Osteopathic medicine in the United States

Editor-In-Chief:DrATStill [mailto:andrewtaylorstill@yahoo.com]

Osteopathic medicine is a branch of the medical profession in the United States. Osteopathic medicine in the US is a complete system of medical training, much like allopathic (MD)  training in the US or the British system of medical education, with all of the medical & surgical specialties and subspecialty training available to its graduates. Osteopathic physicians, known as DOs, are licensed to practice medicine and surgery in all 50 states and have full scope of medical practice in over 50 countries. There are over 78,000 DOs in the US, accounting for about 7% of the total physician population.

Philosophy
Osteopathic medicine is based on the premise that the primary role of the physician is to facilitate the body’s inherent ability to heal itself. These are the four major principles of osteopathic medicine:
 * 1) The body is a unit – an integrated unit of mind, body, and spirit (Triune of Man - A.T. Still)
 * 2) The body possesses self-regulatory mechanisms, having the inherent capacity to defend, repair, and remodel itself.
 * 3) Structure and function are reciprocally inter-related, as such there is an emphasis on the integral relationship between anatomy and physiology
 * 4) Rational therapy is based on consideration of the first three principles.

Disease prevention is a central tenet of this philosophy. There is an emphasis on treating the whole person – body, mind and spirit, rather than just the presenting symptoms.

Education
Physicians who graduate from US osteopathic medical schools may be referred to as physicians or osteopathic physicians. Graduates hold a professional doctorate, the D.O. or Doctor of Osteopathic Medicine degree and have the same have the same rights, privileges and responsibilities as their MDs counterparts. Currently, there are 26 colleges of osteopathic medicine in 34 locations, which are accredited by the American Osteopathic Association’s Commission on Osteopathic College Accreditation (COCA). One in 5 medical students in the United States is attending an osteopathic medical school. In terms of general coursework, the osteopathic medical school curriculum closely mirrors those of allopathic (MD) medical schools. The first two years focus on the biomedical and clinical sciences, followed by core clinical training in the clinical specialties. Osteopathic medical school accreditation standards require training in internal medicine, obstetrics /gynecology, pediatrics, family practice, surgery, psychiatry, emergency medicine, radiology, preventive medicine and public health. In addition to the usual course of medical study, osteopathic medical students spend an added 300-500 hours studying the musculoskeletal system as it relates to functional ability, as well as osteopathic manual medicine treatment methods to aid in the restoration of their patients’ health. Osteopathic principles & practices are both taught as a distinct discipline and integrated throughout the four-year curriculum. Students are trained to use osteopathic techniques for physical diagnosis and treatment of disease. The curriculum emphasizes the relationship of body systems, holistic patient care and disease prevention.

Admission standards are comparable between DO and MD medical schools, with the average GPA of 3.49 (S.D. ± 0.26) and a mean MCAT score of 26.48 for matriculants. The American Association of Medical Colleges lists the average grades and scores of entering students of the medical schools in the annual Medical School Admission Requirements book whereas, the American Association of Colleges of Osteopathic Medicine lists the minimum requirements that may be considered by the colleges listed in the annual Osteopathic Medical College Information Book which has led some to mistakenly believe there is a great disparity between the two education systems. Approximately 50% of matriculants to both DO and MD schools are women.

While the osteopathic medical profession has its own basic board examinations (NBOME/COMLEX), hospitals, specialty training programs and specialty board examinations, American osteopathic physicians (DO) may also choose to sit for the USMLE if they wish to take an allopathic residency; however, if they have taken COMLEX, it may or may not be needed, depending on the individual institution’s program requirements. First-time USMLE pass rates for DO vs. MD students are as follows: Step 1: 80% and 92% and Step 2: 90% and 96%, respectively; however, DO graduates have a higher pass rate than their MD counterparts for Step 3: 96% vs. 93%, respectively. Given that DO graduates have performed competitively with their US trained MD counterparts, the trend is now overwhelmingly towards acceptance of COMLEX.

DO graduates may participate in the National Resident Matching Program’s Electronic Residency Application Service  or may participate in the AOA Match Program, administered by the National Matching Services. In 2008-2009, 44% of osteopathic medical graduates chose to complete allopathic graduate medical education programs and then take allopathic specialty board exams. There is an increasing trend toward residency programs that are dually-certified by the AOA and ACGME. Hospitals may also have parallel (MD & DO) undergraduate and graduate training programs; this is where both AOA and ACGME accredited programs exist in a specialty, but residents are only admitted to one program. and graduate medical education programs. Osteopathic physicians may be credentialed in any hospital. Because of the additional training DOs receive, there is presently no pathway for MD colleagues to be admitted to their training programs or sit for their exams. DOs & MDs are the only two types of complete physicians in the United States. The osteopathic medical education system is recognized as on par with allopathic (MD) training by their colleagues,   medical institutions, professional organizations,  educational accreditation bodies, testing examiners, licensing/regulatory authorities,  the US government   and military.

Demographics
Osteopathic physicians currently comprise 7% of the total physician population in the US. There are currently 26 osteopathic medical schools in 34 locations.

DOs have historically been concentrated in a few states like Michigan, Pennsylvania and Ohio. However, in recent years this pattern has decreased and DO populations are increasing distribution throughout all 50 states. In 2010, the states with the largest numbers of DOs are Pennsylvania, Michigan, Florida, California, Ohio and New York. The states with the highest percentage of DOs relative to the total physician population are Oklahoma (24%), Michigan (21%), Iowa (19%), Maine (17%), West Virginia (16%) and Pennsylvania (15%). The states with the lowest numbers of DO's are North Dakota, Vermont, Wyoming, South Dakota and Louisiana.

Osteopathic physicians have historically entered the primary care fields at a higher rate than their MD counterparts. Currently, 60% percent of all DOs practice in the primary care specialties of family medicine, internal medicine, obstetrics/gynecology and pediatrics. In the 2008-2009 academic year, the percentage of DO residents in AOA or ACGME primary care residencies of family medicine (FP), internal medicine (IM), obstetrics/gynecology & pediatrics (Peds) and combined residencies (FP/ER, FP/OMM, IM/Peds, ER/IM) is 50%, compared to 35% for their MD counterparts. When emergency medicine (including ER/IM, ER/Peds) programs are also considered as primary care, the percentage of osteopathic primary care physicians rises to 61%, compared to 41% for their MD colleagues. According to US News & Report’s 2012 Graduate Schools: Best Medical Schools rankings, osteopathic medical schools took the top five slots for producing the most primary care residents: #1 Michigan State University, College of Osteopathic Medicine (74%), #2 West Virginia School of Osteopathic Medicine (70%), #3 Lake Erie College of Osteopathic Medicine (67%), #4 Texas College of Osteopathic Medicine (TCOM), University of North Texas Health Science Center (67%) and #5 Pikeville College of Osteopathic Medicine (67%). Two schools took the top 20 rankings in primary care: Michigan State University, College of Osteopathic Medicine (#14) and Texas College of Osteopathic Medicine (TCOM), University of North Texas Health Science Center (#20).

Osteopathic physicians are still more likely to practice in rural and medically underserved areas than their MD counterparts; osteopathic physicians “represent 22% of all physicians practicing in rural and underserved parts of the United States.” As John Crosby JD, Executive Director of the AOA, in his testimony before Congress may have described why this is:


 * Medical schools and colleges of osteopathic medicine traditionally place significant emphasis on an applicant's academic achievement-grade point average, undergraduate degree program, and scores on the Medical College Admission Test (MCAT). While I would never suggest that the academic standards required for admittance be lowered, I do recommend that the nation's medical education institutions begin evaluating other factors. An evaluation of the student's life, including an evaluation of where the student was raised, attended high school, and location of family members, provides an indication of where a future physician may practice. For example, an applicant from Princeton, New Jersey is less likely to practice in a rural community than an applicant from Princeton, Indiana. If the two applicants are equally qualified, we should encourage our schools to matriculate the student from Princeton, Indiana, an individual more likely to return to rural southwest Indiana once education and training is completed.

The osteopathic medical profession has been more likely to start medical schools and training programs in such areas as part of its core mission. The West Virginia School of Osteopathic Medicine had the highest number of graduates, 41%, (among MD or DO schools) practicing in rural areas and was recently ranked ninth in the country for its rural medicine program.

It is important to note that medical schools rankings in general have not been without their critics.

History
Frontier physician & surgeon,  inventor     & Kansas legislator, Andrew Taylor Still, MD, DO, founded the American School of Osteopathy (now the A.T. Still University College of Osteopathic Medicine) in Kirksville, MO, as a reformation of the American medical system. This is the second university Dr. Still founded; he was also one of the founders of Baker University in Baldwin, Kansas. “But...when I asked the privilege of explaining Osteopathy in Baker University the doors of the structure I helped build were closed against me." A.T. Still believed that the conventional medical system lacked credible efficacy, was morally corrupt, and treated effects rather than causes of disease. “Baldwin, my old home was never very kind to me. It was there you know I lost my three children (due to meningitis) and decided that drugs were deficient in many things. I advocated bloodless surgery-that there was no efficacy in drugs and they laughed at me.” Still demanded that treatments be shown to be efficacious, he said, "It has been the object of myself and also of my teachers to direct and be guided by the compass that points to nothing but demonstrative truth.”

Still believed that many of the medicines of his day were useless or harmful. The material medica (drugs) commonly included arsenic, castor oil, whiskey, and opium. Osteopathic medicine was founded at a time when medications, surgery, and other traditional therapeutic regimens often caused more harm than good. In addition, unsanitary surgical practices often resulted in more deaths than cures. Dr. Still was in good company regarding his views of the material medica of the day. Sir William Osler, the father of modern medicine and a contemporary of Still’s, (although there is no evidence the two men ever met). Osler also advocated for the very limited use of drugs. He said, “One of the first duties of a physician is to educate the masses not to take medicine.” Early osteopathic medical educators advocated using Osler’s Principles and Practice of Medicine, “the instructor therefore simply has to replace Osler’s drug nihilism by osteopathic procedure based upon the causative lesion and the thing is complete.”

Dr. Still moved to Missouri, and in 1892, founded the American School of Osteopathy (now A.T. Still University), in Kirksville, MO. 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. “We expect to educate our students to a complete preparation, and to use all the time necessary in that preparation in surgery, obstetrics, and general practice…Qualified merit is the best thing a man can possibly possess. We want a full share of that.”

The American School of Osteopathy was chartered under the laws of the state of Missouri in 1892 and appended October of 1894. The charter specifically states. “The object...is to establish a College of Osteopathy, the design of which is to improve our present system of surgery, obstetrics, and treatment of diseases generally, and place the same on a more rational and scientific basis, and to impart information to the medical profession and to grant and confer such honors and degrees of are usually granted and conferred by reputable medical colleges…” Under the charter, ASO was entitled to award the MD degree to its graduates; however, Dr. Still wanted to issue a new degree representing a new philosophy of healing.

He invented the name "osteopathy" to describe his new philosophy. He blended two Greek roots os for bone and pathology for a study of the nature of disease and its causes, processes, development, and consequences – the anatomic or functional manifestations of disease – in order to communicate his original theory that disease and physiologic dysfunction were grounded in a disordered anatomy, beginning with the musculoskeletal system. Thus, by diagnosing, treating and restoring order to the system, he believed that physicians could treat a variety of diseases and spare patients the negative side-effects of drugs.

“Like every other name given to a new science it does not include all the new science embraces, but indicates the germinal point from which the new science started. Osteopathy represents a new view of the science of therapeutics…Osteopathically, it means the discovery of the cause or causes of disease and the correction or removal of the cause or causes of disease…”

Still placed a strong emphasis on the study of anatomy and physiology. “For fear a student will not comprehend what I mean by the books pertaining to a complete knowledge of anatomy, I will give something of an approximate list as follows: Descriptive anatomy, by the very best and latest authors; demonstrative anatomy, human physiology, histology and chemistry…With correct knowledge of the form and functions of the body an all its parts, we are then prepared to know what is meant by a variation in a bone, muscle, ligament, or fiber or any part of the body, from the least atom to the greatest bone or muscle. By our mechanical skill, preceded by our intelligence in anatomy, we can detect and adjust both hard and soft substances of the system. By our knowledge of physiology we can comprehend the requirements of the circulations of the fluids of the body as to time, speed and quantity, in harmony with the demands of normal life.”

State licensing of practice rights
In the United States, laws regulating physician licenses are governed by the individual states. Both the American Osteopathic Association and the American Medical Association were heavily involved in influencing the legislative process. In many states, the debate was long and protracted. The first state to pass legislation placing osteopathic medicine on “equal grounds with other schools of healing and treatment of the sick” was Vermont in 1896. By 1973, DOs had full scope of medical practice rights in all 50 states and the District of Columbia. That same year, Michigan State University College of Osteopathic Medicine, the first publically supported osteopathic medical school, graduated its first class.

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.

During the World War I, the AOA protested the fact that osteopathic physicians were not included in plans to expand the military medical corps as the war escalated. The Surgeon General of the Army, William C. Gorgas (AMA President 1909-1910), was philosophically opposed to osteopathic medicine, despite osteopathic physicians passing the required medical exams. On June 30, 1941, President Franklin Delano Roosevelt signed the Military Appropriations Act which recognized DOs in the nation’s military services, but excluded them from the armed forces medical corps. Public law 604, passed in 1946, gave the US President the authority to appoint osteopathic physicians as medical officers in the Navy. On July 20, 1956, President Dwight D. Eisenhower, which allowed osteopathic physicians to become commissioned officers in the US Armed Services. This recognition opened the doors to training and service for DOs. 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 enlist and take the oath of office was Harry J. Walter, DO, on July 14, 1966; he was sworn in as a first lieutenant in the Air Force Medical Corps and would go on to receive the Air Force Commendation Medal for his service. By 1996, an osteopathic physician, Lt. General Ronald Blanck, DO, MCP, was appointed to serve as Surgeon General of the Army, the only osteopathic physician to hold the post.

The first osteopathic physician to reach flag rank in the United States Public Health Service Commissioned Corps was RADM Murray Goldstein, DO, MPH. He is also the first DO to serve as a Director for one of the National Institutes of Health, specifically – the National Institute of Neurological Disorders and Stroke (1982-1993). Dr. Goldstein would go on to serve as the Assistant Surgeon General of the United States Public Health Service. In 1997, RADM Joyce M. Johnson DO, MA, was named the Chief Medical Officer & Surgeon General of the United States Coast Guard; she is the first woman to attain flag rank with the USCG, and the first physician & first woman to serve on the board of trustees of the U.S. Coast Guard Academy.

Accreditation recognition
1952: The AOA is recognized by the United States Department of Health, Education and Welfare as the accrediting body for osteopathic medical education.

1966: Medicare accepts the AOA as an accrediting agency for osteopathic healthcare facilities.

1967: The Council for Higher Education Accreditation (formerly the National Commission on Accrediting) recognizes the AOA as the accrediting agency for all facets of osteopathic medical education.

Osteopathic medicine vs. the medical establishment
The new profession faced stiff opposition from the medical establishment at the time. The relationship of the osteopathic and allopathic medical professions was often "bitterly contentious" and involved "strong efforts" by the allopathic medicine to discredit other sects, including osteopathic medicine.

It was written in the August 1897 edition of the Journal of Osteopathy: “…For more than a century past, the Allopathic doctors of this country, under the plea of alleviating human suffering and regulating their own quacks, have dominated all of the state and national legislatures and monopolized the passage of laws touching the science of medicine. During all this time they have fought the enactment of any law that would interfere with the monopoly of the Allopathic school. Growing bolder with each victory, privilege after privilege has be wrung from the people until the whole has at last culminated in the formation of the greatest trust that now exists in the nation – the medical trust…The American Medical Association or Trust, is the name of the national organization. It has suborganizations in each state. They meet precisely as another business organization would meet, and devise ways and means of securing themselves against honest competition. Under plea that they are the only genuine alleviators of human suffering, they have secured the passage of laws in each state giving to themselves a monopoly in the art of healing, and this is effectually accomplished they fix the prices that the public must pay. In many states they have been so bold as to have the prices that the public must pay by law, as, for instance, in North Dakota, a physician is allowed one dollar for every mile traveled; and the law allows no exemption when it comes to the collection of these exorbitant fees. The doctor has the power to take the bed from under the invalid. Then to make this protection doubly sure, the trust has secured the passage of laws by which any citizen who fails or refuses to employ a physician in case of sickness can be criminally prosecuted is death occurs in the family. The employment of an “irregular” physician well not extenuate the supposed offense; unless a member of the trust be employed at his own exorbitant price a crime has been committed against the state! And yet all these privileges have been granted for the alleged protection of humanity! The farmer, the businessman, the laborer, and the lawyer are all compelled to meet the competition of the world, but the so-called regular physicians are not only given the exclusive right to practice healing, but in many states citizens are compelled to patronize them or suffer severe penalties, and the bills of drug doctors are practically guaranteed by statutory enactment. And all of this in free America!”

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 1901, he spoke before the Committee on Public Health of the New York General 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."

Osteopathic Medicine & the American Medical Association
At the end of the 19th century, there were several schools of medical thought in the US including homeopathy, eclectic, physio-medico, osteopathy, Thompsonians, etc. Up through the first half of the twentieth century, the policy of the American Medical Association was to label all other schools of medical thought, including osteopathic medicine, as a cult and osteopaths, "cultist."


 * “A sectarian or cultist as applied to medicine is one who alleges to follow or in his practice follows a dogma, tenet or principle based on the authority of its promulgator to the exclusion of demonstration and scientific evidence.”

Determined to establish and maintain its hegemony, the AMA position, since its founding in 1847, was always to declare its means and methods of medical practice “scientific” and to call everything else “quackery;” their members were “regular doctors” and they referred to any other sect as “irregulars.” “Regular medicine, it was claimed, embodied science; the sects did not. The assertion proved strikingly irrelevant at the time, for large numbers of regular physicians were appallingly ignorant while large number of sectarians were amazingly successful in practice. The public had not been impressed by claims of science in medicine.” The AMA declared it unethical for a medical physician to voluntarily associate with an osteopath or teach in an osteopathic medical school. Osteopathic beliefs, education and practice were misrepresented, mischaracterized, distorted and maligned in the Journal of The American Medical Association.

In 1900 the AMA, only represented about 7% of the US physician population. Its membership was unusual for in that many of its members were medical educators or affiliated with hospitals; many, if not most, had received post-graduate education in Europe, particularly Germany. “Because there were no scholarships at the time, the only people who could afford the European training were the wealthy. Their wealth brought them in close contact with the leaders of industry on a social basis as wll as on a professional basis…Because they were independently wealthy, they were able to involve themselves in extraneous issues such as licensure and educational reform and still survive financially. When new licensing laws started being passed in the 1890s, these physicians, by virtue of their financial ability to serve on boards and their stature as medical educators and researchers, gained seats on the licensing boards...(the AMA established a permanent Council on Medical Education in 1904. The Council surveyed the results of state licensing boards in the country and classified medical schools on the basis of the percentage of graduates passing these exams. The AMA, which by then had members on many of these boards, designed exams so that students trained in the scientific medical schools would fare better than students trained in other medical schools…” It was in this competitive environment that osteopathic medicine had to compete for the right to practice medicine.

In 1908, the first AMA report on the osteopathic medical education system was given by M. Clayton Thrush PhM, MD before the 59th Annual Session of the AMA, stating that “During recent years a number of cults or sects have sprung into prominence, the cardinal features of the majority being an alleged cure of diseased states by the employment of other means or agents than drugs…Conspicuous among these is a system called osteopathy, and during the past few years, because of attempts to secure legal recognition, it has come into sufficient prominence to attract the notice of the members of the medical profession and the laity throughout the United States, as its disciples can be found in almost every village and hamlet in this country…There are now thirty-eight states that have laws recognizing and regulating the practice of osteopathy, and the medical profession, as a whole, has been disgracefully apathetic and deserves no credit for permitting this official recognition without, most emphatic protest (p. 2135)…They claim to have had originally four terms of five months each, but this has recently been changed to three terms of five months each. The reason for this change has not been given. The total number of hours devoted to the complete course is about the same as the average medical school. They claim to teach everything the same as the regular schools except material medica, for which they substitute the principles of osteopathy (p. 2136)…The osteopath recognizes that disease may be due to toxic or poisonous compounds which may enter the system… in the case of an ingestion of a fatal dose, the osteopath would give the usual antidote and treat accordingly. They have a course in toxicology in their college course, claimed to be properly taught (p. 2137)…Bacteriology is alleged to be taught in every osteopathic school with the same exactness as in the best regular schools. The osteopath has always held to the germ theory as the cause of certain disease, but the osteopath does not use the same means to recover the health of the patient so infected, yet he recognizes that such conditions exist. The osteopath, emphasizing that disease is primarily of mechanical origin, holds, therefore, that germs are generally a secondary factor in the cause, and he believes that so long as the tissue of the body is healthy no germs can infect the body (p. 2137)…It is frequently stated that osteopaths condemn the use of drugs and are opposed to them. A few examples will prove the falsity of such statements… (p.2139)”

He admits his report is not unbiased. “I presented this paper primarily for three reasons: First, to show…what osteopathy really is (a popular cult – p. 2135) and what constitutes its important principles…Second, to show how dangerous it is. Every one in this room has been asked by a patient whether he should try osteopathy. Often these patients have a disease in which the methods used by osteopaths will do harm and may even cause death. Third, to plead for a one-board medical law…Each man who practices healing, no matter what his cult, should be required to pass the same medical examination and with the same preliminary requirements, etc…”

1950s
In 1952, John W. Cline (AMA President 1951-52) was appointed as Chairman of the Committee for the Study of the Relations between Osteopathy & Medicine by the AMA Board of Trustees(BOT). In 1951, as the president of the AMA, Dr. Cline reported to the BOT that “the relations between medicine and osteopathy presented widespread problems in a majority of states to some degree.” In his remarks to the House of Delegates in June of 1952, the retiring president again called attention to the issue. “…Representatives of the AOA had informed the Committee…that the curriculums of the colleges of osteopathy consisted mainly of courses in medicine and surgery and that the quality of instruction in these colleges could be improved if more doctors of medicine were willing to teach in these colleges. The President further raised the question as to the validity of the classification of modern osteopathy as “cultist” healing.”

The Committee surveyed state and county medical associations and the schools of osteopathic medicine and reported:


 * Osteopathy has undergone a process of evolution that has brought it to a point of such similarity to medicine that no marked fundamental differences exist…The entrance requirements for schools of osteopathy and schools of medicine are identical. The curriculums have the same content, except for the inclusion of osteopathic theory, diagnosis, and treatment. The period of instruction in both instances is four years. The clock hours devoted to teaching basic sciences, medicine, and surgery are as great in schools of osteopathy. The level of instruction in basic sciences is demonstrated by the record of osteopathic candidates in examinations in these subjects. [88% of the MD and 84.5% of the DO candidates passed the 1952 state basic science examinations. (p. 737)]… Instruction in all fields of medicine and surgery has been given in some osteopathic schools for 40 years and formally in all osteopathic schools since 1940. Osteopathic teaching is integrated with these courses to some degree…the committee, after careful study and thoughtful consideration, is of the opinion that the teaching in osteopathic schools at the present time, and for some years past, does not constitute "cultist healing" as defined in our Principles of Medical Ethics and that this stigma should be removed.


 * …Doctors of osteopathy render medical care to millions of patients. The objectives of the American Medical Association and its responsibilities are to improve the health and medical care of the American people. The committee is of the opinion that these purposes would be served by making it possible for schools of osteopathy to draw on the services of doctors of medicine as teachers. We should assist improvement in the education of osteopathic physicians.

The AMA House of Delegates (HOD) deferred action on the report for 2 years; the principal objection was that it was based to a large extent on indirect information. The AMA Committee proposed to the AOA that it be permitted to conduct site inspections of the osteopathic colleges. Five of the six colleges accepted the proposal, with Philadelphia declining to participate.

Questionnaires patterned after those required of allopathic schools at the time, were distributed to all the participating osteopathic medical schools.


 * The purpose was to provide essential basic information concerning organization, authority, administration, finances, facilities, and operation of the college; the organization, personnel, training, authority, and activities of the faculty; the curriculum content; the organization of departments, their objectives, methods of teaching, and equipment; the degree of interdepartmental coordination and cooperation; and details of library facilities and content…”


 * The Committee devoted an average of 14 man days to the study of each of the five colleges and was accorded complete freedom of investigation. The committee attended the classes it wished and had ample opportunity for private conversations with faculty members, students, interns, and residents. The committee was impressed by the frankness, serious purpose, and sincerity of the administrative officers and faculty. The criticisms of the college offered by the committee were accepted in excellent spirit. In most instances the administrative officers concurred in them and means of correcting deficiencies were discussed.

The conclusions of the Committee were as follows:


 * Educational requirements for admission to colleges of osteopathy are identical to those of medical schools.
 * Current curriculums in colleges of osteopathy include all subjects taught in present-day schools of medicine. In addition, there are courses dealing with the musculoskeletal system and manipulative therapy; there was no evidence that these courses interfered with the achievement of sound medical education.
 * All osteopathic colleges face the handicap of insufficient financial support; more endowments and public support is desirable; the proportion of operating funds derived from tuition and student fees is far too high.
 * The teaching of some basic science courses, such as anatomy, is well done. Material improvement is needed in others, i.e. pathology.
 * In some instances the clinical facilities and clinical material do not justify the numbers of students enrolled. These handicaps are being partially overcome and, when achieved, current plans of expansion will improve the situation. The major deficiency in clinical instruction is the lack of trained clinical teachers. It is difficult for graduates of colleges of osteopathy to obtain (postgraduate) training which would fit them for teaching in clinical fields. These circumstances lead to an "inbred" faculty and impair teaching programs.
 * The facts outlined in the three immediately preceding conclusions are recognized by the administrations, faculty members, and some students of the institutions visited. Considerable effort is being expended and some progress is being made in improving the situation. The administrative heads expressed a real desire for the addition of good doctors of medicine to their faculties and for the opportunity for selected young graduates to obtain sound graduate training in medical institutions...
 * The teaching in present-day colleges of osteopathy does not constitute the teaching of "cultist" healing.
 * The AMA is dedicated to the purpose of improving the health and medical welfare of the American people. The osteopathic profession supplies medical care to millions of Americans. In many areas, the only immediately available medical care is rendered by osteopaths. The American Medical Association must decide whether it will assist in improving the medical care rendered by doctors of osteopathy. The committee believes that the only constructive course which can be followed is to enlarge the medical educational opportunities of the students and graduates of schools of osteopathy by elimination of the classification of teaching in colleges of osteopathy as the teaching of "cultist" healing…
 * The number of osteopathic physicians, the scope of licensure, the opportunities for practice, probably the level of practice, and the degree of interprofessional prejudices are extremely variable in different areas. It is obvious that no national policy governing the over-all relationship of doctors of medicine to doctors of osteopathy can be realistic. This should be a function of the several state medical associations and in certain states perhaps of the county medical societies.

Although the majority of the Committee essentially recommended a normalization of relations between the two groups for the good of the American public, one member of the Reference Committee on Medical Education & Hospitals, Milford Rouse, MD(AMA President 1967-1968), submitted a minority committee report claiming an appreciable portion curriculum of colleges of osteopathy definitely did constitute the teaching of cultist healing, and is an index that the "osteopathic concept" still persists in current osteopathic practice. He could not in good conscience approve of MDs teaching in schools where cultism is part of the curriculum. He recommended to the House of Delegates:(1) That the report be received & filed, the Committee be thanked & discontinued. (2) If and when the AOA voluntarily abandons the osteopathic concept, with deletion of it from their college catalogs, they may approach the AMA BOT with a request for further discussion, then the said Trustees shall appoint another special committee. The minority report was adopted.

California 1961
In the early 1960s in California, the California Medical Association (CMA) and the American Medical Association (AMA) sensing increased competition from osteopathic medicine, attempted to assimilate the osteopathic medical profession and end the practice of osteopathic medicine in the state. It seems the AMA and CMA managed to convince the leadership of the California Osteopathic Association that this would benefit them; however, this would later prove untrue. In May of 1961, the CMA and COA signed a merger agreement. In 1962, Proposition 22, a statewide ballot initiative in California, was passed. It “continues (the) Board of Osteopathic Examiners with (the) power to enforce certain provisions of the Medical Practice Act as to osteopaths. Provides that qualified osteopaths who elect to designate themselves “M.D.” will be subject to the jurisdiction of the Board of Medical Examiners. Grants Legislature the power to amend the Osteopathic Initiative Act of 1922 and repeal that act and transfer functions to Board of Medical Examiners when there are 40 or less licensed osteopaths.” Immediately following, the AMA’s Council on Medical Education & Hospitals re-accredited the former College of Osteopathic Physicians & Surgeons as California School of Medicine (now the University of California, Irvine School of Medicine), an MD medical school. Grace Bell, dean of the osteopathic school and professor of biochemistry, was issued the first MD degree from the “new” school on March 7, 1962 and technically becomes its first dean. She is one of the few women in history to be the dean of both an osteopathic and allopathic medical school. The graduating class of 1962 was issued an MD degree. The “new” California School of Medicine issued MD degrees to all DOs in the state of California. By attending 12 Saturday classes 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. However, these MD degrees were not recognized outside the state. It also effectively placed a ban on issuing new physician licenses to DO's moving to California from other states. “…the California Medical Association did not integrate them into the medical society, but instead isolated (try Ghetto-ized) them into a single "District" society that was statewide and contained all, and only, former DOs—thereby limiting their possible influence in any important matters. It was no longer, "Oh, those DOs," it was "Oh, that's just District X talking."

What initially appeared to be a defeat for the profession proved to be a catalyst for full licensure in all 50 states. Because the conversion of the medical school took place with few curricular changes and no real additional training for DOs, by deduction, osteopathic medicine was equivalent to allopathic medicine.

On March 19, 1974, after protest and lobbying by influential and prominent DO's in the state and the AOA, the California Supreme Court overturned Proposition 22 Osteopathic Physicians and Surgeons of California v. California Medical Association, and it was determined that licensing of DO's in the state must be resumed. In 1977, the College of Osteopathic Medicine of the Pacific (now part of Western University of the Health Sciences) was founded in Pomona, CA.

Significant developments between the professions

 * 1961: The AMA House of Delegates (HOD) states it is the prerogative of the state medical associations to determine if an individual DO in their jurisdiction bases his practice on scientific principles. If so, voluntary professional associations between the DO & MDs would not be unethical.


 * 1966: The AMA Council on Medical Education states that “osteopaths who do not hold the MD degree may serve on hospital staffs…as long as they are not appointed to the ‘teaching staffs’ of such hospitals.”


 * 1969: The AMA HOD 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. Six specialty boards declared their intent to accept DOs who have completed AMA approved internships and residencies for board certification. Qualified osteopathic physicians are now eligible for approved residencies in pediatrics, pathology, radiology, internal medicine, preventive medicine, and physical medicine & rehabilitation.


 * 1970: The AOA HOD approves a policy allowing DOs to train in the ACGME system.


 * 1970: Dwight L. Wilbur, MD (AMA President 1968-1969) sponsored a measure in the AMA's HOD permitting the AMA Board of Trustees' plan for the merger of DO & MD professions. “As further evidence of its intent to ‘provide avenues whereby qualified osteopaths may be assimilated into the mainstream of medicine,’ two additional AMA services have been opened to osteopaths. Effective immediately, the AMA Physicians Placement Service and the AMA Classified Advertising Service are making their resources available to qualified doctors of osteopathy who hold an unrestricted license in the states in which they intend to practice. Guidelines have been adopted to accommodate the inclusion of osteopathic physicians in these services.”

Professional relations with the allopathic (MD) profession
Recent years have seen an increasingly cooperative climate between the DO and MD professions. The AOA and AMA each have a delegate’s seat at the other’s House of Delegates. It is common for both groups to work together on issues affecting medical students      and physicians,  particularly on issues regarding quality of education,   residency training,       licensing exams,    licensure,   specialty board exams, continuing medical education, healthcare delivery,  public health     legal  and other professional issues.

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: “We now find ourselves living at a time when osteopathic and allopathic graduates are both sought after by many of the same residency programs; are in most instances both licensed by the same licensing boards; are both privileged by many of the same hospitals; and are found in appreciable numbers on the faculties of each other's medical schools.”

International practice rights
Currently, US-trained DO's have been recognized with full scope of medical practice rights in over 50 countries. The American Osteopathic Association has assigned responsibility for international activities to the Bureau on International Osteopathic Medical Education and Affairs (BIOMEA), which was founded in 1998.

BIOMEA monitors the global licensing and registration practices of regulating authorities around the globe, as it affects medical education and advancing the recognition of US- trained DOs. BIOMEA works with various international non-governmental organizations, such as the International Association of Medical Regulating Authorities (IAMRA), the World Health Organization (WHO), the Pan American Health Organization (PAHO) as well as other groups. In addition, BIOMEA works with US-trained DOs wishing to pursue licensure abroad, supplying information about the profession to the appropriate authorities. The Bureau is also involved in coordinating the international activities of the colleges of osteopathic medicine and specialty colleges. Every year, since 1999, BIOMEA has held an International Seminar at the AOA’s annual Osteopathic Medical Conference & Exposition; updates on current activities and global health research are given. World renown malaria researcher, Terrie Taylor DO,  spoke at the 2010 seminar.

The AOA is strengthening its efforts to work for global osteopathic unity. In the past decade, there has been an increasing need for the osteopathic medical profession to develop an alliance to promote activities of common interest and concern for both US-trained and internationally-trained practitioners. In response, the AOA helped to form the Osteopathic International Alliance (OIA). The OIA represents more than 65,000 osteopathic practitioners around the world and has more than 35 organizational members from a dozen countries.

The procedure by which countries grant licensure to foreign physicians varies widely. There are two issues to be considered, one has to do with practice rights, the other with immigration/visas and workforce needs. Immigration issues will not be discussed here. Many countries recognize US-trained MDs for licensure, granting successful applicants "unlimited" practice rights. The AOA has lobbied various national regulatory authorities as its members have increasingly sought to practice abroad. 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." The American Medical Student Association, which has student chapters at many of the colleges of osteopathic medicine, strongly advocates for the international practice rights of US-trained DOs as "equal to that" of MD qualified physicians.

For-profit medical education
The accreditation of Rocky Vista University College of Osteopathic Medicine (RVUCOM), the nation’s only for-profit medical school, has generated controversy before the school held its first class. RVUCOM currently has provisional accreditation through the American Osteopathic Association’s (AOA) Commission on Osteopathic College Accreditation (COCA) and the Colorado Commission on Higher Education. Critics claim the for-profit school "erodes [the]creditability" of osteopathic medical accreditation. The Liaison Committee on Medical Education, which accredits the MD-granting US medical schools, states that a medical school "should be, or be part of, a not-for-profit institution."

RVUCOM officials insist the for-profit status of the school will not compromise the integrity of its educational mission. Peter B. Ajluni, DO, orthopedic surgeon and AOA president (2007-2008) responded by saying:


 * I caution against a priori condemnation of an institution just because of its tax status.   There are many socially minded for-profit companies that contribute time, resources, and profits to their communities. Conversely, the US Congress is now chastising many nonprofit hospitals for not engaging in charitable missions. I believe it is the leadership of an organization—for-profit or nonprofit—that determines whether an institution has a larger social mission. Rest assured that I have no support for Caribbean and other offshore schools that do not have the accreditation status or the missions that COMs in the United States now have. And I will strongly oppose any Caribbean school setting up a "DO diploma mill.” As the current AOA president, I will certainly advocate only for the best for the osteopathic medical profession. I encourage AOA members to inform me of anything they believe indicates that RVUCOM—or any other COM—is not meeting its responsibility to osteopathic medicine's mission.

The AOA will be monitoring the quality of student produced via COCA. The AMA has stated “…in collaboration with the Association of American Medical Colleges (AAMC), the Liaison Committee on Medical Education (LCME), and the Commission on Osteopathic College Accreditation (COCA), (it) will study new and emerging models of medical school organization and governance, including for-profit models and how medical school accreditation standards can protect the quality and integrity of the education…” The first RVUCOM class is set to graduate in the Spring of 2011; time will tell how its graduates perform on standardized board exams.

Use of Osteopathic Manipulative Treatment (OMT)


Within the osteopathic medical curriculum, osteopathic manipulative treatment is taught as an adjunctive measure to other biomedical interventions for a number of disorders and diseases. However, a 2001 study of osteopathic physicians found that more than 50% of the respondents used OMT on less than 5% of their patients. The number of DO's who report consistently prescribing and performing manipulative treatment has been falling since the 1950s. Interestingly, the AMA’s 1955 report to the HOD stated “The use of manipulative therapy is decreasing in colleges of osteopathy and is increasing in the orthopedic and physiatry departments of medical schools.”

The reasons for the decline are many and varied among osteopathic medical specialists. The greatest usage of OMT is still among family practitioners. In one large study, “Ninety-six percent of the osteopathic physicians…perceived OMT as an efficacious treatment modality, but varied in the extent to which they would prefer to use various treatments…The degree to which practitioners use various techniques may be influenced by many organizational factors, including the educational continuum to which they have been exposed, time available for treating patients requiring OMT, physically and philosophically supportive facilities for OMT, and reasonable reimbursement for the time and effort to provide OMT for selected patients. However, data from this study suggest that the physician’s sense of competence and comfort level with his or her own abilities may be a key factor in determining whether OMT is the treatment of choice as opposed to nonmanipulative options.” There are concerns in the profession that with about half of osteopathic graduates entering ACGME residency programs, physicians will lose their proficiency in OMT. Innovative programs, such as that of Brown University, have attempted to compensate for this.

One area which has been implicated, but not been formally studied regarding the decline in OMT usage among DOs in practice, is the role of reimbursement changes. Only in the last several years could a DO charge for both an office visit (Evaluation & Management services) and use a procedure (CPT) code when performing OMT; previously, it was bundled. "Medical insurance bundling is the process by which payers group separately identifiable charges, as defined by CPT, and then pay for the "bundled" group at a lower rate than the sum of the individual charges." In this case, it was just considered as part of the office visit. If a physician was not getting paid for his/her services, it was easier to write a prescription for medication or PT or give an injection (if indicated - the latter of which would be reimbursed as a procedure), rather than take time to give OMT which wasn’t reimbursed. This has been rectified with regard to Medicare and Medicaid, as long as office notes are properly documented. However, some insurers will automatically flag such claims for denial. Although usually rectified on appeal, it makes the billing process more onerous. Confusion has also arisen among claims processors at insurance companies because OMT an unlimited benefit under health plans, whereas chiropractic or physical therapy are limited to a specific number of visits annually. This is because the decision to utilize OMT is made by the physician after obtaining a current history & physical examination of the patient on a visit by visit basis. It has not been researched how many physicians changed their practice patterns when they could be compensated for their OMT services.

Interest in manipulation has increased among allopathic physicians, with training being added to residency programs. Integrative Medicine Residency and Fellowship Programs such as that at the University of Arizona’s Arizona Center for Integrative Medicine teach osteopathic principles & manual medicine. (The program co-founded the Consortium of Academic Health Centers for Integrative Medicine - a consortium of academic centers and their deans from Duke, Harvard and other leading medical schools.)

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. 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.

Physical therapy has also benefited from osteopathic physicians willing to train students in osteopathic techniques, leading to their inclusion in the physical therapists’ curriculum.

Research was conducted in osteopathic medical schools nearly since their inception. ASO was one of the first places west of the Mississippi to have an x-ray machine. In 1898, William Smith MD, DO’s work entitled Skiagraphy and the Circulation: First Delineation of the Arterial System with X-rays Achieved by the American School of Osteopathy, published in the American X-Ray Journal (now the American Journal of Roentgenology), was the first research emanating from an osteopathic institution published in a non-osteopathic journal. Louisa Burns, J. Stedman Denslow and Irwin Korr were leaders in the basic research that provided a foundation for the profession. Osteopathic manipulative research faces some of the same challenges faced with research in surgical procedures; until relatively recently in medical history, procedure based therapies were not subjected to the randomized, double-blinded clinical trial standard that drug therapies were as the “gold standard for research. Procedure based therapies are notoriously difficult to double blind. There are also ethical issues that must be accounted for in such research, when utilizing “sham procedures” versus treatment, so as to harm the patient. And the sham procedure itself may alter the patient’s range of motion, pain perception, etc.

The American Osteopathic Association has stepped up its efforts 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 via competitive grant opportunities offered through the American Osteopathic Foundation (AOF). In 2001 the national Osteopathic Research Center was started at the University of North Texas, Texas College of Osteopathic Medicine. Certainly not the sole research center for the profession, it is preeminent, receiving sponsorship through the AOF, the Osteopathic Heritage Foundation and the National Institutes of Health-National Center for Complementary and Alternative Medicine (NCCAM).

All clinical trials currently under way at the ORC are funded by NIH-NCCAM. In 2009, approximately $1.7 million was received from NCCAM for ORC-related projects. No longer confined to osteopathic medical institutions, allopathic institutions are now beginning to do OMT research as well.

Research emphasis
Historically, there has been a greater focus on providing an education, and less of a focus on producing research at osteopathic institutions versus their allopathic counterparts. This has its origins in the 19th century, when the goal of osteopathic medical schools was to produce practitioners rather than academics and researchers, as was common in the leading allopathic institutions.

AT Still wanted a quality school with teachers who were academically qualified in the subject matter and able to show demonstrative truth regarding osteopathic principles and practices – the improved or cured patient. He made arrangements with physicians and scientists, trained in the best European and American schools, many of whom had come to Kirksville to learn Osteopathy, to serve as instructors and deans of his new school. This included William Smith MD, DO; John Martin Littlejohn PhD, MD, DO; David Littlejohn PhB, MD; J.B. Littlejohn AM, MD; D.M. Desmond AM, MD, etc In the first few years, he also set out to build an adequate physical building for the school and an Infirmary and Surgical Sanitarium for patients coming to Kirksville for treatment. Still built the buildings at his own expense from the money earned in clinical practice.

The leading allopathic (MD) institutions were recruiting faculty for research potential. It was considered “a disgrace to a university to appoint a man as professor chiefly because he was a good teacher…in medical school, for a man to become the head of a department, the only important consideration was the ability to good research. Teaching apparently, would be done by men in lower grades.” For historical context, Berliner and King extensively document the involvement of private foundations, the Rockefeller Institute, the Carnegie Foundation and the AMA regarding the transformation of medicine occurring at this time. William H. Welch, one of the founders of Johns Hopkins’ Medical School and School of Public Health and president of the Rockefeller Institute summarized the philosophy of philanthropic institutions, “We believe that such aid should be granted only to certain medical schools which should possess the following characteristics: The school should be upon a university basis, an integral part of an important university, completely controlled by the trustees of the university, the teachers supported by salaries paid by the universities and not by a division of fees of students. The school must already be in possession of laboratories which have been productive in research. It must be clear that the heads of these laboratories and the teaching staff in general are selected primarily for their demonstrated capacity to advance and stimulate research to train young men to become independent investigators…”

Allopathic schools were aligning themselves with universities, in order to receive gifts, endowments and government funding. Osteopathic medical schools were founded as stand alone institutions, deriving most of their funding from tuition, fees and clinical services. Given the initial opposition from the allopathic community, the profession was forced to build its own hospitals to care for patients and train young physicians. Research was largely self-funded, which tended to limit research abilities given other demands.

In time, osteopathic institutions would tend to add other graduate health programs to complement their medical programs, such as pharmacy, optometry, dentistry, and the allied health professions. These institutions then became universities of the health sciences. Today, “If the nation’s 152 Liaison Committee for Medical Education(LCME) and American Osteopathic Association-accredited medical schools were arrayed on a spectrum from most research intensive at one end to most community based at the other, at no point could one draw a bright line to separate the institutions into two discrete groups. As a reflection of this overlap, the applicant pools from which entrants to MD and DO schools are selected contain a great many of the same students.”

Rapid expansion
The osteopathic medical profession expanded fairly rapidly in the early years. By 1916, there were six legitimate osteopathic medical schools in operation: American School of Osteopathy (est. 1892), Kirksville, MO; College of Osteopathic Physicians & Surgeons (1896), Los Angeles, CA; Philadelphia College of Osteopathy (1898), Philadelphia, PA; Des Moines Still College of Osteopathy & Surgery (1898), Des Moines, IA; Chicago College of Osteopathy(1900), Chicago, IL and Kansas City College of Osteopathy& Surgery (1916), Kansas City, MO.

Because of the rapid early expansion, educators from legitimate osteopathic medical schools were greatly concerned over the effects on the profession from the “pretender” schools. Meeting in Kirksville in 1898, they organized the Associated Colleges of Osteopathy, now the American Association of Colleges of Osteopathic Medicine]]. “The association set up standards for curriculum, a minimum length of study, guidelines for the selection of faculty and students, and criteria for judging their colleges.”

1961, the College of Osteopathic Physicians & Surgeons in Los Angeles was converted to an allopathic medical school and renamed the California School of Medicine (now the University of California, Irvine School of Medicine). The next school to open and the first publicly supported osteopathic medical school was Michigan State University College of Osteopathic Medicine in 1969. Eight more schools would open in the 1970s, Nova Southeastern University, College of Osteopathic Medicine alone opened in 1980s. During the 1990s, four more schools or branch campuses opened. From 2000 to 2010, thirteen schools, branch campuses or remote teaching sites were opened; two more are scheduled to open in 2011.

Annually, “the American Association of Colleges of Osteopathic Medicine surveys member colleges on planned growth over the coming six years…As of December 14, 2009…based on current projections, 6,297 new students are expected to matriculate into the (current) 26 osteopathic colleges and three branch campuses in fall 2015. This is an increase of 1,193 first-time, first-year medical students over the class that entered in fall 2009 (a 23.4 percent increase). The six public osteopathic colleges project an increase of 177 students (or 17 percent); the 23 private colleges and branch campuses project an increase of 1,016 students (or 25 percent). The projections include one college that will enroll its first class in fall 2010, and two branch campuses or additional teaching sites that are scheduled to open over the next five years.”

The challenge to expanding the physician workforce has been finding clinical rotation sites for medical students, DO or MD. Osteopathic schools have long been able to do this by expanding rotations sites beyond the academic medical centers to community hospitals, while this is a relatively recent phenomena for allopathic schools. A multi-campus clinical configuration leads to challenges in implementing a consistent and standardized flow of learning, this has been overcome by extensive monitoring of student learning outcomes. Learning objectives for both required and clinical rotations are centrally coordinated and locally implemented. “…(T)eaching and learning resources such as student manuals and instructor PowerPoint presentations, introduced specific training in OMM skills into the formal didactic portion of the clinical years…Students' progress is monitored using logs, exit objectives lists, postrotation exams, National Board of Medical Examiners (NBME) shelf exams, end-of-third-year exams, and NBME end-of-rotation exams…” in addition to supplemental telemedicine grand rounds and preceptor evaluations. The flexibility of osteopathic schools has been praised for allowing them to develop schools innovative curriculum models of education in nontraditional locations.

By 2020, the number of osteopathic physicians is projected to be over 100,000, according to the American Medical Association.

The biggest issue facing both DO & MD medical education in the US is developing and maintaining graduate medical education or residency training programs. Graduate Medical Education (GME) has been funded by the Centers for Medicare and Medicaid Services (CMS), since Medicare was created in 1965, to compensate the hospitals for the expense of training young physicians. “…Congress passed a law in 1997 that imposes a hospital-specific limit on the number of residents that Medicare will pay for. In general, the limit is based on the number of residents that a hospital trained in 1996. At present, there is no way to increase the number of paid residency slots unless Congress changes the 1997 law.

Both DO and MD schools are increasing admissions, and therefore graduates, in response to the projected physician workforce shortage. There are currently enough GME programs to accommodate all osteopathic medical graduates as it is part of the accreditation requirements of osteopathic medical schools. However, since approximately half of DOs choose ACGME postgraduate training in any given year, there is concern among osteopathic medical educators that they maybe crowded out of training slots if DOs do not continue to create and maintain their own residency training positions. Current AOA President, Karen Nichols DO, MA, FACOI, is calling for osteopathic specialty colleges to develop and expand residency training programs.

Brand identity
The “DO” degree designation has continued to be a debate almost since the inception of the profession. As far back as 1899, it was entered into the notes of the American School of Osteopathy record book by John Martin Littlejohn MD, PhD, DO, the first dean of the first medical school:


 * Whereas it is provided in the charter of the American School of Osteopathy that this college “shall grant and confer such honors and degrees as are usually granted and conferred by reputable Medical Colleges,” and “issue diplomas in testimony of the same;” and whereas the title of Diplomat or Doctor of Osteopathy had never been conferred by any medical college; it is hereby resolved that the faculty recommended to the trustees the execution of the power of the charter of the school by hereby conferring this degree of Dr. of medicine and in recognition of osteopathy as an independent school of medicine and system of healing as it is so declared by statue in Missouri and other states that have recognized Osteopathy and the requirements of the charter, that the designation and title shall be hereafter M.D. (Osteopathic).


 * The motion laid on the table at the last meeting event, the degree to be conferred by the school was then taken up for consideration. On motion it was accepted by the faculty and was ordered submitted to the trustees for approval with the strongest recommendation of the faculty that the trustees authorize the proposed change in the diploma and take the necessary steps to carry out the proposed change.

This would later cause a rift between Littlejohn and his brothers, who were also teaching at ASO, and Dr. Still. As a result, Littlejohn left ASO and went on to found the Chicago College of Osteopathy (now Midwestern University) and then the British School of Osteopathy. Interestingly, the Chicago school would also confer the Doctor of Osteopathy degree.

The debate continues simply because the profession has not universally established its brand identity in the healthcare marketplace. Osteopathy has done a better job of proliferating in the global medical community, which in the past has led to some confusion when osteopathic medicine is introduced. The establishment of the Osteopathic International Alliance, this has helped facilitate the distinction, particularly in markets where osteopaths and osteopathy is already a regulated profession. In addition, the AOA’s and NBOME’s participation in the International Association of Regulatory Authorities, has helped clarify and validate the training and practice rights of US trained osteopathic physicians.

Domestically, the osteopathic medical profession is well established in the medical, educational, government and military communities, as previously elucidated. But it has not always so well differentiated itself with the public at large. While the profession has long overcome any legal or curricular matters regarding full scope of medical practice, it has not fully resolved its market recognition factor. The issue is geographic and regional; it tends to occur in areas where historically there have been low concentrations of osteopathic physicians. The DO degree designation periodically arises as a subject of debate within the profession. Any resolution to the debate is compounded by the fact that there are 50 state legislatures that have laws regarding the profession that would require statutory changes by their respective state legislatures to implement any change.

The current situation is well described by Arnold Melnick DO, MSc, DHL(hon), FACOP, former president of the American Medical Writers Association and the American College of Osteopathic Pediatricians, and the founding dean, executive vice chancellor and provost of  Nova Southeastern University Health Professions Division in a recent JAOA article.
 * There has been considerable discussion recently of the advisability of changing the DO degree. Good-willed, well-intentioned DOs have strongly suggested a change, and equally well-meaning and competent osteopathic physicians have opposed it. Admittedly, there are a few—very few, I believe—MD-wannabes, and any discussion of degree modification would not satisfy this extreme group; I am not addressing that here…Historically, we changed our degree some years ago from doctor of osteopathy to doctor of osteopathic medicine, but maintained DO as its abbreviation. The disagreement is really about the abbreviation…in the healing arts, there are 2 professions: Allopathic Medicine and Osteopathic Medicine. Both are recognized by each other, by all government agencies, and by almost all of the population. These are 2 separate (not as much as previously), rather distinct, almost parallel, and in some aspects “competitive” professions offering complete healthcare to the public. Most practitioners in each group want the public to be able to recognize what they are instantly—by means of a degree. Would changing the degree alter the public’s conception of what each is or does? Hardly…No change of degree would change ignorant or prejudiced mind-sets. What it would do is create a new problem—explaining to believers and non-believers alike what the new ABC is... What is an ABC? Is it the same as the DO? Or is it the same as an MD? Or is it something new? We would have to explain carefully this change to all our patients (with patience!)—taking a lot of valuable time…And we would not be able reach all those out there we do not reach now. But it would create more questions, more doubts, and more controversy among the rest of the world. We’ve already arrived—why stir things up? …A homely analogy: zebras, seeing the greater popularity and acceptance of horses and the many ways they resembled horses, might opt to change their names to “horses.” They would still be zebras but would continue calling themselves “horses.” Those people who knew what a horse was and what a zebra was would be totally confused. Those who didn’t know what a horse was and what a zebra was really wouldn’t care.

Given this debate has continued now for over 110 years, it will likely continue until the average man or woman on the street, in any town, in any state is as familiar with the “DO” brand of physician as they are with the “Apple” system of computing; the branding issue must be addressed. A 2001 study of the US population demonstrated that the osteopathic medical profession was halfway there.

The DO difference
Since the profession began in the late 1800s, medicine in America has dramatically changed. Bloodletting, purging, puking and opium are no longer the standard treatments. Medications and vaccination now work. Many of the basic tenets of osteopathic medicine are accepted by allopathic institutions. One study found a majority of MD medical school administrators and faculty saw nothing objectionable in the core principles of osteopathic medicine, and some would even endorse them generally as sound medical principles. As with any area of medicine, more research can always be done; however, osteopathic manipulative techniques are utilized by physicians and other health professionals around the world.

Since DOs have proven themselves equivalent, the question then becomes what is the DO difference? The question has been raised, by DOs and prominent MDs - Why maintain a separate system at all? DOs tend to look askew at any attempt to assimilate them into the MD world given the profession’s historical experience; DOs have mistrust for medical hegemony.

A.T. Still repeatedly referred back to the founding charter of the American School of Osteopathy in his writing and speechmaking. Osteopathic medicine as a profession is “to improve our present system of surgery, obstetrics, and treatment of diseases generally, and place the same on a more rational and scientific basis, and to impart information to the medical profession…”

Due to its minority status, the profession has had to be flexible, adaptive and innovative in an ever-changing healthcare environment. While other schools of medical thought have long gone by the wayside, osteopathic medicine has continued to grow and thrive. Its institutions are willing to look at new methods of instruction, teaching, training and examining students, which has won awards from the allopathic profession.

A.T. Still was always looking for a better way of doing things, as evidenced by his inventions & patents; medicine was no different. Finding and fixing the derangements of the musculoskeletal system was just the beginning for the osteopathic physician. He made clear that his definition of anatomy reached to the microscopic and biochemical level, even in the late 1800s. He advocated for evidence-based medicine as only a man of the 19th century could. His vision was for a work that would go on indefinitely. It has been postulated that the next reiteration of osteopathic medicine will be in leading the way in finding the most clinically-effective, cost-effective medicine. The profession will remain distinct and relevant if it remains innovative and true to Dr. Still’s greater vision of finding a better way to practice medicine.

US Osteopathic regulatory bodies

 * American Osteopathic Association (Website)
 * American Association of Colleges of Osteopathic Medicine (Website)
 * National Board of Osteopathic Medical Examiners]
 * American Osteopathic Intern/Resident Registration Program

Journals

 * Chiropractic & Osteopathy An online journal published by BioMed Central
 * International Journal of Osteopathic Medicine
 * Journal of the American Osteopathic Association The official journal of the American Osteopathic Association
 * Osteopathic Medicine and Primary Care An online journal published by BioMed Central
 * The Journal of the American College of Osteopathic Family Physicians.

Student groups

 * Student Osteopathic Medical Association
 * Unified Student Movement for Osteopathic Integration
 * Osteobook.net

Professional associations

 * American Academy of Osteopathy
 * American College of Osteopathic Family Physicians
 * American College of Osteopathic Internists
 * Association of Military Osteopathic Physicians and Surgeons
 * American Osteopathic College of Occupational & Preventive Medicine

Other organizations

 * DO-Online.org
 * Osteopathic heritage foundation
 * The History of Osteopathic medicine museum
 * Still National Osteopathic Museum
 * Pontiac Osteopathic Hospital
 * Centers for Osteopathic Research and Education
 * Osteopathic Center for Children & Families
 * American Osteopathic Foundation
 * Kirksville College of Osteopathic Medicine - A.T. Still University

Ostéopathie אוסטאופתיה Доктор по Остеопатија Osteopathie オステオパシー Остеопатия