emphasizes the role of the primary care physician within the health care system.^[9][34] Others liken the American Osteopathic Association's emphasis of the core principles to professional indoctrination, a process which glorifies osteopathic practices and beliefs while misrepresenting those of the MD community.^[35] Still others point out that there is nothing in the principles that would distinguish DO from MD training in any fundamental way. One study, published in the Journal of the American Osteopathic Association found a majority of MD medical school administrators and faculty saw nothing objectionable in the core principles, and some would even endorse them generally as sound medical principles.^[32]

[edit] History

[edit] A new movement within medicine

Andrew Taylor Still, founder Osteopathic medicine

Frontier physician Andrew Taylor Still, MD, DO, founded the American School of Osteopathy (now the A.T. Still University-Kirksville (Mo.) College of Osteopathic Medicine) in Kirksville, MO, in 1892 as a radical protest against the turn-of-the-century medical system. A.T. Still believed that the conventional medical system lacked credible efficacy, was morally corrupt, and treated effects rather than causes of disease.^[36] He founded osteopathic medicine in rural Missouri at a time when medications, surgery, and other traditional therapeutic regimens often caused more harm than good. Some of the medicines commonly given to patients during this time were arsenic, caster oil, whiskey, and opium. In addition, unsanitary surgical practices often resulted in more deaths than cures.^[37]

He intended his new system of medicine to be a reformation of the existing 19th century medical practices he knew and imagined that someday "rational medical therapy" would consist of manipulation of the musculoskeletal system, surgery, and very sparingly used drugs. He invented the name "osteopathy" by blending two Greek roots osteon- for bone and -pathos for suffering in order to communicate his theory that disease and physiologic dysfunction were etiologically grounded in a disordered musculoskeletal system. Thus, by diagnosing and treating the musculoskeletal system, he believed that physicians could treat a variety of diseases and spare patients the negative side-effects of drugs.

Mark Twain was a vocal supporter of the early osteopathic movement.

The new profession faced stiff opposition from the medical establishment at the time. The relationship of the osteopathic and medical professions was often "bitterly contentious"^[22] and involved "strong efforts" by medical organizations to discredit osteopathic medicine.^[38] Throughout the first half of the twentieth century, the policy of the American Medical Association labeled osteopathic medicine as a cult and osteopaths were seen as "cultist." The AMA code of ethics declared it unethical for a medical physician to voluntarily associate with an osteopath.^[9][39]

One notable advocate for the fledgling movement was Mark Twain. Manipulative treatments had purportedly alleviated the symptoms of his daughter Jean's epilepsy as well as Twain's own chronic bronchitis. In 1909, he spoke before the New York State Assembly at a hearing regarding the practice of osteopathy in the state. "I don't know as I cared much about these osteopaths until I heard you were going to drive them out of the state, but since I heard that I haven't been able to sleep." Philosophically opposed to the American Medical Association's stance that its own type of medical practice was the only legitimate one, he spoke in favor of licensing for osteopaths. Physicians from the New York County Medical Society responded with a vigorous attack on Twain, who retorted with "[t]he physicians think they are moved by regard for the best interests of the public. Isn't there a little touch of self-interest back of it all?" "... The objection is, people are curing people without a license and you are afraid it will bust up business."^[40]

[edit] 1916-1966, Federal recognition

Recognition by the US federal government was a key goal of the osteopathic medical profession in its effort to establish equivalency with its MD counterparts. Between 1916 and 1966, the profession engaged in a "long and tortuous struggle" for the right to serve as physicians and surgeons in the US Military Medical Corps. On May 3, 1966 Secretary of Defense Robert McNamara authorized the acceptance of DO's into all the medical military services on the same basis as MD's. The first DO to take the oath of office to serve as a military physician was Harry J. Walter. The acceptance of osteopathic physicians was further solidified in 1996 when Ronald Blanck, DO was appointed to serve as Surgeon General of the Army, the first osteopathic physician to hold the post.^[39]

[edit] 1962, California

In the 1960s in California, the American Medical Association (AMA), sensing increased competition from osteopathic medicine, spent nearly $8 million to end the practice of osteopathic medicine in the state. In 1962, Proposition 22, a statewide ballot initiative in California, eliminated the practice of osteopathic medicine in the state. The California Medical Association (CMA) issued MD degrees to all DOs in the state of California for a nominal fee. "By attending a short seminar and paying $65, a doctor of osteopathy (DO) could obtain an MD degree; 86 percent of the DO's in the state (out of a total of about 2000) chose to do so."^[35] Immediately following, the AMA re-accredited the formerly-osteopathic University of California at Irvine College of Osteopathic Medicine as University of California, Irvine School of Medicine, an MD medical school. It also placed a ban on issuing physician licenses to DO's moving to California from other states.^[41] However, the decision proved to be controversial. In 1974, after protest and lobbying by influential and prominent DO's, the California Supreme Court ruled in Osteopathic Physicians and Surgeons of California v. California Medical Association, that licensing of DO's in that state must be resumed.

[edit] 1969, AMA House of Delegates approval

Total number of DO's in residency programs, by year.     DO residents in ACGME (MD) programs^[42]      DO residents in AOA (DO) programs.^[43]

In 1969, the American Medical Association (AMA) approved a measure allowing qualified osteopathic physicians as full and active members of the Association. The measure also allowed osteopathic physicians to participate in AMA-approved intern and residency programs. However, the American Osteopathic Association rejected this measure, claiming it was an attempt to eliminate the distinctiveness of osteopathic medicine. In 1970, AMA President Dwight L. Wilbur, MD sponsored a measure in the AMA's House of Delegates permitting the AMA Board of Trustees' plan for the merger of DO and MD professions. Today, a majority of osteopathic physicians are trained alongside MDs, in residency programs governed by the ACGME, an independent board of the AMA.^[44]

[edit] Non-discrimination policies

Recent years have seen a professional rapprochement between the two groups. DO's have been admitted to full active membership in the American Medical Association since 1969. The AMA has invited a representative of the American Osteopathic Association to sit as a voting member in the AMA legislative body, the house of delegates.^[45]

[edit] 2006, American Medical Student Association

In 2006, during the presidency of an osteopathic medical student, the American Medical Student Association (AMSA) adopted a policy regarding the membership rights of osteopathic medical students in their main policy document, the "Preamble, Purposes and Principles."

AMSA RECOGNIZES the equality of osteopathic and allopathic medical degrees within the organization and the healthcare community as a whole. As such, DO students shall be entitled to the same opportunities and membership rights as allopathic students.

– PPP, AMSA^[46]

[edit] 2007, AMA

In recent years, the largest MD organization in the US, the American Medical Association, adopted a fee non-discrimination policy discouraging differential pricing based on attendance of an MD or DO medical school.^[47]

In 2006, calls for an investigation into the existence of differential fees charged for visiting osteopathic and MD medical students at American medical schools were brought to the American Medical Association. After an internal investigation into the fee structure for visiting DO and MD medical students at MD medical schools, it was found that one institution of the 102 surveyed charged different fees for DO and MD students.^[48] The house of delegates of the American Medical Association adopted resolution 809, I-05 in 2007.

Our AMA, in collaboration with the American Osteopathic Association, discourages discrimination against medical students by institutions and programs based on osteopathic or allopathic training.

– AMA policy H-295.876^[47]

Years in which states passed laws granting DO's medical practice rights equal to MDs
     1901-1930      1931-1966      1967-1989

[edit] State licensing of practice rights

In the United States, laws regulating physician licenses are governed by the states. Between 1901 to 1989, osteopathic physicians lobbied state legislatures to pass laws giving those with a DO degree the same legal privilege to practice medicine as those with an MD degree. In many states, the debate was long and protracted. Both the AOA and the AMA were heavily involved in influencing the legislative process. The first state to pass such a law was California in 1901, the last was Nebraska in 1989.^[41]

[edit] Current status

[edit] Education and training

Founded in 1899, Philadelphia College of Osteopathic Medicine is one of the oldest and largest osteopathic medical schools.

According to Harrison's Principles of Internal Medicine, "the training, practice, credentialing, licensure, and reimbursement of osteopathic physicians is virtually indistinguishable from those of allopathic MD physicians, with 4 years of osteopathic medical school followed by specialty and subspecialty training and [board] certification."^[5]

DO-granting US medical schools have curricula identical for the most part to those of MD-granting schools. Generally, the first two years are classroom-based, while the third and fourth years consist of clinical rotations through the major specialties of medicine.

[edit] Graduate medical education

Sources of the 24,012 medical school graduates entering US physician training programs in 2004.^[49]

Upon graduation, most osteopathic medical physician pursue residency training programs. Depending on state licensing laws, osteopathic medical physicians may also complete a one-year rotating internship at a hospital approved by the American Osteopathic Association (AOA).

Osteopathic physicians may apply to residency programs accredited by either the AOA or the Accreditation Council for Graduate Medical Education (ACGME). Currently, osteopathic physicians participate in more ACGME programs than in programs approved by the American Osteopathic Association (AOA).^[44]

[edit] Manipulative therapy

Within the osteopathic medical curriculum, manipulative treatment is taught as an adjunctive measure to other biomedical interventions for a number of disorders and diseases. However, a 2001 survey of osteopathic physicians found that more than 50% of the respondents used OMT on less than 5% of their patients. The survey follows many indicators that osteopathic physicians have become more like MD physicians in every respect — few perform OMT, and most prescribe drugs or suggest surgery as a first line of treatment.^[50]

Osteopathic manipulative therapy (OMT) involves palpation and manipulation of bones, muscles, joints, and fasciae.

The American Osteopathic Association has made an effort in recent years to support scientific inquiry into the effectiveness of osteopathic manipulation as well as to encourage DO's to consistently offer manipulative treatments to their patients. However, the number of DO's who report consistently prescribing and performing manipulative treatment has been falling steadily. Medical historian and sociologist Norman Gevitz^[9] cites poor educational quarters and few full-time OMM instructors as major factors for the decreasing interest of medical students in OMM. He describes problems with "the quality, breadth, nature, and orientation of OMM instruction," and he claims that the teaching of osteopathic medicine has not changed sufficiently over the years to meet the intellectual and practical needs of students.^[32]

At the same time, recent studies show an increasingly positive attitude of patients and physicians (MD and DO) towards the use of manual therapy as a valid, safe and effective treatment modality.^[51] One survey, published in the Journal of Continuing Medical Education, found that a majority of physicians (81%) and patients (76%) felt that manual manipulation (MM) was safe, and over half (56% of physicians and 59% of patients) felt that manipulation should be available in the primary care setting. Although less than half (40%) of the physicians reported any educational exposure to MM and less than one-quarter (20%) have administered MM in their practice, most (71%) respondents endorsed desiring more instruction in MM.^[52] Another small study examined the interest and ability of MD residents in learning osteopathic principles and skills, including OMM. It showed that after a 1-month elective rotation, the MD residents responded favorably to the experience.^[53]

[edit] Professional attitudes

Recent years have seen an increasingly cooperative climate between the DO and MD professions. In 1998, a New York Times article described the increasing numbers, public awareness, and mainstreaming of osteopathic physicians, but said that "some aspects of osteopathic practice can still raise eyebrows among conventional doctors." "Leaders of conventional medicine may no longer use the word quack, but many still look askance at the osteopathic system of medical thought, which they feel lacks the intellectual rigor and the scientific underpinnings of their own practice."^[9]

In 2005, during his tenure as president of the American Association of Medical Colleges, Jordan Cohen described a climate of cooperation between DO and MD practitioners.

Elsewhere, he has remarked that osteopathic manipulative medicine (OMM) can be an aid to the physician in fostering a relationship with the patient, while also a source of skepticism to MDs. In particular, he noted that suggestions that OMM could be used to treat diseases other than back problems, "reinforces lingering feelings among proponents of conventional medicine that osteopathy is simply a less intellectual field all around."^[9]

[edit] International practice rights

International practice rights of US trained DO's      Practice rights generally recognized as equal to U.S.-M.D.s      Unlimited practice rights granted, but difficult to obtain      Limited to manipulation-only      Unknown or previously denied

Each country has different requirements and procedures for licensing or registering osteopathic physicians and osteopaths. The only osteopathic practitioners that the US Department of Education recognizes as physicians are graduates of osteopathic medical colleges in the United States.^[54] Therefore, osteopaths who have trained outside the United States are not eligible for medical licensure in the United States. On the other hand, US-trained DO's are currently able to practice in 45 countries with full medical rights and in several others with restricted rights.

The Bureau on International Osteopathic Medical Education and Affairs (BIOMEA) is an independent board of the American Osteopathic Association. The BIOMEA monitors the licensing and registration practices of physicians in countries outside of the United States and advances the recognition of American-trained DO's. Towards this end, the BIOMEA works with international health organizations like the World Health Organization (WHO), the Pan American Health Organization (PAHO) as well as other groups.^[55]

The procedure by which international countries consider granting physician licensure to foreigners varies widely. For US trained physicians, the ability to qualify for "unlimited practice rights" also varies according to one's degree, MD or DO^[56] Many countries recognize US-trained MDs as applicants for licensure, granting successful applicants "unlimited" practice rights. The American Osteopathic Association has lobbied the governments of other countries to recognize US-trained DO's similarly to their MD counterparts, with some success.

In 44 countries, US-trained DO's have unlimited practice rights. In 2005, after one year of deliberations, the General Medical Council of Great Britain announced that US-trained DO's will be accepted for full medical practice rights in the United Kingdom. According to Josh Kerr of the AOA, "some countries don’t understand the differences in training between an osteopathic physician and an osteopath."^[57] The American Medical Student Association strongly advocates for US-trained DO international practice rights "equal to that" of MD qualified physicians.^[46]

[edit] Osteopathic medicine and primary care

Trends in primary care as a career choice of osteopathic medical students^[58]
     4th year students      1st year students

Osteopathic physicians have historically entered primary care fields at a higher rate than their MD counterparts. Some osteopathic organizations make claims to a greater emphasis on the importance of primary care within osteopathic medicine. However, the proportion of osteopathic students choosing primary care fields, like that of their MD peers, is declining.^[59] Currently, only one in five osteopathic medical students enters a family medicine residency (the largest primary care field).^[60] In 2004, only 32% of osteopathic seniors planned careers in any primary care field; this percentage was down from a peak in 1996 of more than 50%.^[58]

[edit] Criticism and internal debate

[edit] OMM

Traditional osteopathic medicine, specifically OMM, has been criticized for many techniques such as cranial and cranio-sacral manipulation. A recent study questions the therapeutic utility of osteopathic manipulative treatment modalities.^[61] A website cites numerous studies demonstrating that there are some ailments for which the benefit of manipulative therapy has "firmly established" scientific support.^[33] Also, New York University health information website claims that "it is difficult to properly ascertain the effectiveness of a hands-on therapy like OM."^[62]

[edit] Research emphasis

Another area of criticism has been the relative lack of research and lesser emphasis on scientific inquiry at DO schools in comparison with MD schools.^[63][64][65]

[edit] Identity crisis

There is currently a debate within the osteopathic community over the feasibility of maintaining osteopathic medicine as a distinct entity within US health care.^{[4][10][32][66][67][68][69][70][71]} JD Howell, author of The Paradox of Osteopathy,^[35] notes claims of a "fundamental yet ineffable difference" between MD and DO qualified physicians are based on practices such as "preventive medicine and seeing patients in a sociological context" that are "widely encountered not only in osteopathic medicine but also in allopathic medicine."^[72] Studies have confirmed the lack of any "philosophic concept or resultant practice behavior" that would distinguish a DO from an MD^[73][74] Howell summarizes the questions framing the debate over the future of osteopathic distinctiveness thus:

First-year enrollment at osteopathic medical schools, 1968-2007

[edit] Rapid expansion

As the number of osteopathic schools has increased, the debate over distinctiveness has often seen the leadership of the American Osteopathic Association at odds with the community of osteopathic physicians.

The rapid expansion has raised concerns about the number of available faculty at osteopathic schools and the role those faculty play in maintaining the itegrity of the academic program of the schools. Norman Gevitz, author of the leading text on the history of ostoepathic medicine, recently published,

The president of the American Association of Colleges of Osteopathic Medicine commented on the current climate of crisis within the profession.

[edit] For-profit medical education

The accreditation of RVUCOM generated some controversy before the school held its first class. Like all osteopathic medical schools, RVUCOM is accredited by a board of the American Osteopathic Association (AOA) Commission on Osteopathic College Accreditation (COCA). Unlike the other 28 osteopathic and 126 MD medical colleges in the US, RVUCOM is organized as a for-profit corporation.^[17] Critics claimed the AOA's approval of a for-profit school "erodes creditability" of osteopathic medical schools, especially in comparison to their MD counterparts.^[75] The Liaison Committee on Medical Education, which accredits the MD-granting US medical schools, has banned for-profit schools.^[76] School officials insist the for-profit status of the school will not compromise the integrity of its educational mission.^[77] 2007-2008 AOA president and orthopedic surgeon Peter Ajluni, D.O. responded, "there are many socially minded for-profit companies that contribute time, resources, and profits to their communities" and "for-profit institutions like RVUCOM can further the cause of osteopathic medicine in the United States."^[78]

[edit] References

[edit] Further reading

• The DO's: Osteopathic Medicine in America, Norman Gevitz, 2004 (2nd Edition), paperback, 264 pages, The Johns Hopkins University Press, ISBN 0-8018-7834-9 (An excellent review of the history and development of ostepathic medicine and medical education in the United States)
• Science in the Art of Osteopathy: Osteopathic Principles and Models, Caroline Stone, Nelson Thornes, 1999, paperback, 384 pages, ISBN 0-7487-3328-0
• An Osteopathic Approach to Diagnosis and Treatment , Eileen DiGiovanna, Lippincott Williams and Wilkins, 2004, hardback, 600 pages, ISBN 0-7817-4293-5

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