Founded as osteopathy by frontier physician Andrew Taylor Still as a radical rejection of the prevailing system of medical thought of the 19th century, the profession gradually moved closer to mainstream medicine in its practices, and came to be called "osteopathic medicine". Today, the training of osteopathic physicians is virtually identical to that of their MD counterparts. Osteopathic physicians use all conventional methods of diagnosis and treatment but are trained to place additional emphasis on the achievement of normal body mechanics as central to maintaining good health. DO physicians receive training in Osteopathic Manipulative Medicine (OMM), a form of manual therapy shown to be of benefit for patients with certain musculo-skeletal disorders. However, this form of therapy is used by a minority of osteopathic physicians in actual practice. In the United States, osteopathic medicine is considered by some both a profession and a social movement.
Although US osteopathic medical physicians currently may obtain licensure in 47 countries, osteopathic curricula in countries other than the United States differs. DOs outside the US are known as "osteopaths" and their scope of practice excludes usual medical therapies and relies more exclusively on osteopathic manipulative medicine and other alternative medical modalities.
Discussions about the future of osteopathic medicine frequently debate the feasibility of maintaining distinctiveness within the broader US physician community. More recently, the topic of for-profit medical education has become an issue.
From its inception, the osteopathic profession has been smaller than the older MD profession. Currently, there are 25 accredited osteopathic medical schools in 28 locations in the United States and 126 accredited US MD medical schools.
Osteopathic physicians are unevenly distributed in the United States. The states with the highest concentration are Michigan and Oklahoma where osteopathic physicians comprise over 20% of the total physician workforce. The state with the greatest number of osteopathic physicians is Pennsylvania, with 5,500 DOs in active practice in 2007. The states with the lowest concentrations of DOs are Louisiana, Massachusetts and Vermont where only 1-2% of physicians have an osteopathic degree. Public awareness of osteopathic medicine likewise varies widely in different regions.
In addition to the Hippocratic oath, Osteopathic medical students take an oath to maintain and uphold the "core principles" of osteopathic medical philosophy. Revised in 1953, and again in 2002, the core principles are:
Frontier physician Andrew Taylor Still, MD, DO, founded the American School of Osteopathy (now Kirksville College of Osteopathic Medicine of A.T. Still University of Health Sciences) in Kirksville, MO, in 1892 as a radical protest against the turn-of-the-century medical system. A.T. Still believed that the conventional medical system lacked credible efficacy, was morally corrupt, and treated effects rather than causes of disease. He founded osteopathic medicine in rural Missouri at a time when medications, surgery, and other traditional therapeutic regimens often caused more harm than good. Some of the medicines commonly given to patients during this time were arsenic, castor oil, whiskey, and opium. In addition, unsanitary surgery often resulted in more deaths than cures. He intended his new system of medicine to be a reformation of the existing 19th century medical practices he knew and imagined that someday "rational medical therapy" would consist of manipulation of the musculoskeletal system, surgery, and very sparingly used drugs. He invented the name "osteopathy" by blending two Greek roots osteon- for bone and -pathos for suffering in order to communicate his theory that disease and physiologic dysfunction were etiologically grounded in a disordered musculoskeletal system. Thus, by diagnosing and treating the musculoskeletal system, he believed that physicians could treat a variety of diseases and spare patients the negative side-effects of drugs.
The new profession faced stiff opposition from the medical establishment at the time. The relationship of osteopathic and MD professions was often "bitterly contentious" and involved "strong efforts" by medical organizations to discredit osteopathic medicine. Throughout the first half of the twentieth century, the policy of the American Medical Association labeled osteopathic medicine as a cult and DOs were seen as "cultist." The AMA code of ethics made it unethical for an MD physician to voluntarily associate with a DO One notable advocate for the fledgling movement was Mark Twain. Manipulative treatments had purportedly alleviated the symptoms of his daughter Jean's epilepsy as well as Twain's own chronic bronchitis. In 1909, he spoke before the New York State Assembly at a hearing regarding the practice of osteopathy in the state. "I don't know as I cared much about these osteopaths until I heard you were going to drive them out of the state, but since I heard that I haven't been able to sleep." Philosophically opposed to the American Medical Association's stance that its own type of medical practice was the only legitimate one, he spoke in favor of licensing for osteopaths. Physicians from the New York County Medical Society responded with a vigorous attack on Twain, who retorted with "[t]he physicians think they are moved by regard for the best interests of the public. Isn't there a little touch of self-interest back of it all?" "... The objection is, people are curing people without a license and you are afraid it will bust up business."
|Evolution of osteopathic medicine's mission and identity|
|Years||Identity & Mission|
|1892 to 1950||Manual medicine|
|1951 to 1970||Family practice / manual therapy|
|1971 to present||Full service care / multispeciality orientation|
In 1969, the AMA House of Delegates approved a measure allowing qualified osteopathic physicians as full and active members of the Association. The measure also allowed osteopathic physicians to participate in AMA-approved intern and residency programs. However, the American Osteopathic Association rejected this measure, claiming it was an attempt to eliminate the distinctiveness of osteopathic medicine. In 1970, AMA President Dwight L. Wilbur, MD sponsored a measure in the AMA's House of Delegates permitting the AMA Board of Trustees' plan for the merger of DO and MD professions. Today, a majority of osteopathic physicians are trained alongside MDs, in residency programs governed by the ACGME, an independent board of the AMA.
The AMA has stated that:
In 2006, calls for an investigation into the existence of differential fees charged for visiting osteopathic and MD medical students at American medical schools were brought to the American Medical Association. After an internal investigation into the fee structure for visiting DO and MD medical students at MD medical schools, it was found that one institution of the 102 surveyed charged different fees for DO and MD students. The house of delegates of the American Medical Association adopted resolution 809, I-05 in 2007.
|Osteopathic medical schools|
|AT Still Kirksville|
|Des Moines COM|
|Kansas City COM|
|Northeast||Lake Erie COM|
|New England COM|
|New York COM|
|Southeast||Lake Erie COM Bradenton|
|North Texas COM|
|Philadelphia COM Georgia|
|West Virginia SOM|
|West||AT Still Arizona|
DO-granting US medical schools have curricula identical for the most part to those of MD-granting schools. Generally, the first two years are classroom-based, while the third and fourth years consist of clinical rotations through the major specialties of medicine.
In their assigned readings, students learn what certain prominent DOs have to say about various somatic dysfunctions. There is often a theory or model presented that provides conjectures and putative explanations about why somatic dysfunction exists and what its significance is. Instructors spend the bulk of their time demonstrating osteopathic manipulative (OM) techniques without providing evidence that the techniques are significant and efficacious. Even worse, faculty members rarely provide instrument-based objective evidence that somatic dysfunction is present in the first place.|30px|30px
At the same time, recent studies show an increasingly positive attitude of patients and physicians (MD and DO) towards the use of manual therapy as a valid, safe and effective treatment modality. 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. Another small study examined the interest and ability of MD residents in learning osteopathic principles and skills, including OMM. It showed that after a 1-month elective rotation, the MD residents responded favorably to the experience.
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.|30px|30pxElsewhere, he has remarked that osteopathic manipulative medicine (OMM) can be an aid to the physician in fostering a relationship with the patient, while also a source of skepticism to MDs. In particular, he noted that suggestions that OMM could be used to treat diseases other than back problems, "reinforces lingering feelings among proponents of conventional medicine that osteopathy is simply a less intellectual field all around."
Each country has different requirements and procedures for licensing or registering osteopathic physicians and osteopaths. The only osteopathic practitioners that the US Department of Education recognizes as physicians are graduates of osteopathic medical colleges in the United States. Therefore, osteopaths who have trained outside the United States are not eligible for medical licensure in the United States. On the other hand, US-trained DOs are currently able to practice in 45 countries with full medical rights and in several others with restricted rights.
The Bureau on International Osteopathic Medical Education and Affairs (BIOMEA) is an independent board of the American Osteopathic Association. The BIOMEA monitors the licensing and registration practices of physicians in countries outside of the United States and advances the recognition of American-trained DOs. Towards this end, the BIOMEA works with international health organizations like the World Health Organization (WHO), the Pan American Health Organization (PAHO) as well as other groups.
The procedure by which international countries consider granting physician licensure to foreigners varies widely. For US trained physicians, the ability to qualify for "unlimited practice rights" also varies according to one's degree, MD or DO Many countries recognize US-trained MDs as applicants for licensure, granting successful applicants "unlimited" practice rights. The American Osteopathic Association has lobbied the governments of other countries to recognize US-trained DOs similarly to their MD counterparts, with some success. In 44 countries, US-trained DOs have unlimited practice rights. In 2005, after one year of deliberations, the General Medical Council of Great Britain announced that US-trained DOs 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 strongly advocates for US-trained DO international practice rights "equal to that" of MD qualified physicians.
Osteopathic physicians have historically entered primary care fields at a higher rate than their MD counterparts. Some osteopathic organizations make claims to a greater emphasis on the importance of primary care within osteopathic medicine. However, the proportion of osteopathic students choosing primary care fields, like that of their MD peers, is declining. Currently, only one in five osteopathic medical students enters a family medicine residency (the largest primary care field). In 2004, only 32% of osteopathic seniors planned careers in any primary care field; this percentage was down from a peak in 1996 of more than 50%.
The inability to institutionalize research, particularly clinical research, at osteopathic institutions has, over the years, weakened the acculturation, socialization, and distinctive beliefs and practices of osteopathic students and graduates.|30px|30px
If osteopathy has become the functional equivalent of allopathy [meaning the MD profession], what is the justification for its continued existence? And if there is value in therapy that is uniquely osteopathic, why should its use be limited to osteopaths?|30px|30px
As the number of osteopathic schools has increased, the debate over distinctiveness has often seen the leadership of the American Osteopathic Association at odds with the community of osteopathic physicians.
within the osteopathic community, the growth is drawing attention to the identity crisis faced by [the profession]. While osteopathic leaders emphasize osteopaths' unique identity, many osteopaths would rather not draw attention to their uniqueness.|30px