Osteopathic medicine in the United States

Osteopathic physicians on rounds in a US teaching hospital

Osteopathic medicine (also known as osteopathy) is a system of medicine in the USA with a distinct worldview that applies osteopathic philosophy, principles, and treatment to standard medical care. Outside of the United States, "osteopathic medicine" is often used interchangably with "osteopathy".

With a strong emphasis on the inter-relationship of the body's nerves, muscles, bones, connective tissue and organ systems, Doctors of Osteopathic Medicine, or D.O.s, apply the philosophy of treating the whole person (holistic approach) to the prevention (medical), diagnosis and treatment of illness, disease and injury using conventional medical practice such as drugs and surgery, along with manual therapy (OMM).

Thus, like Doctors of Medicine (M.D.s), Doctors of Osteopathic Medicine (D.O.s)educated in the United States are fully licensed physicians and surgeons who practice the full scope of medicine. In most other parts of the world, D.O.s are not medically trained practitioners. Currently, there are 21 accredited D.O.-granting U.S. medical schools and 125 accredited M.D.-granting U.S. medical schools. Because of the abundance of M.D. schools, many people are more familiar with them; however, osteopathic medicine is growing at an unprecedented rate. Many new schools are planned to open in the coming years and existing schools have expanded enrollment to meet the increased demand for the physician workforce, particularly as baby boomers age. The majority of entering U.S. osteopathic medical students hold bachelor's degrees and some also hold master's degrees (M.S., M.A.) or other doctorate degrees (Ph.D., J.D.).

M.D. and D.O.-granting U.S. medical schools have similar curricula. Generally, the first two years are classroom-based, with certain programs providing patient contact, while third and fourth years consist of rotations through the different major specialties of medicine. Upon graduation, M.D. and D.O. physicians pursue residency (medicine) training programs. Depending on state licensing laws, osteopathic physicians may also be required to complete a 1 year rotating internship. Osteopathic physicians also have the opportunity to pursue allopathic (M.D.) residency programs; however, the converse is not allowed. Within the U.S., osteopathic physicians practice in all medical specialties including, but not limited to, internal medicine, dermatology, surgery, radiology, etc. There is no distinction in pay between allopathic (M.D.) and osteopathic (D.O.) physicians, but physician salaries differ noticeably among the various medical specialties.

Osteopaths educated in countries outside of the U.S. do not follow the same curriculum as U.S. trained D.O.'s. Their scope of practice is limited mainly to musculoskeletal conditions and treatment of some other conditions using manual treatment (OMM), not unlike chiropractors in the USA.

History

Osteopathy was founded by Andrew Taylor Still, M.D., D.O., who was born in 1828 in Virginia, in reaction to what he perceived as inadequate medical treatment of his day. Specifically, he believed that other conventionally trained physicians over-prescribed to patients harsh and often toxic medications. He invented the name "osteopathy" by blending two Greek roots osteon- for bone and -pathos for suffering in order to communiciate 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. 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 (e.g. antiseptics, ointments, or laxatives).

Osteopathic medical practice began approximately 120 years ago in the Midwest of the United States, just before chiropractic. From its very inception, early practitioners embraced the movement's philosophy and theories to varying degrees. Some held steadfastly to its core tenets while others were more apt to 'blend' features of osteopathy with other conventional or competing schools of medicine. Thus, early in the twentieth century, the American osteopathic profession adopted the use of medicine and surgery, whereas chiropractors continue to use strictly manipulative techniques. Outside of the USA, osteopaths tended to stay closer to their traditional approach. As biomedical science developed, osteopathy gradually incorporated all its proven theories and practices. Qualified DO's have been admitted to full active membership of the American Medical Association since 1969. Today, except for a stronger primary care emphasis in most osteopathic medical schools and additional education in musculoskeletal diagnosis and treatment, the training and scope of osteopathy in the United States is identical to that of allopathic or conventional biomedicine.

Current status and scope of practice

Because of the varying degrees of acceptance of osteopathic theories and principles among early practitioners, there are two divergent scopes of practice within the osteopathic world. Though they are so different as to be considered two separate professions, there have been attempts in the last few years to enhance exchange and dialogue between them. In other parts of the world, especially Australia, and New Zealand, D.O.'s have a narrower scope of practice limited to manual therapy.

In the United States osteopathic physicians (D.O.'s) are medically trained practitioners. Because only 6% of physicians in the USA are D.O.'s, many patients are unaware that the D.O. degree is the legal and professional equivalent of the M.D. degree. Acceptance by traditional M.D.s and their institutions was once an issue for osteopathic practitioners. Today, D.O.s and M.D.s work side by side in the health care setting. However, this wasn't always the case and osteopathic medicine's historical, and often confrontational, clashes with organized allopathic medicine is ocassionally a point of contention between the fields.

In the 1960s in California, the American Medical Association (AMA) spent nearly $8 million to end the practice of osteopathy in the state. With considerable financial support from the AMA, the state passed a state wide referendum (Proposition 22) ending the practice of osteopathic medicine in California. California D.O.'s were granted the M.D. degree in exchange for paying $65 and attending a short seminar. The College of Osteopathic Physicians and Surgeons became the University of California, Irvine, College of Medicine. However, the decision proved quite controversial. In 1974, after protest and lobbying by a group of influential and prominent D.O.'s, the California Supreme Court ruled that licensing of D.O.'s in that state must be resumed.

File:COPSLA2.jpg

College of Osteopathic Physicians and Surgeons in Los Angeles, c.1920s. From California College of Medicine Records, AS-027 The osteopathic college was eventually absorbed into the University of California system following a state-wide ballot referendum and become the UC Irvine Medical Center.

This decision by the California Medical Association in the 1960s to grant D.O. physicians an M.D. license was one of two turning points for D.O.s in their struggle for parity; the other being the U.S. Army's decision to allow D.O.s to enter the military as physicians. The California Medical Association may have been attempting to eliminate the osteopathic competition by a process of amalgamation by converting thousands of their physicians to M.D.s. While most Californian D.O.s did take the opportunity to become M.D.s in order to improve their access to mixed-staff hospitals and enjoy wider professional recognition, in other parts of the country it provided the osteopathic community with the stamp of equivalency they desired.

Still, there is no doubt that osteopathic medicine, as a progressive social movement, has influenced the general practice of American medicine. Indeed, some osteopathic medical schools in the USA have opened basic courses in osteopathic manual therapy for their M.D. colleagues. Many continuing medical education programs in osteopathic manipulation are also offered to M.D.'s and physical therapists.

Criticisms

Osteopathic medical schools have been criticized for being less focused on research and scientific discovery than allopathic schools. More recently, osteopathic medical schools have consciously worked toward becoming more research focused, but still lag far behind their allopathic counter-parts in NIH dollars, biomedical discovery, and prestige. Critics also have highlighted the lower average academic attainment of matriculants to osteopathic schools--GPA, 3.45 for osteopathic vs 3.55 for allopathic matriculants, and MCAT scores, an average of 25.5 for osteopathic vs 29.7 for allopathic matriculants--as evidence of lower admission standards. While the average GPA and MCAT scores are indeed lower at osteopathic medical schools compared to allopathic schools, some have argued that this difference really reflects osteopathic admission committees' emphasis on a variety of non-academic factors and personal characteristics believed to be centrally important to training physicians with a more generalist or holistic orientation.

In the United States osteopathic medicine has been criticized for including therapies such as cranial and cranio-sacral manipulation, for having a greater tolerance for alternative medical practices, and failing to demonstrate therapeutic superiority of osteopathic treatment modalities, used either alone or in combination with conventional biomedical treatment, over standard medical care alone. The scientific merit of all manipulative therapies continues to be controversial. Within the osteopathic medical curriculum, manipulative treatment is taught as an adjunctive measure to other biomedical interventions for a number of disorders and diseases. The American Osteopathic Association has made an effort in recent years to both support and promote scientific inquiry into the effectiveness of osteopathic manipulation as well as encourage D.O.s to consistently offer manipulative treatments to their patients. However, the number of D.O.s who report consistently prescribing and performing manipulative treatment has been falling steadily. The reasons for this are poorly understood, but are believed to be related to changes in the general financing and delivery of health care, fewer D.O.s training in exclusively osteopathic post-graduate residency (medicine) training programs, and a lack of perceived relevance to a number of specialties and sub-specialties that D.O.'s pursue.

Future challenges

Over 120 years after its founding, the field continues to struggle with core identity issues. While it interfaces, cooperates, and allies itself with the standard biomedical enterprise and industries, it simultaneously retains and defends its own distinct professional identity if for no other reasons than historical or sentimental ones.

Osteopathic medicine first developed its unique and proprietary treatment modalities in the early 19th century as a distinct alternative to conventional medical practice. These modalities moved through stages of discovery, development, refinement, and translation in order to be integrated into a modern biomedically-oriented osteopathic educational curriculum. This curriculum was instituted in largely free-standing educational institutions, community hospitals, and clinics that were relatively isolated from well-established scientific and medical training centers. Both internal and external competing interests shaped this process in a largely serendipitous fashion.

Recently the movement, including its professional organizations, colleges, and specialty societies, has gone to great lengths to define itself in terms of its holistic system of diagnosis and treatment. Critics point out that such a definition implies that the field is somehow separate from mainstream medicine and question if this definition is in reality a false distinction. Others prefer to view the field as being complementary to mainstream medicine by offering a form of patient care and health services that encompasses and extends standard medical practice.

In either case, given its recent unprecedented growth and expansion, osteopathic medicine is about to embark on a new phase in its social evolution. It has tenuously positioned itself as a bridge between medical care that is conventionally considered evidence based medicine versus complementary and alternative medicine. It has developed and implemented a network of colleges, post-graduate training institutions, professional organizations, federally-recognized professional certification standards, hospitals and health care networks in order to deliver a package of health services based on a distinct worldview of patient care.

In order to secure its relevance in a modern, integrated health care system, its success will depend upon conscientious organizational leadership, the stewardship of its academic community, and continued long-term investment in research infrastructure. This will be needed in order to demonstrate cost-effective, positive treatment effects for the services it provides. In order to sustain and perpetuate itself as a social movement within medicine and the health care industry, it will need to attract and garner the support of recent osteopathic medical graduates comprising a generation of osteopathic physicians who have benefited from widespread acceptance, unrestricted practice opportunities, and post-graduate training and mentorship that has occurred, to a large degree, outside of the osteopathic profession.

External links

Apply to US osteopathic medical schools

US osteopathic medical schools

Canadian osteopathic college

Canadian College of Osteopathy

US Osteopathic associations and regulatory bodies

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