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

9. Reaffirmation & Expansion

To many outside observers the events taking place in California, from the initial public announcement of a merger plan to its implementation in 1962, seemed to signal the first step in the inevitable absorption of the DOs as a group into the allopathic medical profession. Whatever agreements had to be worked out, complete countrywide amalgamation was viewed as a foregone conclusion. There was no possibility that the MDs would continue to let the D05 remain independent or that the AOA could continue to resist the pull of the AMA upon its members. Movements such as osteopathy, homeopathy, and eclecticism, it is generally believed, have a natural life cycle. They are conceived by a crisis in medical care; their youth is marked by a broadening of their ideas; and their decline occurs when whatever distinctive notions they have as to patient management are allowed to wither. At this point, no longer having a compelling raison d’être, they die. While examples of this pattern are not difficult to find in the United States and elsewhere, this type of explanation tends to downplay, if not ignore, specific highly individualized historical conditions. Whether osteopathy would be able to survive the California merger intact or would go the way of homeopathy and eclecticism would depend not upon some deductively arrived at natural law but upon actual social circumstances over time.

California Aftermath

Throughout the 1950s it was readily apparent that the AMA could not forge any coherent national policy with respect to the DOs. Indeed, if the AMA executive secretary had not ruled that the amalgamation being arranged in California was a local matter and therefore not subject to ac tion by the House of Delegates, it is entirely possible that the final agreement would not have been allowed. In succeeding years this lack of uniformity and consistency on the part of the AMA and other significant groups within organized medicine would severely hamper their efforts to obtain what they would regard as a satisfactory conclusion to “the osteopathic problem.”

In June 1961, while the California merger was still in process, the AMA Judicial Council delivered a special report on the association’s position on voluntary relations between MDs and DOs. Noting that “there cannot be two distinct sciences of medicine or two different yet equally valid systems of medical practice,” it declared that the changes occurring within osteopathy indicated the desire by a significant number of DOs to give their patients scientific medical care. Because of this, the council said, “Policy should now be applied individually at [the] local level according to the facts as they exist. The test should now be: does the individual doctor of osteopathy practice osteopathy or does he in fact practice a method of healing founded on the scientific basis? If he practices osteopathy, he practices a cult system of healing, and all voluntary professional associations with him are unethical. If he bases his practice on the same scientific principles as those adhered to by members of the American Medical Association, voluntary professional relations with him should be deemed ethical.”l

Many AMA house delegates thought this proposed policy was far too liberal, since it would serve to make the issue of ethical relations subject to the discretion of individual MDs. A number of component societies, particularly those whose states restricted practice rights for DOs, continued to be bitterly opposed to any interprofessional contact and thus were unwilling to support the report as it stood. As a compromise, it was amended to give each state society the right to make the determination as to whether or not its members could voluntarily associate with osteopathic practitioners on a professional basis. In this form, with almost the exact wording of the 1955 Cline committee recommendation, the policy was approved.2 The Judicial Council also urged that local liaison committees, if not already in existence, be established to conduct talks with their DO counterparts, and this was fully accepted. VVlth regard to some states the report noted, “It might be possible to initiate and complete negotiations such as have been and are being carried out in California.”3 To assist the state societies in the formulation and carrying out of their plans, the AMA board created the Committee on Osteopathy and Medicine the following year.

While the AMA was characterized by sharp division within its official ranks over the question of MD-DO relations, the AOA, for its part, was united, at both the national and state levels. At its July 1961 annual meeting, held in Chicago, the AOA delegates in strong language reaffirmed the so-called “Michigan Resolution” of 1959, which declared their intent to maintain the status of osteopathy as a separate and complete school of medicine. Coupled with this was a sharply worded statement by the AOA Board of Trustees attacking the premises of the recent report of the Judicial Council, noting:

It may be true that there cannot be two sciences of medicine, but the AMA fails to recognize that while medicine employs scientific knowledge, the practice of medicine is not science per se. It is unrealistic to hold that the practice of medicine is pure science. It is equally unrealistic to insist that only one system of medical practice, that system officially approved by a political body, can be valid… The AMA holds that if an individual doctor of osteopathy practices osteopathy he is a cultist and all voluntary professional associations with him are unethical. However, if he bases his practice on the same scientific principles as those adhered to by members of the AMA voluntary relationships are ethical. This policy has two fallacies: First, it assumes that the osteopathic concepts are diametrically opposed to accepted scientific fact and that osteopathic physicians do not employ accepted scientific principles in their practice. Second, it condemns a system of practice without understanding or defining it, or, in fact, defining what is accepted scientific medical practice."

As for the mechanisms of declaring whether relations between MDs and DOs were ethical, the AOA house stated that the AMA, in granting their state societies the right to decide who shall and shall not be legitimate, hoped that organized osteopathy would be weakened from within and that through internal dissension it would be eliminated. “The osteopathic profession,” the AOA House of Delegates declared, “will continue as a separate and complete school of medical practice and … it will resist all efforts to be absorbed, amalgamated or destroyed, be it through overt political maneuvering, or through the guise of making its individual members conform to the scientific dictates of the AMA.”5

In dealing with liaison committees established by state medical associations, the AOA divisional societies adopted a common strategy. When approached, osteopathic representatives would announce that before any other interprofessional matter could be brought up, all medical society re strictions on voluntary MD-DO relations had to be removed. In those cases where this was done, the DOs then agreed to discuss mutual problems, though they turned a deaf ear to the subject of amalgamation. By 1965 only fourteen state medical associations had approved voluntary interprofessional relations. In some states the MDs held the approval of voluntary professional association hostage to merger negotiations; in others, MD antipathy towards the DOs precluded any formal discussions whatsoever.6

While organized osteopathy was united against amalgamation, there was some dissension within the rank and file. However, unlike in California, where absorption proponents were an active force within their state society, controlled political offices, and were thus able to maneuver the COA towards their desired goal, in other states DOs who supported the merger concept were more likely not to be members of the AOA or their divisional society; and if they were members, they had not attained positions of influence. Opposition to the AOA policy line, therefore, was mostly scattered, unorganized, and lacking in effective leadership. The one exception occurred in the state of Washington, where in 1962 a faction of dissident DOs broke away from the official state osteopathic association, formed their own group, and sought to arrange a merger between themselves and the state medical society. mm the support of the latter, they founded a “paper college” to award MD degrees, valid for the purposes of licensure, to “qualified” Washington DOs. Nothing came of this plan, however, as the Washington State Supreme Court, in a unanimous ruling, declared that the Washington Board of Medical Examiners’ decision to approve the paper college as a medical school was “subterfuge, was palpably arbitrary and capricious, and was void in all respects.”7

A significant number of DOs around the country were undecided about merger. Troubled by their own special problems, whether it be poor public perception, denial of staff privileges at local hospitals, or ineligibility for participation in insurance plans, they harbored genuine doubts as to the wisest position for them to take. To help counter such wavering, the AOA organized and conducted a series of “regional town meetings” across the country in which officials explained recently adopted policy positions as well as the association’s efforts on the legislative and judicial fronts to break down discriminatory barriers.8 At such gatherings AOA leaders addressed the fears and frustrations of concerned DOs, and they convinced many who attended of the “rightness” of the association’s stand. Nevertheless, other DOs adopted a wait-and-see attitude, letting time pass to enable them to determine for themselves how well the California plan was working out before coming to any hard-and-fast conclusions.

In the years following the California merger it became evident to the ex-DOs who participated that their move had both positive and negative features. On the favorable side, the vast majority seemed to be quite happy with the new MD initials behind their name. Although one AOA leader warned them that they and members of their family would be forever subjected to the whisper, “He is an osteopath who was given an MD degree,” this did not appear to be a significant problem.9 Patients readily accepted the changed designation as well as the new diploma on the wall, and most ex-DOs felt relieved at no longer having to answer such questions as, “What kind of doctor are you anyway?”10 The most satisfied of the exDOs were clearly the general practitioners. Aside from their new degrees, they found that they could now obtain admitting privileges at hospitals that had once barred them, that their malpractice rates as a result of joining the CMA were substantially lower than they had been previously, and that they could freely consult with a wider range of specialists.11

Nevertheless, major problems did surface. As part of the amalgamation contract, all ex-DOs were to be temporarily segregated in a special forty-first component society of the CMA until they could be fully integrated into the other forty county societies. Though most of the ex-DOs had no difficulty in being assimilated, a significant number did. As late as 1967, five years after amalgamation, approximately 10 percent of the original group had not been granted regular local membership. This proved to be a source of some embarrassment and discontent.12

Far more serious was the status of ex-DO specialists—a subject that was left unresolved in the merger agreement. Under existing AMA requirements, all candidates for specialty board certification had to graduate from an accredited medical school and receive their postgraduate training in an AMA-approved hospital program. This meant that ex-DOs, including those who had been certified by an AOA board, could not receive any consideration for such certification. Though CMA officials reportedly pledged to work for changes in allopathic specialty board policies, no movement in that direction was forthcoming. What the CMA agreed to do was to inspect the DO specialists’ osteopathic credentials and then issue a certificate stating that they were found to be in order. While this document may have been suitable for hanging in the office to impress one’s clients, it could not help the practitioner gain staff privileges at other than formerly osteopathic hospitals.13 Another consequence of this lack of proper certification was a decline in the number of patients regularly referred to these specialists. Before the merger, DO generalists would be more likely to send a patient an inconvenient distance to see a DO gynecologist, internist, or surgeon. But now, as the ex-DO general practitioners made new professional acquaintances, they began to refer patients to specialists more on the basis of their credentials and proximity. Furthermore, most of those practitioners whom the ex-DOs called “congenital MDs,” that is, those who graduated from an AMA-accredited school, were unwilling to send patients to “acquired MDs.”14

In the years following the merger agreement, a number of formerly osteopathic hospitals in California found themselves in financial difficulty. Some institutions reported a staff loss of up to 20 percent, as local DO general practitioners began affiliating with MD facilities. In some cases, the loss was made up for by the addition of traditional MD’s to the staff, but when the AOA surveyed the hospitals in 1965 most reported that their occupancy rate was lower than it had been before the merger. A few institutions saw themselves as eventually having to go out of business, while others anticipated that they would become satellite facilities for major MD hospitals.15 Also, all ex-DO facilities lost their intern and residency programs, because, with the exception of the new Los Angeles County Hospital, they were simply too small to qualify for AMA approval. Therefore, these formerly osteopathic inpatient facilities were no longer teaching oriented, a change not a few of the staff regretted.

What was once the private College of Osteopathic Physicians and Surgeons and is now the California College of Medicine became statesupported in 1964; a new campus was established for it at the University of California at Irvine several years later. With a far greater source of revenue at its disposal, new equipment was purchased, and many more fulltime instructors were hired. As it was now an orthodox medical institution, it could become affiliated with a number of large MD hospitals, thus improving training opportunities. Losing out in this process were many part-time and voluntary ex-DO faculty members whose services were no longer required. Also affected were a number of full-time ex-DOs who, while not removed from the staff, found themselves maneuvered out of positions of authority in favor of congenital MDs.16

A final critical problem arising from the merger was the validity of the acquired MD degree as a basis for licensure everywhere outside California. By 1966, courts in ten states had ruled in favor of those examining boards which rejected applications from holders of the 1961 diploma on the grounds that theirs was an academic, not a professional, degree. Only those California College of Medicine students completing their training in 1962 or later were considered graduates of an AMA-accredited institution."

The two major AOA publications, the JAOA and The D.O., continuously pointed out and amplified all these problems to their readers as evidence that amalgamation was a failure. Editorials blasting the holders of what was labeled “the little md” were occasionally coupled with letters from ex-DOs who voiced deep disappointment with all or certain features of the merger. Although the picture drawn by the AOA was one-sided, it was nevertheless apparent from a reading of even generally pro-merger articles in nonosteopathic journals that not everything had worked out as well as all ex-DOs had hoped.18 These perceived inequities and difficulties only served to make many undecided DOs around the country wary of amalgamation—or at least amalgamation of the California variety. In a 1972 mail survey of DOs in twelve geographically scattered states conducted by the independent journal Osteopathic Physician, only 17 (or 7.8 percent) of 218 practitioners responding answered “yes” to the question, “Do you view the merger in California as a satisfactory one?”19

In addition to the California situation, a major factor that would lead undecided DOs to shy away from supporting merger was the perceived continued inability on the part of the AMA and other medical groups to treat them with what they believed was sufficient professional respect. Indeed, where organized medicine altered existing discriminatory policies towards the DOs, its only motivation seemed to be the desire to solve the problem these policies caused for MDs—not to eliminate “gross injustices” against osteopathic practitioners. For example, in 1959 the American Hospital Association (AHA) decided to change its longstanding policy barring joint- or mixed-staff institutions from membership. However, this reversal occurred only after the association became the focus of intense pressure from public hospitals that were being forced by court or legislative action to allow DOs access to their institutions and to give them staff appointments. Under the AHA’s revised rules, DOs could become staff members, but general supervision of the clinical work was to remain the responsibility of MDs alone.20 American Hospital Association membership was a necessary prerequisite for eligibility for accreditation by the Joint Commission on the Accreditation of Hospitals. In 1960, again only under strong pressure from public hospitals, the Joint Commission made the appropriate adjustments to permit these AHA-member mixed-staff institutions to be inspected and accredited.21

To many DOs the “true” attitude of the AMA and other allopathic medical groups towards the osteopathic profession could be seen in a variety of policy decisions. When it came to supporting opportunities and responsibilities for osteopathic physicians and surgeons equal to those enjoyed by MDs in public hospitals, organized medicine said no; when it came to changing practice laws that discriminated against DOs, organized medicine was generally opposed; finally, when it came to pending federal legislation to underwrite the expenses of health profession schools, the AMA would testify that osteopathic institutions should be excluded.22 Furthermore, many of those DOs who read JAMA articles pertaining to osteopathic medicine, either in the original or as reprinted elsewhere, felt denigrated or insulted by their assumptions and tone. Particularly galling was the fact that in article after article, DOs were referred to as “osteopaths” in contradistinction to “physicians”—a title used to denote MDs only. Based on the actions and rhetoric of the AMA, most DOs came to the conclusion that the association was unwilling, or perhaps incapable, of dealing with them as equals. Rather, it appeared that organized medicine regarded the osteopathic profession as nothing more than a nuisance which had to be eliminated one way or another.

The New AMA Offensive

By the mid-1960s it was apparent to the AMA leadership that the osteopathic profession was standing firm. The policy of allowing the state medical societies to decide the cultism issue had not served to bring amalgamation closer to fruition. Furthermore, the unresolved problems of the California merger had caused considerable skepticism among individual DOs. However, most distressing to the AMA leadership had to be the fact that the merger itself was having the unintended consequence of permitting the osteopathic profession to make key political gains, thus serving to increase the strength of the AOA.

National and state osteopathic societies used the facts that DOs in California had become MDs without any additional educational requirements and that COP&S was so quickly accredited as an MD-granting institution to press their case for revision of discriminatory policies against DOs. They argued convincingly that what the merger had shown was that whatever gaps there might be in the quality of training between DOs and MDs, they were no longer significant. As a consequence, legislatures in several limited licensure states subsequently changed their laws to make

DOs eligible for the same scope of license available to MDs. The merger had a similar impact at the federal level. In 1963 the US. Civil Service Commission, specifically citing events in California, announced that for its purposes the MD and DO degrees were henceforth to be considered equivalent. In 1966 Secretary of Defense Robert McNamara, using legislative authority granted to his office a decade earlier, ordered all the armed services to accept qualified DOs as military physicians and surgeons for the first time. Also that same year, the AOA won a major victory when it was accepted as an accrediting agency over osteopathic hospitals for the purpose of determining an institution’s eligibility for participation in the Medicare program (Public Law 89-97, July 30, 1965). Thus, the DOs were increasingly obtaining on their own some of the benefits the MDs could offer through amalgamation."

In response to these important gains for osteopathic physicians, the AMA in the late 1960s adopted a series of new resolutions aimed at destroying the AOA. Aiming to take away many of its colleges, students, interns, and residents, as well as a large proportion of its members, the AMA sought to quickly force the issue of absorption. The first actions came in July 1967, when the AMA House of Delegates authorized its Board of Trustees to begin negotiations promptly with all the DO schools for the sole purpose of converting them to orthodox medical institutions. In order to place pressure upon the colleges to bargain, the AMA house authorized the Council on Medical Education “to establish means by which selected students with proven satisfactory scholastic ability in schools of osteopathy may be considered by schools of medicine for transfer into medical school classes.” In short, the colleges were warned that if they resisted the AMA overture, they would soon find themselves with a sharply depleted enrollment. In adopting these actions, the AMA house noted, “The primary issue at the present time in the relationship of medicine and osteopathy seems to be not that of cultism as opposed to science. Rather the issue appears to be one level of medical education and practice to another and lower level of medical education and practice.”24

The next month, the AOA House of Delegates adopted a resolution that declared in part, “The AMA contention that osteopathic education needs to be improved is obviously not shared by recognized educational accrediting agencies, by state licensing bodies or by the millions of Americans who prefer osteopathic care… The AMA stands alone in its assessment of osteopathic education, but the osteopathic profession stands together in vigorously opposing this arrogant policy of academic piracy.”25

Indeed, the colleges did hold together, although a difficult economic situation at the Des Moines school led its administration to hold talks with AMA and Association of American Medical Colleges representatives. However, this threat to solidarity was eliminated when those college officials resigned under AOA pressure and were replaced by individuals who opposed merger.26

Disappointed with an initial lack of movement, the AMA soon followed with two other major policy shifts. In December 1968, the House of Delegates passed resolutions that, first, encouraged each county and state medical society to change its by-laws so that it might “accept qualified osteopaths as active members,” and, second, urged that each of the boards of medical specialties change its rules in order to “accept for examination for certification those osteopaths who have completed AMA-approved internship and residency programs and have met the other regular requirements applicable to all board candidates.” As specialty boards declared their intent to permit examination of DOs, appropriate AMA-approved residency programs would be opened to qualified osteopathic graduates. Determination of qualification for acceptance into a given program would be left up to the medical staff of the hospital or to the county medical society.27 In June 1969, the AMA house extended to DOs membership in the national association and officially changed the “Essentials of Approved Residencies,” clearing the path for acceptance of DOs into those programs in which the respective specialty boards had agreed to examine them for the purposes of certification. At that time, five boards—pathology, pediatrics, physical medicine and rehabilitation, preventative medicine, and radiology—had done so. By 1971 the number had increased to thirteen.28

These actions posed serious potential problems for the AOA. As early as 1968 the issue of belonging to an allopathic medical association arose in connection with two DOs who had accepted associate membership status in the Michigan State Medical Society. The AOA House of Delegates reacted by adopting a resolution declaring that “any member accepting associate membership in the American Medical Association or any of its political divisions is acting contrary to the best interests of the American Osteopathic Association and shall be subject to discipline up to and including expulsion.” The following July the AOA House of Delegates clarified this resolution by interpreting “political divisions” to mean national, state, divisional, or county medical societies.29

In 1971 both the Iowa and the Pennsylvania osteopathic delegations offered resolutions to the AOA house seeking to reverse this policy. In each of these states, particularly in areas where there were no osteopathic hospitals, DOs found themselves removed from or denied staff privileges at local public and private facilities. This action was not due to their osteopathic identity but because these institutions, as a result of the AMA policy shift, now insisted that all DOs, like their MD physicians, be members of the county medical society. Osteopathic practitioners in these states argued that they had no realistic choice but to comply. During the floor debate in the AOA house, delegates from other state osteopathic associations responded that they had encountered the same allopathic hospital maneuver but had overcome the problem by seeking and receiving legislative and judicial relief. When the Iowa delegates admitted that they had not exhausted their legal options, much of whatever sentiment there was for their measure evaporated. Pennsylvania thereupon withdrew its proposal, and the 1968 policy as amended in 1969 was reaffirmed. Another effort at overturning the established rule was made in 1973, but it met a similar fate.30 At the end of 1978 only 417 osteopathic practitioners (2.4 percent of all listed DOs) had joined the national AMA.31

The issue of postdoctoral opportunities for DOs in allopathic hospitals presented a far more complex and difficult situation for the AOA. While the association had made considerable strides in upgrading its standards regarding internships and residencies in recent decades, serious weaknesses remained, particularly in some of the specialties. Since the DO hospitals utilized for such training were typically smaller than those of their MD counterparts, the range and depth of experience offered was not always comparable. Also, in some established fields like dermatology and proctology, there were no hospital residencies, only preceptorships; and in other specialties, such as psychiatry, few programs existed. Finally, there was the question of those DOs now entering the armed forces and Public Health Service. The only manner in which they could receive formal postdoctoral training while on duty was in federal hospital programs accredited by the AMA.

When the matter of postdoctoral training first came up before the AOA house in July 1969, no definitive action was taken. Instead, it was decided to give the AOA Committee on Post-Doctoral Training the authorization to provide applications for nonosteopathic hospital intern and residency programs on an individual basis.32 This absence of a clear policy led to considerable confusion among the ranks, which was only partly relieved at a joint conference between the AOA board and Associated Colleges representatives held that December. Following this meeting, AOA president J. Scott Heatherington, DO, addressed a letter to all osteopathic students, faculty, and administrators in which he stated the association’s position. “The AOA,” he wrote, “recognizes that there are a few highly technical subspecialty fields in which neither the osteopathic nor allopathic approach to health care can be clearly differentiated at this time. Within these limited fields there may be legitimate grounds which enable osteopathic physicians to participate in training under allopathic auspices, but only so long as such sub-specialty training clearly augments, not replaces osteopathic training in the major specialty fields.”33 Students were warned that before they could receive the AOA’s blessing to enter an AMA residency, they had first to complete an AOA-approved rotating internship—that is, one in an osteopathic hospital recognized for that purpose or a federal hospital, “as long as it fits the rules.” The next step was for the student to provide the AOA with a detailed outline of the AMA residency training program into which he or she had been accepted.

At its July 1970, meeting, the AOA house gave its approval to this basic plan, though again specific criteria under which a candidate might or might not be allowed to take an allopathic residency awaited formulation.34 In the case of some specialties, such as general surgery and internal medicine, for which there was a sufficient number of residency programs in osteopathic institutions to meet the needs of DO postgraduates, both the AOA and the hospitals feared that these might be bypassed by osteopathic trainees unless further restrictions upon allopathic appointments were established. Consequently, in 1970 and 1971, the respective specialty boards in these and other fields began to change their certification requirements to insist that one or more years had to be spent in an osteopathic hospital residency before a student could be given credit for nonfederal allopathic training. Finally, after much delay, AOA policy had taken form.

The optimistic prediction within organized medicine that there would be an immediate mass defection of DOs from AOA-approved postdoctoral programs was not fulfilled, although in the first few years the number of new osteopathic physicians entering nonmilitary allopathic programs upon graduation was certainly significant. According to AOAreleased data, 12 percent of the class of 1970 followed this route." Data subsequently collected suggest that this figure remained stable through 1973. Afterwards the total began to drop: 9 percent in 1974, 3 percent in 1975 and 1976—this despite the fact that more allopathic hospitals were opening up their programs to DOs. In the total number of osteopathic physicians training in allopathic hospital programs, including those approved by the AOA, a similar pattern may be seen. The figure rose rapidly each year, peaking at 608 in 1973, but declined to 449 in 1977. Meanwhile, the number of residents in osteopathic hospitals made a modest gain between the 1972–73 and 1976–77 contract periods.36

Three principal reasons may be offered as to why the large break anticipated by the AMA did not occur. First, most DO students and recent graduates perceived that their postgraduate programs were, by and large, saisfactory and that the training they would receive was comparable to that available in an allopathic hospital. Second, some prospective trainees believed they would be looked down upon or discriminated against in an MD environment. And third, some who wanted to enter an allopathic program were fearful of possible disciplinary actions by the AOA should they not follow its guidelines. One reason a decline in osteopathic participation in non-AOA-approved programs occurred after 1973 appears to be a landmark Arizona Court of Appeals decision handed down that year concerning a DO with strictly allopathic postdoctoral credentials who had been denied a medical license by the state board of osteopathic examiners on the grounds that he had not served a one-year rotating internship in an AOA hospital program as required by law. The DO, backed by the AMA, brought suit, claiming that training under allopathic auspices was equivalent and thus should be accepted. The court, however, turned aside this argument and upheld the board’s decision. Since at least thirteen other state boards, including the osteopathic strongholds of Michigan, Pennsylvania, Florida, and Oklahoma, were covered by similarly worded statutes, some students who had planned to bypass the AOA-approved routes undoubtedly thought better of the idea.37

The College Boom

One of the justifications given by the California delegation for the decision to merge with the CMA was that the osteopathic profession was not growing. As a result, the prospects for its becoming socially visible were not good. Indeed, if one surveys the number of graduates produced by the colleges each year prior to 1962, no pattern of continuous expansion can be discerned, only ups and downs related to entrance requirements, economic conditions, and war. What gains there were in the total number of listed DOs during this period were simply a reflection of the fact that as an occupational group, osteopathic physicians were getting older. Now, with one less college, some two thousand fewer practitioners, and a loss of between ninety and one hundred new graduates each year, leaders within the osteopathic profession saw the necessity not only of replenishing its ranks but of going well beyond its premerger totals of schools and practitioners.

In their struggle to increase their numbers, DOs were aided by outside factors. Throughout the 1950s, claims were being made that there either was, or soon would be, a serious shortage of practicing physicians in the United States since the number of medical schools and graduates was not keeping pace with the postwar growth in population. The issuance of two Department of Health, Education, and Welfare studies, the Bayne-Jones (1958) and Bane (1959) reports, lent weight to these conclusions, and attention soon shifted to what the federal government could do to eliminate the perceived problem. This, along with concern about the overall quality of medical training, led to the passage of the Health Professions Education Act of 1963 (Public Law 88-1929), which authorized a program of matching federal funds for construction and improvement of medical schools, together with a program of making loans to students in medicine, osteopathy, and dentistry. An amendment to this act two years later (Public Law 89-290) established a scholarship program, and all of the aforementioned provisions were later included in the Health Manpower Act of 1968 (Public Law 90-490). Federal aid to osteopathic as well as other professional schools would be further increased with the signing into law of the Comprehensive Health Manpower Training Act of 1971 (Public Law 92-157), which raised support levels for construction, replaced institutional grants with capitation grants to stimulate further enrollment gains, authorized special project moneys, and broadened student loan provisions.38 From fiscal year 1965 through 1976, the Chicago, Des Moines, Kansas City, Kirksville, and Philadelphia schools received a combined total of $65 .8 million through these specific programs.39

Other new sources of funding were made available. The legislatures of Pennsylvania (1966), Illinois (1970), and Iowa (1973) passed bills inaugurating ongoing educational assistance programs to their respective colleges of osteopathic medicine, in addition to authorizing separate grants for new construction. For the first time, assistance was secured from major philanthropic foundations, as well as from the pharmaceutical houses. Increased support from traditional sources also helped. Between 1961 and 1975, the Osteopathic Progress Fund, supported by DOs in the field, channeled slightly over $16 million into the schools, and the colleges themselves roughly tripled their tuition. In a federally sponsored study published in 1974, it was found that, while the median spending level of sampled DO schools was still lower than that of sampled MD institutions, all osteopathic colleges examined were now within the total range of MD schools studied with respect to the amount of money each spent per student for educational purposes.40

Several significant improvements were made in these five colleges between the time of the California merger in 1962 and the late 1970s. First, the qualifications of their students steadily rose. During the 1958* 59 academic year, 72 percent of entrants held bachelor’s or advanced degrees. By 1968–69, this had climbed to 88 percent, and during 1978–79 the total exceeded 95 percent.41 Second, more faculty members, particularly fulltime staff, were hired.42 Finally, equipment and facilities were improved. The Chicago College added two new wings to its existing hospital (1963–70), built a new basic science building (1968), opened a new $12.3 million outpatient clinic (1978), and completed construction of an $18 million, 200-bed satellite facility (1978). The Kansas City College added a new library (1968), lecture halls (1971), and a $29 million, 426-bed teaching hospital (1972). The Philadelphia College built a new campus that included a 250-bed facility (1968), the Kirksville school added a new research building (1963) and completed a major addition to its hospital (1971), and Des Moines moved its campus to more spacious quarters (1972). One indirect measure of improved standards and conditions within these schools was the overall performance of DO candidates before MD and composite licensure boards. Data published byfAJVIA, suggested that by the early 1970s there were no significant statistical differences between DOs and U.S.-trained MDs in passing such examinations.

Even more important to the future of the profession, the perceived overall shortage of physicians helped spur the establishment of new osteopathic schools, particularly as the existing DO colleges had a proven record of producing a high percentage of the type of doctor most in need, that is, general practitioners who were most likely to locate in rural and inner city areas.

The first and most significant battle to establish a new college occurred in Michigan—which, after the California merger, now had the largest number of osteopathic physicians in any state. Although hampered by the lack of a school, many DOs were drawn to practice within Michigan by an attractive licensure law and public acceptance. The limited licensure of its neighbor Illinois discouraged graduates of the Chicago school from staying within that state. However, after Illinois joined the unlimited licensure ranks, in 1955, and COPSIS closed, in 1961, a number of influential Michigan DOS believed they would have to establish their own college if they were to maintain or increase their ranks.

In May 1963, the Michigan Association of Osteopathic Physicians and Surgeons (MAOPSI S) House of Delegates unanimously threw its support behind plans for a new school, which was to be established near East Lansing, home of Michigan State University (MSU). However, when MSU announced shortly thereafter that it was in the process of developing an MD-granting institution, the osteopathic college committee shifted the location to Pontiac. In March 1965 , a charter was obtained and architects were hired to design the campus.43

Meanwhile, representatives and other advocates of the proposed college began lobbying for state aid. They referred legislators to recent surveys conducted by a commission appointed by the governor showing a need for yet another medical school since Michigan ranked only twentyfifth among all states in physician-population ratio.44 As to why this should be an osteopathic rather than an allopathic school, the DOS pointed out that as most of them were general practitioners, disproportionately located in underserved areas, they were filling the health care gaps that the MDs had created. Thus, to solve the perceived physician workforce problem, it made more sense to invest in osteopathic medical education. These arguments interested the legislature, which in June 1965, passed a capital outlay bill providing money for a feasibility study. That same month the MAOP&S house assessed each member of the association $2,000 payable over the next ten years to raise $3 million for the institution, and unveiled plans to amass $5 million elsewhere so as to qualify under the Health Professions Education Act for another $16 million in its two-to-one matching program.45

In October 1966, the Michigan Senate by a vote of 22 to 7 passed a bill creating the authority for the establishment of a state-supported osteopathic school. Not unexpectedly, the Michigan State Medical Society protested. During hearings on the measure before the House State Affairs Committee the next month, the Medical Society’s president appeared, forcefully arguing that amalgamation between the two professions was imminent. A state-financed school “just for osteopaths,” he maintained, would be absurd, since at least 75 percent of all Michigan DOs favored merger. This assertion was vigorously rebutted by MAOP&S representatives. With no concrete data available, the House State Affairs Committee could not determine the accuracy of either contention, so it decided to commission a confidential mail ballot addressed to all DOs and MDs practicing in Michigan to measure their opinions. The results, released in early 1967, were unambiguous. To the question “Do you believe amalgamation of allopathy and osteopathy would be in the best interest of the state?” 87.3 percent of the DOs who responded said “no.” On the question “Should the state give support to the osteopathic school?” 93.3 percent of the DOs answered “yes.” Results from the MDs polled revealed opposite responses in approximately the same proportions. With this new information, the house committee voted 10 to 1 in favor of the College Authority.46

The Michigan State Medical Society however, did not give up. When the measure came before the full house for consideration in mid-1967, it lobbied intensively and successfully for the bill’s defeat, which was by a margin of only two votes. The legislature, though, had not closed the door on the project, having already allocated another $50,000 for further study and development. The following year it appropriated $75,000 more. Finally, in 1969 the question of state support came before the legislature once again. This time the osteopathic forces were much better prepared. They responded well to the objections raised by the medical opposition and helped push their bill through both houses and secure the governor’s signature.47

Under the new statute, the osteopathic college would become an integral part of one of the three existing state universities. Further details were to be decided by the Michigan Board of Education and agreed to by the board of trustees of that institution. After involved negotiations, Michigan State University was chosen and accepted. Meanwhile, the board of trustees of the proposed school had previously voted to press ahead with or without state aid. It had already begun its first class in Pontiac in the fall of 1969 and would start a second year there before the whole campus would be transferred to East Lansing, where existing buildings were being remodeled for its use. The new Michigan State University College of Osteopathic Medicine (MSU-COM) would share some facilities with the MD-granting school that had been created on campus—the College of Human Medicine—but each would be governed by a separate budget and administration. While each college would use the same pool of basic science faculty, some classes for DO and MD students would be held separately.48

The establishment of MSU-COM was significant in at least three major respects. It was the first new school of osteopathic medicine to have been founded in several decades and helped to show that the profession was not content with merely maintaining its existing number of colleges and graduates. Second, it was the first university-based osteopathic school, thus allowing the profession to achieve greater status in the academic community. Third, having a DO and an MD college existing side-by-side on the same campus gave visible expression to the contention by AOA leaders that the two medical professions were “separate but equal.”

At the same time that Michigan DOs were making plans for their new school, osteopathic practitioners in Texas were working towards the same end. Enrolling its first class in the fall of 1970, the Texas College of Osteopathic Medicine (TCOM) began inauspiciously, housed initially on the top two floors of Fort Worth Osteopathic Hospital. However, the following year more suitable facilities for basic science instruction were obtained and utilized. Although founded as a private institution, TCOM began receiving some state aid in 1971, and the next year it signed a contract with North Texas State University (NTSU) in Denton for the use of classrooms, faculty, laboratories, and offices. In 1973 state assistance was significantly increased with the passage of an appropriations bill providing TCOM with capitation funds—$11,625 for each bona fide Texas resident enrolled. Two years later a formal agreement was negotiated and signed under which TCOM would become a public institution under the control of the Board of Regents of NTSU. Thus, the profession had its second university-affiliated medical school.49

Given the successful efforts of Michigan and Texas, DO groups in other states began pushing in earnest for their own institutions. The next to be established were the Oklahoma College of Osteopathic Medicine and Surgery in Tulsa and the West Virginia School of Osteopathic Medicine in Greenbriar, both opening in 1974. In the case of Oklahoma, the legislature was impressed by what DOs were already accomplishing in the state—providing medical services in high-need areas—and was therefore willing to expand their role by creating a freestanding public college.50 In West Virginia, on the other hand, DOs had made comparatively little impact on health care delivery, since there were only about seventy active practitioners. Nevertheless, a determined West Virginia Osteopathic Society, recognizing the dire need for more physicians in the Appalachian region, decided that they were best able to fill the gap. It purchased and remodeled a former military academy and began operations on a limited budget, backed by the necessary, although reluctant, AOA approval and the support of federal agencies that saw the school as an important experiment in increasing the physician workforce in economically depressed areas. The West Virginia legislature soon agreed, and the following year the institution was converted from a private to a freestanding public college.51

The drive to create more schools continued. In 1975 the Ohio legislature passed a bill authorizing the establishment of a state osteopathic school at Ohio University, which immediately transformed existing dormitories into offices, classrooms, and laboratories, enabling the school to accept its first class the following year.52 In 1977 two more colleges began operation: the NewJersey School of Osteopathic Medicine, a state institution, part of what became known as the University of Medicine and Dentistry of NewJersey; and the New York College of Osteopathic Medicine, a private school affiliated with the New York Institute of Technology.53 In 1978 another two private schools were established: the New England College of Osteopathic Medicine in Biddeford, Maine, a component of what became known as University of New England; and the College of Osteopathic Medicine of the Pacific (now a component of Western University), based in Pomona, California. This last school was made possible in part by a 1974 California State Supreme Court ruling that overturned the section of the merger legislation that barred any new osteopathic licensing in California.54 Buoyed up by their success, California DOs who had remained loyal to the profession vowed to multiply their small numbers quickly and once again make osteopathic medicine a significant part of the health resources of the state.55

Between 1968 and 1980 the number of osteopathic schools rose from five to fourteen—an incredible leap in so short a period. These new institutions, along with increases in enrollment at already established osteopathic colleges, put the number of students far beyond the premerger average. In 1960 there were 1,994 students; by 1980 this number stood at 4,940. In 1960 there were 427 graduates, in 1980 there were 1,151. The reduction in number of osteopathic physicians nationally caused by the loss of the ex-DOs in California was quickly made up. The AOA directory premerger figure of 14,000 in 1961 was reached and surpassed in 1973. As of 1980 there were more than 18,000 listed DOs, and one study projected that there would be approximately 30,000 active osteopathic physicians and surgeons by 1990.56

To most DOs across the country, particularly those who had been in practice at the time of the California merger, all of this growth produced a psychological lift. The college boom, along with the success of their profession in withstanding AMA pressure for amalgamation, demonstrated to them that osteopathic medicine was not on the wane. Indeed, despite their growing concern with external economic and political forces increasingly impacting the entire health care industry, most DOs believed that the osteopathic profession was entering the most fruitful period of its history.

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