...a couple of thoughts for Tim (of New York City)
1) The Macy Foundations conferences were productive, but not the end all and be all of DO/MD relations. Many things were left unsaid, many points of view unappreciated. It was only a starting place.
2) Osteopathic medicine was founded as a reform movement in medicine. A.T. did not intend to create a separate branch of medicine; he believed that when his ideas saw the light of day all medical schools in the country would become osteopathic medical schools. The reform, as invisioned by Still, was not simply the addition of a new treatment modality to the physician's armamentarium, but the inclusion of a philosophy of healing, based upon scientific precepts, in medical education as a means to provide physicians with...a lens, a metaphor, a point of view, etc, etc...through which to view the physician-patient relationship. The fact that allopathic medical education also tries to provide this to their students does not diminish the osteopathic approach to patient care. Being a DO means many different things to different people. I'm sure it's the same for MD's. Here's an excerpt from an essay I've been tinkering with on the subject:
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Some might argue that this hand wringing about ?reform? and ?philosophy? begs this question: Hasn?t evidence-based medicine singly reduced all competing philosophies of patient care to a handful of common factors? Put differently, Do the way physicians? understand the meaning of illness in patients' lives, or their appreciation for the distinction that some patients draw between being cured of disease and being healed from illness measurably affect the way that they practice medicine?
Data from research examining the patient-physician relationship establish that indeed such philosophical understanding and appreciation does (4,5,6). Also, these data demonstrate that American physicians and their patients aren?t as connected as they used to be. That kind of connection, a hallmark of many indigenous healing traditions, and the keystone of generalist medical training, used to be a bridge between the technical knowledge that physicians possess and the patient?s day to day experience of living with pain and disease. Such a shared understanding addresses not only why a person is sick, but also helps patients cope with what it means to be sick. As Arthur Klienman explains in The Illness Narratives (1988): "Nothing so concentrates experience and clarifies the central conditions of living as serious illness [does]. The study of the process by which meaning is created in illness brings us into the everyday reality of individuals like ourselves, who must deal with exigent life circumstances created by suffering, disability, difficult loss, and the threat of death."
The physician-poet Williams Carlos Williams also writes about how patients? inherent vulnerability, combined with medicine?s lack of an experiential language of healing thwarted efforts to relieve human suffering. In his short story, ?The Practice? (1951), he hammers home the message that physicians, even in their role as healers, still miss opportunities to engage others in ways typically outside the realm of everyday experience: "Do we not see that we are inarticulate? That is what defeats us. It is our inability to communicate to another how we are locked within ourselves, unable to say the simplest things of importance to one another, any of us, even the most valuable, that makes our lives like those of a litter of kittens in a wood-pile. That gives the physician?his opportunity?a wonderful opportunity to actually witness words being born."
American medical schools have long struggled to help students ?witness words being born.? That is, they have struggled to teach their students a framework, a worldview, a way of thinking to help them understand their patients? experiences. All medical schools introduce students to Engel?s biopsychosocial model of patient care. However, according to many medical educators, the model is a tough sell outside the classroom. It demands from students a degree of psychological-mindedness and an understanding of sociological ideas not emphasized in traditional premedical or medical curricula. Frankly, some medical students dismiss the model?s expectations as too ?touchy-feely? and too at odds with the conventional expectations of how a physician should behave.
Before Engel, the Canadian physician William Osler worked to provide medical students a viable conceptual framework for the foundation of a modern medical. He too knew that language and communication are an essential part of a physician?s work, "There is no more difficult art to acquire than the art of observation, and for some men it is quite as difficult to record an observation in brief and plain language." Widely known for his rigorous approach to medical education, he demanded that his students take exhaustive histories and perform meticulous physical examinations. Almost single-handedly he moved medical education from the lecture hall and laboratory to the bedside. Sadly, today?s technology has robbed physicians of all but the most perfunctory opportunity to engage in this close work. Careful palpation, observation, and auscultation have largely been replaced with sophisticated imaging and laboratory diagnosis. Many fundamental physical diagnostic skills, along with the larger ideals of Oslerian medicine, have been virtually forgotten in the modern hustle of managed care.
...It is a connection to healing that I argue osteopathic medicine emphasizes in its approach to patient care; laying hands on patients reaches back to the most ancient healing traditions, it builds trust, affirms human relationships, and when applied therapeutically, it heals. Holism is only another expression for total care of the mind, body, and soul. Related structure and function is a scientific principle that is the foundation of modern physiology. Prevention of disease is sine qua non of good primary care. When these four ideas are packaged together and shared between doctor and patient what is communicated is tantamount to the tenets of osteopathic medicine.
The obvious convergence of these ideas reminds me of a comment I heard a DO make during a conversation at a recent conference. In introducing his colleague he said, "I practice with Jim who is an MD,? and then quickly added, ?but he practices osteopathically.? That after-thought says it all. It highlights the fact that all medicine and the fruits of its labor?technological, philosophical, and intellectual?ultimately exist in the public domain. If taken seriously it is a sentiment that begs all physicians to focus less upon turf and guild issues in medicine and more upon bringing osteopathic ideals out of the closet to share with colleagues, nurses, managed care organizations, and most importantly, the patients who seek our care.
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3) This topic reminds me of an article I read about the merger of an osteopathic hospital and catholic charity hospital up in Ohio a while back. The author, a nun with a MBA in health care financing (take a moment to consider that!), wrote about the challenges of brokering the merger. The osteopathic hospital wanted to retain its "osteopathic identity" in the deal, but had a difficult time saying exactly what that meant specifically. After hours and hours of meetings she said that she finally had an epiphany when she understood that a dedication to osteopathic principles did not so much reflect specific "things" or procedures that DO's do as much as it reflects a "feeling about the meaning" of your work. I know that sounds kind of woo-woo, but I think that captures it. In essence, the osteopathic group wanted to make sure that the newly-merged group's mission retained certain convictions about the practice of medicine: Strong generalist-physician participation in hospital activities and committees (usually specialists call the shots), the retention of an OMM service, maintaining strong ties to the community, etc.
Ideas, philosophy, and abstractions are slippery things, which is why the profession has this conundrum in the first place.
[This message has been edited by drusso (edited August 24, 1999).]
