Osteopathic NMM Program Director- AMA

[bones]

For those genuinely interested in Osteopathy, its future, and its potential- I am here to answer questions.

The art and science of osteopathy is in its infancy, but the future is bright.

Due to merging of MD and DO residencies, the higher ACGME standards will now be present for all residency programs doing osteopathic training (this is a good thing). Those that want to use osteopathic manipulation in their practice will do a residency with Osteopathic Recognition (meaning they continue to receive osteopathic training through their chosen residency).

The board certification for those that wish to specialize in osteopathic manipulation is now called Osteopathic Neuromusculoskeletal Medicine (O-NMM). Many will do another residency first and will end up dual board certified, while others will specialize just in O-NMM. We will be re-evaluating the theories passed along as part of osteopathy, and will perhaps have to rethink them using a first-principles approach (look at what data points we have and develop newer more simple theories built on data rather than opinion). This wont be comfortable, but it is a necessary process for any evolving science.

This is the best time in history to be a DO. You have full practice rights, you can enter any residency specialty based on merit (of course, you’ll need the merit to get in). Research opportunities for osteopathic manipulation abound, and there are leadership and teaching opportunities everywhere for anyone willing to develop the requisite skill set.

In a practice environment where patients believe that minimally invasive low-cost care is important, an Osteopathic approach to care is a great answer. We see amazing efficacy with our patients, get them to a point where they are asymptomatic and healthily off their medications, no longer require surgeries etc. This is not enough, however. Wherever good outcomes seem to occur, we need to replicate them under objective conditions. When effective, we need to clarify the mechanism (theories are no longer enough). This is the work we are doing in ACGME residencies now. We have a lot of work to do and we will need your help in the years to come.

AMA- Ask me anything

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[sab3156]

@libertyyne

 

[DrfluffyMD]

What’s your opinion on Larry Nassar?

 

[Isoval]

How do you think the merger will affect DO students graduating in 2020 and beyond?

Do you think that DO graduates will see a drop in residency placement with a subsequent uptick in the following years? I’ve heard this theory passed around in the past.

 

[sab3156]

I guess my first question is - what's the real substantive difference between treatments performed within homeopathy, voodoo, and OMM? Not really looking for an answer like "we are physicians" or "I have seen it work", but more of a direct piece of evidence from any reputable study that shows that OMM is not simply based on anecdotal evidence (like homeopathy and voodoo).

 

[User8888]

For those genuinely interested in Osteopathy, its future, and its potential- I am here to answer questions.

The art and science of osteopathy is in its infancy, but the future is bright.

Due to merging of MD and DO residencies, the higher ACGME standards will now be present for all residency programs doing osteopathic training (this is a good thing). Those that want to use osteopathic manipulation in their practice will do a residency with Osteopathic Recognition (meaning they continue to receive osteopathic training through their chosen residency).

The board certification for those that wish to specialize in osteopathic manipulation is now called Osteopathic Neuromusculoskeletal Medicine (O-NMM). Many will do another residency first and will end up dual board certified, while others will specialize just in O-NMM. We will be re-evaluating the theories passed along as part of osteopathy, and will perhaps have to rethink them using a first-principles approach (look at what data points we have and develop newer more simple theories built on data rather than opinion). This wont be comfortable, but it is a necessary process for any evolving science.

This is the best time in history to be a DO. You have full practice rights, you can enter any residency specialty based on merit (of course, you’ll need the merit to get in). Research opportunities for osteopathic manipulation abound, and there are leadership and teaching opportunities everywhere for anyone willing to develop the requisite skill set.

In a practice environment where patients believe that minimally invasive low-cost care is important, an Osteopathic approach to care is a great answer. We see amazing efficacy with our patients, get them to a point where they are asymptomatic and healthily off their medications, no longer require surgeries etc. This is not enough, however. Wherever good outcomes seem to occur, we need to replicate them under objective conditions. When effective, we need to clarify the mechanism (theories are no longer enough). This is the work we are doing in ACGME residencies now. We have a lot of work to do and we will need your help in the years to come.

AMA- Ask me anything

Thank you for offering this AMA. I look forward to hearing your perspective on things.

1. You seem to say we need more trials to explore the efficacy of OMM. How do you interpret existing literature that, from my understanding, supports OMM for low back pain but nothing else?

2. When you say “we see amazing results from our patients”- why hasn’t that been reflected in the literature? I see chiropractors and acupuncturists making statements like this- it is easy to do so, and I’m sure they believe it because you really do see positive results, but it is impossible to understand if it is placebo or time, etc.

2. Is there any part of OMM that you believe should be discarded?

3. If not mentioned in 2, what is the evidence for cranial and Chapman’s points?

3. What do you think of removing OMM from DO program curriculums and reserving it for residencies?

4. While I believe the residency merger was over all a good thing- wasn’t it better for DOs entering competitive specialties pre-merger? Without protected AOA spots, competitive specialties will probably be more difficult than the past, especially with more applicants per residency. I do understand that the merger simplified applications for DOs.

 

[bones]

How do you think the merger will affect DO students graduating in 2020 and beyond?

Do you think that DO graduates will see a drop in residency placement with a subsequent uptick in the following years? I’ve heard this theory passed around in the past.

Hi Isoval,
My answer to this can only be speculation. I think there will be a number of AOA programs that dont make the transition by next year, and many of these wont transition at all. The ones that do will be much stronger for the change. This may mean fewer spots overall, and may make for a tough match for everyone for a couple of years until more spots open.

If you are a stronger DO student and/or have reasonably good social skills I dont think there will be any problem. Weaker students and those that have struggled on rotations will have to compete with FMGs and MDs...

The best advice I can offer is to make sure you bring value wherever you go, make strong connections with attendings and residents along the way and pass your boards on your first try and you will do great.

 

[bones]

What’s your opinion on Larry Nassar?

I dont recall ever meeting him, and I only know what I've heard on the news. From what I read it sounds like he's a man that abused his power in the worst way. His actions have hurt a lot of people.

 

[bones]

I guess my first question is - what's the real substantive difference between treatments performed within homeopathy, voodoo, and OMM? Not really looking for an answer like "we are physicians" or "I have seen it work", but more of a direct piece of evidence from any reputable study that shows that OMM is not simply based on anecdotal evidence (like homeopathy and voodoo).

Hello,
I dont know if you are posing this seriously or not, but I'll do my best to respond. Homeopathy works through the placebo effect. We have double blind trials that show this clearly, with no discernable effect beyond placebo. Voodoo appears to work through the "nocebo" effect, as notifying your victim is an important piece of the puzzle. Modern medicine, including osteopathy, is clinical practice built on a foundation of basic science. Unfortunately, as you so clearly state- much of what we do in medicine is still "expert opinion", and often poor opinions at that. Cranial theory and Chapmans points should be removed from training, testing and boards so far as Im concerned, but I dont have a say over these things yet.

Like surgery, Osteopathic treatment is procedural and these tools are particularly challenging to study in large blinded trials. This makes poor and anecdotal practices particularly enduring in these fields. Outcomes seem to be king- and there are large placebo effects that need to be overcome for any study that is done.

I'd say we need to consider procedures that fall into one of three categories:

1. purely anecdotal treatment w no theoretical scientific foundation but possibly a large placebo effect (homeopathy, voodoo, kinesiology, massage)
2. treatment with a scientific foundation that is flawed or pseudoscienfic- without improving symptoms better than placebo (vertebroplasty, epidural steroid injections, spinal fusion surgery, meniscal repairs, narcotics for chronic pain, shotgun high velocity techniques without diagnosis such as some chiropractors use)
3. effective clinical practice of procedural medicine that resolves the underlying condition immediately and permanently (spinal decompression for stenosis, discectomy, fecal transplants, joint replacement, etc.)

When practiced appropriately, Osteopathy is #3. Immediate and permanent remission of the symptom is a good indication that you have achieved this.

When practicing Osteopathic Medicine, you can form a hypothesis based on your knowledge, history and physical exam. You can test this hypothesis at little to no risk to the patient. For example, pressing on L3 to see if it reproduces the patient's knee pain (L3 dermatome)- if correct, you can use gentle BLT technique to normalize L3 mechanics to see if it resolves the patient's symptom. If so, the knee pain may be resolved for good. The patient need not believe anything... In fact, they are typically skeptical, and completely confused when their symptoms are resolved. This is the rule rather than the exception. I get frequent referrals by MD pain specialists, MD neurosurgeons, MD orthopedists, MD rheumatologists and the whole gambit of other specialists both MD and DO. Once they see this approach work so rapidly for patients that they have referred to our practice, they send more. We get daily referrals and most of our referral base are MD specialists and a mix of MD and DO primary care docs.

Osteopathy by its very nature needs to be very personalized to patients, which makes doing any sort of reproduceable trial treating a single structure or approaching a condition in a single manner not particularly a good representation of how we actually practice. I have ideas for how to overcome this, but it won't been easy.

If you want to do some reading on whats being published on Osteopathic tx, UNT is doing some promising work-
https://www.unthsc.edu/texas-colleg...com-research/the-osteopathic-research-center/

 

[bones]

Thank you for offering this AMA. I look forward to hearing your perspective on things.

1. You seem to say we need more trials to explore the efficacy of OMM. How do you interpret existing literature that, from my understanding, supports OMM for low back pain but nothing else?

2. When you say “we see amazing results from our patients”- why hasn’t that been reflected in the literature? I see chiropractors and acupuncturists making statements like this- it is easy to do so, and I’m sure they believe it because you really do see positive results, but it is impossible to understand if it is placebo or time, etc.

3. Is there any part of OMM that you believe should be discarded?

4. If not mentioned in 2, what is the evidence for cranial and Chapman’s points?

5. What do you think of removing OMM from DO program curriculums and reserving it for residencies?

6. While I believe the residency merger was over all a good thing- wasn’t it better for DOs entering competitive specialties pre-merger? Without protected AOA spots, competitive specialties will probably be more difficult than the past, especially with more applicants per residency. I do understand that the merger simplified applications for DOs.

I see you doubled a few numbers which makes this a little challenging to answer- so im correcting them.
1) existing literature is insufficient. The problems we have is that OMT is procedural and personalized. Both of these make it very difficult to do the kind of large blinded uniform trials that we consider the standard for EBM. On top of this, few OMT practitioners get truly amazing results, and those that do often go and do cash practices far from academia. DOs in general are very poor at their EBM skills- both reading papers and writing research. We need to work on this. These are explanations, not excuses. I am doing my part to move the science forward, but this is very much a work in progress.
2) see #1. Actually acupuncture does have some solid research (thousands of studies).
3) chapmans and cranial theory need to be set to the side. I wouldnt discard them, as I think some value could possibly be mined from them by someone at some point. That said, it shouldnt be the job of medical students or even every OMM specialists to figure this out. We treat heads to great effect- but there is no need to feel a CRI or believe any theory to do what I do. You can stop many migraines in seconds with proper balanced pressure through the trigeminal ganglion region (even untrained hands can partially relieve a migraine w pressure on the temples, this shouldnt be that surprising).
4) see #3
5) I think I see where you are going. One option is to award everyone graduating medical school with an MD and make Osteopathic training an elective. I dont particularly like this, but it may be the only option if current trends dont change. I am proud to be a DO but i know not everyone is, and having unenthusiastic DOs is really bad for the brand.
6) yes. DOs will have a harder time placing in some specialites. I am not convinced that those specialty DO residencies were truly unique or osteopathic however, so there is no reason in principle to maintain this separation. Now if an orthopedic program or a neurosurg program really wants to be unique they could offer Osteopathic Rec- and actually be somewhat osteopathic, and accept a few DOs that have skills plus numbers for those slots. Thats what DO specialty residencies were supposed to have been.

I hope that helps!

 

[Goro]

For those genuinely interested in Osteopathy, its future, and its potential- I am here to answer questions.

The art and science of osteopathy is in its infancy, but the future is bright.

Due to merging of MD and DO residencies, the higher ACGME standards will now be present for all residency programs doing osteopathic training (this is a good thing). Those that want to use osteopathic manipulation in their practice will do a residency with Osteopathic Recognition (meaning they continue to receive osteopathic training through their chosen residency).

The board certification for those that wish to specialize in osteopathic manipulation is now called Osteopathic Neuromusculoskeletal Medicine (O-NMM). Many will do another residency first and will end up dual board certified, while others will specialize just in O-NMM. We will be re-evaluating the theories passed along as part of osteopathy, and will perhaps have to rethink them using a first-principles approach (look at what data points we have and develop newer more simple theories built on data rather than opinion). This wont be comfortable, but it is a necessary process for any evolving science.

This is the best time in history to be a DO. You have full practice rights, you can enter any residency specialty based on merit (of course, you’ll need the merit to get in). Research opportunities for osteopathic manipulation abound, and there are leadership and teaching opportunities everywhere for anyone willing to develop the requisite skill set.

In a practice environment where patients believe that minimally invasive low-cost care is important, an Osteopathic approach to care is a great answer. We see amazing efficacy with our patients, get them to a point where they are asymptomatic and healthily off their medications, no longer require surgeries etc. This is not enough, however. Wherever good outcomes seem to occur, we need to replicate them under objective conditions. When effective, we need to clarify the mechanism (theories are no longer enough). This is the work we are doing in ACGME residencies now. We have a lot of work to do and we will need your help in the years to come.

AMA- Ask me anything

Do you believe that in the past few years, too many new DO schools have opened?

 

[Ho0v-man]

With the merger, will you consider US MDs and carib MDs for your program?

 

[Doc_Ock]

When will you accept the fact that OMM is not science based and needs to be retired?


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[DNC127]

When will you accept the fact that OMM is not science based and needs to be retired?


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If you eliminated all fields/techniques lacking sufficient evidence based medicine we would lose a lot more fields/techniques than OMM.

 

[Nurse-to-Doctor]

You had me at me at “Cranial theory and Chapmans points should be removed from training, testing and boards so far as Im concerned.” OMT has definitely grown on through 1st and 2nd year. I have been reluctant to considering an O-NMM residency, mainly due to the lack of research backing it. I completely understand the difficulty with studying manual therapy. I followed a NMM doc a few months ago and it was truly amazing watching the immediately results he achieved after one session. So, here are a few of my questions:

1. Do you belief the profession is willing to change current practices and teachings, if the data points don’t add up in favor of those practices.

2. In the future, could see O-NMM residency being a pre req for pain med fellowships?

3. Could you give me examples of a few theories that are high on the list to be re evaluated, besides cranial.

Thanks,

OMS II

 

[Doc_Ock]

If you eliminated all fields/techniques lacking sufficient evidence based medicine we would lose a lot more fields/techniques than OMM.

Lmao what a pathetic defense (and I’d happily lose them).


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[bones]

Thank you very much for taking the time to do this. Excuse any rude responses, some people on this site don't seem to have manners.

1. Do you believe there should still be a distinction between Osteopathic Medical Physicians and Medical Physicians?

2. Are there any parts of OMM you believe deserves discontinuation in use? Some DO students seem to really dislike things like Cranial, and ever claim its useless. Any thoughts on this?

Hello Dr Sina,
I appreciate your politeness. Professionalism is one of the 6 priorities in the development of a physician per the ACGME. I spend a lot of time with medical students and residents correcting them on professionalism missteps with patients, staff, each other and their attendings. Physicians are human just like everyone else, just held to a much higher standard which can sometimes be pretty hard. In this environment of anonymity I expect the frustrations to come out, so some disrespect doesn't surprise me. I don't see a lot of positive and informed voices on here regarding Osteopathy, which is why I decided to do this regardless.

I believe Dr Still founded Osteopathy hoping to create a different kind of medicine. His idea was to have it based on science (unlike most of the modern medicine of his day) and to have it address the cause of disease whenever possible rather than just manage disease. He prioritized the self-healing mechanisms of the body, and a minimally invasive approach. I can see why he wanted his students to have a different set of initials. I also think his students fell short of what he was hoping for, and I also think in the modern era many MDs do a great job of addressing a number of these things.

To answer your questions- I believe in principle there is a lot of value to practicing medicine in an "Osteopathic" way, and to do this correctly takes a lot of additional training. I am not sure that the DO initials have the distinct meaning that they once did, and Im not sure what I would say if someone proposed a merger today... there could be a lot lost but I see a number of advantages too. ACGME allows both MDs and DOs to apply to our program- and given the right applicant with the right pre-requisite training and recommendations I would certainly consider an MD for one of our spots. The lines have truly blurred.

As for cranial. I believe there is value there. I have table trained for cranial courses (but they wouldnt let me lecture- I think they were afraid of what I'd say). I have used some of the cranial techniques to great effect. There are a number of big problems with it.

• It is theory built on theory. The foundation hasn't been adequately verified (to what degree the sutures are mobile, that there is a CRI, that the SBS can carry strain and that this is physiologically relevant to disease).
• The diagnosis is based on feel rather than objective testing
• The primary thing being felt is through bone and inches away from the fingers. Even if this is possible, which i suspect it is, it would take an incredible amount of calibration to make sure you are feeling what you think you are feeling in order to claim any confidence in your diagnosis. People who do this are way too confident given the data they have...
• Inter-rater reliability for diagnosis is sometimes way off by people that teach these courses. This not at all surprising given the last point, but it doesn't lend credibility to the field.

AT Still was very clear- he said "don't believe any untested theory" and that every treatment should be based on a foundation of anatomy and basic science. He wouldn't like cranial in its current form. Those that follow AT Still's work should at least know the most important things he was saying and follow his advice. In summary, I would keep Osteopathic treatment of the head very simple as we do with the rest of the body. Hypothesize the diagnosis based on your knowledge of pathophysiology matched with what you feel, verify with palpation to reproduce the symptom in question, fix abnormal anatomy to remove symptoms on the spot, leave patient in remission. This is what we should be doing clinical research on, and what Osteopathy is really about. Cranial theory may still hold some value, but it is too complicated and depends on too many unknowns to treat it as a science. This is why I believe it should be removed from schools and tests.

 

[bones]

Do you believe that in the past few years, too many new DO schools have opened?

yes. we do need more physicians, but the brand of whatever it is to be a DO requires Osteopathic faculty. People who actually get awesome results are few, and those that get results and can lecture in front of a room and organize a lesson plan? very few. We dont have enough people like this to even place one at every school we have now, much less place 3-5 at every school or keep up with the new schools popping up everywhere. You have one poor guy up there who doesn't know what he's doing in front of 150 students... trying to teach them a complicated nuanced procedural skill... This is why i'm doing residency training. I am training people who could do this job. If you are thinking about going to DO school and you wish to embrace it, it would be good advice to get to know the OMM departments of your prospective schools. Shadow them if you can, or at least ask discerning students and residents what they think of them.

 

[bones]

With the merger, will you consider US MDs and carib MDs for your program?

If they had enough prerequisite training, yes. They would need to likely do some Osteopathic CME and spend at least a month or two rotating with me or someone I've trained beforehand so I know their capabilities. They would have to be competitive with the DO applicants I am getting, some of whom have aced their boards, have great personalities and have dedicated much of their training to Osteopathy. I am not looking for any one particular type of person though, and I think the more diversity of skill and talent of our trainees the better. Most DOs are particularly weak in reading research and most haven't published. An MD with advanced leadership skills, teaching skills, excellent medical knowledge and/or extensive research background could more than make up for a weaker background in Osteopathic skills in their application.

 

[bones]

You had me at me at “Cranial theory and Chapmans points should be removed from training, testing and boards so far as Im concerned.” OMT has definitely grown on through 1st and 2nd year. I have been reluctant to considering an O-NMM residency, mainly due to the lack of research backing it. I completely understand the difficulty with studying manual therapy. I followed a NMM doc a few months ago and it was truly amazing watching the immediately results he achieved after one session. So, here are a few of my questions:

1. Do you belief the profession is willing to change current practices and teachings, if the data points don’t add up in favor of those practices.

2. In the future, could see O-NMM residency being a pre req for pain med fellowships?

3. Could you give me examples of a few theories that are high on the list to be re evaluated, besides cranial.

Thanks,

OMS II

Hello,
1) I think they wont have a choice. The old guard at AOA gave up almost all their power with the residency merger. I'm not sure they realized they were doing this at the time. There will be a ripple effect and many things will need to change.
2) I know of someone who did a pain fellowship out of an AOA NMM residency. I know another that did sports med out of AOA NMM. AOA applications to ACGME fellowships have been somewhat challenging for the more competitive fellowships. Now with the single accreditation I think things will be much simpler. It isn't a common pathway yet though, so if you are thinking Pain I'd probably do PMR with Osteopathic Rec or anesthesia with Osteopathic Rec if you an find one at this point. Check the statistics in another year or two if pain is really what you want.
3) Im not sure about Fryettes principles even though that is a foundational theory they push pretty hard in first year, and it seems to be true (I dont have enough data to know either way). Chapmans points appear anecdotal, and when I've tested them as objectively as I can I haven't been convinced of their diagnostic value. I'll keep an open mind if someone can show me otherwise but I dont think something I cant wrap my head around or verify should be on the boards or taught in school. Viscerosomatic and somatovisceral reflexes appear to check out very well on the whole based on my anecdotal experience, but I'd like to see these mapped out and clarified in a more comprehensive way using more modern techniques. I also think we should also incorporate scars into our diagnostic and treatment system (pressure on a scar can precisely replicate symptoms you wouldn't initially expect until you consider the autonomics, and scar desensitization often resolves these symptoms).

hope that helps!

 

[Goro]

yes. we do need more physicians, but the brand of whatever it is to be a DO requires Osteopathic faculty. People who actually get awesome results are few, and those that get results and can lecture in front of a room and organize a lesson plan? very few. We dont have enough people like this to even place one at every school we have now, much less place 3-5 at every school or keep up with the new schools popping up everywhere. You have one poor guy up there who doesn't know what he's doing in front of 150 students... trying to teach them a complicated nuanced procedural skill... This is why i'm doing residency training. I am training people who could do this job. If you are thinking about going to DO school and you wish to embrace it, it would be good advice to get to know the OMM departments of your prospective schools. Shadow them if you can, or at least ask discerning students and residents what they think of them.

You don't believe the residency window is closing and we're approaching the point of having more medical graduates than there are residency slots for them? This is my concern.

 

[YeezyQ]

Dr. Bones,

In your professional and personal experience, what single trait do you believe makes a great osteopathic physician? And why did you choose osteopathic medicine?

 

[Ho0v-man]

Dr. Bones,

In your professional and personal experience, what single trait do you believe makes a great osteopathic physician? And why did you choose osteopathic medicine?

Someone’s writing some secondaries...

 

[bones]

You don't believe the residency window is closing and we're approaching the point of having more medical graduates than there are residency slots for them? This is my concern.

I share your concern. I think residencies will respond in time but it may be tight for a couple of years. I think FMGs will be hurt more than DOs, but in most programs each individual is judged on their own merit regardless of where they trained. As a PD I can say it mostly comes down to personality. Would you enjoy spending gobs of hours with the person you see in front of you and make their future your life... or would they annoy you or bog you down by not doing charts, not showing up on time to work, or not know what you just taught them yesterday. You can get this info from body language in an interview and letters of rec, but seeing the person perform on an audition rotation is better. Second, but also very important- is knowledge base. You want to show them how to think like a specialist in your field rather than telling them to memorize their dermatomes again for the third time. Attitude about learning and capacity to learn is probably more important than knowledge base, but a good knowledge base makes your work as a teacher much easier (and is much easier to quantify). If you suggest a resident learn something and come back and impress you by knowing it well and knowing it forever your job gets a ton easier. Notice this is much easier to demonstrate in person... audition rotations are great, or at least knowing people who a PD trusts can get you an in. A high profile audition rotation with a leader in the field may potentially get you into multiple residencies with a great recommendation letter.

Think of it from the PDs point of view and you'll match- even in a competitive residency.

 

[Nurse-to-Doctor]

For those genuinely interested in Osteopathy, its future, and its potential- I am here to answer questions.

The art and science of osteopathy is in its infancy, but the future is bright.

Due to merging of MD and DO residencies, the higher ACGME standards will now be present for all residency programs doing osteopathic training (this is a good thing). Those that want to use osteopathic manipulation in their practice will do a residency with Osteopathic Recognition (meaning they continue to receive osteopathic training through their chosen residency).

The board certification for those that wish to specialize in osteopathic manipulation is now called Osteopathic Neuromusculoskeletal Medicine (O-NMM). Many will do another residency first and will end up dual board certified, while others will specialize just in O-NMM. We will be re-evaluating the theories passed along as part of osteopathy, and will perhaps have to rethink them using a first-principles approach (look at what data points we have and develop newer more simple theories built on data rather than opinion). This wont be comfortable, but it is a necessary process for any evolving science.

This is the best time in history to be a DO. You have full practice rights, you can enter any residency specialty based on merit (of course, you’ll need the merit to get in). Research opportunities for osteopathic manipulation abound, and there are leadership and teaching opportunities everywhere for anyone willing to develop the requisite skill set.

In a practice environment where patients believe that minimally invasive low-cost care is important, an Osteopathic approach to care is a great answer. We see amazing efficacy with our patients, get them to a point where they are asymptomatic and healthily off their medications, no longer require surgeries etc. This is not enough, however. Wherever good outcomes seem to occur, we need to replicate them under objective conditions. When effective, we need to clarify the mechanism (theories are no longer enough). This is the work we are doing in ACGME residencies now. We have a lot of work to do and we will need your help in the years to come.

AMA- Ask me anything

For the purpose of proving the validity OMM, where do you believe future OMM research should be focused? Are there any particular areas of reasearch that should be considered high priority? Such as, producing better data on the effectiveness of OMT on pain syndromes. Are there any types of OMM research that you believe should be put on the back burner for the time being?

 

[THEBACKANDFORTH]

Hi, I was accepted to my state school after interviewing at and being accepted to several DO schools. I was impressed by and enjoyed all of these schools. Currently, the rural and small hospital/clinic I work at is hiring an increasing number of DOs, and most use OMM on an occasional basis. Eventually, I wish to practice family med at this clinic or similar. Do you think that the climate is such that I could do residency at a former AMA program and become certified to use OMM as an MD?

Edit: Assuming, of course, that I am an equivalent or better applicant than those whom the program typically ranks highly, and show a demonstrated interest in OMM.

 

[QuickStitch23]

For those genuinely interested in Osteopathy, its future, and its potential- I am here to answer questions.

The art and science of osteopathy is in its infancy, but the future is bright.

Due to merging of MD and DO residencies, the higher ACGME standards will now be present for all residency programs doing osteopathic training (this is a good thing). Those that want to use osteopathic manipulation in their practice will do a residency with Osteopathic Recognition (meaning they continue to receive osteopathic training through their chosen residency).

The board certification for those that wish to specialize in osteopathic manipulation is now called Osteopathic Neuromusculoskeletal Medicine (O-NMM). Many will do another residency first and will end up dual board certified, while others will specialize just in O-NMM. We will be re-evaluating the theories passed along as part of osteopathy, and will perhaps have to rethink them using a first-principles approach (look at what data points we have and develop newer more simple theories built on data rather than opinion). This wont be comfortable, but it is a necessary process for any evolving science.

This is the best time in history to be a DO. You have full practice rights, you can enter any residency specialty based on merit (of course, you’ll need the merit to get in). Research opportunities for osteopathic manipulation abound, and there are leadership and teaching opportunities everywhere for anyone willing to develop the requisite skill set.

In a practice environment where patients believe that minimally invasive low-cost care is important, an Osteopathic approach to care is a great answer. We see amazing efficacy with our patients, get them to a point where they are asymptomatic and healthily off their medications, no longer require surgeries etc. This is not enough, however. Wherever good outcomes seem to occur, we need to replicate them under objective conditions. When effective, we need to clarify the mechanism (theories are no longer enough). This is the work we are doing in ACGME residencies now. We have a lot of work to do and we will need your help in the years to come.

AMA- Ask me anything

I'm a third year OMS student and am looking into IM/NMM programs, but with the merger, there aren't many more programs left. I am thinking of therefore doing a +1 program. Do these programs look down on DO students pursuing a +1 from an ACGME residency? Thanks in advance!

 

[AlbinoHawk DO]

What do you think of vaginal release and other similar techniques that are invasive and could easily be seen as sexually abusive? How do you teach these in your program?

 

[bones]

For the purpose of proving the validity OMM, where do you believe future OMM research should be focused? Are there any particular areas of reasearch that should be considered high priority? Such as, producing better data on the effectiveness of OMT on pain syndromes. Are there any types of OMM research that you believe should be put on the back burner for the time being?

This is a tricky subject. First we need more quality case studies published in peer reviewed journals. Without these, doing a good prospective randomized trial is problematic since you dont have a target. Also, short quality review articles on topics that DO's frequently treat would be helpful (drawing heavily on basic science, and looking at cases and looking at current randomized trials relevant to the topic). The goal of a review study also is to form a basis for future research, and it should not be kind to existing poorly done studies, or poorly written cases.

Of course we also need prospective randomized controlled trials, but to get the funding we need the foundation laid. Only a little of this foundation is there now.

We will start phasing out a lot of the dogma taught in the classrooms as future department chairs are graduates from acgme-quality Osteopathic NMM programs. Unfortunately this may take another 5-10 years.

 

[bones]

Hi, I was accepted to my state school after interviewing at and being accepted to several DO schools. I was impressed by and enjoyed all of these schools. Currently, the rural and small hospital/clinic I work at is hiring an increasing number of DOs, and most use OMM on an occasional basis. Eventually, I wish to practice family med at this clinic or similar. Do you think that the climate is such that I could do residency at a former AMA program and become certified to use OMM as an MD?

Edit: Assuming, of course, that I am an equivalent or better applicant than those whom the program typically ranks highly, and show a demonstrated interest in OMM.

You should have no trouble getting into an ACGME residency with osteopathic recognition and enter the track with the right preparation. So long as you do a few CME courses first, maybe do a single 2-4 week OMT elective, and you check with the OR track director as you're looking at residencies you should be fine. As an MD you can do OMT from a billing and legal perspective- your initials give you the right to do most procedures (and thats how its categorized). From a competency perspective it takes a really great mentor to make it a life-changing skill, but by following the above recommendations you can do it.

Edit: if you want to do an Osteopathic NMM residency where you specialize in OMM like I do, then it may be harder, but not impossible. I would certainly consider a strong MD applicant, especially if they had a research skills and experience and/or were strong in other areas that made them superior to other applicants.

 

[bones]

I'm a third year OMS student and am looking into IM/NMM programs, but with the merger, there aren't many more programs left. I am thinking of therefore doing a +1 program. Do these programs look down on DO students pursuing a +1 from an ACGME residency? Thanks in advance!

I have suggested to my students that they consider IM and then doing a plus one, and I've already graduated one of these and I have another coming in next year. IM is great for thinking in terms of pathophysiology and seeing the big picture of cases, and this blends very well with OMM. If you do this, try to use OMT a LOT during your IM residency, either in a program with Osteopathic Recognition, elective rotations with a top notch OMM specialist, or lots of OMM CME (which you then use on your patients to the best of your ability under someone who will let you).

A plus one is essentially giving a resident a years worth of advanced placement into an Osteopathic NMM residency (which is normally 2 years plus a TRI/Transitional year). So you need some significant skill coming in, or other outstanding skills that offset only "good" OMT skills (research, teaching, leadership are examples). Doing relevant rotations (ortho, rheum, neuro, neurosurg, PMR, sports med, pain, radiology) will help your application too.

 

[bones]

What do you think of vaginal release and other similar techniques that are invasive and could easily be seen as sexually abusive? How do you teach these in your program?

Since my practice is mostly musculoskeletal cases, patients dont seek me out to treat vagismus- thus I don't teach techniques like this nor do I find need to use them for the cases I see. I feel this type of treatment is best done by OBs or the patient's primary care doctor who would be doing pelvic exams on these women anyway- and it could be appropriately done in the context of pre-delivery stalling of labor, post delivery spasm, or to deal with vagismus and other related conditions that these physicians will be managing. If we get an OB or an FP/OB here for a plus one some year I'll have to discuss this with them. The skills they get in standard training with MFR would be easy to apply internally and they'd be able to do this. We might get them this training on their private panel if they recruit the appropriate patients.

If someone presented to me and vagismus was their chief complaint- likely they wouldnt be able to get this fixed with their OB or primary care. I'd first try a non invasive approach through the clothes, but if i wasnt able to get it all I'd consider doing this treatment with a chaperone if it meant a big difference in a patient's life. You would need to document a case like this extremely carefully and have good justification in any sort of clinic outside a womens health clinic.

 

[Trollest]

@bones let go over the match results.
The number of Match registrants was the highest ever at 43,909. The increase was due primarily to students/graduates of U.S. osteopathic medical schools, whose numbers grew by 1,054 over 2017 to 6,054 this year.

1- Do you see anything wrong with it?

2- I have also heard somehwere that more than 8000 4th year resident didn't match this year. So, what is this data telling you?

 

[bones]

@bones let go over the match results.
The number of Match registrants was the highest ever at 43,909. The increase was due primarily to students/graduates of U.S. osteopathic medical schools, whose numbers grew by 1,054 over 2017 to 6,054 this year.

1- Do you see anything wrong with it?

2- I have also heard somehwere that more than 8000 4th year resident didn't match this year. So, what is this data telling you?

The increase is because a number of DO programs are now ranked in the acgme match, so more DOs are applying in acgme.

I am more concerned about next year, as there will be a single match and all the DOs will be applying in the acgme match. AOA programs that aren't high enough quality to qualify for acgme standards will be shut down. There will be a lot more than don't match next year than this year, and I suspect there will be many next year won't have a spot to scramble into.

1) yes. What's wrong is we keep opening new DO schools (and now a few new MD schools) because they are profitable yet the government isn't excited about spending more on residencies, and with the merger we will be losing residency spots next year.

2) this data tells me that you need to be a strong candidate to assure yourself a position. Many Caribbean graduates won't match, and some DOs and us/international MDs won't match. Many of these will be able to scramble a spot but next year there will likely be a real gap between total spots and applicants. I do think this will eventually close, but this is a major issue in medicine now.

I suspect more will chose to practice as GPs with an internship. Also we will start seeing more unfunded spots popping up for the free labor and weaker applicants will take them.

The key to success in medicine is people skills (can be learned), passion for what you do (you get this by loving learning/service/or your chosen specialty), and self-management skills (can be learned).

The passion will make you stand out by having areas of specialized interest, skill or knowledge. Residencies like this a lot. People skills will help you shine on rotations and self management will serve you through your all of your training and will affect grades and board scores. All of these together will get you into a decent residency no problem. Missing any one of them could be problematic, and if you miss all three these are the people who will struggle to match the most.

 

[deleted600623]

The increase is because a number of DO programs are now ranked in the acgme match, so more DOs are applying in acgme.

I am more concerned about next year, as there will be a single match and all the DOs will be applying in the acgme match. AOA programs that aren't high enough quality to qualify for acgme standards will be shut down. There will be a lot more than don't match next year than this year, and I suspect there will be many next year won't have a spot to scramble into.

1) yes. What's wrong is we keep opening new DO schools (and now a few new MD schools) because they are profitable yet the government isn't excited about spending more on residencies, and with the merger we will be losing residency spots next year.

2) this data tells me that you need to be a strong candidate to assure yourself a position. Many Caribbean graduates won't match, and some DOs and us/international MDs won't match. Many of these will be able to scramble a spot but next year there will likely be a real gap between total spots and applicants. I do think this will eventually close, but this is a major issue in medicine now.

I suspect more will chose to practice as GPs with an internship. Also we will start seeing more unfunded spots popping up for the free labor and weaker applicants will take them.

The key to success in medicine is people skills (can be learned), passion for what you do (you get this by loving learning/service/or your chosen specialty), and self-management skills (can be learned).

The passion will make you stand out by having areas of specialized interest, skill or knowledge. Residencies like this a lot. People skills will help you shine on rotations and self management will serve you through your all of your training and will affect grades and board scores. All of these together will get you into a decent residency no problem. Missing any one of them could be problematic, and if you miss all three these are the people who will struggle to match the most.

This makes going DO sound horrific. Is it even worth the risk of going DO because of the increase in medical students and decrease in residency spots? We're talking 6 figure debt with no guarantee of even being able to practice as a physician.

 

[NontradCA]

How long is an NMM residency and what does it actually entail? Do you intend to expand at all? What kind of candidates apply to your program?

 

[bones]

This makes going DO sound horrific. Is it even worth the risk of going DO because of the increase in medical students and decrease in residency spots? We're talking 6 figure debt with no guarantee of even being able to practice as a physician.

It is a tough time to be a doctor, no doubt, but DO is no different than MD in this regard. All the residencies are in a single match system. If you are strong or at least well rounded with either set of initials you will be fine. It may be worth a look at your perspective school's match rates however just to be sure (again, this applies both MD and DO).

I'd be concerned about joining a carribean school now. Most of their grads have a tough time placing and it will be getting worse over time. If your scores aren't good enough for US-trained MD or DO, PA school is actually a lucrative option that doesn't pose these risks.

 

[bones]

How long is an NMM residency and what does it actually entail? Do you intend to expand at all? What kind of candidates apply to your program?

This could be a long post. I think it's the most undervalued and misunderstood specialty in all of medicine. I'll give you the cliff notes and if you want to know more please ask a specific question.

Osteopathic NMM is a specialty for those that want to master using their hands as a medical diagnostic and treatment tool while learning in depth about how the body functions and heals itself. You learn musculoskeletal medicine, injections, and in some programs will be doing musculoskeletal ultrasound (and I'm hoping to eventually get an emg for ours). You can function as a specialist or a primary care doctor upon graduation (much like an OB or psychiatrist).

Some graduates go on to do a pain or sports med fellowship afterwards, though this isn't typical.

Some grads end up in academia or cash omm practices.

All omm department chairs at DO schools, most omm faculty, and all O-NMM program directors need to be boarded in this area. There aren't nearly enough for all the new DO schools popping up everywhere.

There is huge hidden demand by patients for these services nationwide, but almost nobody knows we exist.. so marketing can be tricky when you first break into an area. I once easily supported my practice in a town of 2000, yet cities as large as 3 million may only have 2-3 specialists for the whole city. You will be crazy busy once you get the word out. We are a voice for extremely effective minimally invasive evidence-based management (which everyone wants but everyone struggles to find). When you can use omt to prevent the need for surgeries or get patients healthily off expensive meds- there is a lot of value provided. They typically send you all their friends and family, and you should have cases like this daily if you are doing things right. Your training should be strong enough to diagnose most musculoskeletal, neurological and pain conditions, and you can opt to either treat them or refer.


The training entails a general internship (transitional year/TRI- which should have an osteopathic manipulation continuity clinic if you intend to track into osteopathic NMM

This is followed by 2 years of clinic/hospital work, heavy on osteopathic manipulation continuity (3-4 half days per week) and osteopathic didactics 1 half day per week).
You also do rotations in musculoskeletal medicine (such as orthopedics, neurology, neurosurgery, physical medicine and rehab, rheumatology, pain, etc). you also cover the inpatient osteopathic service.

You may alternatively get a year of advanced placement in the 2 year nmm training by instead of doing an internship- doing a full residency with osteopathic recognition in another area. Many opt to do this if they intend to do primary care or want to see a certain type of patient in their practice (peds, etc). This option is classically called a "plus one" meaning one more year to get an O-NMM board cert. Applicants should already know a lot of omt and have a number of their required rotations already done coming in.

 

[RNthenDoc]

I’m interested in osteopathy, but probably wouldn’t want to pursue a residency or really go beyond the basics.

Are there available rotations for allopathic medical students to didactically and clinically absorb a little bit of OMM?

 

[bones]

Yes, you should be able to arrange for a student elective rotation in omt and/or you may apply to a residency with osteopathic recognition and elect to join the osteopathic track. To do this you will probably need an omt rotation or some omt cme training first.

 

[Nurse-to-Doctor]

I will be starting my 3rd year rotations soon. I know my OMM exposure will be very limited during my core rotations. Do you have any suggestions on ways to keep up and further my skills during this year? Are there any OMM books that you would recommend that are not just technique manuals?

Off topic question - Sidebending or rotational emphasis for cervical hvla: In your opinion, is one better than the other? Your personal preference? ( Feel free to ignore this last question if you want. I’m just curious. )

Thanks again!

 

[Faustian]

I will be starting my 3rd year rotations soon. I know my OMM exposure will be very limited during my core rotations. Do you have any suggestions on ways to keep up and further my skills during this year? Are there any OMM books that you would recommend that are not just technique manuals?

Off topic question - Sidebending or rotational emphasis for cervical hvla: In your opinion, is one better than the other? Your personal preference? ( Feel free to ignore this last question if you want. I’m just curious. )

Thanks again!

If you’re treating the typical cervicals C2 on C3 and down, then I believe you would find more success to choose sidebending if you notice the sidebending component is more restricted vs treating with rotational emphasis if that is the more restricted component. Feel free to correct me. We’re learning this as well in our OMS-1 curriculum.

 

[Nurse-to-Doctor]

If you’re treating the typical cervicals C2 on C3 and down, then I believe you would find more success to choose sidebending if you notice the sidebending component is more restricted vs treating with rotational emphasis if that is the more restricted component. Feel free to correct me. We’re learning this as well in our OMS-1 curriculum.

After following different docs in clinic, they seem to only stick with one emphasis in practice. This is just my observation. Personally, I prefer sidebending. It’s just easier for me to localize that way. I believe the majority prefer rotation though.

 

[DrfluffyMD]

This is a tricky subject. First we need more quality case studies published in peer reviewed journals. Without these, doing a good prospective randomized trial is problematic since you dont have a target. Also, short quality review articles on topics that DO's frequently treat would be helpful (drawing heavily on basic science, and looking at cases and looking at current randomized trials relevant to the topic). The goal of a review study also is to form a basis for future research, and it should not be kind to existing poorly done studies, or poorly written cases.

Of course we also need prospective randomized controlled trials, but to get the funding we need the foundation laid. Only a little of this foundation is there now.

We will start phasing out a lot of the dogma taught in the classrooms as future department chairs are graduates from acgme-quality Osteopathic NMM programs. Unfortunately this may take another 5-10 years.

Or you know, I imagine you can recruit some patients with lower backpain or whatever indications, perform OMM and sham OMM by using similar but modified technique on them, and see if there is an outcome difference.

I would have a hard time believing so little funding can be secured for a technique that an entire medical profession is based on.

Any comments? A solid study should be doable.

 

[FistLength]

Hello,
I dont know if you are posing this seriously or not, but I'll do my best to respond. Homeopathy works through the placebo effect. We have double blind trials that show this clearly, with no discernable effect beyond placebo. Voodoo appears to work through the "nocebo" effect, as notifying your victim is an important piece of the puzzle. Modern medicine, including osteopathy, is clinical practice built on a foundation of basic science. Unfortunately, as you so clearly state- much of what we do in medicine is still "expert opinion", and often poor opinions at that. Cranial theory and Chapmans points should be removed from training, testing and boards so far as Im concerned, but I dont have a say over these things yet.

Thank you. Really. As a graduating DO, I had to endure these hallucinated concepts and regurgitate them on my COMLEX. In fact, I purposefully did not touch cranial when studying for boards, I accepted the loss (scored very well so it didn't matter). Sir, I do not say this lightly, but I would allow you to HVLA my neck. It would be my honor.

 

[Nurse-to-Doctor]

For those genuinely interested in Osteopathy, its future, and its potential- I am here to answer questions.

The art and science of osteopathy is in its infancy, but the future is bright.

Due to merging of MD and DO residencies, the higher ACGME standards will now be present for all residency programs doing osteopathic training (this is a good thing). Those that want to use osteopathic manipulation in their practice will do a residency with Osteopathic Recognition (meaning they continue to receive osteopathic training through their chosen residency).

The board certification for those that wish to specialize in osteopathic manipulation is now called Osteopathic Neuromusculoskeletal Medicine (O-NMM). Many will do another residency first and will end up dual board certified, while others will specialize just in O-NMM. We will be re-evaluating the theories passed along as part of osteopathy, and will perhaps have to rethink them using a first-principles approach (look at what data points we have and develop newer more simple theories built on data rather than opinion). This wont be comfortable, but it is a necessary process for any evolving science.

This is the best time in history to be a DO. You have full practice rights, you can enter any residency specialty based on merit (of course, you’ll need the merit to get in). Research opportunities for osteopathic manipulation abound, and there are leadership and teaching opportunities everywhere for anyone willing to develop the requisite skill set.

In a practice environment where patients believe that minimally invasive low-cost care is important, an Osteopathic approach to care is a great answer. We see amazing efficacy with our patients, get them to a point where they are asymptomatic and healthily off their medications, no longer require surgeries etc. This is not enough, however. Wherever good outcomes seem to occur, we need to replicate them under objective conditions. When effective, we need to clarify the mechanism (theories are no longer enough). This is the work we are doing in ACGME residencies now. We have a lot of work to do and we will need your help in the years to come.

AMA- Ask me anything

I’ve recently seen the NBOME advertising the “CORRE” for residency programs with osteopathic recognition. I imagine this is mainly meant for MD applicants. Will Residency programs ever require a DO student to take this exam?

 

[John1513]

I guess my first question is - what's the real substantive difference between treatments performed within homeopathy, voodoo, and OMM? Not really looking for an answer like "we are physicians" or "I have seen it work", but more of a direct piece of evidence from any reputable study that shows that OMM is not simply based on anecdotal evidence (like homeopathy and voodoo).

MOPSE study

 

[John1513]

I describe Nmm as training in Sports Med + pain Med + rheumatology + neurology all intertwined with OPP and OMT.

 

[868651]

For those genuinely interested in Osteopathy, its future, and its potential- I am here to answer questions.

The art and science of osteopathy is in its infancy, but the future is bright.

Due to merging of MD and DO residencies, the higher ACGME standards will now be present for all residency programs doing osteopathic training (this is a good thing). Those that want to use osteopathic manipulation in their practice will do a residency with Osteopathic Recognition (meaning they continue to receive osteopathic training through their chosen residency).

The board certification for those that wish to specialize in osteopathic manipulation is now called Osteopathic Neuromusculoskeletal Medicine (O-NMM). Many will do another residency first and will end up dual board certified, while others will specialize just in O-NMM. We will be re-evaluating the theories passed along as part of osteopathy, and will perhaps have to rethink them using a first-principles approach (look at what data points we have and develop newer more simple theories built on data rather than opinion). This wont be comfortable, but it is a necessary process for any evolving science.

This is the best time in history to be a DO. You have full practice rights, you can enter any residency specialty based on merit (of course, you’ll need the merit to get in). Research opportunities for osteopathic manipulation abound, and there are leadership and teaching opportunities everywhere for anyone willing to develop the requisite skill set.

In a practice environment where patients believe that minimally invasive low-cost care is important, an Osteopathic approach to care is a great answer. We see amazing efficacy with our patients, get them to a point where they are asymptomatic and healthily off their medications, no longer require surgeries etc. This is not enough, however. Wherever good outcomes seem to occur, we need to replicate them under objective conditions. When effective, we need to clarify the mechanism (theories are no longer enough). This is the work we are doing in ACGME residencies now. We have a lot of work to do and we will need your help in the years to come.

AMA- Ask me anything

Is a DO a waste of time when it comes to getting accepted to a residency?

 

[John1513]

Is a DO a waste of time when it comes to getting accepted to a residency?

Would you please be more respectful to an Attending Physician?

You are just trolling with this question.