Interesting article about MD vs DO

[drusso]

TITLE: Comparison of osteopathic and allopathic medical Schools' support for Primary care [In Process Citation]

AUTHORS: Peters AS; Clark-Chiarelli N; Block SD

SOURCE: J Gen Intern Med 1999 Dec;14(12):730-9

[MEDLINE record in process]

CITATION IDS: PMID: 10632817 UI: 20098970

ABSTRACT:

OBJECTIVE: To contrast prevailing behaviors and attitudes relative to primary care education and practice in osteopathic and allopathic medical schools. DESIGN: Descriptive study using confidential telephone interviews conducted in 1993-94. Analyses compared responses of osteopaths and allopaths, controlling for primary care orientation. SETTING: United States academic health centers. PARTICIPANTS: National stratified probability samples of first-year and fourth-year medical students, postgraduate year 2 residents, and clinical faculty in osteopathic and allopathic medical schools, a sample of allopathic deans, and a census of deans of osteopathic schools (n = 457 osteopaths; n = 2,045 allopaths). MEASUREMENTS: Survey items assessed personal characteristics, students' reasons for entering medicine, learners' primary care educational experiences, community support for primary care, and attitudes toward the clinical and academic competence of prJgiary care physicians. MAIN RESULTS: Primary care physicians composed a larger fraction of the faculty in osteopathic schools than in allopathic schools. ***Members of the osteopathic community were significantly more likely than their allopathic peers to describe themselves as socioemotionally oriented rather than technoscientifically oriented.**** Osteopathic learners were more likely than allopathic learners to have educational experiences in primary care venues and with primary care faculty, and to receive encouragement from faculty, including specialists, to enter primary care. ****Attitudes toward the clinical and academic competence of primary care physicians were consistently negative in both communities.**** Differences between communities were sustained after controlling for primary care orientation. CONCLUSIONS: In comparison with allopathic schools, the cultural practices and educational structures in osteopathic medical schools better support the production of primary care physicians. However, there is a lack of alignment between attitudes and practices in the osteopathic community.

Some questions to consider:

1) Does the statement that, "Members of the osteopathic community were significantly more likely than their allopathic peers to describe themselves as socioemotionally oriented rather than technoscientifically oriented." support the hypothesis that DO schools and admission committees seek different qualities in their students than MD schools do? Or, does osteopathic education teach "socioemotional" values?

2) Why do both MD's and DO's hold low esteem for primary care doctors?




[This message has been edited by drusso (edited 01-15-2000).]

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[turtleboard]

1) No, I don't believe you can accurately correlate that statement with the admissions selection practices at DO schools. There's no national sampling of premed applicants to both MD and DO schools where we examine their applications, who among them are selected for MD or DO school, and who among them eventually enter MD or DO school.

PreMDs and preDOs take the same science-based curriculum before application and matriculation. I don't see how any of these students can develop, with respect to medicine, "socioemotional" values rather than "technoscientific" values. It may be the case that osteopathic schools do teach socioemotional values (e.g., "We treat the patient, not the disease.")

2) I believe this has much to do with competitiveness within the profession. Our society is somewhat meritocratic, and those who are the best eventually win out over those who are just mediocre. Within medicine it's the same thing. Because primary care residencies are less competitive than non primary care residencies, we see those who enter primary care as less than stellar, and therefore, less deserving of our respect. That's not to say that in the eyes of the lay public primary care physicians aren't put up on a pedestal, however.

A recent "60 Minutes" broadcast on foreign medical graduates and graduate medical education reported that many students at Texas Tech, who were primary care bound, would not enter the Texas Tech primary care residencies. The reason: the programs at Texas Tech are perceived to be less competitive because of the high number of FMGs, and therefore less desirable and less esteemed.

Tim of New York City.

 

[RollTide]

Tim,

I am nearly speechless concerning your post. You have always provided valuable information for those seeking it and I have respected your opinion on many issues on these boards but your recent comments leave me believing that you are either an absolute ***** or an uncaring, unsympathetic person with little understanding of the present state of healthcare in this country. I mean come on Tim, do you really believe that we as human beings and future physicians are really that different? The "best" will eventually win out over the "mediocre" by securing a more competitive residency?give me a break! I really don't think this is what Darwin had in mind. If you really feel this way, I would hope that your future colleagues never come to understand your true feelings about them. Your own logic would lead me to believe that you think as a future "specialist" that you are not only more important than the "primary care" docs out there but also more important than the RN, the PT, the SW, and other members of a healthcare TEAM just because your area of expertise was more difficult to obtain training in. So next time you see your attending, DME, professor or a nurse at your local hospital, make sure you let them know that they are "less deserving of your respect".

-Joshua

 

[drusso]

I take quite the opposite view: I don't think that DO schools emphasize socioemotional values over MD schools. Certainly not MD schools like Rochester, UCSF, Harvard, Oregon, Yale, and many others. These latter schools pioneered the concept of "biopsychosocial" medicine. Biopsychosocial medicine is the sine quo non of good primary care medicine. Obviously something inherent in "osteopathic principles and practice" overlaps and complements the "biopsychosocial" concept. I've long believed that both concepts express the same notions. I agree with Tim (of New York City) that what is needed is a more comprehensive survey and, ideally, a rigorous examination of the admission practices of MD versus DO schools. I have anecdotal information from a PhD who served on both kinds of committees that DO adcoms do seek out students with broader life experiences and people skills---i.e. the "nontraditional types." And, while preMD and preDO students do take the same science classes it is still possible that preDO's take other classes in the humanities or have had certain life experiences that bias them toward an osteopathic medical education...we just don't know. The other explanation is that DO students are just MD rejects. Based upon my own experience and innumerable conversations with others, this explanation is not accurate.

Importantly, if a difference in adcom practices does exist, does it matter? There is no data showing that these purported differences affect the quality of patient care, although the prevailing perception is that it does. WE NEED MORE DATA!!!

Nevertheless, data from this admittedly small survey supports a widely held perception among some premeds, medical students, and practicing physicians: The perception that something DOES differs in the self-concept of MD and DO physicians when it comes to practicing medicine. Some argue that this difference might affect the types of interactions that occur between patients and physicians. That is, if you believe your role as a physician to be one of a highly skilled technician you might be biased against certain kinds of information compared to someone who sees themself as a socioemotionally oriented empathic healer. And, it goes without saying, the two views aren't mutually exclusive. Someone could believe that they are BOTH a high skilled technician AND an empathic healer.

Moreover, it is inappropriate to use this aggregate data to make individual predictions. All we can say is that in this survey, on average, it appears that DO students and residents embrace a more "socioemotional" attitude---whatever the hell THAT means---compared to MDs. Is this the Holy Grail of "osteopathic distinctiveness" or an artifact of admission practices?

It also begs another important question: Is one world view more valuable or appropriate to medicine than another? The Strawman answer is posit the old scenario, "Well, would you rather have an empathic neurosurgeon who's a klutz or an assholic surgeon who extremely skilled and practiced?" My answer is, Why can't I have both a skilled and empathic surgeon? I don't think that it does the issue justice to assume that "socioemotional" and "technoscientific" are opposite anchors of a spectrum, although that is the way it is traditionally viewed. They could be perfectly orthonganol. We just don't know....

Any other thoughts??

[This message has been edited by drusso (edited 01-16-2000).]

[This message has been edited by drusso (edited 01-16-2000).]

 

[turtleboard]

Joshua,

What I believe this society to be, whether in or out of medicine, is a product of my upbringing. From my perspective, our society is deeply rooted in a meritocracy. The ones who perform the best, do the best job, and score the highest, are the ones afforded the best opportunities for advancement. Competition is at the core of every aspect of American society, whether it be in business, science, or industry.

Take, for example, schooling in America. For myself, I had to take an entrance examination to attend one of the best high schools in the country. The admissions process examined little more than the outcome of ONE competitive, written exam. To go to a decent college and be awarded a ton of merit-based scholarships, one had to do well on the SATs and have good grades from a good school. To go to medical school one undoubtedly had to do well in college, maintain a certain academic ranking, do better than at least 80% of all people taking the MCATs, all the while doing things to prove you were worthy of entrance to medical school.

Whether you agree with me or not, our society is more meritocratic than we'd like to admit. Those who attend lesser schools are often times viewed as being lesser in ability. That's the way it's always been. A student in Boston who attends the Latin School is seen as being at the top of his game, but a student who attends a somewhat less celebrated school, the Latin Academy, is viewed as a less capable student (at least at the time of admissions).

I have nothing but respect for all healthcare professionals I've met over the years, and these ranged from the internationally recognized orthopod to the ward nurse at a local city hospital. These are all important people, all of whom deserve my undying respect, but it is not up to me to decide what the entire medical profession feels.

You've misread some of the things I wrote. I was making general comments on our society, none of which I necessarily believe. I've grown up in a meritocratic society, as far as I'm concerned, and whether or not I agree with it, I have to play by its rules. This does not, in any way, say that I won't be a primary care physician. If ultimately this is what makes me happy, then so be it. Will our meritocratic society view me differently than a specialist? As far as I'm concerned, and unfortunate as it may be, it will.


Tim of New York City.

 

[RollTide]

Tim,

Thank you for clarifying your position, your argument is solid although I do not necessarily agree. My older brother is a surgical resident and and it is extremly frustrating for me to witness the overall lack of respect he shows toward those in primary care. We often discuss his reasons for believing that surgical specialties are more elite than others and he usually points to the length of his residency program(6 years) or to the long hours he puts in each week. Both of these seem very unattractive to me. I think the bottom line here is that we all rank professions according to the length of time required to obtain training and salary. Specialist spend more years in training and thus deserve a higher salary for their services but I do not think this should equate to them deserving more respect. Primary care physicians are truely the quarterback of any healthcare setting and for persons like myself who have a broad interest in medicine and who desire knowledge in each specialty, primary care specialties are the only ones that provide what we are looking for. For you to imply that persons seeking primary care are just mediocre students with no other options is absurd. Some of us do pursue medicine for altruistic reasons and feel that primary care is where we are able to help the most. Once again, thanks for clarifying.

[This message has been edited by RollTide (edited 01-16-2000).]

 

[turtleboard]

Data aside, and operating on the fact that preDOs and preMDs have the same premed requirements and share equal representation among all majors, where else can "socioemotional" values be instilled?

As a first year student, I'm being spoon-fed a lot of this biopsychosocial stuff, as have previous generations of first-years. One quick look at my curriculum, however, shows that come second-year, we spring board from discussing "the patient's agenda" to more technoscientific topics that completely escape biopsychosocial medicine. In fact, it's almost as if the faculty is teaching biopsychosocial medicine for the sake of teaching it -- not because they want us to practice with those values as physicians, but because the AAMC requires it.

Where does it all go? Out the window, if you ask me. Third and Fourth years are spent almost entirely in a tertiary care facility without the kind of intimate patient contact you'd find in a more ambulatory setting (where students can actually begin to develop biopsychosocial concepts of their own).

The DO curriculum is structured a little differently, with more work in community-based hospitals. I'd imagine that being in a community-based institution would be much more conducive to intimate doctor-patient contact than within the halls of an academic medical center.

Without having experienced the DO curriculum firsthand, I can't say for sure, but it is very possible (at least in my own mind) that DO schools teach socioemotional values.


Tim of New York City.

 

[spunkydoc]

quite the interesting debate here--

but in the end, is not the practice of medicine still the practice of medicine? the goal is still the same--to heal...whether you do that within the "framework" of one medical philosophy or another (homeopathy and naturopathy aside), the goal is achieved...


i fail to see the logic or efficacy in debating which philosophy is better...i for one rarely see any major differences in practice between allopathy and osteopathy--sad as this may be..however, i am told that as an osteopath, my behaviors are different..

oh well, still, either as an MD or DO, we are all just trying to be good docs and provide good care..

if you are a DO, you've got an extra tool--use it when you feel appropriate..all these silly studies seem to me to be statistically insignificant..don't believe everything you read--follow your gut and how you feel as a DO or MD..

nuff said.

 

[turtleboard]

I don't think the current debate has anything to do with which philosophy is better.

The article Dave posted shows that DO students are more likely to describe themselves in one way, whereas MD students are more likely to describe themselves in another.

If they both follow essentially the same path to get to medical school, where do they split? At the admissions process or in the classroom?

The interesting part here is that there is a proven difference between how future DOs and future MDs view themselves, all the while providing the same high standard of care. Since there have been questions in the past as to the uniqueness of osteopathic medicine, Dave posed whether the differences between socioemotional values and technoscientific values were enough to finally say, "Yes, Osteopathic Medicine is different and distinct and here's why."

Tim of New York City.

 

[Sheon]

What would be interesting to see would be the patient perceptions of physicians that saw themselves as technoscientific or socioemotional in their orientation.

Imagine the ramifications if the treatment outcomes were consistent, but the patients' perceptions were vastly different among physicians that viewed themselves as socioemotionally or technoscientifically oriented.

For example, two patients with the same illness receive the same treatment with the same outcome. One having a physician with a socioemotional orientation, the other with a technoscientific orientation. One leaves happy the other leaves disappointed. While alone the situation means nothing, if one group consistently has more postive patient perceptions, it becomes very significant.

At some point we all have to ask ourselves what matters to us, the outcome of the treatment or the patient's perception of the outcome of the treatment?

Also, I think there is are significant third alternative to explain this phenomenon: students with socioemotional orientation are more likely to seek DO schools (for what ever reasons). The study should have examined the impact of age, undergraduate grades, and socioeconomic status to guage whether these intervening variables were exerting influence on the results (all of which could concievably be skewed one way or the other).

 

[reed0104]

I just wanted to point a few things out for Tim.

1) biopychosocial really means being personable and showing concern for patients overall well-being. It's more or less being well liked by patients, and it is a SKILL, not to be disreguarded. Think about it, how many doctors do you know that are dinguses (condescending, rude, arrogant) to patients? I know a few myself.

2) Many doctors don't WANT to become surgeons, that really doesn't say much about their ability or intelligence.( this goes for all specialties)

3)Vet school's admissions are more competitve than med school. Do vets look down on docs? Maybe, I don't know.

Your implied heirarchy of MD/DO, specialty vs. primary, and different colleges is kind of naive, I agree with RollTide. Your tone is one of somebody with a chip on their shoulder. I am refering not only to this thread but others also. Your remarks about D.O. school's letting in folks that have, "trouble with the numbers" is offensive to me and implies D.O's aren't as bright as M.D.'s. I disagree, and would offer up that you might have, "trouble with your ego."

Just an observation, nothing personal


Bryan

 

[turtleboard]

Heya there reed,

I try not to take things personally, because it clouds my argument. What I will do is discuss the points of your post, and hopefully offer you a better understanding of my perspective.

1) Biopsychosocial medicine. You missed my point. You've jumped to conclusions, like others have on this board, about my "perceived" prejudice against the osteopathic world. As anyone on this board who's spoken to me outside this forum will tell you, my only prejudice in the world is incompetent physicians.

I never once said that patient-centered medicine was a skill that should be tossed to the fire. My point was that it can't be taught in lecture, and it certainly is NOT reinforced in a tertiary care facility. I don't see why you would take that as a knock against DO schools. My curriculum is structured such that we're taught how to be "caring" physicians, but come as early as second-year, we're thrown into the middle of an understaffed public hospital doing H&Ps and not being told to consider the "patient's agenda." By THIRD-YEAR we're doing rotations through inpatient care facilities that are, essentially, technologically advanced medical centers. Tests, the differential diagnosis, and treatment plans are the most important and most emphasized points. The "patient's agenda" is never a part of the standard H&P. I am describing the curriculum at my allopathic medical school.

My comment about osteopathic medical students was that because many more of the patient care experiences are ambulatory-based, and therefore there is more of an emphasis on what the patient's here for, the osteopathic medical curriculum is more conducive to socioemotional practices. If you believe that this is condescending toward the osteopathic profession, then please discuss it with me on the forum.

Tim of New York City.

 

[reed0104]

Tim,

1) Your tone is why people jump to those conclusions about your positions on D.O.'s. Although, I don't think I jumped to coclusions, maybe I did, or maybe you didn't come across like you wanted to.

2)I guess the only other opinion I have to offer is that the D.O.'s are separated from the M.D.'s in the admission process, I beleive. Sheon is really on point on a lot of what he/she said.

3) Tim, IMHO, competance encompasses a lot more than the right dosages and procedures. Incompetance (which you distain) can also be found in physicians who alienate their patients. Personally, I am much less inclined to follow the orders of a doctor that I find to be aloof, or that takes a tone similar to some of your posts. Therefore, treating the patient less effectively. I realize you will never please everyone, but a patronizing attitude is easily spotted. (and incompetant)

What I took as a knock was the "trouble with the numbers" thing. Your implication was the M.D. wannabe argument. This can be true, but it definately isn't the rule, but rather the exception these days.

just my own little opinion, no offense intended,


Bryan

Q: What is more important; That the sky is actually falling, or that your patient beleives it is falling? I think the latter.

 

[turtleboard]

My "trouble with numbers" comment was something that had been posted time and again.

A student posts, "I have X GPA and Y MCATs. I really want to be an osteopathic physician. Will this keep me out?" Given that both X and Y are borderline, the response that is almost always given is: "A lot more goes into an appliation than just GPA and MCAT. Osteopathic medical schools also consider other things and have been known to 'look past the numbers.'"

I've flipped through all 19 DO school catalogs as a premed student. I remember distinctly reading in one that "Our school often 'looks past the numbers' of prospective applicants for admission."

"Looks past the numbers" is a favorite line used by many. It was in use on this board at least two years ago. It's nothing new. That's the traditionally-held view.

Why take it as a knock? Why could you not just reply to my message and say that it's now the exception and not the rule at osteopathic med schools? Why is it all of a sudden a knock coming from me?


Tim of New York City.

[This message has been edited by turtleboard (edited 01-21-2000).]

 

[reed0104]

"Looks past the numbers" and "trouble with the numbers" are different.

One implies the D.O.'s have acedemic difficulty where M.D.'s don't.

The other statement speaks to the fact that there is more to being a good doc then GPA's alone.

Guess which is which.


Bryan

 

[turtleboard]

They carry essentially the same meaning I think.

Tim of New York City.