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More Osteo Less Pharmaco?

Discussion in 'Pre-Medical - DO' started by Mung, May 6, 2007.

  1. Mung

    Mung 2+ Year Member

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    So are there any opinions on which schools are more focused on teaching, implementing and integrating actual osteopathic techniques?

    From what I can tell it seems that most schools are devoting from 120 to about 200 actual class hours to actual osteopathic manipulations and techniques. There are massage therapists that get more training in osteopathic techniques than that.

    It seems to me that for most schools, students and practicing DOs the osteopathic techniques are just a token part of the curriculum for most, interesting to a few, and an emabarrassment to others.

    So if I was really interested in learning osteopathy as much or more than pharmaceuticals and surgery any suggestions?

    Thanks and see you all at the all night disco dance party USA!
     
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  3. spicedmanna

    spicedmanna Moderator Emeritus 7+ Year Member

    Do an undergraduate medical fellowship in OMM/OMT while you are in medical school. You'll get more exposure, teach the material, and learn it more extensively.

    If you want more than that, after your internship year, you can do a residency in OMM/NMM.
     
  4. scpod

    scpod Physician Moderator Emeritus 10+ Year Member

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    Awfully opinionated for your second post, aren't you? Then again, based on your first post, you've already told us you're the Devil, and I have little sympathy for you. Are you actually old enough to quote the Stones?

    By the way, what are you here to mung (destroy)?
     
  5. DragonWell

    DragonWell Moderator Emeritus 10+ Year Member

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  6. Taus

    Taus . Moderator 10+ Year Member

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    You can't expect to be good at any aspect of practicing medicine after years 1/2....thats what rotations and residency are for.....when you're in school you can join the UAAO, attend extra conferences/training sessions or even become an "OMM Fellow" to really be come proficient at OMM if it interests you
     
  7. Mung

    Mung 2+ Year Member

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    I stuck around St. Petersburg when I though it was a time for a change.

    Oh Anastasia, pipe down over there!

    Aren't we all old enough? They just keep rolling on and on and on...

    So a residency in OMM/NMM (NMM?) would I also have to do a residency in another area e.g. orthopedics, primary care, to practice?
    I have an interest in orthopedics but not as a surgeon is there such a thing?

    Why is it that foreign osteopathic schools seem more focused on osteopathy?
     
  8. Taus

    Taus . Moderator 10+ Year Member

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    You can practice OMM in any field you want....but the majority of DO's who use it often are in primary care (ie FP, IM, Peds) and PM&R/Sports Med. All you really HAVE to do is a 1 year internship....but there are other issues w/ that.
    There is actually some really good information on this exact topic in the mentor forum...I think you should check that out.

    Regarding foreign trained DO's....they are trained in manipulation only....ie they DO NOT go through a medical curriculum as Osteopathic Physicians in the US do....they are basically mid-level providers and work in a similar role as PT's and Chiro's in the US.
     
  9. spicedmanna

    spicedmanna Moderator Emeritus 7+ Year Member

    I chose MSUCOM as my example, for no reason other than it was the first program that came up in a Google search:

    Here is the outline of a typical OMM/NMM (Osteopathic Manipulative Medicine/Neuromusculoskeletal Medicine) residency, from MSUCOM:

    http://www.com.msu.edu/omm/images/residency_description.pdf

    There is an undergraduate medical fellowship (often referred to as a +1 year) in OMM that you can do while you are in medical school; again, here's the MSUCOM description of the program:

    Because in most of the world, Osteopaths are not complete physicians, they focus on manipulation rather than evidenced-based medicine.
     
  10. Dr JPH

    Dr JPH Banned Banned 10+ Year Member

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    I would like to know where you developed your opinions. Perhaps we can speak about what you observed that caused you to feel this way.

    From your post it seems you are more interested in becoming an "osteopath" or a chiropractor as opposed to a physician who uses OMT.

    Just for a little perspective...DO schools spend more time on OMT than any other discipline (cardiology, pharmacology, renal) except for anatomy. This is in addition to having those other courses in the curriculum.

    If you are interested in learning about osteopathy and NOT pharm and surgery, then a US DO school isnt what you are looking for.
     
  11. Bingo.
     
  12. Dr JPH

    Dr JPH Banned Banned 10+ Year Member

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    Again...another insightful response coming from someone who have never set foot on the campus of a DO school, sat in a DO class or never seen OMT performed.

    How can you be so worldly when your OMT experience comes from conversations with a handful of DOs you see in passing at the hospital?

    Oh wait...you read Gevitzs book...nevermind. :rolleyes:
     
  13. Dustbunny

    Dustbunny 2+ Year Member

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    I don't pretend to know much, but I sat in on what amounts to an allopathic school's "fundamentals of doctoring" at UNECOM -- don't remember the class name -- and was completely blown away by just how tightly integrated into just about everything OMM actually is.

    It was actually pretty cool seeing the myriad ways it could be applied where the outside, ignorant observer (myself) would never dream it could be applied before actually seeing it done. Perhaps "seeing" isn't the right word because it wasn't an OMM lab; it was a small group analyzing case studies, but OMT maneuvers were being suggested left and right, and even an instance of when OMT was contraindicated. I thought that was really cool. (They even let me participate, which was nice of them. But I opted to keep my mouth shut most of the time.)

    It only solidified my desire to attend a DO school over an allopathic one any day of the week. Why wouldn't I want to know OMM??
     
  14. Dr JPH

    Dr JPH Banned Banned 10+ Year Member

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    Your experiences with OMT are far greater than of some other people posting here (DKM) and your responses are more thorough and informative. :thumbup:
     
  15. Actually, I haven't. I have had OMM performed on me for musculoskeletal injuries though.....and you know I openly support its use for that purpose. I also support the OP's assessment that I quoted: for many people it is just one more class, another hurdle to jump through (this would be the group in which I fall). A few are even embarassed by the continued insistance that OMM has a bigger place in the course of proper medical treatment than is supported by the literature (the quackery that is cranial notwithstanding). Those of you (yourself included JP) that are major proponents of it are in the minority- something I don't believe you refute.
     
  16. Dustbunny

    Dustbunny 2+ Year Member

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    Thanks. My first choice of schools is PCOM. Wanna put in a good word for me there? :laugh:
     
  17. What solidified my decision to apply to DO programs was the fact that they turn out excellent physicians. The knowledge of OMM is something that, like a knowledge of how to do a cholecystectomy, it is nice to know, but chances are I will get infrequent use out of it in any field I could possibly see myself going into.

    You only think that because of the fact that he agrees with you. God bless observational bias, eh JP? :laugh:
     
  18. Dr JPH

    Dr JPH Banned Banned 10+ Year Member

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    What lack of research?

    There are hundreds of papers supporting the use of OMT and manual medicine. Just because they dont come with big drug company money or arent in JAMA doesnt make t hem any less valid. Nor does the fact that the leading producer of manual medicine research is not the US.

    Anyone who uses "lack of research" as an excuse for not taking OMT seriously is just plain lazy. It takes mere minutes to do an online search of the literature and you will indeed find studies out there that are controlled, have more than a handful of participants, are multi-centered and have significant data & results.

    You want to know the REAL reason many DO students blow off OMT? Because they are lazy.

    I have been teaching OMT lab for 3 years and dI see it every single class.

    Its easier to fall asleep on an OMT table than it is to pay attention.

    Well, people HAVE to learn cardiology and pharmacology...because that stuff kills people.

    But no one takes OMT seriously because it (god forbid) is something that benefits the patient.

    No one ever took derm or opthalmology seriously either...unless thats what you wanted to do.

    Unless a student truly feels that what they are learning is something they will someday use in their own practice then they wont pay attention to learning it...they wont put the effort in.

    Now in order to learn Derm you need to flip through a book with pictures.

    In order to learn OMT you need to attend lab and participate.

    In going through the suturing clinics with students I see the same apathy. The future surgeons are hard at work while everyone else is busy writing their name with 4-0 vicryl in the pig foot.

    So why doesnt anyone ever talk about how the typical DO doesnt care about opthalmology or foot fungus?

    From working with most of the students over the past few years I can say that I am not totally upset that most of them will never use OMT professionally...for many they will be putting their patients and their medical license on the line.

    But I am always amazed at the number of students I see in the office on a regular basis who I KNOW dont do well in OMT, dont pay attention in lab and generally dont care...but when THEIR back hurts they are making an appointment with me.

    So is the problem a lack of evidence or outcome with OMT? No.

    Its a lack of desire to get off your ass and learn anything that isnt spoon fed to you.
     
  19. Mung

    Mung 2+ Year Member

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    I may be way off. I have spent some time looking at threads on this particular forum and have not seen much in the way of students being very excited about using OMM. (I have not read all the posts so I could be writing out of turn) Some it seems make fun of it, and some seem to find it useful for some minor ailments, and I guess I am sensing a some what pejorative connotation when comparing OMM to "evidenced based medicine" (and I do not want to start such a debate-just commenting)

    I am not familiar with how the residencies etc work and how OMM fits into all of that. Or how you go from osteo/med school to practicing physician-Although I am learning thanks to the posts. I did not spend time comparing hours/units of OMM to hours spent on everything else-so thank you for that perspective. I was going to be surprised if the hours of OMM in school would be enough to really know what you are doing. And most of the people that I hear about practicing OMM techniques (with in their scope of practice) are massage therapists that take CE from DOs

    I am out of your loop, and I apologize if I have made generalities that are untrue or in the least misguided.

    How many of you are planning on using OMM in your practice? Do you think that most DOs are practicing OMM?

    It is not that I do not believe or want to prescribe meds or surgery, it is just that my bias would be towards the OMM, thus why I am not posting on the MD forum.

    My original question perhaps is better worded as: I am wanting to know if some schools have a stronger reputation for the OMM part of the program? I did read some ideas about this in the mentors forum, but would like to hear from the people actually in the programs.

    Advice that I have seen posted many times is to find the school that fits most with what I want and value. So instead of asking which school is best I thougt I would ask which schools do you think would make the most sense for me.

    As for going to osteopathic school out of the country, my guess is that I would not be able to get licensure here, is that correct?

    I have gone to the Mentors page and did find more posts that were of help. Thank you for the tip.
     
  20. No, for what it is useful for, there is plenty of data. This I do not deny. Why else would the first doc I go to when I pull a muscle in my back while working a structure fire be one of the few DOs in our area who does OMM (the fact that it's free to me as a volunteer firefighter notwithstanding). But I have seen some pretty outlandish claims made that it is useful for this condition or that condition and the "evidence" is a study in dogs or something that is methodologically sketchy at best. I think it detracts from the real utility of this type of therapy- which is for musculoskeletal issues. You can not convince me that it is not useful for that.

    I don't doubt that in the slightest. Just like MD students, RT students, EMT students, and basically 99% of the human race. :laugh:

    I take it seriously in certain aspects for that very reason, but I just feel that there is a fringe element (the cranial quacks and the extreme minority that think you can fix anything with OMM) that needs to be reigned in. It is much the same as one of the research projects I am involved with on whether bronchodilators are OVERprescribed and abused by a certain subset of patients.....I don't doubt that they benefit a lot of people- and have saved people I love- but I am of a skeptical sort and don't tend to like to have things spoonfed to me, otherwise I never would have looked at this idea with anything other than disdain. But I do it because I want to make sure I'm doing right by my patients and that everyone is doing likewise, whether it be a popular choice or not.
     
  21. Mung

    Mung 2+ Year Member

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    This kind of influenced my first post:

    I was able to spend some time with students at AZCOM. When I started asking about OMT, they gave the impression that they were really not into it, but there was 1 (ONE) guy in their class that was-these were I believe 3rd year students.

    So I thought maybe some schools might lean a bit heavier towards it than others-perhaps thru curriculum, professor choices, and picking students that have a stronger interest in OMT.
     
  22. Depakote

    Depakote Pediatric Anesthesiologist Rocket Scientist Physician Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

    I'll put my skepticism aside and comment:

    OMM is really up to the student/physician to embrace. There is no requirement that the student be enthusiastic about its practice and do anything beyone the requirements, and there is no requirement that DOs employ OMM in their daily practice. That said, there are plenty of DO students and plenty of practicing DOs that do use OMM regularly. If this is your interest, I would suggest you find a DO that uses OMM (perhaps even an OMM specialist) and shadow him/her.

    As for programs, any DO program will provide you all the necessary OMM training you need, but you may wish to look for and apply to schools that have OMM Fellowships and find out more about those.
     
  23. Dustbunny

    Dustbunny 2+ Year Member

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    Unfortunately, the things that don't interest you have a tendency to come back and bit you in the ass as I've unfortunately found while trying to recall some aspects of physiology. "Oh gee I remember not paying attention during this part because it was I'd never need to remember it..." :thumbdown:
     
  24. MaximusD

    MaximusD Anatomically Incorrect Physician 10+ Year Member

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    Why would you want less pharmacology? Proven biochemical pathways seem like a fluke to you?

    Go sit in a corner and think about what you've done...:smuggrin:

    Do an OMM fellowship but for the love of God.. never EVER think that you should compromise your understanding of pharmacology to achieve that end... unless, of course, you want to be a european DO.
     
  25. Static Line

    Static Line America's Guard of Honor 5+ Year Member

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    If you want to learn more osteopathy than medicine then go to chiropractic school. Many Chiro's are better than most DO's at manipulation anyhow.

    To be a good DO it requires a lot of devotion to learning both, not one more than the other. That's what makes DO's special, we are physicians with a supreme understanding of the NeuroMusculoskelatal system. We know where to draw the line with manual treatment and move forward with medical or surgical therapies. Or better yet, we have an understanding of how to combine all the modalities together because that is what we are here for, a better outcome of the patient.

    And yes, you are right, it is token training for many. Those are the ones who wanted to go allopathic but weren't good enough. Medical school is hard enough. If you want to be even more misserable going through it then go to DO school not wanting to learn osteopathy. Having to learn that extra load is what makes DO school more challenging than any allopathic school.
     
  26. Mung

    Mung 2+ Year Member

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    Touche.

    Now with reflection my query could be reversed.
     
  27. Static Line

    Static Line America's Guard of Honor 5+ Year Member

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    That is comparing apples to oranges. You are comparing a broad category vs one body system (cardiac). OMT is such a broad category and more difficult than pharm anyhow. Pharm is a breeze. And all the board questions I study whether, Kaplan, First AID, or other board questions proove it to me.
     
  28. Mung

    Mung 2+ Year Member

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    StaticLine-Thank you. I would reckon that seems to be the true culmination of being a DO in this country.

    Are all schools equal in trying to foster this type of understanding and skill? And it is just that some of the students are choosing to not embrace?
     
  29. Dr JPH

    Dr JPH Banned Banned 10+ Year Member

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    If you are a cute female, yes. :thumbup:

    Also I love the idea of a DO premed (depakote) being skeptical about OMT. "I want to be a pharmacist but I have doubts that medications work." Um. Ok.

    Another "DO as a means to an end".
     
  30. I would imagine this to be applicable to about ~75% of the DO students out there.

    Just because you doubt something about a particular career field that still has unanswered questions about it, should not be reasons to be brushed off regarding it. If I recall correctly, this is how things are improved- by people who weren't unquestionably allegiant to the party line about something and went out and proved or disproved a facet of that group's beliefs. Pardon me, but I actually believe (if I remember correctly the story I was told during my visit to KCOM) osteopathic medicine got their start this way by Dr. Still thumbing his nose at the allopathic establishment after his kids died.
     
  31. spicedmanna

    spicedmanna Moderator Emeritus 7+ Year Member

    I doubt everything is equal; you may wish to look into the OMM depts of the schools in which you are interested in applying. Do some leg work research about these schools. Look at their curriculums and the quality of their OMM fellowships/residencies. There are certainly differences. For example, some schools teach Cranial-Sacral, like WU/COMP, while others have left it out of the OMM curriculum. Also, some OMM departments have well-known OMM professors.

    In any case, I think the answer to your second question is, "yes." School is what you make out of it. I bet there is more than you can absorb at each school, regardless of the minor disparaties in OMM training. Take advantage of every available resource, join the OMM clubs at school, become an OMM fellow, and practice. It is my understanding that manual therapy requires lots of practice.

    Good luck.
     
  32. Depakote

    Depakote Pediatric Anesthesiologist Rocket Scientist Physician Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

    I'm sorry if I came across as being skeptical about OMT. This is not the case. I do believe it has many practical applications and I do look forward to learning it (jury is still out on the integration of it into my practice).

    My reference to being skeptical was merely a reference to the OP's intentions behind posting this thread (troll?).
     
  33. supersport

    supersport supersport 2+ Year Member

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    Here's an interesting article that is pertainate to this discussion. The author is an attending (DO) at an allopathic institution, Un of Mississippi, and presents an interesting perspective.

    http://www.jaoa.org/cgi/content/full/106/5/252
     
  34. Dustbunny

    Dustbunny 2+ Year Member

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    Am I not cute and fluffy enough for you???

    [​IMG]

    You know... my ex was in pharmacy school, but she ultimately wanted to be a naturopathic doctor. (WTF)

    So... yeah. She never implied that allopathic meds didn't work though. If she had, we wouldn't have been together. Now, of course, she wants to be an MBA and a BCPS and wouldn't give an ND the time of day. :laugh:
     
  35. Dustbunny

    Dustbunny 2+ Year Member

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    Those first 3-4 letters were quite good. :thumbup:
     
  36. Mung

    Mung 2+ Year Member

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    Thank you all for the links, articles and suggestions!

    So here is what I have gleaned thus far:

    So to find out about the fellowships/residencies what would be the best way to go about this? Online searches? Call schools and ask?

    If I want to shadow a DO, do I just start calling offices and ask?

    Do you all have any suggestions for good questions to ask prospective schools? DOs?

    I believe this quote from the article submitted by supersport resonates with me and ties in to the intent of my question

    Again thank you for all the posts, and I look forward to more. In just the 24 hours since I posted my thinking and questions continue to evolve.

    Mung-I-I-I- Love you all!
     
  37. Bleurberry

    Bleurberry 5+ Year Member

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    Hi Mung. I'm a big fan of the bean.

    Actually, I'm as committed as a pre-medical student can be without just plain being a jerk about it, to OMM. Osteopathy, and PCOM, is my choice.
    I think the origins of Osteopathy and OMM is a fascinating and rich history, I definetly suggest you pick up some materials and dig in! It's the best place to start... then you'll pick up all kinds of stuff like that the founder wasn't an ivory tower academic, but a battlefield physician.
    But I digress. Basically OMM is a specialty like any other. Even more basic, what you put in, you get out. JP said all this.

    If you begin to reach out to OMM-savvy physicians, I would venture to guess that none of them feel their life is wasted or they only have a minor impact on their patients well-being. Of course everythings relative, but OMM is something you really CAN get GOOD at, from what I've understood.

    Um.. you're going to find CCOM, MSUCOM, PCOM and UNECOM programs you'll gravitate toward. There's so many factors that go into making your choice, I'd just keep at it and let the choice evolve naturally from your investigations. I've never done research, I don't know what research is like, I can't say I'll be good at it, but that PCOM, for example, has a solid OMM research bent to them attracts me. I like that their teachers are grounded in the nitty gritty biodynamics-mechanics-whathaveyou and the study of measuring effect. (Whatever, I went to the open house, I've done my homework and continue to on different programs, I know me and I'm going there if they'll have me, no doubts.) I like that the residency program north of us, in the Bronx, is a really well regarded in-patient OMM/NMM residency.
    Don't be afraid to ask "What about the Breathe of Life?" or "The CSF tide, what about the tide, for the love of ...!!?" But, hah, i tricked you, because i'm old and non-traddy enough to know if I go around asking places to teach me this stuff before I learn the very basic, the rudimentary, I'm asking for trouble. I mean that in the most innocent way. I'm satisfied enough that once I get out of med school, I'll have a working knowledge of the human body like I never dreamed. After that, it's all fair game, take it and run with it where you may. All that being said, I'm the first to pull out a Dr. William Sutherland article and just feel good about what direction my life has taken, if you know what I mean.

    The Osteopathy schools I've looked at in the United States, for all the crap they get from the altern nation, seem to have kept OMM suprisingly well intact and are taking it to the next level, hopefully...
    Hope my ramblings serve you in some, obscure way.
    How am I doin'? I'm doing a 10 page research paper with 13 sources in el castellano due in like 10 hours or so and I'm on page 4 and my 40th cup of coffee... oh man how great is it to be a pre-med spanish major, I'll tell you what!!
     
  38. Bleurberry

    Bleurberry 5+ Year Member

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    There's a lot that could be said about this article, but what if I just ask a followup. Anyone want to put in their two cents about how substantive
    his observation of the "couple of students" who passed the osteopathic boards but not the MD allopath boards is?
    Just the overall tone of the article seems he feels a bit alienated or something?
     
  39. Bleurberry

    Bleurberry 5+ Year Member

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  40. Static Line

    Static Line America's Guard of Honor 5+ Year Member

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    Well there is no difference in that and the USMLE COMLEX debate. W/O some extra study I am not going to pass the USMLE either. I am not any less because of that. I will rock the COMLEX however with my osteopathic curriculum. And the same is reverse for an allopath trained student and the COMLEX, he won't pass it.

    The article is a good one and I agree with many of his points. I think the AOA does get in our way and makes things more difficult for us. I also think the AOA should minimize (not cut it out of curriculum totally) our exposure to OMM in med school. If you like it and it's your flavor then you can do a fellowship in OMM. That way it can be treated more as a specialty and even billed as one the way OMM/NMM is in certain cases. However, the powers that be disagree (at least for now). A new, younger generation of leaders will have to fight that fight. Right now the old guys who were discrimintaed against in the past are in charge and will defend the status quo to the death. I certainly think there is a place for OMM in medicine but not all DOs should, or are even good enough to do it. Some just don't want to do and that is fine too. That's why OMM should be more specialty driven.

    Now to address your point about failed board attempts by the osteopaths. It all depends what their curriculum is and what is important in their training. I don't know how vastly different the allo and osteo curriculums are. There are too many variables in that. I don't think the author addresses whether the allos could go take the osteo exam and pass it either. So, whose curriculum is wrong or right? I believe one thing though, If we as osteos want a fair shake but we can't pass their exam but only ours then something is wrong. Now if they can't pass the osteo exam there we are again, USMLE and COMLEX.

    I can only answer this from an MSII standpoint though and someone with more expeience may need to clear things up.
     
  41. Bleurberry

    Bleurberry 5+ Year Member

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    ¡Orale!,

    Hablas bien, [SIZE=-1]buey[/SIZE]. ;)
    Digo que tuvo experiences ahí sur
    de la frontera, casi no sobreviví esa ultima vez...
    ¡Oof! Pero desvio del tema.
    La noticia del día, ya he lo completado mi propósito
    y lo he sometido a la profesora.
    I´m going to check out those articles ASAP,
    thanks for thinking of me.
    Nos hablemos pronto.
     
  42. Bleurberry

    Bleurberry 5+ Year Member

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    I appreciate the time and thought you put into that response, something I've been painfully neglectful in these past few weeks (Sorry SDN'rs, bad me).
    The thing of it is... well, don't you feel you'd have missed out, for one, on the bonding experience? Doesn't OMM bring your class together? Granted, and I quite agree, some of your class and some in every class should probably just drop the whole idea of using advanced OMT techniques, but I guess my question is, aren't some of the best things learned in life from those experiences we wouldn't necessarily choose? I have to defer to the powers that be in the AOA on this one, I think they're spot on. What are your thoughts?
     
  43. Mung

    Mung 2+ Year Member

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    Don Lovepark del Norte,

    Las felicitaciones, nosotros sonreímos sobre usted y sobre la espera para su regreso a San Miguel de Allende. Los artículos, nada de particular acabo de pensar ellos les quizás agreguen algún sabor a ésos que parecen aminorar OMT y el esplendor de la forma de physcial.

    ¡Y por favor no es demasiado impresionado, mi español es mínimo pero el traductor hace los demás!

    Tu Amigo Y Mio!
    Mung

    Y paras los gringos: "Muy moderno, muy scientifico, para los hombres de NASA!"
     
  44. Dustbunny

    Dustbunny 2+ Year Member

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    Why minimize OMM? If you don't want to learn it, don't go to DO school. :rolleyes:
     
  45. Mung

    Mung 2+ Year Member

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    huh?
     
  46. Dr JPH

    Dr JPH Banned Banned 10+ Year Member

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    But the greatest number of DOs using OMM are not OMM specialists. They are primary care docs.

    By that reasoning, surgery should only be taught to those who are interested in surgery.

    Both are based on procedures intended to treat or cure a disease or pathology.

    And in my experience, which is quite extensive, the students who are not good at OMM are the ones who dont practice it. There is not inherent OMT ability that is lacking in certain parts of the population...its a matter of desire to to well academically.
     
  47. Dustbunny

    Dustbunny 2+ Year Member

    103
    0
    Apr 17, 2007
    Massachusetts
    That was in response to someone else, sorry, should have quoted the relevant bit, which is:

    I couldn't disagree with this premise more.
     

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