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

8. The California Merger

For most DOs the problems connected with their identity did not undermine the desire for professional autonomy. Even many of those who failed to advertise themselves as osteopathic practitioners and favored the schools’ awarding an MD degree continued to believe they were part of a distinctive group that should remain politically separate and independent. Their displeasure with the AOA was with its policy, not its legitimacy as the voice of osteopathy. However, this attitude was not universally shared. For some DOs the various changes taking place within the profession, combined with their specific situation at the local level, led to a vastly different interpretation and outlook. Nowhere was this more evident or widespread than in California.

The COA and the CMA

In the decades prior to 1960 there were more DOs practicing in California than in any other state; they constituted at any given time 10 percent of all its physicians, and perhaps 15 percent of its total population were their patients.1 In terms of legislative victories, public acceptance, and average practice income, no other state group approached their achievements; however, a deep disenchantment with their lot belied their outward success.

Even before the turn of the century California DOs were beginning to establish themselves as the progressive wing of osteopathy. In 1896 the Pacific College became the first school to introduce a mandatory two-year course and later was one of the earliest to expand to three years. The state attracted and became the stronghold for the “broad osteopaths,” and under their influence the Los Mgeles College became the first institution to place in its curriculum a course on materia medica. The College of Osteopathic Physicians and Surgeons (COP&S)—the result of combining the aforementioned schools—was the first to require one year, then two, and ultimately three years of prior college work as an entrance requirement. Finally, with respect to clinical facilities, it was the first and only school to utilize a large municipal hospital for bedside and outpatient teaching.

The Los Angeles County General Hospital-Unit #2 trained many of the profession’s leading specialists and was well regarded in the community for the quality of care that patients received. As it was a government institution, the hospital administration published annual statistics, and those numbers appeared to demonstrate year after year that the mortality rates and length of patient stay (every tenth patient was admitted to the osteopathic unit) were consistently better than the much larger Unit #1 next door, run by the MDs. The MDs claimed that a significant number of sicker patients were transferred or diverted to their unit, a charge the DOs dismissed. As a result of these continuing unfavorable comparisons, the MDs pressured the hospital administration in 1934 to change the rules regarding admissions and publish only statistics that represented the combined totals of the two units.2

Pointing with pride at their various achievements, California DOs generally regarded themselves as the best qualified osteopathic physicians and surgeons in the country. Most also considered themselves the most “scientific,” which meant that the decline in distinctive osteopathy was more pronounced in California than elsewhere. Furthermore, because of the stringent requirements of California law as well as tougher regulations adopted by the state board of osteopathic examiners, graduates from other DO schools were for many years ineligible for unrestricted licenses. This made for a comparatively homogeneous osteopathic population.

California DOs placed a high priority on securing for themselves com: plete equality with the MDs in their state. It was thus a source of continuing frustration for them that whatever progress they collectively made, significant gaps between the two groups remained. This was reflected most clearly in the matter of college finances. From the 1930s through the early 1960s, COP&S could raise and spend only one-half to three-fifths the amount MD schools could allocate for the education of each of their students. Unlike MD-granting schools, it could not count upon state support, general university funds, and philanthropy. Although COP&S employed more full-time faculty than other osteopathic colleges, it could not approach the numbers characteristic of an AMA-accredited institution.3

Far worse was their postgraduate situation, particularly with respect to training facilities for residents. Only a small number of positions were available annually within the entire state, and the great majority of those were offered at Los Angeles County General Unit #2. While several dozen DO facilities were founded in California after 1930, the bed capacity of most was too limited to provide for adequate specialty programs. Those applicants not successfully placed had to either go out of state or resign themselves to a general practice. At the same time, California DOs could only look with envy at the number and quality of allopathic hospital residencies in their midst, appointments for which they as osteopathic physicians were ineligible.

Added to these educational problems was lack of visibility. Public knowledge of the DOs, particularly the scope of their services, was far less than what was known of the MDs, in spite of the fact that a significant minority of the California population was served by osteopathic physicians and surgeons. Part of this problem may be attributed to the continuous waves of new residents arriving from areas of the country where the profession had far fewer representatives and limited practice rights. Some California DOs argued that in one sense they were being victimized by the national image of osteopathy, and they held the AOA responsible, alleging that it was too tolerant of the lower standards maintained by the other colleges and was not working hard enough to eliminate remaining legal and social inequalities elsewhere.4 This combination of elementsnamely one group of DOs thinking of themselves as a breed apart from the rest, added to the other problems that faced the profession generally, such as poorer educational opportunities, lack of public recognition, and a decline in the use of distinctive osteopathic procedures—led an increasing number of California practitioners to consider the possibility and advantages of leaving organized osteopathy for organized medicine.

While more California DOs were coming to this conclusion, so too were the leaders of the state’s medical association, but for entirely different reasons. For the most part, organized medicine within California saw the DOs as an inferior group of practitioners who were lowering the general quality of health care in the state. For decades they had tried through various legislative means to eliminate the profession, but to no avail. Despite their small number, the DOs had been able to wield considerable political power, effectively blocking the passage of threatening measures. When in 1942 the California Medical Association supported a ballot initiative to create a basic science board, the DOs along with the chiroprac tors led a vigorous campaign against it. The proposal lost by a two to one margin.S With no other viable strategy left open to them, California MDs came to believe that the only way to destroy osteopathy was through the absorption of the DOs, much as the homeopaths and eclectics had been swallowed up early in the century.6

In 1943 Forest Grunigen, DO (1905-1999), president of the California Osteopathic Association (COA), appointed what was called the FactFinding Committee, to meet with representatives of the California Medical Association (CMA) following five years of informal contacts concerning merger.7 At this first official meeting the CMA offered a proposal for amalgamation which they had already discussed with the AMA Council on Medical Education and the Association of American Medical Colleges. This plan called for the granting of MD degrees, by one of the existing four medical schools in the state, to all DOs licensed as physicians and surgeons in California; the elimination of the osteopathic licensing board; and the conversion of COP&S into a medical school.8

In February 1944, the COA committee was advised by its counterpart that both the council and the American Association of Medical Colleges had given their tentative approval to the outline of their plan. However, within a month the Federation of State Medical Boards announced that it would refuse to recognize the validity of this MD degree and warned that any medical college issuing such a diploma would lose the right to have any of its regular graduates examined for licensure. Strong opposition was also voiced by certain influential AMA leaders, notably Morris Fishbein, MD, editor of the Journal of the American Medical Association, who was ready to fight any accommodation between “physicians” and “cultists.”9 These moves forced the American Association of Medical Colleges and the AMA Council on Medical Education to back away from their proposal. At the spring 1944 COA convention, the head of the Fact-Finding Committee noted that any possibility for amalgamation in the near future had disappeared.10

Staff members at the AOA headquarters in Chicago as well as key national leaders were kept apprised through their local contacts of the events in California. Their strategy seems to have been to do and say nothing. First, they did not want to be viewed as interfering in the affairs of the organization’s largest component society; if they were to do so, those who favored a merger might capitalize upon the issue and gain support. Second, they believed that the merger talk would probably lead nowhere. And third, they believed this effort to be triggered by the desire to obtain an

MD degree just to be eligible to serve in the military medical corps. Once victory overseas had been achieved, they figured, sentiment in this direction would undoubtedly lessen. As a result of the AOA decision not to print any information or commentary in its journals, most DOs outside California remained ignorant of the entire matter.

In the late 1940s, however, the attention of the profession was focused upon California when a group of dissident DOs set up their own “medical college” for the purpose of granting “academic” MD degrees to any osteopathic physician and surgeon who paid his or her tuition fee and attended thirty-six hours of lectures. During 1947 and 1948, at least 137 DOs secured one of these MD degrees. Graduates of this institution, known as Metropolitan University, then set up what they called the Pacific Medical Association, which began lobbying for its own legislative program.11 Both the COA and the AOA took a strong stand against these activities. In 1948 the AOA House of Delegates unanimously amended the code of ethics to prevent any DO from possessing or displaying any unaccredited degree, and the following year, through national and COA pressure, both the Metropolitan University and the Pacific Medical Association were forced to disband.12

The position taken by the COA in this matter seemed to convince many of those AOA leaders acquainted with the merger attempt of a few years earlier that such a threat had passed. However, the action of the COA was primarily motivated by its belief that the Metropolitan people, with their worthless degrees, were embarrassing the profession and that the establishment of a rival lobbying group would only sap its own political strength. In fact, the desire for a merger by some COA leaders and many California DOs in the field had not diminished. In 1947, Dr. Grunigen was appointed head of the COA Fact-Finding Committee, and he and his committee members over the next fourteen years held formal and informal discussions with CMA representatives on how this goal might be achieved.13

The AOA-AMA Conference Committee

Both DO and MD discussants in these continuing COA-CMA talks came to recognize that as long as the medical profession generally and AMA officials in particular held a decidedly negative view of osteopathy, a merger would be most difficult, if not impossible, to arrange. One possible way to break down this hostility would be to get their respective national leaders to hold conferences about common concerns. Such interactions could very well lead to a better understanding between the two larger associations and an upgrading of the status of the osteopathic profession, which in turn would facilitate their local efforts. Since both MDs and DOs from California held significant leadership positions in their respective national associations this plan was soon followed.14

In 1949 the COA House of Delegates, through its representatives, urged the AOA Board of Trustees to establish a fact-finding committee that would be prepared to meet with any healing arts group. The Californians, notably Grunigen, who was then first vice-president of the AOA, pointed out that in recent years their own Fact-Finding Committee had been able to resolve differences with the CMA and even with other state health associations over proposed legislation and had reduced mutual mistrust. If any of the AOA board members were skeptical as to the motivation behind the California proposal, they kept their doubts off the public record. Instead, the board quickly and quietly approved the measure, although the mechanics of how such talks might be initiated, particularly with the AMA, remained unresolved for more than a year.15

In October 1950, Floyd Peckham, DO, of New York, president-elect of the AOA, addressed the Kentucky Osteopathic Association. At the instigation of a DO member of the state board of health, he was able to meet informally with AMA president Elmer Henderson, MD, a local resident. During their friendly chat, a legal problem faced by the Chicago College of Osteopathy was raised. Although its graduates were then eligible for unlimited licensure in thirty-five states, this was not true in Illinois itself. As a result of their talk, both agreed that a conference should be arranged between representatives of their associations to discuss Illinois licensure in greater depth.16 In December the AOA board appointed a committee of five DOs, including two Californians, which met with a similar group from the AMA in February 1951. One of the latter committee’s members was John W Cline, MD, of California, president-elect of the AMA, who had played an advisory role in furthering the CMA amalgamation proposal eight years earlier.17

At this meeting the MDs were of one mind that the question of the Chicago school was a matter for local, not national, action; and so, with the DOs acquiescence, the matter was dropped. Some of the MDs brought up the issue of amalgamation of the two professions, but this was coldly received. In all, nothing of substance was accomplished. Yet, de spite this lack of agreement on topics to be discussed, it was the feeling of the participants that future conferences might prove useful.18

That June, Cline, newly installed as AMA president, reported to his Board of Trustees that “the relations between medicine and osteopathy present … widespread problems involving a majority of the states to some degree,” and he therefore urged that it appoint a committee for the second time to discuss these matters with AOA representatives.19 The board acceded to this request, and soon afterwards a similar committee was appointed by the AOA. At this conference, held in March 1952, discussion centered on the question of the longstanding AMA position designating the DOs as “cultists.” Obviously, this was a stumbling block that had to be overcome if the two associations were to resolve other problems, particularly the matter of interprofessional consultation and the issue of DOs and MDs serving on the staffs of public hospitals. This meeting ended with a greater degree of understanding on both sides.20

In his farewell presidential speech in June 1952, Cline, addressing the AMA House of Delegates, briefly mentioned the work of the Conference Committee, declaring that osteopathy had in recent years come much closer to medicine and that “removal of the stigma of cultism would hasten that process.” As a first step, Cline recommended that the Council on Medical Education and Hospitals be permitted to aid and advise osteopathic schools, and that any ethical barrier now preventing MDs from teaching in these colleges be removed. No action was taken on Cline’s suggestions, though the board agreed to let its Conference Committee meet again with the AOA “when or if requested.” Meanwhile, the AMAJudicial Council was asked to prepare an opinion.21

Up until this time, the Conference Committee discussions had taken place without the knowledge of the rank and file of either profession. However, with Cline’s address the meetings had become public knowledge. In some osteopathic circles this news was interpreted as meaning that the two associations were conspiring to arrange a merger, which in turn caused an outpouring of angry letters, telegrams, and phone calls to the AOA headquarters from outraged DOs across the country. In successfully allaying their fears, the AOA board and house in July 1952, reaffirmed “in the strongest terms possible the policy of maintaining a separate, complete and distinctive school of medicine.” This was followed up by editorials in AOA publications explaining the history of the conference committees and the content of the discussions to date.22

In December 1952, the AMA House of Delegates was informed by the Judicial Council that it had no report from the Conference Committee that had been appointed in June. Lacking any additional information on osteopathy, it could do nothing more than “reassert its opinion that all voluntary associations with osteopaths are unethical.” Cline, who had been made head of the Conference Committee, pointed out in response that the wording of the June resolution, namely that they would meet “when or if requested,” was holding up future talks. As a result, the AMA removed the troublesome precondition, giving Cline a free hand. The AOA board in response gave its committee a similar charge, and another meeting was scheduled.23

In preparation for this third session, Cline set about collecting what historical and current data he could find on osteopathy—its schools, hospitals, and laws. He and other committee members consulted with various DOs and the AOA central office staff and sent out questionnaires to osteopathic colleges as to the elements of osteopathic education. When the two conference committees met in May 1953, they jointly reviewed the information the MDs had gathered, and the AOA representatives furnished further materials?"

The following month Cline presented a detailed report on osteopathy to the AMA Board of Trustees for their consideration. In it he declared that while the original teachings of Andrew Taylor Still “could be classified as ‘cultist’ healing,” a great evolutionary change had since taken place within the profession. While he noted that he was unable historically to trace this progress due to an absence of adequate secondary sources, Cline observed that over the previous several decades osteopathic colleges had fully integrated pharmacology, surgery, and all other orthodox modalities into their curricula and had reduced the time allocated to distinctively osteopathic features. Furthermore, the “osteopathic concept” or philosophy had been broadened. Though DOs had differences of opinion among themselves in this regard, the concept consisted of three basic principles: first, the normal body contains within itself the mechanisms of defense and repair in injuries resulting from trauma, infections, and other toxic agents; second, the body is a unit, an abnormal structure or function in one part exerts abnormal influence in other parts; and third, the body can function best in defense and repair when it is in correct structural alignment. Cline went on to describe the colleges in terms of their facilities, class sizes, curricula, and quality of instruction. He noted the geographic distribution of DOs, the" volume of care they delivered, the scope of li censure, postgraduate education, and the current state of relationships between MDs and DOs.

In concluding his presentation, Cline and his committee made four recommendations: (1) that the House of Delegates declare that, as so little of the original concept ofosteopathy remained in the way medicine was currently taught in osteopathic schools, it could not be classified as the teaching of cultist healing; (2) that it be the policy of the association to encourage improvement in undergraduate and postgraduate education of doctors of osteopathy; (3) that the state medical associations determine for themselves whether professional relations between MDs and DOs were ethical; and (4) that the Conference Committee be established on an ongoing basis. After mulling the matter over, the AMA board decided, because of the length of the report and the controversial nature of the subject, that the House of Delegates would need further time for its study and, in addition, that the component state medical associations should have the opportunity to express their opinions. The committee was continued, but action on the report was deferred for one year until June 1954.25

The following September, Floyd Peckham, DO, head of the AOA Conference Committee, telephoned Cline to express appreciation for his efforts and to find out if there was anything more he could do to assist in removing the cultist label. Cline, in response, suggested the possibility of on-campus visits by the committee to osteopathic schools, explaining that the most telling criticism of his report was that his information was secondhand and hearsay. While he himself knew the data to be reliable and his statements factual, this did not satisfy the skeptics, and many of these individuals would have to be won over if his recommendations were to have a chance of passage next year. An on-campus visit by the committee, accompanied by distinguished medical educators, would help to undermine the opposition.26

In October the AOA Conference Committee formally met and Peckham conveyed the substance of his conversation with Cline. The committee agreed that they would give his plan due consideration when it was submitted, but that this was a matter to be decided by the Board of Trustees. Early in December, following the annual AMA house meetings, Cline telephoned Peckham with the news that he had cleared his proposal with all the necessary authorities within the AMA and could provide the details of his plan, which he did in a letter dated December 8, 1953. As a pattern for the visits, Cline suggested the same type of unfocused, com prehensive survey routinely carried out by the Council on Medical Education and Hospitals for the purposes of accreditation. Peckham immediately realized that this would be unacceptable; nevertheless, a special session of the AOA board was convened for a hearing. As expected, the Cline proposal was formally rejected; however, the board decided not to preclude the possibility of any on-site visitations per se. It instead directed its Conference Committee to meet with its counterpart to see if they could agree on a satisfactory compromise.27

On January 16, 1954, the two conference committees again met, whereupon the DOs listed a number of conditions they believed would facilitate approval of a visitation. The conditions included: (1) language within the AMA proposal stating clearly that their on-campus inspection would have nothing to do with accreditation and affirming that the AOA Bureau of Professional Education and Colleges was the only authoritative body that had the right to accredit osteopathic schools, and that under no circumstances was it the will of that committee to disturb or upset that responsibility; (2) wording to the effect that the primary purpose of the visitation was to determine whether or not “medicine as currently taught in schools of osteopathy constitutes the teaching of ‘cultist healing’”; and (3) the establishment of the right of the AOA to reject any of the visitation advisors proposed by the AMA. Cline and his committee immediately accepted all of these conditions.28

The following month another special meeting of the AOA board was convened, which was attended by a representative from each osteopathic college as well as by other key members of the profession. Cline’s revised proposal, despite integrating all of the suggestions made by Peckham’s committee, still met with serious objections. Some board members were afraid that the resulting report would be negative and therefore might seriously harm the profession in its legislative efforts. They had not forgotten the problems caused by the Etherington-Ryerson survey of two decades earlier. There was also fear of the outcome should the report be favorable. This conclusion might signify to lawmakers that the need for independent osteopathic licensure boards had passed and in this way give impetus to the push for their elimination. Furthermore, a positive report might lead the AMA not only to remove the cultist label but to launch a campaign to bring about complete amalgamation. These doubts led the board to defer immediate action and to put the matter before the next regular session of the House of Delegates, which was to meet one month af ter Cline’s original recommendations were to be voted upon.29

At the AMA board and house meetings in June, Cline won approval of another year’s delay, based on the prospect of an AMA inspection of osteopathic schools in fact taking place. This left the decision to the DOs. During its session in July the AOA house debated the same issues that had come up at the February board meeting. This time, however, the members of the Conference Committee took a far more active role in the discussion, arguing that unless the AMA visitation was approved, there was no chance that the cultist label would be removed. The argument proved persuasive. The opposition was overcome and the Conference Committee was given full authority to negotiate with its counterpart in making final arrangements.30

An Amalgamation in California

The reaction of the AOA Conference Committee members who met two days after the AMA house vote was one of bitter disappointment. Al though they were far from pleased with “the Cline Report” in its entirety, they concluded that on the whole it was reasonably fair. As far as the decision of the AMA house was concerned, it simply reinforced their belief that politics was at the heart of the cultism issue.36 At the AOA House of Delegates meeting the following month, the actions of the AMA were largely ignored in the official sessions. The association restated its position of cooperation with any group whenever such cooperation might be expected to lead to improved health care for the American people. It retained its national Conference Committee for that purpose and urged the establishment of similar committees on the local level.37

As in the case of their national association, leaders of the California Osteopathic Association were greatly upset by the AMA house vote on the Cline Report. Nevertheless, they clearly recognized that the on-site visitations had opened many of the delegates’ eyes to what was actually taught in osteopathic schools and in so doing had helped to raise DOs’ standing and status among MDs generally. What now remained to be done to facilitate a local merger was to push the AOA towards meeting the Rouse conditions, so that the stigma of the cultist label would be removed, thereby eliminating any possible AMA objections to amalgamation. At its May 1957, meeting the COA House of Delegates passed a resolution urging the deletion from all AOA printed materials of those statements referring to the osteopathic profession as a separate, independent, and complete school of medicine, and the removal of all possibly “cultist” terminology employed by the colleges and hospitals, and it directed its delegation to the AOA house to make every effort to implement these changes.38

That July, during the national convention, debate centered on the AOA constitution, which then read in part:

The objects of this Association shall be to promote the public health and the art and science of the osteopathic school of practice of the healing arts, by maintaining high standards of osteopathic education and by advancing the profession’s knowledge of surgery, obstetrics, and the prevention, diagnosis and treatment of disease in general; by stimulating original research and investigation, and by collecting and disseminating the results of such work for the education and improvement of the profession and the ultimate benefit of humanity; that the evolution of the osteopathic principles shall be ever growing tribute to Andrew Taylor Still whose original researches made possible osteopathy as a science.39

In place of this awkward, “cultist”—sounding testament, a majority of the members of a Special Reference Committee of the house proposed that this part of the constitution, known as article 2, be amended to read simply, “The objects of this Association shall be to promote the public health, to encourage scientific research and to improve high standards of medical education.” This was moved by the California delegation from the floor. A minority report, supported by representatives from Michigan, the second largest delegation, strongly argued that this statement led to questionable interpretations and argued substitution of the term osteopathic education for medical education. A seemingly certain bitter floor fight was narrowly averted when both sides agreed to compromise language: medical education in osteopathic colleges. This change was approved for publication and set for final action at the next year’s meeting, where the house overwhelmingly approved it.40

At the December 1958 meeting of the AMA house, the Indiana delegation, following the Cline recommendations, again proposed that the state societies be given the responsibility for determining whether relations between MDs and DOs were ethical. This was rejected once more; however, the committee studying this resolution made the suggestion, which was approved, that the Judicial Council consider this matter further and submit a report.41 During the next house meeting, in June 1959, the Judicial Council, specifically citing the recent AOA constitutional changes, now proposed a significant revision of association policy, recommending, “It shall not be considered contrary to the Principles of Medical Ethics for members of the AMA voluntarily to associate professionally with physicians other than doctors of medicine, who are licensed to practice the healing art without restriction and who base their practice on the same scientific principles as those adhered to by members of the AMA [and for AMA members] to teach students of osteopathic medicine who seek to develop and improve their ability to provide a better quality of medical care.”42

To the surprise of many, this recommendation was opposed by the California delegation, which argued that the changes were too generous and which announced publicly that the CMA was then actively involved in negotiations with the COA to amalgamate the two professions and take over the osteopathic college. If the AMA were to give DOs all they asked for now, the bargaining position for the CMA w0uld be weakened. On the AMA house floor the Californians led a successful fight to amend the entire resolution to read, “It shall not be considered contrary to the principles of medical ethics for doctors of medicine to teach students in an os teopathic college which is in the process of being converted into an approved medical school which is under the supervision of the AMA. Council on Medical Education and Hospitals.”43 Needless to say, the eyes of organized osteopathy now turned towards California.

The next month, at the AOA House of Delegates meeting, retiring association president George Northup, DO (1915–1996), focused on what appeared to be happening. In his address, Northup reviewed in some detail the discussions held in the early 1940s pertaining to merger and noted that, since then, rumors had periodically circulated that further talks along these lines were being held. Now, with the public statement by the CMA representatives that a merger between the two California groups was imminent, some clear and straightforward answers were due the AOA by its divisional society. Northup forcefully stated:

In fairness to the remainder of the profession, its educational system, and its programs for the future, this profession and the House of Delegates has the right, yes, the responsibility to know whether there is any validity in these statements so that the AOA can act accordingly. If we are about to lose one of our prominent and best qualified colleges, we should face the possibility fairly and honestly. If the largest divisional organization of this profession is conducting through its leadership, official or unofficial, private negotiations with one of the largest divisional medical societies which might lead to the loss of their membership in the AOA that too must be faced realistically and honestly. Northup then asked the entire House of Delegates four questions:

​(1) Do we wish to maintain the independence of our colleges or do we desire to convert them into medical schools under the supervision and jurisdiction of the Council on Medical Education and Hospitals of the AMA? (2) Do we wish to take steps leading to the abandonment of our intern and residency training programs, our approved and registered hospitals; our certification and recognition of our specialists and their certifying programs; our program of development and recognition of our general practitioners; and our hard earned acceptance of the AOA as a recognized accrediting agency, or are all of these to be turned over and placed under the protective custody of agencies of the AMA? (3) Do we or do we not have a contribution to make to medicine not now being accomplished through the efforts of any other organization? (4) Do we wish to continue as an independent osteopathic profession, cooperative with all and subservient to none?44

Northup’s questions were answered with demonstrations of loyalty from seemingly all present except the California delegation, who sat, angry and silent, refusing to offer any explanation for their position. Michigan’s delegation then introduced a resolution in direct opposition to the California House of Delegates’ policy statement of 1957, reading in part, “Be it resolved that the osteopathic school of medicine, in the interest of providing the best possible health care to the public, shall maintain its status as a separate and complete school of medicine cooperating with all other agencies and groups that sincerely promote the same objective when that cooperation is on an equal basis granting full recognition to the autonomy and contribution of the osteopathic school of practice.”45 This passed 9522, with California delegates dissenting.

Despite the AOA resolution, secret negotiations between the leaders of the COA and the CMA continued apace.46 When in early 1960 word of these talks filtered back to AOA officials, a full accounting was demanded. At the July 1960 AOA house meeting, the Californians asked for and received permission to present their case before a closed-door executive session. Drs. Dorothy Marsh and Nicholas Oddo reviewed past differences with the AOA over legislation and setting of standards, noted the problems of obtaining adequate postgraduate training, observed the inadequate financing of all phases of osteopathic education, the poor status of the DO degree, and the exclusion of DOs from group health insurance plans. The profession’s organizations, they maintained, were simply not moving fast enough to resolve these problems. Through amalgamation, these difficulties could be eliminated.47

DOs who opposed the merger argued that these various problems could be successfully dealt with in other ways. The Californians, they declared, simply wanted a quick fix, and in the process they were even willing to sell out their heritage. On returning to open session, the house resolved: “That any divisional society which is in the process of negotiation leading to unification and/ or ‘amalgamation’ or merger, or a process of a similar nature, of the osteopathic profession with or into any other organized profession involved in health care shall cease such negotiations or be subject to the revocation of its charter by the AOA.”48

Now for the first time under a direct threat, the COA leadership notified its members that it was inStructing its Fact-Finding Committee to cease its discussions with the CMA. However, on November 13 the full COA house, in a defiant mood, voted 66-40 to ignore the AOA directive and resume talks. The AOA board reacted quickly. Meeting in special ses sion the following week, it voted 18-1 to revoke the COA charter.49 This left the COA in a precarious position, particularly if a merger agreement could not be worked out. In early December a new group, known as the Osteopathic Physicians and Surgeons of California (OPSC), was organized by loyalists and was quickly chartered as the official AOA divisional society.50 Hopes by the OPSC leadership that it would soon represent over half the DOs in the state soon proved unrealistic. Only about onesixth of all California DOs joined its ranks. The AOA decision to remove the COA’s charter had the unanticipated effect of increasing the social solidarity of most California DOs and strengthening their identification with their established state society.51

By May 1961 a contract between the CMA and COA was ready to be acted upon by each house of delegates. The executive vice-president of the AMA had already assured the CMA that if unification was effected, “it would not be reviewed by any board or agency of the AMA for the purpose of approving or disapproving it”52 This was essential, for the cultist label had not been removed and it was quite possible that the AMA house, if it had the chance, might very well veto the merger plan. Among the major provisions of the contract were, first, that the College of Osteopathic Physicians and Surgeons, which would change its name to the California College of Medicine, would offer to all of its living graduates and those DOs from other schools who held valid physician and surgeon licenses in the state a Doctor of Medicine (MD) degree. This would be an academic degree, the recognition of which for the purpose of licensure would depend upon the laws of the various states. However, in California, statutory provision would be made to accept it for all purposes connected with the practice of medicine. Second, those DOs who chose to accept this MD degree would thereafter cease to identify themselves as osteopathic practitioners in any manner. Third, the California College of Medicine would henceforth be a medical school affiliated with the Association of American Medical Colleges and end its teaching of osteopathy. Fourth, the CMA would absorb ex-DOs within the existing forty-county medical society structure, although during the transition period they would be segregated into a special forty-first society. Finally, the ex-DOs would support legislative action implementing the agreement, including the revision of the 1922 osteopathic initiative that gave them an independent board, to insure that there would be no new future licensing of DOs in the state. Those DOs already licensed in California who decided not to join the merger and retain their DO degrees would continue to Come un der the jurisdiction of the independent osteopathic licensure board until they numbered fewer than forty, at which point the board would be completely abolished and its activities taken over by the MD board.53

The CMA house on May 3 passed the agreement by a vote of 296 to 63. Two weeks later the COA house voted 100 to 10 to accept it. Later that month the Board of Trustees of COP&S were assured by representatives from the Association of American Medical Colleges that with some relatively minor organizational and staffing changes their institution would become a fully accredited medical school. The COA leadership also promised that the new Forty-First Medical Society would continue to financially support the institution. After a bitter debate, the Board of Trustees narrowly voted, 13 to 11, to go along with the conversion. On the 14th and 15th of July, some two thousand DOs, gathered in the auditorium of Los Angeles County General Hospital, received their new MD degrees.54

After these actions, the battle over the ballot initiative implementing the merger, played out during the next year, seemed anticlimactic. The measure was supported by the ex-DOs, the CMA, both houses of the legislature, the Democratic governor, Pat Brown, and his Republican challenger, Richard Nixon, as well as numerous civic organizations. The OPSC, which had been unable to stop any of the previous legal steps on the road to amalgamation as they moved through the courts, had to face this opposition alone. A pledge by the AOA to provide a sizable war chest had been withdrawn when it became clear that such a contribution was political and would remove the association’s tax-exempt standing, since it, unlike the AMA, was registered as an educational organization with the Internal Revenue Service. With OPSC unable to generate sufficient capital to get its message across, their defeat was all but assured. A final count of the votes revealed 3,407,957, or 69 percent, marking their ballots “yes”; only 1,536,470 or 31 percent, registered “no.” The merger had been completed.55

The AMA Inspection

Under the terms of the agreement between the two associations, each osteopathic school had the right to decide whether or not it would participate in the inspections. By late October five of the six colleges had given their approval; the Philadelphia school argued that the visitations still looked too much like an accreditation process and therefore declined. As the original AMA mandate called for a survey of all six colleges, Cline’s committee had to wait until the AMA clinical meeting in December to receive official authorization to inspect only five.31

Prior to the visitations, which took place between January and March 1955, each participating school filled out a questionnaire patterned after that required of colleges seeking accreditation by the AMA Council on Medical Education and Hospitals. The inspection team requested essential information concerning organization, authority, administration, finances, facilities, and operation of the colleges; the personnel, training, authority, and activities of the faculty; the curriculum content; the organization of departments, their objectives, methods of teaching, and equipment; the degree of interdepartmental coordination and cooperation; and the details of library facilities and contents.

Each institution was visited by at least two members of the committee, which then consisted of Cline, James Appel, MD, Leonard Larson, MD, Thomas Murdock, MD, and Cleon Nafe, MD, accompanied by one of the mutually agreed upon educational advisors: L. R. Chandler, MD, recently retired dean of the Stanford University School of Medicine, J. Murray Kinsman, MD, dean of the University of Louisville School of Medicine, and W Clarke Wescoe, MD, dean of the University of Kansas School of

Medicine. Floyd Peckham accompanied each team. It was agreed beforehand that the inspection committee would have access to all the information they believed essential to their efforts and that the observations would be of such breadth, depth, and duration as they deemed necessary. At the end of each on-site visit, the advisor prepared a report, one copy of which was transmitted to the college, while the other was held by the AMA committee as a confidential document. Following completion of all visitations, the committee drafted a final document containing the answers to four questions posed to it by the AMA board: (1) Is modern osteopathic education the teaching of “cultist” medicine within the definition of the principles of medical ethics? (2) If the first question is at all true, to what degree? (3) If to some degree, does this element interfere with sound medical education? (4) What is the quality of medical education?

In its findings, presented to the AMA House of Delegates in June 1955 , the committee noted that all of the schools were attempting to give their students a rounded general practitioner-type of training, expecting that the majority of their graduates would become primary care physicians and that a high percentage would locate in traditionally underserved communities. Examining student records, the committee observed that all students had completed the educational requirements for admission to an AMA-accredited college and that a considerable number of them could have obtained admission to medical school. Interviews conducted with students revealed that the motivation to become a physician was strong in most. While some were disappointed medical school applicants, more had previous contacts with the osteopathic profession and were thereby influenced to enter DO institutions. A small number, in fact, had been accepted by MD colleges but had chosen an osteopathic school instead.

All of the schools, the committee observed, were handicapped by limited finances; endowments were small or nonexistent, and too much of their funding was derived from tuition. Because of this financial situation, the schools were not able to hire more full-time faculty and improve their facilities and equipment to the extent that the colleges would have liked. Though the committee noted that in recent years additional sources of funding (for example, the Osteopathic Progress Fund, federal teaching grants, and Hill-Burton monies) had allowed the schools to make some significant changes, considerably more support was necessary.

In terms of curriculum, the committee found that the clock hours of osteopathic instruction exceeded those of schools of medicine by several hundred. This, it felt, was not advantageous to the student, since it crowded too much into too limited a period. As a result, there was insufficient time for individual student projects, library use, and reflection and assimilation of the knowledge the student acquired. Furthermore, the situation did not encourage a scholarly attitude or an interest in research.

In the basic sciences, the committee concluded, subjects were fairly well taught and the students were well grounded in these fields. Some departments—most frequently anatomy—were outstanding, although some, particularly pathology, were comparatively poor due to a shortage of trained personnel. In the clinical years, the committee believed, there was too much didactic teaching and a tendency to treat the student as an observer rather than as a part of the patient care team. The methods and quality of clinical instruction, it found, varied from school to school, and to a considerable degree within different courses in the same college. A similar finding was made of the qualifications, teaching abilities, and interests of the faculty members. Finally, the committee felt that, in a majority of the colleges, the clinical material available was inadequate for the number of students.

On the most controversial aspects of osteopathic instruction, the committee believed, what was being taught simply reflected a difference in emphasis in both theory and practice between MDs and DOs, rather than a conflict between science and nonscience. What DOs referred to as the “osteopathic concept” was merely the expression of these differences. “Modern osteopathic education,” the report noted, taught “the acceptance and recognition of all etiological factors and all pathological manifestations of disease as well as the utilization of all diagnostic and therapeutic procedures taught in schools of medicine.”32

In the committee’s view, the curricula had relegated osteopathic manipulation to the status of an adjunct to therapy within the sphere of medicine. Nowhere did it occupy a preeminent place in instruction. When applied to hospital inpatients with clinically recognized disease, for example, the committee found that manipulative treatment consisted mainly of relaxing, soft tissue manipulation or that designed to increase respiratory excursion. Some heads of clinical departments believed that OMT had considerable value when used in conjunction with standard therapy, while others did not. “The use of manipulative therapy,” the report observed, “is decreasing in colleges of osteopathy and is increasing in the orthopedic and physiatry departments of medical schools.”33

At the conclusion of its report the committee restated, though in somewhat revised form, the recommendations originally submitted in 1953. It urged the house to declare that current education in osteopathic colleges did not constitute the teaching of cultist healing; that MDs be encouraged to assist in osteopathic pre- and postgraduate training programs in those states where such participation was not contrary to the announced policy of the state medical association; that these same state associations assume the responsibility of determining the ethical relationship between MDs and DOs or request that their component county societies to do so; and that the Conference Committee be continued to meet with AOA representatives concerning common or interprofessional problems at the national level.34

Upon submission, the report was sent to the AMA Reference Committee on Medical Education and Hospitals, which in turn presented a majority and minority opinion. Both declared that, unlike the inspection team, they were not satisfied that current education in D0 schools was free of the teaching of “cultist healing.” However, beyond this the committee members sharply differed. The majority report, representing four out of the five members of the Reference Committee, urged the passage of the Conference Committee’s last three recommendations. The minority report, consisting of the views of one member, Milford Rouse, MD, of Texas, urged rejection of all four recommendations and the adoption of two substitutes: first, that the Conference Committee be thanked for its diligent work and be discontinued, and second, “that if and when the House of Delegates of the American Osteopathic Association, its official policy-making body, may voluntarily abandon the commonly so called ‘osteopathic concept,’ with proper deletion of said ‘osteopathic concept’ from catalogs of their colleges and may approach the Board of Trustees of the American Medical Association with a request for further discussion of the relations of osteopathy and medicine, then the said Trustees shall appoint another special committee for such discussion.” After a vigorous and emotional debate on the floor of the house, the motion to adopt the majority report was amended to substitute the minority report in its place. Upon further discussion, the house by a vote of 101 to 81 passed the Rouse resolutions. All the findings of the college inspection team were thus repudiated, and the DOs officially remained “cultist” in the eyes of the AMA.35

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