med99 said:
While that is interesting and all, the differences are still in the end minor. One can say that an MD and a DO's differential would be much different but really they would be say perhaps 25 things for an MD (obviously depending on symptoms and how far you want to stretch) vs. maybe 27 for a DO. Ideally a MD's differential should include those 2 other possibilities also. In the end isn't it really just a matter of emphasis.
These 2 differentials, in my mind at least, don't constitute a whole other boards, residency, school system. What about just making DO schools allopathic with a twist. All schools do this to some extent. My school emphasizes rural medicine and outreach to the underserved. Some school emphasize research and EBM.
What you miss with EBM is the art of medicine. Physicians that live ONLY by EBM will become technicians- treating symptoms based on what the statistics show. While such an approach may temporarily help a good many patients some of the time, such an approach fails to see the unique challenges of the individual, nor does it allow for artistic innovation when a particular med's side effect may be advantageous for that patient, for example- or it is used skillfully off-label or to treat multiple issues. A good osteopath does not have a larger differential diagnosis than a good MD. Instead, they use additional tools and knowledge (and a careful history) to reason back to the source of symptoms. An great MD once told me... "you know.. thats a good idea. It would be nice to figure everything out. We just dont have time to think that way though, and we can help patients with what they come in for." That is a valid statement, but it showcases the difference in philosophy.
For example, instead of just treating a pneumonia with the EBM IV antibiotic and discharging the patient, an osteopath uses the antibiotics- but also mechanical tx for the thoracic lymphatics, checks the thoracic anatomy for assymetry or signs of autonomic disturbance to the lungs (characteristic upper thoracic tissue texture changes), checks the cervical spine for phrenic nerve impingement, and corrects what they find- and according to one poor small pilot study in the JAOA this reduces the time of hospital stays by 2 days on average- better studies currently in progress
You then ask yourself what has lowered the patient's immune response enough to allow the invaders to win for so long? ...what stressors are in the patients life? does the patient exercise? smoke? underlying depression? what about diet? poor mechanical ventilation due to rib cage dysfunction? could their diabetes be better controlled? You can bet with such a comprehensive approach thier chances of a relapse go way down. Sure a great MD could ask all these questions and maybe call in an OMM specialist consult on every pneumonia patient, but osteopaths are trained to reason this way for every patient- and we have the tools and knowledge to easily see the connections.
Remember, in both cases pneumonia is the working diagnosis, its not like osteopaths have more diagnoses to choose from (just perhaps more ways to understand the same diagnoses).
another example: a patient has chronic pain and signs of depression. He/She is somewhat overweight, and they complain that they can't excercise due to pain. sound familiar?
The allopathic approach would be to send to PT for long weeks of painful stretches (maybe slow improvment, maybe not) or go to the pain clinic for lumbar cortisone injections or nerve ablation (sometimes effective, sometimes very painful- and always many thousands of dollars in cost with high co-pay). They prescribe percocet or oxycodone to numb the patient up, stop their bowels and give them addiction issues- and then have them pop an SSRI for the rest of their life. If you have worked with these patients, you know the long term prognosis is usually not to good with this approach, and how frustrated most MD's get with these people.
As an osteopath by simple palpation you know if there is a deep muscle in spasm that is stopping them from exercising (usually psoas, pirformis or deep intervertebral)- and if so, with counterstrain you are able to correct it permanently right there on the spot in a few seconds- and you can then spend the rest of your visit educating the patient about exercise possibilities and how important exercise is to help their depression (shown to be as efficacious as SSRI's in outcome studies- but can be used in addition to SSRI's for maximal effect). After artful persuasion, you use SSRI's along with a regular moderate exercise program that is suited to the patients interests and capabilities. The patient on follow up reports that they can exercise daily since their pain has lifted and their depression has lifted significantly as well, and they have lost weight as a side effect (which in turn further helps build confidence and stablilize mood). Usually they are functional enough in a short period of time that if they continue their exercise- they can get off disability and resume their careers (or enjoy retirement). In about 6 months they often no longer need their depression meds to stay stable, and they are relatively healthy and independent.
sound overly optimistic? I've seen MANY of the above patients many times over- for each of the 4 above cases (pneumonia and chronic pain examples for both allopathic and osteopathic care). I have seen them all on extended follow up as well. This happens all the time.
Dont get me wrong, osteopathy is not a cure-all. If the back-painer's pain was due to a compression fracture or severe spinal stenosis one's osteopathic advantage is limited. Conventional medicine offers most of our best options in these cases- however, osteopathic thought may still help you manage post surgical rehab for them, or maximize function for them even in light of constant unremitting pain.
As the OP stated, there are stilll DO's that practice the allopathic approach listed above, copying their MD (or DO) mentors that practice this way- but in good DO schools you will get enough of an education in osteopathic thinking that the osteopathic approach will feel like the natural one. When you see the majority of docs practicing the other way out there in hospitals you can get in there early and help their patients out (or at the very least remind yourself in the back of your mind about your other options for when you're on your own).
Since osteopathy is a philosophy and a way of practicing medicine rather than a mere treatment modality, it doesnt lend itself well to double blind studies. Perhaps all MD's should learn to work the way we do- it is very attractive in pain management and rehabilitation medicine to have these skills (and any primary care field as well). Then again, its a lot of work to practice this way. You cant see as many patients (even if you make more per hour since you can bill for OMM in addition to the consult). plus most patients dont know what a DO is, so if you have ego issues thats a rub. It aint always an easy road, but sometimes its worth it. And yes, the road is VERY different, even if many DO's choose not to take it.
it has been a long slow call night lol... hope i'm not getting too incoherent
be well,
michael
