The following is a call for reform of osteopathic education
Thanks to the efforts of osteopathic forefathers to gain equality with allopathic medicine at every level, osteopathic medicine has enjoyed its greatest growth over the past few decades. Unfortunately, the call for changing the DO degree title has become louder and louder; www.osteoreform.com has launched a grassroots campaign for change to MD, DO degree. Even though people entering this profession are well aware of its minority position in the medical field, they still choose it because they want to become a different and better kind of physician with a holistic approach to patient care. It is true that there is lack of public recognition of the DO degree, but the underlying lack of pride in the profession is the main reason because the profession has failed to train them to become a different kind of physician. It should be reminded that 15% of 2000 DOs in California refused to trade in their degree during the DO and MD merger in 1962 because they were proud of their professional skills despite blatant discrimination and limited access to care for their patients at that time.1 Nowadays, graduating and practicing DOs see more similarities than differences with allopathic medicine, the perception that OMM is the only distinction separating the profession from allopathic medicine and the use of OMM has been in decline.2 Sadly, extra 200 hours of OMM instruction to our students failed them miserably according to the examination of basic competence levels in Musculoskeletal Medicine by orthopedic standards designed by Freedman and Bernstein5; 70.4% of osteopathic students and 82% of allopathic failed the test.6
No other health professions than osteopathic medicine is better equipped to respond to the trend of healthcare demand of an increasing public interest in complementary and alternative medicine in recent years. According to the National Institutes of Health’s National Center for Alternative and Complementary Medicine (NCCAM), Americans spent more than $27 billion on alternative or complementary therapies in 1997. An estimated 629 million visits to alternative practitioners in 1997 exceeded the 386 million visits to all U.S. primary care physicians15. Furthermore, musculoskeletal conditions and injuries are among the most common reasons for visits to physicians in the United States. It accounted for more than 131 million patient visits in 199516 and incurred a cost of 215 billion annually17. According to the survey of the Steering Committee on Collaboration among Physicians Providers Involved in Musculoskeletal Care, 31% and 10% of allopathic physicians felt adequately prepared to assess physical problems of low back pain and for foot pain, respectively. In contrast, 84% and 41% of osteopathic physicians felt well prepared to assess low back pain and hand problems, respectively16.
The above stated statistics should make DO degree more desirable rather than being challenged. However, the 2009 AOA match results showed again the continuing trend of more than half of graduating DOs opted to choose ACGME programs.3
These should be a wake-up call for our profession to reform urgently our undergraduate and post-graduate medical education curriculum by integrating fully the osteopathic principles and practices (OPP) in the training so that future osteopathic physicians have a sense of being a different kind of physicians and being part of a special branch of medicine.
Undergraduate Osteopathic Medical Education
The formative years of any training is life-time lasting; therefore, a strong OPP11,12 curriculums in undergraduate medical education is very important regardless of the specialties or the residency trainings either by OGME or ACGME that the students intend to go into. For example, I am a foreign-born and my English is broken, my training has been osteopathic pathway until I am doing a vitreo-retinal surgery fellowship. My patient population has blinding diseases, my approach to patients’ visual problems with a different angle from a pure vitreo-retinal surgeon because of my fellowship background in neuro-ophthalmology. I look for possible visual pathway disorders that may cause patients’ visual impairment. With my osteopathic background emphasizing on the power of touch, I always give my patients a compassionate touch or holding their hands with my two hands to show that I care. The difference of patient interaction by osteopathic and allopathic physicians has been evaluated.7
Therefore, I propose that extra-time be allocated to the undergraduate curriculum to incorporate OMM, prevention, nutrition, spirituality and other forms of alternative medicine so that our graduates can be confident to provide informed advice to the increasing interest of the public in their health. Our students need extra-time to acquire the uniqueness of our holistic approach to the patient care and still have sufficient time to acquire the tremendous and increasing amount of information of Basic Sciences during the first two years of medical school. Therefore, our medical school should start slightly earlier, i.e., in June instead of August, which gives an extra 320 hours of instruction. If we claim that we have something extra to offer than our allopathic counterparts, it should be reflected in our curriculum. Sufficient numbers of OMM faculty members at undergraduate medication and exposure to basic research related to OMM are important to impregnate the merits of OMM and the distinctiveness of OPP. Furthermore, core rotation and hands-on in OMM and CAM, a dissertation of OPP or holistic philosophy of care should be instituted as a requirement for graduation. The firm foundation of OPP imparted in our graduates will give them a sense of confidence, pride and being different and of something else than our allopathic counterparts regardless of GME pathways they choose to go into.
I can also anticipate the argument that more schooling time will incur more students debts, which is already phenomenal, graduating DOs have an average of $150,000 student loan debts for their medical education.14 Also, the argument of OMM should be a specialty and not all DOs should be proficient in it and only a small number DOs actually use OMM in their practice. First of all, OMM is not equivalent to OPP. OMM is only a diagnostic and therapeutic tool. My counter-argument would be if my rotations in other specialties during my training were wasteful because I am now an ophthalmologist. The answer is so obvious that no answer to the statement is required. OMM is another specialty that makes a DO well-rounded. By the way, manual medicine is specialty that only physicians in Germany can practice and they need 710 hours of training in manual medicine and OMM before attaining their specialty qualification.4
Osteopathic Graduate Medical Education
Currently, 49% of OGME residency positions and 52% of OGME internship positions are filled10 while 60% of osteopathic graduates are being trained in ACGME residency programs. Migration of DOs to ACGME programs because they believe in the better quality training and prestige of the allopathic programs, urgent and radical reform OGME is required in order to preserve the funding of the unfilled slots, attract quality graduating DOs and expand OGME programs. With the dwindling number of osteopathic hospitals, either closed or merged with bigger allopathic institute, osteopathic students and residents are being and will be trained by MDs alongside with DOs. It is time to end our self-imposed segregation and isolation of our medical training to the allopathic graduates and IMGs. Besides, we are trying to establish new OGME programs in “virgin” hospitals, which are mostly staffed by MDs, the allopathic support is crucial to the success of new programs. By integrating MDs in our osteopathic training programs, hospitals will not be seen as only osteopathic teaching hospitals. In addition, competition fosters improvement and excellence in our OGME programs. Therefore, creating pathways are needed for MDs and IMGs to acquire the knowledge of OPP and OMM, to join our ranks and to be trained in OGME programs. Our uniqueness of OPP should be fully integrated in the practice and training at the host hospitals with the presence of OMM specialists or extenders, such as non-physician osteopaths trained abroad.
It is also realistic that medical education has become more expensive and ways should be found to shorten the length of medical training. About 36 allopathic institutions have offered combined 6-7 year BS/MD, BS/DO medical program.8 LECOM have designed a three-year accelerated curriculum designed to encourage students to choose primary care careers and also in hope of saving the cost of education and living of an extra-year.13 In 2006, restructuring the traditional internship in 3 different categories that allowed each specialty college to choose its preferred model is a step in the right direction.9. At least, medical students can match or track to the specialty of their choices in their senior year. Moreover, more choices of non-primary care specialty trainings need to be developed in order to attract our graduates and also respond to their career aspirations.
In conclusion
As the golden age of medicine has long gone, medical profession faces hostile environment by practicing defensive medicine, medical training is a long journey and requires lots of sacrifices, education is exorbitantly expensive, what are the main reasons most osteopathic medical students have chosen this minority medical profession? The prestige of the DO degree is the least concerning reason for choosing this profession as DOs have reached the parity with MDs at all levels of the government and healthcare industry. However, the expectations of uniqueness and quality of education and training of osteopathic medicine are high. Only failure of the profession to respond to these expectations will make its members disgruntled. Pride in the special skills and in the uniqueness of the profession’s philosophy is the answer to put an end to the debate of the degree title. "Let's the light so shine before men that the world will know that you are an Osteopath pure and simple, and that no prouder title can follow a human name." A.T. Still.
References
1. JD Howell, MD PhD The Paradox of Osteopathy. N Engl J Med. 1999 Nov 4;341(19):1465-8.
2. Richarson ME. Tracing the Decine of OMT in Patient Care. J Am Osteopath Assoc. 2006; 106(7):378-379.
5. Freedman KB, Bernstein J. The adequacy of medical school education in musculoskeletal medicine. J Bone Joint Surge Am. 1998; 80: 1421-27.
6. Stockard AR, Allen TW. Competence Levels in Musculoskeletal Medicine: Comparison of Osteopathic and Allopathic Medical Graduates. J Am Osteopath Assoc. 2006; 106(6): 350-55.
7. TS Carey, TM Motyka, JM Garrett, and RB Keller. Do osteopathic physicians differ in patient interaction from allopathic physicians? An empirically derived approach
J Am Osteopath Assoc, 2003; 103(7): 313 -18.
J Am Osteopath Assoc, 2003; 103(7): 313 -18.
9. Joyce L. Obradovic and Pamela Winslow-Falbo. Osteopathic Graduate Medical Education. J Am Osteopath Assoc, 2007; 107(2): 57 - 66.
10. Burkhart DN, Lischka TA. Osteopathic Graduate Medical Education. J Am Osteopath Assoc 2008; 108:127-137.
11. Special Committee on Osteopathic Principles and Osteopathic Technic, Kirksville College of Osteopathy and Surgery. Interpretation of osteopathic concept prepared by committee at Kirskville. J Osteopath, October 1953; 60:7-10.
12. Rogers FJ, D’Alonzo GE, Glover JC, Korr IM, Osborn GG, Pattterson MM, et al. Proposed tenets of oseteopathic medicine and principles for patient care. J Am Osteopath Assoc. February 2002; 102: 62-63.
13. Bell HS, Ferretti SM, Ortoski RA. A Three-Year Accelerated Medical School Curriculum Designed to Encourage and Facilitate Primary Care Careers. Acad Med 2007; 82 (9): 895-99.
15. Gaylord S, Mann JD. Rationales for CAM in Health Professions Training Programs. Acad Med 2007; 82:927-933.
16. National Center for Health Statistics, National Ambulatory Medical Care Survey. Washington, DC: U.S. Government Printing Office, 1995
17.Praemer A, Furmer S, Rice DP. Musculoskeletal Conditions in the United States.Rosemont,IL:American Academy of OrthopaedicSurgeons, 1999
The DO's should be given an option to change their designation to MD for the purpose of public recognition. FMG's with MBBS degrees do it all the time. They don't use MBBS, they use MD.
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