The DOs: Osteopathic Medicine in America, 2nd Ed.

11. The Challenge of Distinctiveness

Osteopathic medicine occupies the same professional space as its older, larger, and more socially dominant counterpart, which wishes to absorb it. Given its increasing closeness in standards and services to its dominant rival and the greater association between the practitioners of both professions, it makes little sense for the osteopathic profession, if it wishes to retain its independence, to continue stressing its similarities with allopathic medicine. The public is unlikely to believe that DOs can ever practice allopathic medicine in all of its manifestations as well as can MDs. Nor does professional mimicry appear to be a viable way of obtaining public favor or recognition. As is readily apparent by the billions patients spend on the many forms of alternative medicine, they want choices. Therefore, from a market perspective, osteopathic medicine should find and develop the resources to produce not only qualified physicians but practitioners widely perceived by the public and themselves to be different from MDs and arguably better in some aspects of the way they care for patients. However, given the state of the osteopathic profession’s current infrastructure, funding sources, and the degree to which distinctiveness is now practiced and taught, this will be no easy challenge.

Osteopathic Colleges

Osteopathic medicine is now the fastest growing segment of the US. physician and surgeon population (see Table 5). In 1962, just after the California merger, there were approximately 11,000 DOs in practice. In 2002, there were 47,000. Based on current trends, by 2020 there will be approximately 80,000 DOs. There are now 15 active DOs per 100,000 Americans compared to 6 per 100,000 forty years ago. In 2000, office-based DOs received 66.7 million patient visits or 24.3 visits per 100 persons in the United States. DOs are presently involved in providing for the health care needs of as many as 30,000,000 Americans.1 Despite their growing numbers, DOs are not evenly distributed throughout the United States. In many parts of the country there are so few DOs that the profession is socially invisible. Michigan and Pennsylvania have the most practitioners, with more than 4,500 active DOs apiece; ten other states each have more than 1,000 DOs and DOs in these twelve states comprise approximately 77 percent of active osteopathic physicians and surgeons not in military service. Nevertheless, in the past dozen years the largest percentage gains of DOs have been in those states with smaller osteopathic representation.2

This recent rapid growth has been fueled by the development of additional schools and expansion of the class size in longstanding as well as newer institutions. In 1962, there were five osteopathic colleges, in 1982 fifteen. In 2002, 19 of 144 U.S. medical schools were osteopathic institutions. In the past twenty years new private DO-granting schools were established in Florida, Arizona, Kentucky, Pennsylvania, and California, and in 2003 an osteopathic college in Virginia admitted its first class. Between 1962 and 2002 DO graduates have increased sevenfold, and almost 14 percent of all U.S. medical school graduates are now DOs. Plans are being developed to establish additional osteopathic colleges.3

All this occurred despite the recommendations of most health workforce experts, who argued that the United States needed fewer not more physicians. The leadership of the AOA pointedly countered that contention, saying that, given the number and percentage of DO graduates who enter primary care fields and practice in underserved areas, osteopathic colleges have done a better job than either U.S. or foreign MDgranting schools of providing the types of physicians this country needs.4 According to a 1998 study by the American Medical Student Association, of all U.S. medical schools the top twelve producing the highest percentage of graduates entering primary care residencies were all DO-granting schools, with the other four DO institutions in the survey falling among the top twenty. This is not surprising, since osteopathic colleges focus on primary care in student recruitment, curriculum, role models, and opportunities. In 1999, approximately 60 percent of all active DOs were in primary care (48 percent in family medicine, 8 percent in internal medicine and 3 percent in pediatrics).5

Osteopathic colleges are not research-oriented institutions. Indeed, unlike most MD schools, which boast of substantial numbers of faculty and research grants, DO schools have comparatively few full-time faculty members and their mission is service directed.6 Many osteopathic faculty members have been hired and promoted on their ability to teach a broad range of curricular subjects rather than on their research credentials. Thus, while contributing a significant number of graduates to areas of the physician workforce that MD schools have insufficiently addressed, osteopathic schools have made comparatively little contribution to creating new knowledge or producing graduates who will be active researchers. Indeed, one recent study concluded that if all nineteen osteopathic schools were treated as one institution, it would rank 202nd in National Institutes of Health funding.7

Within osteopathic undergraduate education there are notable funding disparaties between the six public and the thirteen private osteopathic schools. In the 2000 fiscal year, the average current fund revenue for the six public colleges was $48.5 million per school, compared to an average of $32.6 million per private institution. The private colleges are heavily dependent upon tuition, which constitutes an average of 70 percent of their current fund revenues, compared to 12 percent for the public schools. The state schools, on the other hand, draw 39 percent of their revenues from legislative appropriations and 30 percent from practice plans. Unlike MD schools, neither public nor private DO colleges have attracted significant philanthropic support or developed substantial endowments.8

The state schools, given their broader sources of funding and their legislative mandates, have limited and kept stable their enrollments, which in 2000–2001 averaged 101 new students. The private colleges, so reliant upon tuition, averaged 178 new students and have used an increase in the number of matriculants as well as increases in tuition as the most dependable ways of generating additional revenue to support their educational programs. The average number of full-time faculty in public schools is more than double that found in the private colleges, making for a more favorable faculty-student ratio. As a consequence of their more limited resources, private colleges are more likely to rely on part-time and voluntary instructors, to depend upon large lecture formats, and to use web-based self-study technology to deliver their curriculum.9

In the 1980s and 1990s several of the once freestanding private osteopathic schools expanded their educational mission and evolved into “health science universities,” establishing accredited colleges of pharmacy, podiatry, physical therapy, optometry, dentistry, and physician assistant programs. This expansion appears to have increased the overall economic viability of the resulting institution through cost-sharing of faculty, support staff and facilities. Some of these health science universities have been able to raise the capital needed to erect large and modern buildings specifically for osteopathic education, and DO students now get to interact and in some instances take classes with other health professionals in training.10

Ironically, the public osteopathic schools, though more adequately funded, have faced a greater challenge to their continued existence than the private colleges. Governors and state legislatures have periodically threatened their respective schools with closure or consolidation, under the pressure of chronic shortages in state revenues and the perception of an oversupply of physicians. However, each of the public osteopathic colleges has a stronger record than their MD college counterparts in their state in producing graduates who remain within its borders, enter primary care, and practice in underserved, particularly rural, areas. As a result, osteopathic colleges have successfully fought such efforts, and in general the resulting review process strengthened their standing and reputation among lawmakers.11

The educational credentials of matriculants to osteopathic schools continue to improve. Osteopathic students enter with baccalaureate degrees, some with advanced training, and most have graduated from their undergraduate college or university in the top 25 percent of their class. MCAT scores on average, however, are significantly lower than matriculants at MD schools, although they are likely to be more consistent with the scores of allopathic students who enter primary care careers. Osteopathic students tend to be slightly older than their MD counterparts, because a greater percentage of these matriculants enter school after having pursued another career. A majority of students who enroll in osteopathic colleges are quite knowledgeable about the profession—many having had a DO as a physician. However, a significant minority enter osteopathic schools after having been unsuccessful, despite good academic credentials, in gaining acceptance at an MD school. DO-granting colleges therefore face a special challenge acculturating these “second-choice” students with osteopathic beliefs and practices.12

DO-MD Relations

Interactions between members of DO and MD groups have become significantly less contentious in recent decades. Many state osteopathic associations work with their allopathic counterparts to lobby for legislation such as malpractice tort reform, public health initiatives, and combating the efforts of nonphysician providers to expand their scope of practice. On the national level, the AOA and the American Association of Colleges of Osteopathic Medicine (AACOM) are members, along with the AMA and the American Association of Medical Colleges (AAMC), of various coalitions of health-related interest groups. These osteopathic and allopathic associations communicate regularly about pending federal legislation. Nevertheless, allopathic organizations and prominent MDs continue to question the independence of the osteopathic profession. For example, at two sets of well publicized meetings in the mid 1990s between DO and MD organizational leaders sponsored by the Josiah Machr. Foundation, several MD representatives opined that, given the great similarities now existing between the two professions, they could see no reason why there should not be only one great united house of medicine.13

Some MD groups, however, more directly challenge osteopathic autonomy, most notably with respect to licensure. Some state medical associations periodically support legislation to eliminate independent osteopathic licensure boards, particularly in those states with smaller osteopathic representation." On the national level, MD members of the Federation of State Medical Boards launched a campaign in 1998 questioning the existence of a separate osteopathic pathway to licensure. For decades the federation, made up primarily of members of state medical licensing boards, has had as its goal the creation of a uniform single examination to license physicians in all states. In the process it has championed the test of the National Board of Medical Examiners (NBME) known as the United States Medical Licensing Examination (USMLE), which was designed to assess the qualifications of MD candidates. Nevertheless, all states—except Louisiana—also accepted the test of the National Board of Osteopathic Medical Examiners (NBOME) as an equivalent examination for assessing DOs. When the NBOME dcvc10pcd a new, and arguably better, test for DOs called the Comprehensive Osteopathic Medical Licensing Examination-USA (COMLEX-USA), many MD members of the federation took the opportunity to challenge both the principle of a sep arate osteopathic licensing mechanism and the validity of the new exam. With federation members demanding that the NBOME provide sufficient evidence that the COMLEX-USA was the equal of the USMLE, the NBOME met the standard; and in 2001 its opponents withdrew their objection to COMLEX-USA, though not their long-stated goal of a uniform pathway to licensure. Shortly thereafter, the state of Louisiana changed its requirements, making COMLEX-USA an acceptable test for licensure of DOs in all states.15

Despite these interprofessional conflicts, there is now widespread MD acceptance of DOs as colleagues, and this acceptance presents a real dilemma for organized osteopathy. For most of its history the AOA derived a great deal of internal cohesion and social solidarity among its membership from the menacing actions of the once-powerful AMA. Older DOs, who fought the long and sometimes brutal battle to achieve recognition and equality, observe that where the AMA once used every opportunity to “kill osteopathic medicine,” now organized medicine just wants to “love us to death.” Indeed, the AMA has abandoned its forced amalgamation efforts, partly because they didn’t work and partly because they likely violated anti-trust laws.16 Instead, the AMA has tried to build bridges. It recently designated two seats at its House of Delegates for representatives of the AOA—but to date the AOA has rejected the offer and the seats have gone unfilled.17

What the AMA once tried to achieve through organizational amalgamation, it now hopes to accomplish through individual assimilation. DOs and MDs increasingly practice together in the same hospitals and in medical groups, and by and large enjoy cordial relations. The fact that approximately 60 percent of all osteopathic residents are now enrolled in programs approved by the Accreditation Council for Graduate Medical Education is the strongest evidence that this process of assimilation will continue. This trend is especially troubling to the AOA. The prospects for the allegiance of ACGME-trained DOs, particularly those who bypassed AOA approval, are not promising. Indeed, a sizable number of these practitioners have instead joined the AMA and identify more with their allopathic colleagues. As of November 2002, 7,936 DOs (or 17 percent of all active osteopathic physicians) were AMA members. Nevertheless, the AOA continues to draw significant support among DOs. Overall, the percentage of osteopathic physicians who have joined the AOA has remained stable in recent years and in 2002 stood at 63 percent. On the other hand, the AMA, despite an infusion of osteopathic physicians into its ranks, has been struggling to enlist new members and now represents only 30 percent of all active post-residency MDs.18

Osteopathic Principles and Practices

The AOA is strongly committed to maintaining the osteopathic profession’s independent status, and there is no evidence that it will change that position in the foreseeable future. But if it is to remain independent and to flourish, osteopathic medicine must both create a clearer vision of its role and develop a recognizable identity. Having achieved legal and professional equality, a growing number of DOs are urging their colleagues to reexamine their roots. Leaders of the AOA increasingly highlight the value added to patient care by traditional osteopathic philosophy. They seek ways to strengthen the teaching of distinctive osteopathic diagnostic and therapeutic practices in osteopathic colleges and hospitals and dualaccredited graduate programs and to promote their utilization in osteopathic practice. Ironically, after decades of striving to convince legislators and the public of the close similarities between DOs and MDs, many within the profession now see the importance of stressing the differences between the two types of practitioners.19

Osteopathic medicine is a social movement as well as a profession. As a social movement it espouses a philosophy of medicine and a set of principles that distinguish it from its allopathic counterpart. Indeed, extolling the virtues of a medical philosophy at all makes the osteopathic profession different. Although policymakers, social scientists and others refer to the MD profession as “allopathic medicine,” the term itself is an historical artifact not reflecting any body of beliefs embraced and shared by its own members. For well over a century the MD profession has pointedly rejected the adoption of any philosophical belief system governing health and disease“, equating philosophy with dogma and arguing that its professional approach to medicine is dependent solely upon scientific evidence.

In the 1920s the faculty at the Kirksville school codified a set of fundamental osteopathic principles that were widely accepted throughout the profession. These were somewhat revised at midcentury. Four tenets were enunciated: first, the body is a unit and the person represents a combination of body, mind, and spirit; second, the body is capable of self-regulation, self-healing, and health maintenance; third, structure and function are reciprocally interrelated; and fourth, rational treatment is based upon an understanding of body unity, self-regulation, and the interrelationship of structure and function.20 Several authors have explained how these particular principles both link the osteopathic profession to conventional medicine and provide what they believe is a more holistic, patientcentered approach. Embedded in the philosophy is a rationale for the incorporation of osteopathic manipulative treatment. The neurophysiologist Irwin Korr put forward four related propositions in this regard. First, he noted, the vertical human framework is highly vulnerable to gravitational, torsional, and shearing forces. Second, since the massive, energy-demanding musculoskeletal system has rich two-way communication with all other body systems, it is, because of its vulnerability, a common and frequent source of impediments to the functions of other systems. Third, these impediments exaggerate the physiological impact of other detrimental factors in the person’s life, and, through the central nervous system, focus that impact on specific organs and tissues. Fourth, the musculoskeletal impediments or somatic dysfunctions are readily accessible to the hands and responsive to manipulative treatment and other methods developed and refined by the osteopathic medical profession.21

Whatever the rationale, the use of osteopathic manipulative treatment in overall patient management has declined. In 1972 the independent journal Osteopathic Physician published the results of a mailed questionnaire returned by 234 DOs located in ten states. Asked the question “On what percentage of your patients do you make use of manipulation,” 66 percent replied, “Less than 50 percent” and 37 percent responded, “Less than 20 percent.”22 In the 1974 national ambulatory medical care survey carried out by the National Center for Health Statistics, it was estimated that fewer than 17 percent of all patient visits to office-based DOs included osteopathic manipulative treaUnent.23 More recent studies by Fry (1996), Johnson, Kurtz, and Kurtz (1997), and Aguwa and Liechy (1999) all confirm a continuing downward trend.24

In the latest study byjohnson and Kurtz (2001), 30 percent of 375 osteopathic family physicians surveyed reported that they employed OMT on “less than 5 percent” of their patients, 50 percent reported using OMT on “from 5 to Z 5 percent” of patients, and only 20 percent used it on “more than half” their patients. Only 30 percent of 580 surveyed specialists reported using OMT on “more than 5 percent” of patients. Interestingly, the great majority of all DO respondents had favorable attitudes towards OMT; 96 percent agreed or strongly agreed that it is an efficacious treatment. Over 70 percent agreed or strongly agreed that they personally received OMT or provided it to friends, colleagues, or relatives outside their practice.25 The factors explaining the lessened use of OMT on patients include the diminished number of hours spent on osteopathic diagnosis and treatment in the undergraduate curriculum, the greater emphasis given to other modalities, restriction of opportunities for use in clerkship and postgraduate settings, poor or no reimbursement for distinctly osteopathic procedures, and increasing percentages of new graduates going into specialties in which the use of ,OMT is not regarded as necessary.

During the first two years of osteopathic school, students receive an average of 218 contact hours in osteopathic principles and practices (OP&P). This time constitutes approximately 24 percent of the clinical science curriculum and 12 percent of the total curricular hours for those years.26 Students spend some of these OP&P hours in lecture halls, but they are primarily in clinical labs, that is, large rooms with treatment tables for teams of students led by one faculty member with several other faculty and student fellows serving as table-trainers. In this setting the students learn both structural diagnostic methods and manipulative techniques. Students take turns being the “operator” and the “patient.” Of all subiects students take, this is the most critical in developing an osteopathic identity. The degree to which students grasp the basic principles, see the utility of the methods taught, and gain palpatory literacy may largely shape their future professional choices. This is especially true for the significant minority for whom an osteopathic school was a second choice. The Educational Council on Osteopathic Principles of the AACOM has worked to standardize the curriculum, osteopathic techniques utilized, and descriptive nomenclature. The publication, under the auspices of the AOA, of a comprehensive introductory textbook, entitled Foundations for Osteopathic Medicine, has also helped to standardize what is taught. The text, now in a second edition, has been adopted by every osteopathic school as either required or recommended student reading.27

The colleges vary appreciably, however, in terms of the fiscal and faculty resources devoted to the teaching of osteopathic manipulative medicine (OMM). Some schools, such as the private University of New England College of Osteopathic Medicine, built beautiful and well-equipped OMM labs that are the centerpiece of the institutions. In addition, some colleges employ several full-time OMM faculty members. Other schools, facing chronically tight budgets, are more dependent upon part-time and volunteer practitioners to deliver the OMM curriculum, and have labs that are in serious need of updating.

All students in the first two years of their education obtain a basic grounding in osteopathic fundamentals. However, there is often inadequate attention to further developing what skills students have already mastered in their third- and fourth-year clinical rotations. Although in many osteopathic hospitals students will routinely perform an osteopathic structural examination as part of the overall history and physical, they generally do not record findings of somatic dysfunction on the chart, and they administer manipulative treatment only to a small number of hospitalized patients. Some trainers and students regard palpation-based structural findings as not directly germane to their patients’ problems and believe that manipulative procedures are more appropriate to a primary care office setting. Whatever the relative merits of their arguments, if administrators and preceptors at the clinical sites are not committed to promoting the diagnostic or therapeutic distinctiveness of the profession, then whatever skills the student has previously learned simply wither.28

The newly developed Osteopathic Postdoctoral Training Institutions provide osteopathic colleges with the means to introduce and incorporate a formal didactic curriculum in OP&P during the third and fourth years and into graduate education. Some college departments of osteopathic principles and practices have developed innovative programs in their OPTI that their proponents regard as successfully addressing this problem. However, a significant number of third- and fourth-year clerkship sites are at hospitals that are not part of OPTIs, and several OPTIs have had great difficulty adhering to AOA accreditation rules or abiding by their own organizational bylaws with respect to the integration of osteopathic principles and practices during the internship and residency years.29

Public demand for the services of “ten-fingered” D05 is reportedly high in many localities as is patient satisfaction with osteopathic manipulation.30 Whether younger DOs employ palpatory diagnosis and manipulative treatment in their practice depends in part upon how well they are compensated for integrating these methods. Some private insurers and Medicare will reimburse for both osteopathic evaluation of somatic dysfunction and the use of manipulative intervention. Nevertheless, the fact that these procedures may add time and cost to patient visits can make third party payment problematic, and DOs have often had to justify to others the inclusion of these procedures that, for them, constitute fundamental cornerstones in the practice of their profession.

Third party payers want evidence that a distinctly osteopathic approach works for given complaints and that it is cost effective. Consequently, the osteopathic profession will be under increasing pressure to demonstrate that its distinctive health care services add value to patient encounters. But third parties are not the only ones calling for documentation. DO students and graduates over the decades have consistently urged the profession to underwrite and conduct research studies carefully and objectively examining the clinical significance of “somatic dysfunction” and the relative value of osteopathic manipulative treatment.

Osteopathic Clinical Research

Although several osteopathic schools have produced empirical studies related to distinctive osteopathic practices since the 1960s, the most significant and sustained efforts until the late 1990s occurred at the Michigan State University College of Osteopathic Medicine, performed by William Johnston, DO (1921–2003) and his colleagues, and at the Chicago College of Osteopathic Medicine, now a component of Midwestern University. Scientists at the Kirksville College had examined the neurophysiologic basis of the “osteopathic lesion,” what became known as “somatic dysfunction”; now investigators at these two schools researched the clinical aspects of the phenomenon.31

Currently, somatic dysfunction is defined as “impaired or altered function of related components of the somatic system: skeletal, arthroidal, and myofascial structures, and related vascular, lymphatic, and neural elements.” The definition further specifies that the positional and motion aspects of somatic dysfunction are best described using at least one of three parameters: the position of the body part as determined by palpation and referenced to its adjacent defined structure, the directions in which motion is freer, and the directions in which motion is restricted."

Over the past twenty years there have been three broad lines of inquiry regarding somatic dysfunction: the establishment of interexaminer agreement of findings, the measurement of somatic dysfunction through instrumentation, and the documentation of clinical correlations between somatic dysfunction along the spinal column and conditions elsewhere.33 This research has yielded evidence that, if appropriate training is provided, several examiners can achieve through palpation a high degree of agreement on the presence or absence of somatic dysfunction at specific spinal locations.34 Researchers have also shown that electromyography can provide instrument-based evidence confirming palpatory findings of somatic dysfunction.35 In addition, several investigators have associated patterns of somatic dysfunction with cardiovascular, pulmonary, renal, and mental diseases.36 Remarkably, though, in the past two decades, no articles have been published in thejA 0/1 that empirically test whether somatic dysfunction as specifically and objectively identified along the spinal column can be eliminated through the use of osteopathic manipulation and whether such treatments are correlated in any way with demonstrable physiological changes elsewhere in the body. Such studies are absolutely essential to testing the fundamental premises upon which the profession rests.

In the early 1990s, the AOA Bureau of Research decided that clinical investigations under osteopathic auspices which showed good results for osteopathic manipulative medicine would either be open to question or simply ignored by a nonosteopathic audience. Consequently, using several hundred thousand dollars raised through a special assessment on the general membership, the AOA funded a prominent and experienced MD investigator at Rush University Medical School in Chicago to develop and conduct a study based in Rush’s facilities directly comparing the outcomes of MDs and DOs in treating lower back pain. The results were published in an article in the New England Journal of Medicine in 1998.37

In this study researchers randomly assigned to treatment groups 178 subjects who had had back pain for at least three weeks but not as long as six months. All patients were treated either with one or more standard medical therapies or with osteopathic manipulative treatment. The results showed that there were no statistically significant differences between the two groups in any of the primary outcome measures. However, the osteopathic treatment group required significantly less medication (analgesics, anti-inflammatory agents, and muscle relaxants) and used less physical therapy.

These published results were interpreted along predictable lines. MDs and some DOs argued that since the findings showed no significant difference in primary outcome measures, distinctly osteopathic medical intervention had not made any improvement over conventional medicine in patient care. However, the AOA and many DOs claimed that this study had in fact demonstrated that patients could be safely and effectively treated through osteopathic manipulation with less exposure to pharmaceuticals and their associated side effects. As much attention was drawn by both sides to the underlying political implications of the study—that is, to the question of whether osteopathic medicine should remain an independent profession—as to the perceived or actual methodological shortcomings of the research.38

Needing to facilitate more varied studies on osteopathic manipulative treatment, the profession has once again turned to funding its own investigators and trying to build a credible research base in osteopathic colleges. The AOA has annually provided almost one-half million dollars in a competitive application process to support pilot studies, some of which have eventuated in reports published in the JAOA. In recent years osteopathic researchers, with or without AOA funding, have, for example, compared thoracic manipulation with incentive spirometry in preventing postoperative atelectasis, examined the effect of suboccipital dermatomyotonic stimulation on digital blood flow, measured the effect of lymphatic and splenic pump techniques on the antibody response to hepatitis B vaccine, examined whether osteopathic manipulative treatment improves gait performance in patients with Parkinson’s Disease, explored whether OMT benefits elderly patients with pneumonia, and considered whether OMT in addition to medication relieves pain associated with fibromyalgia syndrome.39 Unfortunately, to date pilot projects under osteopathic auspices have rarely led to larger and more scientifically rigorous studies.

In 2001, the profession embarked on a more ambitious program. The AOA, AACOM, and the American Osteopathic Foundation pledged to contribute $1.1 million to one school—the Texas College of Osteopathic Medicine at University of North Texas—which has significantly increased its external research funding in recent years. Designated by the AOA as the Center for Osteopathic Research and Excellence these osteopathic granting agencies hope that their modest seed money will lead to federal support for this center as research projects multiply and come to fruition.40 Increased public or private funding at this school or elsewhere will likely be dependent upon the degree to which osteopathic researchers can demonstrate that they can conduct and publish controlled outcome studies with large sample sizes that can definitively answer research questions. The ability of the profession to show conclusively that osteopathic management has benefit to patients with specific conditions would add significantly not only to the scientific reputation of osteopathic medicine but also, and just as importantly, to its public visibility.

Visibility and Recognition

Osteopathic medicine may well be the best-kept secret in American health care. After more than a century of existence, the osteopathic medical pro fession is the least known of the major health care professions in the United States. Separate studies commissioned in the late 1990s by the AOA and AACOM reveal that less than 15 percent of Americans know the scope of osteopathic medical licensure and can articulate meaningful differences between DOs and other health care practitioners.41 This problem can be attributed to their comparatively small numbers, their strength in the relatively unglamorous field of primary care, and the fact that their schools and hospitals are not research-oriented institutions. DOs are also underrepresented in the overall physician population in the national media capitals of New York, Los Angeles, and the District of Columbia.

The sheer numbers of allopathic physicians, dentists, and nurses reflect the widespread visibility and social dominance of these health care professionals. They have carved out fields and activities that are generally recognized as falling appropriately within their domains. But large numbers do not tell the whole story. The public recognizes the much smaller health care professions of optometry, podiatry, and chiropractic, and most people have a basic understanding of the range of services that the members of these smaller professions provide. Even more striking is that extremely small groups of health care providers, notably acupuncturists and homeopathic physicians, because of their marked differences in beliefs and practices from those of conventional medical providers, are better known for what they do than are osteopathic physicians.

One of the great ironies of osteopathic medicine’s development is that, as the profession broadened its curriculum and obtained for its practitioners the same legal practice privileges as allopathic physicians, DOs became less distinguishable from MDs. Thus, even though the number of osteopathic physicians has dramatically increased, the profession remains socially invisible. This social invisibility has had numerous and severe consequences for the profession. On the societal level, osteopathic invisibility has led federal and state lawmakers to craft health care bills that either ignore osteopathic medicine or do not take into consideration its special circumstances and needs, health care planners to overlook osteopathic physicians in their forecasts, and health reporters to either be unaware of or ignore the osteopathic profession in stories to which the profession’s positions or role in health care are relevant.42 On the individual level, DOs experience their profession’s social invisibility first hand. A practitioner who identifies him or herself to strangers as a DO or as an osteopathic physician usually receives the response “What’s that?” Even after being told what a DO is, strangers are likely to ask additional questions, such as “How does a DO differ from an MD?” and “How does a DO differ from a chiropractor?” From the time they begin their medical education, osteopathic students know that they have to contend with this identity problem.43

During the past several decades, the profession has tried various means of educating the public. These have included such standard public relations methods as distributing news releases; forming speakers’ bureaus; encouraging newspapers, magazines, and television programs to do news and human interest stories on DOs; producing short films, audiotapes, and public service announcements; publishing pamphlets for osteopathic physicians’ offices; and placing advertisements in journals and magazines targeted to specific audiences.44

In 1998, the American Osteopathic Association launched what became lmown as the “Unity Campaign.” Working with AACOM, state and specialty associations and other groups, the AOA gave renewed attention to the problem of public recognition and understanding of the profession. The intended goal of their efforts was to highlight osteopathic distinctiveness.45 The AOA taught DOs in the field how to make effective contacts with the media and to develop story lines that health reporters might cultivate. Also, the association unveiled two series of magazine advertisements—both of which were eye-catching and had the potential of effectively conveying to the public the scope of practice of DOs and the wide range of specialties in which they are engaged. However, the annual funding for this national advertising campaign has to date been in the range of only half a million dollars, far too little to buy large and repeated ads in the magazines they have selected and thereby make any appreciable audience impression.46

Some younger members of the profession have tried to circumvent the problem of limited funding for public education by contacting producers of prime time network medical series and trying to convince them to prominently feature DO characters in their programs. This effort has yet to be successful. However, in the fall of 2002, a new cable television weekly drama, “Body and Soul” premiered with one of the central members cast as a DO. In addition to incorporating osteopathic philosophy and manipulative medicine, she uses a variety of alternative approaches as well as conventional procedures in her patient management. Though her osteopathic identity has not been a story line during the initial season, this nonetheless appears to have been the first DO character to be incorporated in a US. television program.

The Future

As a profession, osteopathic medicine will face difficult challenges in the near future. It will need to develop increasing financial support for its schools to broaden and strengthen their undergraduate programs. It will have to find ways of creating more good-quality, well-funded internships and residencies under osteopathic auspices. It will need to deal with both governmental and private third party payers over the level of reimbursement and coverage of osteopathic services. It will have to draw back into its orbit many allopathically trained DOs who either have been alienated from the profession or simply see no reason to reestablish their osteopathic ties. The profession will also have to determine in what ways and to what extent it or certain aspects of some of its practitioners’ methods constitute “alternative medicine,” for the purposes of self-identification and for explaining itself to external audiences.47 It will have to consider what relationships it should establish or maintain with colleges and societies in more than a dozen countries where there are practitioners who go by the title “osteopaths” and who teach and espouse a drugless, manipulation-based approach to health care.48 The profession must answer challenges from other health professions—from allopathic medicine, which desires the absorption of DOs into their ranks; from chiropractic, which seeks to legally prohibit any group other than themselves from administering spinal manipulation; from physician assistants and nurse practitioners, who are increasingly duplicating the functions of primary care practitioners and who are seeking the right to practice largely if not completely independently of licensed physicians.49 The profession must also consider its rationale for its independent existence. Osteopathic medicine was founded in the late nineteenth century on the idea that a new type of practitioner—the DO—could make a significant difference and improvement in health care. More than 125 years have elapsed since Andrew Taylor Still metaphorically first waved “the banner of osteopathy,” yet this initial reason for existence continues to motivate many of those who practice osteopathic medicine. Though the scope of osteopathic teaching and practice has radically changed, the challenge of doing something distinctive and arguably better remains very much a part of the social movement aspect of osteopathic medicine. Many DOs continue to believe that despite the considerable similarities between themselves and their MD counterparts, there are some essential qualities that make them truly different—whether it be their ability to diagnose and treat through their hands, the quality of their interpersonal skills, their emphasis upon primary care, their commitment to practicing in underserved areas, or their holistic approach to the patient. Some of these perceived differences may be more imagined than real, but the shared beliefs themselves are important to osteopathic identity formation and provide the basis for an ideological rationale for maintaining an independent professional existence.50 The strength of the internalized belief that DOs are different and in some respects better than their MD counterparts will likely be dependent upon how the profession is perceived in society. The two prizes that most DOs wish for their profession are, first, convincing scientific evidence that the distinctive aspects of their practice do make a positive difference in patient care and, second, widespread public understanding and appreciation for who they are and what they do. How well and how quickly osteopathic medicine progresses in reaching these goals may determine whether it will exist in the future as an independent and parallel profession of medicine. Failure to make significant progress in these areas may well mean a diminished confidence in the value of maintaining their independence and greater assimilation into the medical mainstream. However, if the osteopathic profession increasingly proves the value of its approach to patient care, and is so recognized by the public, another more remarkable possibility could occur. The potential would exist for osteopathic medicine to not only survive but conceivably begin a new chapter in its history—one that no similar medical movement or parallel profession, such as homeopathy or eclectic medicine, has ever achieved. It could make the leap from being regarded only as a “medical minority” to becoming more broadly recognized as a “medical elite.” The DO degree—long viewed as a handicap to public understanding by some practitioners—might instead come to symbolize a special and esteemed type of practitioner, and its use by osteopathic physicians might provide them with a competitive advantage over others in the medical market place.

Realistically, given its current medical and social position, it would likely be a lengthy, difficult, and expensive process to achieve this most desirable status. It would require a large number of committed practitioners and supportive laypersons and significant public and private resources to underwrite and support excellence in osteopathic education, research, and clinical services. Nevertheless, some in this profession have already taken a necessary first step. They have dedicated themselves to furthering core osteopathic beliefs and practices and they are emphasizing to patients and others their distinctiveness from rather than their similarities to other physicians. But many other DOs, particularly younger practitioners, would need to follow that lead and choose to practice distinctively, to engage in research on the fundamental precepts upon which their profession rests, and to fight for their continued autonomy and independence. What course they will pursue is by no means clear. Literally as well as figuratively, the future of osteopathic medicine may ultimately rest in the DOs’ own hands—and how they use them.

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