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

7. A Question of Identity

Osteopathy as originally conceived by Andrew Still was a radically different approach to healing. Its philosophy, view of pathology, and system of patient care shared little with the components of orthodox medicine. Indeed, the founder cast himself and his followers as nothing less than revolutionaries seeking to overturn the entrenched allopathic order. However, as the DOs came to adopt a multidimensional conception of disease and as their scope broadened, the clarity of the objective differences between the two groups began to fade. This trend would later be accelerated by two further developments: first, the progress made in improving their educational system and opportunities for complete licensure, as just described; and second, by their growing reliance upon orthodox medical modalities. However, these transformations were not accompanied by a commensurate change in the general public’s perception of who the osteopathic practitioner was and what he or she did. As a result, most DOs would suffer, to varying degrees, from status inconsistency.

The Displacement of Osteopathic Manipulative Treatment

The one feature of osteopathic practice that most readily distinguished the DOs from the MDs was, of course, manipulative treatment. After 1930, however, the application of this modality in total patient management began a steady decline. This trend can be attributed to, first, institutional changes, that is, alterations in the social structure of the colleges, the hospitals, and office practice; and second, to scientific changes, that is, transformations in the DOs’ knowledge base.

The improvements that were undertaken in the colleges beginning in the 1930s were all initiated with the idea of raising their graduates’ chances of becoming eligible for and passing unlimited licensure examinations. Since the distinctive elements of osteopathic education had no specific relevance to these goals, the colleges had no incentive to emphasize or build up this area of the curriculum. Indeed, some of the improvements were often instituted at the expense of distinctive osteopathy. Many of the full-time non-DO teachers hired to upgrade the standards of basic science instruction, for example, did not have the background necessary to integrate osteopathic theory into their lectures, as their predecessors had done.1 Also, the time spent on the subjects of pharmacology and surgery was increased to meet state requirements, and this seemed to have a detrimental effect on osteopathic instruction. The consequence, complained George Woodbury, D0, of Los Angeles, was that too many students were becoming “sadly confused and sorely disillusioned before their day of graduation… The lavish display of therapeutic methods and modalities explained and utilized in college, hospital and clinic demonstrations had a tendency to weaken the emphasis on and minimize the need and value of distinctly osteopathic procedures.”2

In the first osteopathic hospitals, the DO who admitted the patient would perform the surgery or at the very least handle the patient’s preand postoperative manipulative care. However, with the advent of larger facilities and the establishment of a more clear-cut division of labor between DO specialists and general practitioners, the latter were less involved in such management. As a result, osteopathic manipulative treatment (OMT) waned. Besides claiming that they were “too busy” to administer such treatment themselves, DO surgeons increasingly viewed such intervention as impractical from a technical standpoint, particularly when the patient was in an oxygen tent, or hooked up to assorted monitors and intravenous lines. Indeed, many DO surgeons argued on these grounds alone that OMT was only suitable in ambulatory settings.3

This deemphasis and growing exclusion of OMT from the hospitals had a significant impact upon the colleges’ postdoctoral programs. In his 1946 AOA presidential address, Dr. C. Robert Starks, referring to the undergraduate students, cited a fellow practitioner who had complained, “As soon as these individuals are graduated and put into the osteopathic hospitals they are immediately ‘deosteopathized’ [so] that by the time they finish their internships the osteopathic phase of their training has been discredited in large measure by osteopathic surgeons and other members of the staff, and those individuals go into practice with an apologetic attitude towards the osteopathic phase of their professional work.”4 Needless to say, graduates who went on past the internship to take hospital-based residencies were even more likely to develop a negative opinion of OMT.

After the war the AOA began to respond to this criticism. In 1947 its Committee on Hospitals announced that it would start enforcing its policy, in effect since the beginning of the AOA accreditation program, that house staff record distinctive osteopathic diagnostic and therapeutic procedures on all patient charts. The hospitals, however, offered little cooperation, and within five years the advocates of enforcement were labeling their own efforts a failure.5

Institutional changes at the level of office-based DOs were also affecting OMT use. With the shift from an essentially chronic to a broad-based practice, DOs saw more patients during the average workday. This increase in demand served to reduce the frequency and length of osteopathic treatment. To make more efficient use of their time, some practitioners turned to physical modalities that did not require their continued presence, such as the “spinalator,” a device that could be set to manipulate vertebrae mechanically. However, to a far larger number of DOs, pharmacotherapy seemed a much more convenient substitute. The efficiency of writing a prescription or giving an injection over administering OMT appears to have been, in itself, a significant factor in a DO’s decision on how he or she would manage a given patient.6 Also critical in this regard were the patients’ expectations of how they should be treated. Clients simply seeking physicians and not previously socialized into the traditional osteopathic approach were less likely to desire or expect OMT for disorders not directly involving the musculoskeletal system.7

As noted, scientific issues also had an impact on the relative frequency of OMT. Early basic research on animals, the bulk of which was carried out by Dr. Louisa Burns and her associates, lacked valid controls and provided at best only inferences that the osteopathic lesion played any direct or indirect role in the pathogenesis of visceral disease in humans. Indeed, some DOs came to feel that in many illnesses they treated the presence or ,absence of the lesion was irrelevant. In 1916, during the fight over the relative merits of the diphtheria antitoxin, Dr. Henry Bunting, editor of the journal Osteopathic Physician, asked his colleagues:

Would we rather hang on to our dogma that—no matter what the facts show—it has always got to he a mechanical lesion? Nothing is easier to prove in the case of diphtheria, at least, that the word “mechanical” has no business to be inserted as a necessary condition for getting that disease. The exciting cause is vital, not mechanical—the Klebs-Loeffler bacillus. Inject 100 guinea pigs, each of 250 grams weight, with an equal amount each (or 1–100th part) of minimum lethal dose of diphtheria toxin. Each guinea pig will be “sure dead” in 96 hours. Repeat the experiment with 1000 guinea pigs, the thousand will die. Repeat it with 1,000,000. The million will die on the same schedule. Does this mean anything? What caused the disease? What killed? Some unknown and different anatomical lesion in the case of each guinea pig, or the well known Klebs-Loeffler bacillus through its toxins.8

Carefully controlled research on the lesion under osteopathic auspices began in the late 1930s as a byproduct of the search by the profession for philanthropic support of its schools. J. Stedman Denslow, DO (19061982), then at the Chicago College, met with Alan Gregg, PhD, of the Rockefeller Foundation, who advised that outside funding might be more readily secured if the DOS scientifically demonstrated that they had a distinctive contribution to make to the healing arts. Through Gregg’s help, Denslow, who had decided he would prepare himself for a research career, was introduced to a number of prominent neurophysiologists. Among those who provided him with counsel and assistance were Ralph Waldo Gerard, MD, PhD, of the University of Chicago, and Detlev Bronk, PhD, of the University of Pennsylvania, both leaders in the new field of electromyography.9

Denslow, after he had built one of the early differential amplifiers and recorders for simultaneous electromyographic observations of paravertebral musculature, moved to Kirksville to launch his research. Unlike Burns, he purposefully confined himself to asking limited, testable questions regarding the lesion phenomena, particularly what local neurophysiological manifestations were associated with those spinal areas designated as lesioned through palpation. Between 1941 and 1943 Denslow and his associates published four articles in two prominent nonosteopathic basic scientific journals, demonstrating that the motor neurons (anterior horn cells) at those segmental levels in the spinal cord associated with musculoskeletal stress had lower reflex thresholds than those at other, “normal,” levels in the spinal cord. This was shown by applying measured amounts of pressure necessary to evoke contractions of the paravertebral muscles at that segmental level. These muscular contractions were detailed and recorded electromyographically. He further found that reflex motor thresholds of the paravertebral muscles, that is to say, their motor neurons, differed at different levels of the trunk, and that the reflex thresholds for both muscle contraction and pain were low in lesioned areas as compared to nonlesioned or normal areas.10

After the Second World War Denslow was joined in his work by Irwin M. Korr (b. 1910), who had received his PhD from the University of Pennsylvania. Continuing this general line of experimentation, the two men demonstrated in 1947 that diffuse and remote stimuli from many sources preferentially excited the motor neurons of lesioned segments while nonlesioned segments remained quiescent. Their research indicated that the neurogenic mechanism responsible for this phenomenon was facilitation (that is, reduced threshold of excitability) of the motor neurons of the spinal cord. Although the source of the facilitation was not at the time conclusively demonstrated, Korr and Denslow hypothesized that it might have its origin in a sustained afferent muscle bombardment from segmentally related somatic or visceral structures. These impulses would have the effect of lowering the threshold of excitability of the neurons at the segmental level in the spinal cord’s associated stress area.11

This research effort at Kirksville, which continued for decades, was of great import to the profession. It provided the first objective evidence of the presence of what the DOs had discerned through palpation and designated as the “osteopathic lesion”; it showed that a DO could do reputable studies on the lesion phenomenon and have the results accepted by the outside scientific community; and it paved the way for federal support of osteopathic research. However, the investigations, while breaking new ground, could not resolve two key questions. First, what was the significance of the lesion, or what was later called “somatic dysfunction,” in the etiology of disease? Second, what effect, if any, would the elimination of the lesion through manipulation have on the disease process?

Controlled clinical research on manipulation might have been able to resolve this second issue; however, no such studies were undertaken during this era. The failure to pursue this course can be attributed in large part to the serious methodological challenges inherent in such a project. Though one could easily standardize the content and strength of a pill, it would be most difficult to have the same control over the amplitude and velocity of physical manipulation. Furthermore, with pharmaceuticals it was relatively simple to set up a single- or double-blind study with a capsule. Neither the patient nor the doctor would be able to distinguish the test drug from the placebo. However, what would constitute a manipulative placebo? The fact that one could not easily eliminate the subjective element from clinical studies on manipulation convinced those DOs within the AOA who controlled the association’s limited funding for scientific projects to put their energy and money into basic research.12 The clinical investigations that were carried out and published in osteopathic journals consisted of a small number of case studies, many of which were anecdotal in content.

Thus, DOs were told by their colleagues that the lesion was significant and that OMT worked, but they had to accept the concepts on faith or on circumstantial evidence. A growing number could not. As Louis Chandler, D0, of Los Angeles, noted in 1950, “Too much still seems to be in the realm of uncertainty both as to what will result from manipulation in the area of the spinal vertebral lesion and in the physiological consequences [elsewhere]… These uncertainties constitute a great obstacle to many scientifically trained men in maintaining an interest in osteopathy. Uncertainty regarding an observation to them means that it probably is not valid.”13

While clinical research in distinctive osteopathic procedures was standing still, the value of new chemotherapeutic discoveries was steadily being demonstrated. In 1935, the first of the synthetically produced sulfonamides useful against hemolytic streptococci and staphylococci was introduced. Early in the 1940s penicillin, effective against the range of gram positive bacteria, became available. Beginning in 1945 streptomycin, which destroyed gram negative bacteria, was marketed. This was followed by aureomycin, chloramphenicol, and tetracycline. In addition to these antibiotics, between 1945 and 1960 a number of new analgesics, antiinflammatory agents, muscle relaxants, and tranquilizers, as well as other forms of drug therapy were introduced.14 The pharmaceutical manufacturers could provide tangible (if not always reliable) statistical evidence supporting the value and safety of their products, but the advocates of OMT could offer little more than testimonials. As a result, the “scientifically trained” D0 to whom Chandler referred was likely to put greater trust in these modalities than in manipulation.

The relative decline in dependence on osteopathic manipulative treatment over the years is imperfectly reflected in the changing focus of the journal of the American OsteopatbiCAssocizztion. In the early 1930s OMT was still included in the majority of articles and was described with great care and detail, but by 1948 the AOA Board of Trustees felt compelled to pass a resolution urging that “every effort be made by the writers of scientific papers for publication in the officialJournal of the Association or in other osteopathic periodicals to include wherever feasible discussion of the relationship of the osteopathic concept to the subject of the paper.”15 However, as the contributors were increasingly specialists who had eschewed structural diagnosis and manipulative treatment in their own practice, this resolution had little if any impact. By the end of the 1950s mosthOA articles failed to mention OMT, and when they did it was only briefly and more as an adjunct than as an integral part of patient management. Articles devoted solely to osteopathic principles would still appear, but with far less frequency.16 Those practitioners who did employ palpatory diagnosis and manipulative treatment increasingly referred to themselves as “ten-fingered” DOs as opposed to “three-fingered” DOs-the latter needing just that many digits to write a prescription.

Precisely how many DOs in the 1950s were performing manipulation and to what extent is impossible to determine, although one can come to certain general conclusions. Hospital-based DOs were utilizing OMT infrequently, and only a minority of surgeons saw to it that their patients received pre- and postoperative treatments. In office-based general practice,

OMT appears still to have been used with some regularity, but less time was devoted to it and it was increasingly restricted to the treatment of local joint and muscle problems. While approximately 10 percent of all active DOs, either through choice or because of state laws, exclusively employed distinctive osteopathic procedures, this group (comprised mostly of older DOs) was steadily shrinking each year. For younger practitioners, the data are more substantial. In 1954 the AOA mailed out a confidential questionnaire to all active DOs who had graduated between 1948 and 1953. Close to 60 percent responded. Only 44 percent of those answering the question “What percentage of your patients receive manipulative treatment?” responded, “over 50 percent.” Considerable variation by school was noted; 53 percent of Kirksville graduates responded with this figure, compared to 16 percent of Los Angeles graduates.17 Clearly, the DOs as a group were coming continually closer to the MDs in means of patient management.

Those DOs who strongly believed in the appropriateness of OMT for a wide range of conditions did what they could to alter this trend. In 1938 a group callingitself the Osteopathic Manipulative Therapeutic and Clinical Research Association, which after 1944 was renamed the Academy of Applied Osteopathy (AAO), was granted affiliate status with the AOA. The academy arranged programs focused on osteopathic principles and practice at the national AOA conventions, circulated papers to members, provided speakers for state and local AOA meetings, conducted short postgraduate refresher courses, and sponsored the writing or distribution of books relating to distinctive osteopathic approaches. Although these activities kept traditional osteopathy before the profession, the influence of the academy was limited. Only 12 percent of all DOs in the AOA were affiliated with the academy group at its peak.18

Other DOs viewed the AAO with skepticism, because it embraced members who made broad claims that ran counter to scientific facts or conventional understandings, the most controversial of which were promulgated by a Minnesota practitioner named William Garner Sutherland, DO (1873–1954). Based on his experiences, which dated from his training at the Kirksville School, Sutherland wrote and self-published a volume entitled The Cranial Bowl in 1939.19 Sutherland argued that there was a “primary respiratory mechanism” which c0111d be felt by placing both hands on the skull until the practitioner can gain the palpatory sensation of widening and narrowing. He believed that this primary respiratory mechanism consisted of five elements: the inherent motility of the brain and spinal cord, the fluctuation of the cerebral spinal fluid, the motility of intracranial and intraspinal membranes, the articular mobility of cranial bones, and the involuntary mobility of the sacrum between the ilia. Sutherland claimed that through palpatory techniques one could ascertain abnormal positions of cranial and adjacent structures which could be “guided carefully, gently, firmly, and scientifically into normal relationship.”20 Left alone, these “cranial lesions” could interfere with normal physiological processes throughout the body. Though this book had a largely mechanistic orientation, other of his writings and presentations were vitalistic in orientation. Sutherland believed that cerebrospinal fluid, membranes, and bones were propelled by an external force or energetic potency that he called the “breath of life.” Sutherland’s belief in the mobility of cranial sutures past infancy, as well as a number of his other ideas, ran directly counter to prevailing scientific evidence and opinion. He and many of his followers were noted for the zeal and enthusiasm with which they promoted his doctrines, which in turn alienated those DOs who were seeking external legitimacy for the profession. Eventually, Sutherland’s followers formed the Cranial Academy, which became an affiliate of the


Status Inconsistency

The most vexing problem for the DOs as they expanded their scope of practice and improved their educational standards was the public’s failure to recognize the complete range of services they could provide their clients; along with this oversight came a concomitant lesser deference and lower social standing than was accorded MDs. To the many DOs who believed themselves as well trained or as competent as their allopathic counterparts, these circumstances led to considerable frustration and alienadon.

Part of their difficulty lay in their small numbers. From the turn of the century up through 1960, DOs constituted approximately 3–4 percent of the total US. physician population (MD and DO totals combined). Furthermore, as previously noted, the DOs were distributed disproportionately, and in many sections of the country osteopathic care was unobtainable. Indeed, as late as 1960, twenty-two states had fewer than fifty DOs apiece. This scarcity helped to make the profession socially invisible.22

Another handicap preventing widespread recognition and approval was their difficulty in securing the same legal privileges enjoyed by MDs. This applied not only to unlimited licensure but to winning the right to handle workers’ compensation cases, becoming state or local health officials, entering the military medical corps, gaining access to public hospitals, and having their services covered under private insurance plans sanctioned by special enabling acts. Not having any or all of these rights and privileges served “officially” to brand the DOs as inferior practitioners.

Because of these various circumstances the great majority of Americans were unclear as to who the DO was and what precisely he or she did. In 1936 the AOA hired a public relations counselor, who conducted several on-the-street interviews in downtown Chicago. To the question “What is an osteopath?” a magazine writer responded, “An osteopath is a fellow who sets your spine, an MD who specializes in that method.” A women’s clothing stylist answered, “He’s a man who has something to do with the spine.” A bus driver declared, “Well, I don’t know if I can word it. He massages people.” Displaying an anatomical focus not surprising given his occupation, a postal clerk replied, “An osteopath has something to do with care of the feet.” Another postal clerk asserted, “An osteopath has something to do with massage like a chiropractor. Osteopaths I believe are outlawed in New York and some other states too. I read about some of them being arrested in New York.” A department store clerk exclaimed, “Oh yes, I know, I went to one once. They are especially for nervous people and treat them by massaging. The difference between a doctor and an osteopath is that an osteopath is drugless.” A policeman reflected, “Let’s see. He’s a guy that when somebody gets all bent up, they put him on a table and twist him around and sorta put him together again. Ain’t that right?” And finally, a stockbroker remarked, “He’s a man who lays you on a table and massages. A doctor can be an osteopath but an osteopath can’t be a doctor.”23 Although these beliefs were expressed in what was then a limitedpractice state, the situation in states where osteopathic practice was unlimited or nearly unlimited was not much better. During the same year, Professor George Hartman of Columbia University published a study of the relative social status of twenty-five medical careers as judged by 250 Pennsylvania laypersons. The category “osteopath” was ranked eighteenth overall, one notch below “dietician.”24

The profession acted in a number of ways to change its image. The first effort, which gained some momentum in the 1920s, concerned the matter of occupational title. Because the term osteopath had been so closely identified with manipulative treatment, many DOs believed new labels were needed. Dr. Alice Foley, writing in the JAOA, related the story of an attorney who said to her, “‘Now you osteopaths do so and so, but the physician does thus and so.’ The thought came to me that the public does differentiate. They call the allopath their physician and think of us as osteopaths.” Foley recommended the use of the term osteopathic physician. “That explains the kind of physician we are, and it also leaves the word ‘physician’ in their thoughts concerning us.” M. F. Hulett, DO, agreed, stating, “many of our friends are not yet aware of the fact that we are physicians at all, and some still seem surprised that we really treat the sick.” Commenting upon osteopathic physician and osteopathic physician and surgeon, Hulett added, “I am quite sure the repeated use of these terms will add to the dignity of our school.” This move received support from then-AOA editor Cyrus Gaddis, DO, who sermonized: “Let no piece of literature be circulated or none go out with simply ‘osteopath.’ Let it stand out ‘osteopathic physician’ and then be sure that we are ready to live up to that name… Are you an osteopathic physician or just an osteopath? Times are changing. Are we willing to have the public consider us simple treatment givers?”25 By 1940 the great majority of DOs were using the new labels.

Concurrent with the move by DOs to modify their shingles and office stationery, the national and state associations sought to bring up to date those references to osteopathy found in dictionaries and encyclopedias. Phrases or definitions which suggested that DOs were not in favor of drugs, or that they placed chief attention in their work upon finding and removing structural lesions through manipulation, were excised in favor of language that emphasized that osteopathy was a complete school of healing.26 Telephone directory listings were also altered, substituting osteopathic physician or osteopathic physician and surgeon, depending on the licensure law, for the now increasingly discarded word osteopath.27

The AOA also worked to improve the DOs’ social standing through the legislatures and the courts. As a result, many licensure laws would be revised in their favor; DOs became included in some of the health-related New Deal programs; they would win attorney general and judicial decisions on their participation in workers’ compensation cases; they triumphed in some key battles over their right to access to hospitals built with public money; and they qualified for some federal aid, mostly in the form of Hill-Burton hospital construction grants.28

All of these efforts helped to improve the DOs’ public image through the 1950s, but the rate of progress as perceived by many osteopathic practitioners was far from satisfactory. One of the principal reasons for their failure to make larger inroads in lay understanding was a consequence of their inability to convince the print media to notice them. National and state conventions, as well as DO speaker tours, were not considered particularly newsworthy; and when such events were reported, the resulting story was usually no more than a few paragraphs in length and was placed in an inconspicuous section of the newspaper. Most national general feature magazines also seemed to see little of interest in the profession, and those that did focused entirely upon the manipulative aspect. Typical was Mark Sullivan’s “If I Need Relaxation,” published in the Reader’s Digest, an article that, while most complimentary, cast the DOs as highly skilled “rubbers” rather than broadly trained physicians, thus reinforcing the image the movement wanted to shed.29

When newspapers and magazines gave prominent attention to the activities of individual MDs, it was often in connection with the introduction of a new drug or a new life-saving surgical technique, or the reception of a prestigious award. Other MDs were regularly featured in periodicals by contributing health columns. The DOs, the great majority of whom were in the unglamorous field of general practice and made no spectacular contribution to research, were thus cut off from such favorable coverage. Indeed, when reporters focused on the exploits of individual osteopathic practitioners, it was almost invariably in connection with alleged or actual deviant 'margin-top:1.2pt;margin-right:0cm;margin-bottom:1.2pt; margin-left:0cm;text-indent:18.0pt;line-height:normal'>During the 1950s, the national press focused on one osteopathic practitioner, Dr. Sam Sheppard of Ohio, who in a highly sensationalized trial, was convicted of the murder of his wife, a verdict later reversed. Sheppard’s saga became the inspiration for the long-running television show and, much later, the movie entitled The Fugitive, in which the doctor protagonist was portrayed as an MD. Though Sheppard was repeatedly referred to as an “osteopath” in articles and on television, most accounts also noted that he Specialized in neurosurgery. This latter piece of information undoubtedly surprised many readers and listeners, who thereby learned that a DO could concentrate his or her efforts in a field other than manipulation.30

The continual lack of public awareness of who DOs were and what they did and their positive contributions to American health care generated a considerable degree of frustration among many members of the profession. Although most practitioners simply accepted the fact that a certain portion of their work consisted of answering questions relating to how much educational training they received, what their scope of practice was, and how precisely they differed from the MD, other DOs found this situation intolerable. This problem of poor public perception affected the DO’s family as well. During social interaction, wives and children were always at risk of being put into the uncomfortable or embarrassing position of having to explain or even defend their spouse’s or parent’s occupation. In 1955 AOA editor Dr. Raymond Keesecker, addressing the student doctor’s wife, noted that such situations “Give you the best opportunity in the world for some important public relations work.” However, some wives saw this as a terrible burden, and even Keesecker admitted that in dealing with any question about osteopathy, “it is not too easy to give a specific answer.”31

Many DOs came to believe that the primary cause of their identity problem was the letters behind their names. The American public, they argued, recognized the MD degree as the universal symbol for a physician and surgeon; thus it was not all that surprising that patients seeing any other designation would be confused as to its meaning, even if the title physician and surgeon were added to their stationary or their shingle. In the opinion of some DOs, the easiest way of changing their image was to change the degree awarded by osteopathic colleges to that of MD. During the 192 Os and 193 Os, such calls were occasionally sounded in the journals, but they gained no support within organized osteopathy as a whole.32 However, with America on the verge of entering the Second World War, some students and alumni of two of the schools pleaded with their administrations to adopt the MD designation, believing that through this maneuver they could become eligible to serve their country as military physicians. To take the onus off the school officials and put an end to such hopes, the AOA Board of Trustees in 1941 declared that “the only degree to be issued by an approved osteopathic college qualifying for licensure to practice the healing art shall be the degree of doctor of osteopathy.”33 As far as the AOA was concerned, this decision was absolute and irrevocable.

The refusal by the AOA to accommodate this dissatisfied minority led some DOs to obtain diploma-mill MD degrees to hang in their offices. Such certificates, while totally worthless for the purposes of licensure, were nonetheless thought useful by their possessors as a means of convincing new patients that they were after all “real doctors.”34 However, a larger group of unhappy practitioners were not willing to go that far. They simply decided to leave all mention of their DO degree and reference to osteopathy off their stationery and shingle and just go by the title “Dr. ‘So-and-So’, Physician and Surgeon.”35 Thus, while the general public was confused as to what DOs did, a significant number of osteopathic practitioners were coming to the conclusion that the best way to deal with the confusion of laypersons was to hide their identity.

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