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

6. The Push for Higher Standards

With DOs increasingly duplicating the role and services of MDs the focus of the debate over the relative merits of osteopathy gradually shifted from its underlying philosophical and therapeutical beliefs to an analysis of its educational system. The central question became whether the standards maintained by osteopathic colleges were adequate to ensure the production of qualified physicians and surgeons.

The Revolution in Medical Education

The issue of standards did not apply solely to osteopathy. At the turn of the century medical education in the United States was noted for its disparities. On one end of the continuum was a relatively small number of prestigious university-affiliated colleges, on the other were the profit-motivated proprietary schools. Despite the gulf between the two types of institutions in terms of staffing, facilities, and equipment, licensing laws made it as easy for the graduates of one type to obtain the right to practice as it did the graduates of the other. Most existing boards of registration and examination either did not have the power to set meaningful standards for the colleges or had declined to do so.1

In 1904 the recently reorganized AMA formed its Council on Medical Education to suggest methods of improving academic requirements and to serve as an ongoing agency for advancing the association’s policies. In order to determine the actual situation in the colleges, the AMA Board of Trustees the following year authorized the council to undertake a complete on-site survey and to rate all 160 MD-granting schools. Although the grading was reportedly lenient, only 82 were given Class A, or ap proved, ranking; 46 were placed on Class B, or probation, and 32 were designated as Class C, or unapproved. While this information was not revealed to the public, it was made available to each state licensing board for its consideration; as a result several of the boards decided they would henceforth refuse to examine graduates of schools not receiving the council’s approval. Many colleges were thus motivated to begin making needed improvements, and others simply shut their doors. Between 1906 and 1910, the number of MD-granting institutions decreased by 29.2

The lay public’s first detailed knowledge of the still generally lamentable school conditions came with the publication of Abraham Flexner’s Medical Education in the United States and Canada (1910), an on-site survey carried out under the auspices of the Carnegie Foundation for the Advancement of Teaching and in cooperation with the AMA council. Though Flexner found some colleges upholding what he considered to be satisfactory standards, these constituted a decided minority. With respect to matriculation, only one of four was insisting upon either a high school diploma or liberal arts college credit as the minimum prerequisite for admission; the remainder were permitting even the barely literate to enroll. Most schools lacked fully equipped laboratories for the first two years of instruction, and in the third and fourth years too many students were not being given the necessary hospital and dispensary experience to prepare them for practice.3

In his report Flexner suggested several reforms. First, he urged that all proprietary schools be closed down. Since the United States then had far more MDs per 100,000 people than in the industrialized European nations, it was unlikely that the loss of these institutions and their graduates would lead to a physician shortage. He further recommended that each surviving college become an integral component of a major university, thus ensuring higher academic standards. Finally, he strongly suggested that the financing of medical education be altered. Since tuition fees could cover only a fraction of the expenses necessary to support an adequate program, other sources of income had to be cultivated.4

This survey had a considerable impact upon the American consciousness. In the era of muckraking journalism, Flexner’s overall findings and vivid descriptions of individual schools made excellent copy and were widely circulated by the nation’s press. Now in a position to mobilize public opinion, the various groups committed to change went forward in their efforts to accelerate the progress already being made.5 In the twenty-five years following the appearance of the Carnegie Foundation study several significant improvements were made along the lines Flexner had laid down. First, the number of schools steadily dropped. Commercial and otherwise weak institutions were forced out of business as more state boards accepted the continually updated ratings of the Council on Medical Education.6 By 1935 there were but 66 AMA-accredited colleges, 57 of which were connected with a university.7

Higher entrance standards were also set and maintained. In 1918 the council ruled that all incoming students had to have completed two years of college work. As of 1936, 83 percent of all matriculants exceeded this minimum, while 49 percent enrolled with a baccalaureate degree. The educational program itself was greatly enhanced, this due in large part to the changes in the colleges’ fiscal condition. During the 1934–35 and 193536 academic years, 55 percent of the total income of all medical schools was raised through taxes, public and private general university funds, and philanthropy.8 With the additional revenue these sources brought, the colleges built more completely outfitted laboratories, hired full-time basic science instructors (mostly PhDs), and upgraded their hospital and dispensary facilities.

These advances helped spur considerable progress on the postdoctoral level. With the schools’ rise in quality, graduate programs ceased being “undergraduate repair shops.”9 In 1912 the AMA council conducted its first inspection of hospitals offering internships. From then through the mid-1930s, standards for internships were regularly strengthened as this additional year of training became all but obligatory.10 In 1927 the council published its first list of approved residencies, and in 1933 the AMA established the organizational machinery to create boards of certification in the various specialties. These changes, along with those on the predoctoral level, would provide the American people with a more uniform corps of highly skilled MDs.

Osteopathic Evolution

Flexner included all eight osteopathic colleges in his grand tour of the nation’s medical schools. The impetus behind the inclusion of osteopathic medical education in Flexner’s study probably came from Henry Pritchett, head of the Carnegie Foundation. He and Flexner attended a meeting in December 1908 with the members of the AMA Council on Medical Education to discuss the impending survey. According to the minutes:

President Pritchett related his experiences with an osteopath in a small Colorado town, making his lame leg an excuse for calling as a patient but seeking information about the osteopath’s methods and what kinds of cases he treated. It was found he was treating even adenoids and appendicitis. Therefore, it was clear that osteopaths (at least this one) were diagnosing the same diseases which physicians were called upon to treat, therefore osteopaths should have the same training in fundamentals.11

While members of the council asked Pritchett about his encounter, they expressed no apparent interest in including osteopathic education in the Carnegie Foundation study. In his report, Flexner echoed and extended Pritchett’s reasons for evaluating DO colleges as medical schools in his survey in spite of the differences in approach between DOs and MDs. Flexner argued:

Whatever his notions on the subject of treatment, the osteopath needs to be trained to recognize disease and to differentiate one disease from another quite as carefully as any other medical practitioner… Whether they use drugs or do not use them, whether some use them while others do not does not affect this fundamental question… All physicians summoned to see the sick are confronted with precisely the same crisis: a body out of order. No matter what remedial measures they include—medical, surgical, manipulative—they must ascertain what is the trouble. There is only one way to do that. The osteopaths admit it when they teach physiology, pathology, chemistry, microscopy.12

Having, for the purpose of his analysis, placed the osteopathic profession on an equal footing with orthodox medicine, Flexner was quick to emphasize that not one “of the eight osteopathic schools is in a position to give such training as osteopathy demands.” The teaching of anatomy, for example, was “fatally defective.” Most of the students’ time during this course was spent listening to lectures; too few cadavers were available to provide adequate laboratory dissection. This pattern characterized the other basic sciences as well. “A small chemical laboratory is occasionally seen,” Flexner noted.

At Philadelphia it happens to be in a dark cellar. At Kirksville, a fair sized room is devoted to pathology and bacteriology; the huge classes are divided into bands of 32, each of which gets a six weeks course following the directions of a rigid syllabus, under a teacher who is himself a student… A professor at the Kansas City school [the Central College] said of his own institution that it had practically no laboratories at all; the Still College at Des Moines has in place of laboratories laboratory signs; the Littlejohn at Chicago, whose catalog avers that the “physician should be imbued with a knowledge of the healing arts in its widest fields, and here is the opportunity” has lately in rebuilding wrecked all its laboratories but that of chemistry without in the least interfering with its usual pedagogic routine.

Clinical instruction fared no better. “The osteopath,” he declared, “cannot learn his technique and when it is applicable except through experience with ailing individuals. And these for the most part he begins to see only … after receiving his DO degree.” Bedside training was, in fact, either very limited or nonexistent. The Kirksville College had the largest hospital, a mere fifty-four beds, while the Chicago school had twenty, the Pacific College fifteen, the Boston school ten, and the Philadelphia college three. The Des Moines, Kansas City, and Los Angeles schools had none at the time of his visit. Outpatient contact was similarly restricted. Each of the colleges operated a pay clinic that was staffed by the faculty, in which student participation seems to have been limited to the care of charity cases.13

In characterizing the entire osteopathic educational program, Flexner wrote:

The eight osteopathic schools now enroll over 1,300 students who pay some $200,000 annually in fees. The instruction furnished for this sum is inexpensive and worthless. Not a single full time teacher is found in any of them. The fees find their way directly into the pockets of the school owners, or into school buildings, and infirmaries that are equally their property. No effort is anywhere made to utilize prosperity as a means of defining an entrance standard or developing the “science.” Granting all that its champions claim, osteopathy is still in its incipiency. If sincere its votaries would be engaged in critically building it up. They are doing nothing of the kind.14

Angry protests by school officials and other DOs greeted the publication of Flexner’s report. Responding to his critique, the AOA Board of Trustees declared, “We have no apologies to offer for our colleges. They have done well, and we take pride in their attainments and in their ambitions and determinations to teach most thoroughly and scientifically all that pertains to disease in all its phases and manifestations. We demand that they be allowed to do this, according to the needs of our profession and not in accord with the wishes of any self-appointed, self-seeking, tyrannical and prejudicial judges.”15 Interestingly, this view was not completely shared by the AOA Committee on Education. In its annual report for 1910, it substantially agreed with Flexner on the problems of low entrance standards, poor basic science laboratories, lack of sufficient clinical facilities, and an inadequate teaching corps. Its own surveys had noted the same deficiencies, albeit in less caustic language.16 However, unlike Flexner, who evaluated the schools with an ideal in mind, DO inspectors considered themselves pragmatic to the extent that they recognized the limited possibilities for amelioration under existing conditions. Reform, they believed, would have to be slow.

The twenty-five years following the issuance of the Flexner report saw some improvements in college requirements and in the quality of training offered; nevertheless, osteopathic institutions did not keep pace with the changes incorporated by the MDs. With respect to preprofessional education, the AOA Board of Trustees in 1920 stipulated that henceforth each school must maintain an entrance standard of no less than a high school diploma or its equivalent to keep its accreditation rating. However, no attempt was immediately made to enforce this provision, and it was not until the early 1930s that all the schools appeared to be fully complying.17 Those in favor of further stringency in entrance requirements were a decided minority. The Los Angeles college established a compulsory one year of preprofessional qualification in 1920, but this was in response to a new California law. Most DOs sided with Dr. George Laughlin, who in 1925 observed, “We make a mistake as a profession when we attempt to ape the medical man in matters of requirements.”18 Laughlin, the founder’s son-in-law and then head of the Kirksville College, argued that the requirement by MD institutions of two years of prior college work was hurting the underprivileged, since they could least afford the cost of additional schooling. As many of these disappointed students came from farms and small towns, the standard had the indirect effect of causing a decline in the percentage of recent MD graduates deciding to locate in sparsely populated areas. Without this qualification, DO schools could meet the needs of the economically disadvantaged student and help alleviate a growing rural physician shortage.19

Whatever the merits of Laughlin’s views, the main reason militating against a further increase in preprofessional requirements was the economic condition of the colleges themselves. Although all of the schools had evolved into nonprofit institutions, the sources of their revenues remained the same. They received no direct tax support, no general university funds, and, in comparison with MD institutions, little outside philanthropy. In 1932 reportedly 92 percent of the gross receipts of all the colleges was secured from tuition fees alone.20 Given this form of financing, the schools’ very survival depended on their ability to obtain a base line of new matriculants each fall. If they set the preprofessional entrance standard at the MDs’ level of two years or more, the osteopathic schools would drastically cut their pool of eligible applicants, and the number of students necessary to meet expenses would very likely not be reached.21

During this era a large percentage of the schools’ annual tuition income was devoted to establishing more permanent facilities. In 1921 the Los Angeles College moved to a new campus, where three large buildings were erected over the next decade. The Kansas City College of Osteopathy and Surgery, founded in 1916, had two homes before finding a suitable location four years later, where it raised five new structures by 1933.22 The Chicago school left the downtown area for the Hyde Park section of the city in 1918, renovating a large four-story working girls’ residence to provide classrooms, laboratory, hospital, and clinic space. The Des Moines College in 1927 relocated from one entire office building to another, while the Kirksville College of Osteopathy and Surgery added a new facility for laboratories and classrooms along with a second hospital. Only the Philadelphia school, which in 1929 established a new campus, costing $1.1 million, was able to finance its plans through private donations.23

The educational program of the schools underwent a number of important changes between 1910 and 1935. The colleges added a mandatory fourth year, introduced a graded curriculum, and integrated the teaching of biological and chemical agents into the course of study. As a result, in its promotional literature the profession could boast that in terms of subjects presented and time devoted to them, MD and DO schools were equivalent. Indeed, on paper osteopathic institutions offered students a few hundred more hours of training than the typical orthodox medical college. However, this was a deceptive figure. Although the length of basic science courses in osteopathic colleges was greatly expanded, the instruction itself continued to be weak.24 By the early 1930s some preclinical teachers were employed on a full time basis, but few of these DOs possessed a graduate degree in the subjects they taught. The new buildings provided more adequate facilities, yet the equipment remained meager, and most laboratories were fitted out with the barest of necessities.

Money that could have purchased additional, improved apparatus had to be diverted into mortgage payments. Finally, the courses were often not as encompassing as those in allopathic colleges, partly because the preprofessional backgrounds of MD and DO matriculants differed. Osteopathic curricula, for example, included elementary biology and chemistry, which medical students had mastered before beginning their formal professional education.

Clinical training was also beset by severe difficulties. All of the schools were operating larger hospitals in the mid-1930s than previously; however, most were still quite small. While most MD colleges easily surpassed the minimum of 200 beds available for teaching purposes in the guidelines set by the AMA Council on Medical Education," the Chicago, Des Moines, Kansas City, Kirksville, and Philadelphia osteopathic schools averaged only 66 beds apiece.26 Where a minimum of 2,000 curriculum hours were devoted to bedside and outpatient teaching at MD-granting institutions, an average of approximately 700 hours of training were provided by these five colleges.27

The one osteopathic school that was able to offer clinical training approaching that found in orthodox medical schools was the College of Osteopathic Physicians and Surgeons (COP&S) of Los Angeles. This was made possible through its utilization of a 203-bed public hospital, which enabled each student to receive 1,770 hours of inpatient and dispensary experience.28 The establishment of this institution was an unintended byproduct of the “standardization of hospitals” plan inaugurated in 1918 by the American College of Surgeons, which eventually partnered with the AMA in running this program. These groups required that any hospital seeking their approval for the purpose of training graduate MD physicians prohibit DOs from having admitting or staff privileges. As a result, osteopaths throughout the country who had managed to secure such rights found them abruptly terminated.29 The Los Angeles County government, responding to pressure from DOs, who were numerous in the metropolitan area, built and opened a separate public hospital for the training and service needs of COP&S, whose faculty had been denied privileges at the existing public facility.30 Unfortunately for the profession, this type of arrangement was not repeated elsewhere.

With clinical experience in the colleges generally limited, it is hardly surprising that postgraduate training was also far from satisfactory. By the middle 1930s there were no more than eighty osteopathic hospitals in the country, of which only one-quarter were offering opportunities for advanced work.31 In 1932 there were but seventy-five internships, few approaching the standards governing MD programs." Formal residencies were scarcer. Those osteopaths who could not enter one of these had to learn their specialty by attending short courses given at the colleges or by taking a preceptorship with a private practitioner. Clearly, such conditions, as well as those on the undergraduate level, left much to be desired.

The Price of Lower Standards

Although osteopathic colleges during most of this period attempted to prepare their students to become full-fledged physicians and surgeons, their graduates faced difficult problems in being licensed as such. By 1937 only twenty-six legislatures had agreed to extend them privileges commensurate to those enjoyed by the MDs, and in some of these states a majority of DOs continued to be ineligible, since sixteen mandated preprofessional college work and eight stipulated a year-long internship.33 Furthermore, even when these requirements were met, other hurdles remained. In those jurisdictions where DOs had to be examined before medical or composite boards, they fared rather poorly on the same written tests taken by allopathic candidates. Between 1927 and 1931, for example, only 48 percent passed compared to 95 percent of the MDs.34 Consequently, many DOs avoided these examinations altogether, choosing an unlimited-license state whose tests were devised and graded by an osteopathic board and where the rate of failure was negligible. This reinforced the disproportionate geographical distribution of DOs that had existed since early in the century and that had been directly related to the location of the colleges.35

Unable to convince state legislatures to eliminate independent osteopathic boards, the MDs adopted the strategy of lobbying for a common test in the basic sciences that was to be taken prior to an actual licensing examination. This preliminary exam, which would be required of MDs, DOs, and chiropractors, would cover such subjects as anatomy, physiology, bacteriology, and pathology and would be written and administered by a separate committee independent of the licensing boards. In 1925 Connecticut and Wisconsin became the first to create basic science boards; they were followed by Minnesota, Nebraska, and Washington two years later.36 In opposing such measures, the AOA House of Delegates argued, ‘’Such an arrangement creates superfluous and unnecessary machinery of administration, erects another financial barrier to the recent graduate who is starting upon his life’s work of helping the suffering; is an inadequate practical test in the fundamental subjects considering the varying viewpoints and methods of the different schools of practice; eliminates reciprocity between existing osteopathic boards which are now functioning in a manner to insure the public osteopathic physicians who are well qualified; and furnishes the opportunity for domination by so-called ’regular medicine.’“37 The real fear of the osteopathic profession, however, was that their graduates would not be able to do as well as the allopathic practitioners, and this was soon confirmed by early results. In 1930, before seven basic science boards, the pass rate was 88.3 percent for MDs, 54.5 percent for DOs, and 21.9 percent for chiropractors.38 As a consequence, osteopaths began avoiding states that mandated such exams. One AOA spokesman noted,”In the three states of Minnesota, Nebraska, and Washington where the figures are available to make such a comparison, we find that those states jointly licensed 158 DOs in the two and one half year period prior to the adoption of the basic science boards. In the two and one half year period since … they have licensed but 35 or about one-fifth as many.“39

In accounting for their mediocre performance on basic science as well as medical board tests, the DOs asserted that they were being discriminated against, since osteopathic emphases were being ignored. If such examinations contained a fair number of questions bearing upon the mechanics of vertebral articulations or upon the role of nerves in controlling physiological functions, they argued, the results would be quite different.40 This claim may have had some validity; however, it seems unlikely that these alleged biases contributed significantly to the rate of failure by DOs. A more likely reason is that the MDs as a group had a superior overall educational background.

The Great Leap Forward

With almost one-half of the states refusing to grant DOs unlimited privileges, with an ever-increasing number of states setting preprofessional and postdoctoral requirements that most DO graduates could not fulfill, and with DOs doing so poorly on outside examinations, the osteopathic schools rec0gnized a need for fundamental change in the structure and quality of their educational programs. A mere continuation of their slow, evolutionary approach to reform was not likely to achieve the privileges their students sought, and it could conceivably cause DOs to lose what legal ground they had already gained.

The specter of this second possibility was raised by a 1934 survey of four osteopathic schools made by two Canadian academicians, Frederick Etherington, MD, and Stanley Ryerson, MD, as a consequence of a small number of DOs in Ontario seeking additional practice rights from the provincial government. Comparing these U.S. osteopathic institutions with the province’s three medical colleges, Etherington and Ryerson showed that the DO schools were characterized by inferior laboratories and equipment, smaller hospital and clinic facilities, lower matriculation requirements, and less-qualified faculties. As osteopathic colleges did not, in their opinion, adequately prepare students to become physicians and surgeons, their graduates should not be licensed as such.41 These findings and conclusions were widely publicized by the AMA, which brought this survey to the attention of United States lawmakers.42 Put on the defensive, the DOs maintained that this “so-called inspection” was hastily done, that the examiners were obviously prejudiced, and that much of the information published was either misleading or blatantly untrue.43

While some state legislators gave the DOs the benefit of the doubt, others called for an unbiased legislative inquiry. With a few states on the brink of authorizing such investigations, the Associated Colleges of Osteopathy hired an outside consultant to prepare his own separate and confidential evaluation. The investigator, L. E. Blauch, PhD, was a nationally known educator who several years earlier had headed a Carnegie Foundation study of the curricula of American dental schools. In 1936 Blauch, with the approval and cooperation of the AOA, accompanied the chairman of the Bureau of Professional Education on his regular inspection of five osteopathic colleges. If the DOs anticipated a more favorable portrait of educational conditions, they were to be disappointed. In a detailed and dispassionate series of reports, Blauch cited the same deficiencies noted in the Canadian survey.44 Obviously, should state legislatures decide to commission their own investigations, the legal status of the colleges would be placed in considerable jeopardy. In view of this prospect, educational reformers within the osteopathic profession now gained the upper hand.

The MDs had made their largest strides in raising standards during the first twenty-five years after the Flexner report; the DOs made theirs during the second. One of the earliest reforms they effected was in admission requirements. In 1934 the Philadelphia college began enforcing a prerequisite of one year of college, and in 1937 it followed COP&S, which twelve months earlier had increased its minimum to two years. The Chicago and Kansas City schools went directly from requiring a high school diploma to a prerequisite of two years of college, in 1938, while the Des Moines and Kirksville colleges, meeting an AOA-imposed deadline, instituted a one-year condition in 1938 and a two-year requirement in 1940.45

As anticipated, enrollment suffered. In 1937 there were 1,977 students in the six accredited colleges; by 1940 the number had dipped to 1,653, a decline of 21 percent. This trend was accelerated by the entry of the United States into the Second World War, which drastically reduced the number of undergraduate college students available to enter any professional school. In 1945 total osteopathic enrollment had shrunk to 556by far its lowest point in the century.46 Immediately after the war, the AOA hired a full-time vocational counselor, who visited liberal arts colleges across the country, meeting with placement officers and students and acquainting them with the osteopathic profession.47 This campaign, in conjunction with the schools’ individual recruiting drives, which were aimed not only at current undergraduates but at returning veterans, soon brought the desired results. In 1947 total matriculation had climbed back to where it had been prior to the establishment of the two-year prerequisite, and it remained stable for more than a decade. Indeed, during this period the ratio of qualified applicants to available freshmen positions rose to roughly two to one, making admission into the colleges competitive for the first time.48 This served to strengthen the credentials of osteopathic students and encouraged each of the schools to raise its entrance requirements to three years of college work. Los Angeles did so in 1949; Chicago, Des Moines, and Kansas City in 1952; and Kirksville and Philadelphia in 1954. By 1960, 71 percent of all new osteopathic students were entering with a bachelor’s or an advanced degree.49

As higher prerequisites for admission were being introduced, osteopathic schools were enriching their basic science curriculum. Although the total combined average number of hours in anatomy, physiology, biochemistry, pathology, and microbiology remained virtually unchanged from 1935–36 to 1948–49, the percentage of time spent in the laboratory as opposed to the lecture hall increased from 48 percent to 59 percent, a figure that continued to climb in subsequent years.50 Three of the schools—Chicago, Kansas City, and Los Angeles—erected new basic science buildings, while other colleges upgraded existing facilities and equipment. Furthermore, after 1945 each of the schools hired more full-time instructors with MS and PhD degrees, thereby enhancing the quality of their faculties.51 An even greater transformation occurred in the second half of the undergraduate osteopathic curriculum. Actual bedside and outpatient experience for each student was increased in all six schools from an average of 862 hours in academic year 1935–36, to 1,883 hours in 1948–49, to 2,214 in 1958–59.52 This can be attributed both to the expansion of the colleges’ hospitals, from a combined total of 530 beds and bassinets in 1935 to 1,334 in 1959, and to the fact that each of the schools made arrangements with other osteopathic hospitals for the training of externs.53

Quite a few of these changes in undergraduate education were possible only because the schools put themselves in more financially secure positions. Since the annual number of qualified applicants far exceeded the freshman places available, the colleges could institute sizable tuition boosts without jeopardizing the number of matriculants. Between 1935 and 1960 fees climbed from an average of $223 to $900 per year.54 Outside sources were also solicited. In 1943 the AOA launched what became known as the Osteopathic Progress Fund. With student enrollment then dropping towards dangerously low levels and with several of the schools facing the prospect of having to close their doors, DOs in the field were pressured to contribute. By mid-1944, at the end of the first campaign, an impressive total of $962,535 had been subscribed and directly channeled into the college treasuries.55 In 1946 a new, continuous, Osteopathic Progress Fund program was organized which raised $8,956,625 between then and 1961.56 This era also marked the genesis of federal support. In 1951 the US. Public Health Service awarded all six schools renewable teaching grants previously designated only for MD and dental colleges. By 1956 this source of income amounted to $383,000 a year. Another federal program aiding the schools came in the form of hospital construction funds made possible under the Hill-Burton Act of 1946.57 Among the major grants made under this law was one awarded to the Kansas City college for a new clinic, one to the Kirksville school for a modern inpatient facility, and a third to COP&S for a rehabilitation center.

The advances in predoctoral education during this period were accompanied by significant changes on the postgraduate level. In 1936 the AOA Bureau of Hospitals undertook its first inspection of institutions offering internships. Since the primary objective of the association was to provide a position for every new graduate, requirements were initially set low in order to qualify as many of their hospitals as possible.58 During the Second World War the DOs, who as a group were exempt from the draft and had been declared ineligible for voluntary service with the military medical corps, began taking care of the clients of inducted MDs. With allopathic hospitals still refusing DOs admitting and staff privileges, satisfied new patients stepped forward to help underwrite the costs of building and maintaining separate private osteopathic institutions. In 1945 there were approximately 260 osteopathic hospitals operating in the country, more than triple the total of a decade earlier.59 This increase in turn served to alleviate the internship shortage, and by 1951 available positions had surpassed the number of that year’s graduating seniors, thus making possible a toughening of standards.60 In 1947 the Bureau of Hospitals made its first inspection of osteopathic residency programs. That year, 71 were approved; by 1959 there were 389 available.61 As formal residencies increased in number, the requirements governing them, as well as the process of certification of specialists (under machinery created by the AOA in 1939) were considerably strengthened.62

The push for higher standards between 1935 and 1960 resulted in progress on the legal front. At the end of this span of time, the number of states in which DOs became eligible for unlimited licensure rose to 38; osteopathic schools were now able to meet the requirements of certain medical boards and other governmental agencies which had been empowered to approve them; and DO graduates possessed a preprofessional background and postgraduate training matching or exceeding the minimum called for by each state.63

Osteopathic performance on outside examinations also showed significant gains. While from 1942–44 to 1951–53 results obtained by MDs and chiropractors on basic science tests remained Virtually unchanged, the DOs went from a 52 percent to an 80 percent pass rate. Substantial increases were also made before state medical and composite boards of licensure. Here too, while the results of graduates from US. medical schools remained consistent from 1940–44 to 1955–59, the rate of passage for DOs climbed from 63 percent to 81 percent. Clearly, whatever educational problems remained, the DOs had placed their academic house upon a more solid foundation.

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