DO and Lifestyle Medicine

[krzysio]

Too Long; Won't Read: I am interested in being a primary care physician that actually practices consistently the kind of preventative and lifestyle medicine that family physicians are in theory supposed to. Osteopathic programs still claim to be superior in training these kinds of physicians, but it's hard to tell from looking at the formal curriculums. Do DOs learn more about nutrition? Have more education on metabolism? More opportunity to practice lifestyle counseling and referrals? Do you notice in your education any particular special preparation for this kind of practice? Thank you very much for any help. I know you're likely very busy so I appreciate any answers. 🙂

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I was tired of physicians that wrote you a prescription for your most pressing symptoms and rushed you out the door without an explanation. Of doctors who neither made a strong impression of competence or even at least interest. And of clinics and hospitals that are more like material for nightmares than what you would imagine when you think of being healthy and happy. I really had a hard time understanding why physicians received so much respect. Since I had my most recent family physician I could see that at least a few outwardly demonstrated interest in how their patients understood their own health. But I still now think that I could do a better job at running a primary care clinic that maintains people's health and happiness.

For a while I had been looking at naturopathy. But apparently naturopathic medicine in practice tends to be quackery first and reasonable philosophy as an afterthought. Too bad. I can only assume there would be a huge niche for practitioners that could practice real lifestyle medicine. Practitioners who you could get your vaccines and occasional antibiotics and codeine from but who also worked on your diet with you and could prescribe appropriate physical activities. Who could act as the science and health educators most MD/DOs seem too busy to be for their patients. To explain to their patients why aspartame won't kill them, for instance.

But I think too many people (MDs and DOs included) treat "humanistic" to mean "unscientific". Learning acupuncture and hydrotherapy might not be entirely pointless if it would allow me to without misrepresenting their efficacy perform them safely for patients who absolutely insist on them. But forcing ND students to learn and practice these unproven modalities can't be any better than the influence of the pharmaceutical industry NDs complain about. And getting an ND degree would be an uncertain future. Will the state keep prescribing rights or will I have to move again? Will the pharmacology CME course be offered this year or has it been replaced by a tutorial on homeopathy? It would be an uphill battle to actually practice real medicine let alone have any respect.

So that leaves me essentially with practicing concierge medicine or standard clinic medicine and hoping years upon years of terrible toil don't jade me, and the promise of fast cash doesn't turn me into the physicians that my dislike of which was part of what drove me towards health care in the first place.

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[Iquitos]

IMHO, you will be sorely disappointed if you go to a DO school in hopes of getting a more "holistic" take on medicine. Modern DO and MD curricula are virtually the same, save OMM. Having my eyes opened up to how medicine works in the real world as a third year has helped me understand why physicians sometimes have the "rushed, treat your most pressing Sx and send you out the door" stereotype. Insurance companies, practice overhead, and the government have helped shape the medicine we see today and it will only get worse in the future.

It's pretty tough to make a living when you bill $99 for a 30 min visit, the insurance company pays you 60-80% of that (medicaid/medicare are even worse) and your office has 42-50% overhead. So you walk away with $25-40 from that 30 minute visit leaving you with an hourly wage of ~$50-80/hr then subtract your $250K+ student loan payments, malpractice ins, taxes, health/life/disability insurance.

These are actual numbers one of my FP attending ran past me. Not to mention what would happen if congress passes that ~20%+ cut in medicaid reimbursement. So concierge medicine might not be a bad option in the near future if that is something you would like to do.

 

[krzysio]

IMHO, you will be sorely disappointed if you go to a DO school in hopes of getting a more "holistic" take on medicine.

I'm not really looking for holistic medicine. (For example as far as I hear OMM isn't even used by DOs in practice.) I'm simply wondering if there is any point to attending a DO school based on the goal of being a physician that actually practices the preventative medicine and lifestyle counseling that both good DOs and MDs practice. DO schools often claim to do this better than MD schools but I've never been able to find any details on this.

 

[Iquitos]

DO schools often claim to do this better than MD schools but I've never been able to find any details on this.

This is one of the biggest BS claims perpetuated throughout the DO school interview trail. Honestly, as far as I have seen, MD schools teach the same things the DO schools teach besides OMM. I can't stand it when DO schools make the claim that they produce more compassionate/preventative med/whole body doctors than the MD schools. There may be exceptions, but I haven't seen any personally.

 

[ceftazidime]

I agree with the above. With your goals in mind, you should look at the curriculum of each school individually, regardless of whether it is a DO or MD school, and pick one that best suits your criteria.

Although I'm sure some DO schools do emphasize preventive medicine more than the average school, there are obviously some MD schools that do as well.

You have one misconception about OMM, however. It IS used in practice by the DOs that are comfortable using it. These are likely the DOs that made the effort to practice and refine their skills during their rotations and residency, unlike the majority of DOs who learn enough to pass their tests and then forget it. In my opinion, OMM is definitely a useful tool that one can use in outpatient medicine to truly ease the suffering of some of their patients, without having to resort immediately to medications (which may ultimately lead to addiction and a whole new set of problems). This is truly one advantage of being a DO, and I reap the benefits of it whenever I have clinic. I'm currently a lowly intern at an allopathic institution, but at times I feel like I'm already a step ahead of my MD attendings when the patient has musculoskeletal complaints.

 

[nlax30]

Yea, with things like nutrition and preventative health there is going to be variation among individual school curriculum, regardless of being DO or MD school...... so as a whole/in general I'd say no difference. You would just have to look at specific curriculum of individual schools to see how they approach that aspect of medicine.

That said, being on rotations has definitely had an impact on how I view things. Nutrition counseling and preventative medicine are all great and good to address, but unless you plan on specifically focusing your practice on those areas and taking a large financial hit (or catering to to the more wealth on a cash basis) then I just don't see how a physician can spend a whole lot of time dealing with those sort of issues when the yield of patients who are actually going to implement those changes is seemingly so low.

So far the physicians I've been around (MD and DO) have all been fairly good about addressing nutrition changes and lifestyle/preventative issues to their patients, yet I have not seen much change from the pt come from those encounters. At that point I just don't know what else could be done unless you plan to go home with them and monitor eveything they do, or assign a nutritionist to be with them 24hrs a day.

Last month on my OB/GYN rotation I was at a place that dealt mainly with mid/high risk OB patients and the majority I dealt with were smokers. I think I had one single patient who told me they had actually quit smoking during their pregnancy. Frankly I was kind of shocked when she told me that during clinic because by that point I was used to hearing how they are now down to half a pack/day or down to 5/day and outright told her she was my first pt that actually quit.

At least so far it's been hard not to get at least somewhat jaded.

 

[krzysio]

You have one misconception about OMM, however. It IS used in practice by the DOs that are comfortable using it. These are likely the DOs that made the effort to practice and refine their skills during their rotations and residency, unlike the majority of DOs who learn enough to pass their tests and then forget it. In my opinion, OMM is definitely a useful tool that one can use in outpatient medicine to truly ease the suffering of some of their patients, without having to resort immediately to medications (which may ultimately lead to addiction and a whole new set of problems). This is truly one advantage of being a DO, and I reap the benefits of it whenever I have clinic. I'm currently a lowly intern at an allopathic institution, but at times I feel like I'm already a step ahead of my MD attendings when the patient has musculoskeletal complaints.

Interesting. I'd love to know how your patients usually react when you employ manual therapy. Are they often confused? What kind of explanation is usually required? Do you ever have patients that ask to see another resident or the attending because they assume you are taking their complaints too lightly if you propose attempting a mt therapy?

 

[ceftazidime]

Interesting. I'd love to know how your patients usually react when you employ manual therapy. Are they often confused? What kind of explanation is usually required? Do you ever have patients that ask to see another resident or the attending because they assume you are taking their complaints too lightly if you propose attempting a mt therapy?

Very good questions. During my 4th year of med school I did a month of Sports medicine, and I emulated my attending who had a great way of introducing the topic. If someone has musculoskeletal complaints and I'm thinking about incorporating OMM, after I do the history and physical exam, all I say is:
Me: "Now you may not have realized, but I'm actually a DO and not an MD. Do you know the difference between the two?"
Pt: "No" (usually)
Me: "Well as DOs, we're equivalent to MDs in every way, but during medical school we also learn techniques to relax the muscles and manually adjust and realign joints. These techniques may help you with your pain/problem. Would you like me to use some of them on you today?

The patient has always responded with a "yes". At times, they bring up the fact that they see a chiropractor or physical therapist who does these kinds of techniques on them as well. They're never confused by it, and if they are, you can just say it's similar to what chiropractors and physical therapists do. It's funny how the lay person views chiropractors as an actual medical subspecialty, like a cardiologist.

And no, I have never had a patient ask to see another resident or the attending. There is no reason for them to do so, because if they decline the OMT (which they never have for me), as a DO you have the medical expertise and ability to say "Ok then, I can go ahead and refill your prescription for Percocet and order an MRI to evaluate for any underlying abnormalities". By offering OMT, they don't assume that I am taking their complaints lightly... in fact, it's quite the contrary. By laying your hands on the patient and taking extra time to ease their pain, you are going above and beyond their expectations, so they're always satisfied. I have had patients who requested to specifically see me for their next appointment. And most of the time, they are on chronic pain meds anyway and will get a refill on the way out, but hopefully if you truly know what you're doing with OMM and treat their musculoskeletal problems consistently, you can start weaning them off the meds.

 

[krzysio]

And no, I have never had a patient ask to see another resident or the attending. There is no reason for them to do so, because if they decline the OMT (which they never have for me), as a DO you have the medical expertise and ability to say "Ok then, I can go ahead and refill your prescription for Percocet and order an MRI to evaluate for any underlying abnormalities". By offering OMT, they don't assume that I am taking their complaints lightly... in fact, it's quite the contrary. By laying your hands on the patient and taking extra time to ease their pain, you are going above and beyond their expectations, so they're always satisfied.

Very helpful post 🙂

Just one quick follow up: Do you remember if patients reacted differently on occasions where you brought up manual therapy without reference to it as a distinctive part of your training? I'm wondering if the average patient without knowledge of OMM might be surprised that a physician is familiar with it.

 

[krzysio]

Having my eyes opened up to how medicine works in the real world as a third year has helped me understand why physicians sometimes have the "rushed, treat your most pressing Sx and send you out the door" stereotype. Insurance companies, practice overhead, and the government have helped shape the medicine we see today and it will only get worse in the future.

It's pretty tough to make a living when you bill $99 for a 30 min visit, the insurance company pays you 60-80% of that (medicaid/medicare are even worse) and your office has 42-50% overhead. So you walk away with $25-40 from that 30 minute visit leaving you with an hourly wage of ~$50-80/hr then subtract your $250K+ student loan payments, malpractice ins, taxes, health/life/disability insurance.

Not only this, but there is the fact that in many cases visits have to be short even just to provide medical care to all those looking for it. Sometimes this might be a result of patients not having a great understanding of when they need to come in, but also just because there are a lot of patients.

Which is another reason why I am kind of disappointed that there doesn't seem to be an established that has preventative health as one of its foundations. I guess we might assume that if it was easily done and worth doing, it would have been done already. But then again I'm not sure how far that's true.

 

[krzysio]

That said, being on rotations has definitely had an impact on how I view things. Nutrition counseling and preventative medicine are all great and good to address, but unless you plan on specifically focusing your practice on those areas and taking a large financial hit (or catering to to the more wealth on a cash basis) then I just don't see how a physician can spend a whole lot of time dealing with those sort of issues when the yield of patients who are actually going to implement those changes is seemingly so low.

Then again there are many patients who are actively seeking information on their health and well being. And if we're just taking a stab at it, I'd say a lot of these people would love to get more information from their physician rather than crazy books in Barnes and Noble or sensationalist news reports.

Now of course FPs can't be the authorities on all matters of everyday science. We might not even want them to be. Verifying what a physician tells the patient to believe about socially or politically sensitive science is harder than verifying what prescription they wrote or what surgery they performed, and I guess there would be room for abuse. Plus there's the whole issue with time.

But it'd just be nice if an FP could at least point out which health and diet books in Barnes and Noble are the least terrible. Or better yet tell the patient that their secretary can give a printed list of resources and the name of a kinesiologist who can answer questions about exercise (and why their plan of doing some crunches to try and lose their beer gut won't work.) And more importantly maybe create an environment where patients are comfortable asking questions on these matters.

 

[ceftazidime]

Very helpful post 🙂

Just one quick follow up: Do you remember if patients reacted differently on occasions where you brought up manual therapy without reference to it as a distinctive part of your training? I'm wondering if the average patient without knowledge of OMM might be surprised that a physician is familiar with it.

Well, if I take the time to bring up the subject, I always explain how it's a distinctive part of my training. I figure I might as well take the extra 5 seconds to do some word-of-mouth advertising for DOs. But oftentimes I don't explain anything, I'll just treat with OMT while doing the physical exam (unless I'm doing HVLA, for which I always give a disclaimer).

During these occassions when I don't explain anything, the patient never reacts differently. They never seem to think it's unusual... in fact as physicians (including MDs) we are trained do A LOT of unusual things during the physical exam such as percussion of the liver span, listening for egophony, palpating the abdominal aorta, feeling for inguinal lymph nodes, etc. In comparison, a little soft tissue OMT seems a lot more practical and logical to the patient than hooking your fingers under their rib cage to feel their liver, or tapping your finger on their forehead to see if they blink (Myerson's sign). So to answer your question... no, patients don't react differently if OMT is not explained. They just assume it's part of the established protocol for their condition (and it should be for a well-trained DO).

 

[krzysio]

Well, if I take the time to bring up the subject, I always explain how it's a distinctive part of my training. I figure I might as well take the extra 5 seconds to do some word-of-mouth advertising for DOs. But oftentimes I don't explain anything, I'll just treat with OMT while doing the physical exam (unless I'm doing HVLA, for which I always give a disclaimer).

During these occassions when I don't explain anything, the patient never reacts differently. They never seem to think it's unusual... in fact as physicians (including MDs) we are trained do A LOT of unusual things during the physical exam such as percussion of the liver span, listening for egophony, palpating the abdominal aorta, feeling for inguinal lymph nodes, etc. In comparison, a little soft tissue OMT seems a lot more practical and logical to the patient than hooking your fingers under their rib cage to feel their liver, or tapping your finger on their forehead to see if they blink (Myerson's sign). So to answer your question... no, patients don't react differently if OMT is not explained. They just assume it's part of the established protocol for their condition (and it should be for a well-trained DO).

Thanks a lot for your responses. You don't necessarily get to learn about these things even when you speak to med students and practicing physicians about their experiences.

And I'm glad I have something more to look into regarding OMT. In my experience I have only ever (though this is likely a coincidence) spoken to jaded DOs who consider their OMT training as alternately useless or beneath them. So to get an actual account of how it plays out and works in a clinical setting is useful for me.

 

[DrWBD]

And I'm glad I have something more to look into regarding OMT. In my experience I have only ever (though this is likely a coincidence) spoken to jaded DOs who consider their OMT training as alternately useless or beneath them. So to get an actual account of how it plays out and works in a clinical setting is useful for me.

It's not a coincidence. The overwhelming majority of DOs use little to no OMT in their practice. If you want to see DOs who use lots of OMT regularly, seek out those who are FAAOs (Fellows of the American Academy of Osteopathy) - basically specialists of OMT.

 

[LifestyleMedMD]

I'm a resident in a four year family and preventive medicine program who went to an MD school. I plan on devoting the rest of my career to learning about and practicing lifestyle medicine. I have to admit that going into medical school I expected to receive instruction on nutrition, exercise, stress management, etc... but found that the instruction was less than I hoped for. And from what I can tell my school was perhaps more progressive in the area than many other med schools. Because of that I actually stopped med school half way through and did a masters in public health majoring in public health nutrition. I think all our med schools DO or MD need a major overhaul in regards to lifestyle medicine teaching.

I am surprised in the current discussion over health care that little discussion has centered around the diseases that are contributing to the majority of the costs: obesity, hypertension, type 2 diabetes, obesity-related cancers and all the complications that result from these problems. I'm surprised that more effort isn't going into restructuring payment so that physicians are incentivized to practice lifestyle medicine so they'll spend the time it takes with each patient to motivate and educate them.

As far as getting lifestyle medicine training, from my discussions with residents from DO schools neither MD schools nor DO schools teach nearly enough in the area. How many graduating med students feel competent in smoking cessation counseling and prescribing, weight loss management, taking a dietary history...etc???

There are several organizations that are looking into how to train physicians on a large scale in this area. The American College of Sports Medicine has put a lot of effort into their Exercise is Medicine training. The American College of Lifestyle Medicine has started in the last few years with the goal to train physicians from multiple specialities in this area. The ACLM has been working with the American College of Preventive Medicine and several other colleges to develop scope of practice guidelines and knowledge guidelines. I expect a training and testing process will be formulated at some point in the future to help physicians develop competency in the area. One organization I am looking into right now is the Institute of Functional Medicine which seems to have a lot of insight into helping physicians understand more deeply the physiological processes connected to disease, how to better test the function of those processes, and how lifestyle change and nutritional change can affect those processes. This seems to me lessens the need to rely on medications for symptom control and gives more expertise in solving the underlying process.

 

[facetguy]

A nice editorial on lifestyle medicine:
http://www.functionalmedicine.org/content_management/files/News/HymanEditorial.pdf

I agree with the previous post that the Institute for Functional Medicine is doing a lot of good work. It's easy to envision an increasing incorporation of functional medicine into everyday practice...someday. This whole topic reminds us why the 'healthcare reform' we hear about isn't necessarily about true reform.