paradox of osteopathy?

[prolixless]

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I recently read an article titled "The Paradox of Osteopathy" in The New England Journal of Medicine, Nov. 4, 1999. The article points out that although DO's are trained in osteopathic manipulation, the majority of them do not use it that often in treatment. The implication here is that DO's, for the most part, are allopaths in practice since they commonly use the same modes of treatments as do MD's. At the end of the article, the paradox is put forth: "if osteopathy has become the functional equivalent of allopathy, what is the justification for its continued existence? And if there is value in therapy that is uniquely osteopathic--that is, based on osteopathic manipulation and other techniques--why should its use be limited to osteopaths?"

I thought this was an interesting article. Does anyone believe that 1) osteopathy ought to abandon osteopathic manipulation and hence become allopathy or 2) allopathy ought to adopt osteopathic manipulation and hence become osteopathy or 3) both branches of medicine ought to continue to exist. Please back up your choice with reasons.

 

[BretSebastian]

Originally posted by prolixless:
I recently read an article titled "The Paradox of Osteopathy" in The New England Journal of Medicine, Nov. 4, 1999.

Why they should remain seperate:
There is more to being an Osteopathic physician than OMM alone. There is a philosophic difference in clinical practice and treatment of patients.

It is also my personal opinion that Osteopathic physicians are screened differently during the admissions process. The personality factor plays a big part in the Osteopathic admissions process. Lets face it...it doesn't take a genius to become a physician, but one should do it for the right reasons.

A friend of mine is an Allopath from Penn and he sought training in OMM to be a better trained family practice physician. There is no doubt that OMM is beneficial. I look at it as an extra tool in my box.

Thanks for sharing the article!

 

[alceria]

I have two questions/comments. Perhaps the reason that DO's fail to use OMM is because the public in general isn't informed about OMM and so they don't seek treatment for problems that OMM can help with? Maybe they go to chiropractors instead? Perhaps the patients know nothing about OMM and feel apprehensive about it? It would be interesting to see if this trend continues as the public becomes better informed abut osteopathy, or if it reverses.

My second thought, and don't be offended because I don't want to rustle feathers here, is that maybe a lot of DO's, especially in the past, went to DO school because they couldn't get into MD school, and so they never really cared much about OMM to begin with. Now, I personally have a lot of respect for DO's and I don't think of DO schools as saftey schools, but looking at the posts here, it seems like a lot of people still think of them that way. So I guess my question is, how many DO's in this study really wanted to be MD's instead? This is another trend that may very well reverse as students as well as the public become better informed about what a DO is.

I have never gone to a DO myself, but right now, I don't actually have a family doctor, so I plan getting a referral to a DO eventually, and this is something I'd like to pick his/her brain about. My heart is personally set on MD school, because my first choice school is an MD school that's on my campus, and I would rather not have to move and sell my condo. But the more I learn about Osteopathy the more I like its philosophies, so I think I'm going to have some serious thinking to do.

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^v^

 

[kidterrific]

I believe that there are two types of DOs - the purists and the non-purists.

The purists are those who are very big into manipulation, and practice it wholeheartedly. The fact is manipulation is a big deal to those who seek out DOs. For DOs, it means repeat business, and if a DO is good at it, oftentimes he/she will be seen ONLY for manipulation.

Some doctors don't want to be lumped in this category, so they take the non-purist approach, and save manipulation for when their family needs it

!

Of course, there are always exceptions to the rule, yadda yadda yadda....

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KidT
[email protected]

 

[turtleboard]

Originally posted by prolixless:
I recently read an article titled "The Paradox of Osteopathy" in The New England Journal of Medicine, Nov. 4, 1999. The article points out that although DO's are trained in osteopathic manipulation, the majority of them do not use it that often in treatment. The implication here is that DO's, for the most part, are allopaths in practice since they commonly use the same modes of treatments as do MD's. At the end of the article, the paradox is put forth: "if osteopathy has become the functional equivalent of allopathy, what is the justification for its continued existence? And if there is value in therapy that is uniquely osteopathic--that is, based on osteopathic manipulation and other techniques--why should its use be limited to osteopaths?"

I thought this was an interesting article. Does anyone believe that 1) osteopathy ought to abandon osteopathic manipulation and hence become allopathy or 2) allopathy ought to adopt osteopathic manipulation and hence become osteopathy or 3) both branches of medicine ought to continue to exist. Please back up your choice with reasons.

The NEJM article assumes that the only thing that separates osteopathy from medicine is manipulation. Few in this forum will agree that DOs are MDs who are trained in OMT, however, so I take issue with some of the article's claims.

In any event I believe that "allopathic medicine" and osteopathy are two entities -- perhaps two "branches" of medicine -- that will peacefully co-exist so long as the AOA has it their way.

There are differences in training between the DO and the MD, and from what my DO friends tell me, this has to do with their approach to a diagnosis. I can't explain the subtleties of diagnosis and how they (DOs) think and how we (MDs) think because I don't understand diagnosis all that well myself. Perhaps next year I can better discuss this topic.

I think the majority of DOs are happy being DOs and would never want their profession to go the way of the 1960 CA DOs who sold out their profession for about $2,000 and a worthless MD.


Tim W. of N.Y.C.

 

[prolixless]

All of the comments posted so far suggest to me good points and strong insights. But I'm still left wanting to understand more.

To begin, I can see how osteopaths might want allopaths to eventually embrace and practice an integrative and holistic approach to treating patients because, quite simply, they believe it is the most effective and humanistic treatment approach. And I can see how they would want allopaths to embrace and practice osteopathic manipulation and all it's treatment theories because, once again, they believe it is an effective--if not extremely effective--treament mode. In short, whether justified or unjustified, I can see how osteopaths might want allopaths to become osteopaths.

I can also see how allopaths might want osteopaths to abandon osteopathic manipulation and it's treatment theories because it is difficult to objectively show the effectiveness of this treatment mode. And I can see allopaths (particularly primary care allopaths) telling osteopaths "We along with all other health care providers take a whole-person approach to treating patients; therfore it's unfounded for you to claim you own that philosophy." Essentially, whether justified or unjustified, I can see how allopaths might want osteopaths to become allopaths.

But what I cannot see is how an osteopath would want allopaths to remain a distinct practice of medicine. If osteopaths truly believe their philosophies to be superior, then why would they desire an inferior practice of medicine to continue to exist? If, on the other hand, the osteopaths believe their philosophies to be inferior or nondistinct, then why would they desire to remain distinct as osteopathy? Next, I cannot see how an allopath would want osteopaths to remain a distinct practice of medicine. If allopaths truly believe osteopathic theory to be inferior or nondistinct, then what could allopaths possibly believe the field of osteopathy has to offer to health care? If, however, they believe osteopathic theory to be superior, then why would they desire to remain distinct as allopathy?

 

[ewagner]

A big point of the article is such:

If manipulation is supposedly so helpful and clinically effective...why don't DO's share their techniques with other professions?

I think this is an issue worth considering. Why is the entire field resisting the teaching of techniques to PT's, MD's, and others? And I think I have seen a partial answer after my first 2 years in a DO program. With such a lack of good manipulative research (no double blinds, poor selection of trial patients, poor control) the practice seems to be an "old boys club" and a teaching "the wisdom of the old ways"...it is certainly different than any ortho lab or rehab lab I had in PT school.
my 2 cents

 

[Pikevillemedstudent]

prolixless,
The questions you ask and the reactions you expect would only occur in a perfect world. Truth is perhaps some DO's don't desire for allopaths to exist, but what could they do about it. Osteopaths only make up 7% percent of all physicians. Perhaps some MD's don't desire for allopaths to exist. Some have tried to get rid of osteopathy in the past, but failed. If a DO feels OMT to be useless then all he has to do is not use it. If an MD feels OMT to be useful then all he has to do is take a bunch of CME's on OMT(although the MD probably won't be as competent as a DO:CME's veruses two years of DO school). In summary, everyone just wants to get along and not stomp on the others toes and create distractions from everyones goal: helping patients.

ewagner,
It has been my experience that DO's do share their techniques with others. If that truly is the point of the article(I have not read it in quite some time), the author is way off base. Friends have told me that they used Principles of Manual Medicine by Greenman(a DO) in PT school. Also, OMT CME's are available to MD's. Our chair of the OMT department gives lectures on OMT to other health professionals on a weekly basis.

 

[ewagner]

Pikesville,
Greenman is certainly a dynamic and well read author. When I was a PT I read some of his articles in Journal of Manipulative Medicine. His strength is kinesiology.
Here lies the problem...why don't DO's who wish to do good research on the kinesiology of manipulation, the physiological affects of manipulation, in dwelling EMG studies of muscular activation during muscle energy techniques, precise movement studies of the "so called" cranio-sacral rhythm etc etc AT MAJOR UNIVERSITIES? Why huddle around in OMT lab saying "did you feel it move!" when you could do fluroscopy at a major institution and watch it!!
gotta go.
e

 

[prolixless]

Originally posted by Pikevillemedstudent:
prolixless,
The questions you ask and the reactions you expect would only occur in a perfect world. Truth is perhaps some DO's don't desire for allopaths to exist, but what could they do about it. Osteopaths only make up 7% percent of all physicians. Perhaps some MD's don't desire for allopaths to exist. Some have tried to get rid of osteopathy in the past, but failed. If a DO feels OMT to be useless then all he has to do is not use it. If an MD feels OMT to be useful then all he has to do is take a bunch of CME's on OMT(although the MD probably won't be as competent as a DO:CME's veruses two years of DO school). In summary, everyone just wants to get along and not stomp on the others toes and create distractions from everyones goal: helping patients.

ewagner,
It has been my experience that DO's do share their techniques with others. If that truly is the point of the article(I have not read it in quite some time), the author is way off base. Friends have told me that they used Principles of Manual Medicine by Greenman(a DO) in PT school. Also, OMT CME's are available to MD's. Our chair of the OMT department gives lectures on OMT to other health professionals on a weekly basis.

Pikevillemedstudent:
Your response makes a lot of sense to me. I can see how osteopaths and allopaths would be willing to refrain from attacks on the treatment approaches of one another in order to maintain a greater goal, achieving patient health. This seems like the most practical approach for both branches of medicine.

I still wonder, though, if one branch will some day be assimilated to the other. My interpretation of the article is that it seems to suggest that osteopaths are slowly but surely being assimilated. The inference here is that eventually the title "D.O." will be nothing but an empty name, and that the outcome will be a pure breed of M.D.'s. This would not be a radical inference by the article since other unconventional though perhaps popular treatment approaches have dwindled over time.

 

[turtleboard]

I believe that the osteopathic profession is being crushed under its own weight. It lacks the ability to train its own graduates through postgrad residency prorgams, forcing many DOs to head off to allopathic programs to seek training.

Once a DO takes the MD residency route, what about his training from the day he receives his DO will be distinctly osteopathic? Most likely nothing.

The AOA needs to re-formulate its goals and instead of spending millions of dollars on campaigns for public education (which is important) re-establish an extensive system of osteopathic residency programs. Some schools like PCOM and NYCOM have very able programs that offer a DO a ton of opportunities, but there is only one PCOM and only one NYCOM.

You need a profession to promote, not just an idea.


Tim W. of N.Y.C.

 

[drusso]

Originally posted by ewagner:
Pikesville,
Why don't DO's who wish to do good research on the kinesiology of manipulation, the physiological affects of manipulation, in dwelling EMG studies of muscular activation during muscle energy techniques, precise movement studies of the "so called" cranio-sacral rhythm etc etc AT MAJOR UNIVERSITIES? Why huddle around in OMT lab saying "did you feel it move!" when you could do fluroscopy at a major institution and watch it!!
gotta go.
e

Excellent question. Two observations: 1) The osteopathic profession has been very slow to train clinical researchers in general and clinical researchers in manipulative medicine specifically. This is only just beginning to change. There is a nascent movement afoot (sponsored by the AOA, AACOM, AAO, and others) to train clinical and basic science researchers in basic and applied manipulative research. Researchers don't just happen, they're made. And, making researchers requires an investment of time and capital. 2) There has been a lack of federal funding opportunities for OMM research. The federal government has bank-rolled biomedical research in almost every arena, but has relatively neglected nonpharmaceutical research, rehabilitation research, and physical medicine research. Thankfully, this is beginning to change too. NIH is beginning to offer opportunities for manipulative research and is working very closely with the osteopathic profession (they would much rather deal with DO's, and physiatrists than chiropractors, PTs, or other non-physician manipulators). NIH recently funded TCOM $1.5 million to develop a research fellowship program in OMM research. Momentum is gaining for a NIH-funded center for osteopathic research.

Keep in mind that OMM has evolved largely as a clinical art. DO schools have historically lacked a "culture of research" in which to prepare osteopathic scientists. However, there are some very, very interesting developments underway at some of the larger, university-affiliated DO schools in the way of research in manipulative medicine. Stay tuned.

It has been said that every generation of DO's has faced unique challenges and has managed to advance the osteopathic profession in it own significant way. Every time it was thought that the death of the profession was just around the corner. Every time, the profession managed to escape extinction. First, there the was the challenge of standards, the challenge of licensing, then the challenge of legitimacy, the challenge of identity/automony, and now more recently the challenge of scientific credibility. If the future reflects history, then the osteopathic profession will indeed step to the plate and make meaningful inroads in establishing the clinical effectiveness of manipulative medicine. Thrillingly, it'll be our generation to do it. Are you ready?

 

[ewagner]

DRUSSO,
Thank you for your response. I must be brief.
I agree with most of what you said, but let us not kid ourselves into thinking that DO's have entered into the new age of research. DO's have for a long time isolated themselves from allopathic academia, and I am sure it also goes both ways. But I have seen FIRST HAND the refusal of research at my university for purely political reasons...these research projects were not "osteopathic enough" too "reductionist" (verbatum!)...they required strict controls of subjects and that was just not DO friendly I guess.

Why? Perhaps the results may not have been favorable? (one project was the affect of supine and weight bearing positions on the Q-angle, while the other was the effect of cervical spine position on the double inclionometer measurement of the modified fingertip to floor assessment of lumbar spine flexion). These were both my projects...
I had never seen so much Bulls@#t opposition on simple research in my life! Mind boggling.
Much of this research must go through an osteopathic review board...and if you don't get the results that will support the osteopathic position...do you really think it will get published or funded?! No way.
So...that leaves us in a quandry. How do we validate our "ancient secrets of osteopathy" without offending the powers that be??
Take the research and share it with other institutions!
To graduate, PT's need to perform a research project...most of these projects are very good and get published in major journals. Why hasn't the profession used this untapped resource? Fear? Isolationism?
What better way to get the "osteopathic philosophy" into the mainstream world?

Perhaps, the powers that be, just don't want the world get a hold of the art for fear of losing it?
That may be the crux of the NEJM article...and my argument.


Turtleboard...I agree with you 100%!
e

[This message has been edited by ewagner (edited 01-02-2001).]

[This message has been edited by ewagner (edited 01-03-2001).]

 

[turtleboard]

Dave,

Your post is inspiring even to men who, like me, are of the allopathic cloth, but do you still think the osteopathic profession is in the middle of the "challenge of identity?"

Given the discussions I've participated in since being a part of SDN, I think the question of identity is still lingering in the minds of the next generation of DOs.


Tim W. of N.Y.C.

 

[drusso]

Originally posted by ewagner:
DRUSSO,
Thank you for your response. I must be brief.
I agree with most of what you said, but let us not kid ourselves into thinking that DO's have entered into the new age of research. DO's have for a long time isolated themselves from allopathic academia, and I am sure it also goes both ways. But I have seen FIRST HAND the refusal of research at my university for purely political reasons...these research projects were not "osteopathic enough" too "reductionist" (verbatum!)...they required strict controls of subjects and that was just not DO friendly I guess.

Equally brief:

Again, it comes back to cultivating a "culture of research" in osteopathic institutions. The culture of most DO schools has been almost exclusively SERVICE oriented. That's not a bad thing, it's just different and creates problems when it comes to making osteopathically-minded scientists. Read Norman Gevitz for further analysis on this topic.

I'm a predoctoral research fellow in OMM at UNTHSC-TCOM and am not nearly as pessimistic as you are about OMM research. Yes, we're starting at ground zero in terms of high quality osteopathic research; yes, there is a considerable amount of cultural/political changes in the infrastructure of osteopathic education that must occur to support meaningful reform, but it IS happening. I've seen it with my own TWO eyes. The change is not be driven by a love of science, but for the simple reason that third-party payors demand outcome data for manual medicine procedures. As physicians trained in manual medicine, DO's are uniquely positioned to do this work. The profession is beginning to wake up to this fact. Ewanger, don't be so pessimistic about the whole thing. Find a cadre of like-minded, scientifically-inclined individuals who want to evaluate OMM and go for it. With your background in PT you have a lot to offer...

Tim, I'll respond when I get a chance.


-Dave

 

[doctor jay]

This has been really thought provoking and rather non-bias -- very cool!

In many discussions with DO residents, attendings, and faculty members, etc, I am too understand that a major part of the lack of actual use of OMM/OMT in clinical practice is the result of managed care and the grueling schedule of the modern physician. OMM/OMT usually requires at least 45 minutes for examination and application, however when a physician has maybe 15 minutes ( a friend at MSU recently told me of seeing patients every 5 minutes --yikes!) it is obviously difficult to do more than just say hello and write a 'script.

A few mentioned the lack of research, which is a major hurdle that the DO academic community is attempting to reverse.

A very important point that must continue to be raised, however (in my opinion) is that if a treatment modality is effective, regardless of who discovered it, it needs to be available to all patients. In other words, if OMM/OMT is a viable form of treatment for various forms of illness, then DO's and MD's should be able to offer it to their patients.

Perhaps the AMA and AOA would be better off to embrace each other (DO's and MD's as well) in the practice of medicine, realizing a common goal to serve the health needs of an ailing society. Moreover, their collective efforst should focus energy on the ramifications of managed care's continued push to utilize PA's and NP's more for the care of the patient and the physician as the case manager. The threats to the quality of patient care and the viability of the physician are enormous!

 

[drusso]

Originally posted by doctor jay:
A very important point that must continue to be raised, however (in my opinion) is that if a treatment modality is effective, regardless of who discovered it, it needs to be available to all patients. In other words, if OMM/OMT is a viable form of treatment for various forms of illness, then DO's and MD's should be able to offer it to their patients.

Perhaps the AMA and AOA would be better off to embrace each other (DO's and MD's as well) in the practice of medicine, realizing a common goal to serve the health needs of an ailing society. Moreover, their collective efforst should focus energy on the ramifications of managed care's continued push to utilize PA's and NP's more for the care of the patient and the physician as the case manager. The threats to the quality of patient care and the viability of the physician are enormous!

I agree with you 110% as do other reasonable people. There still remains, however, a group of DO's who want to keep osteopathic medicine "in the family" out of spite for the bad old days of attempted absorption and annihilation of the osteopathic profession by the AMA. Old biases die hard. Moreover, many of these individuals see the interest in OMM by MD's as threatening.

 

[OldManDave]

I too have witnessed "osteopathic research" studies that suffer from fundamental design flaws: unacceptably low numbers of subjects, 'favorably-selective' exclusion criteria and very high p-values. In fact, several of the abstracts, released prior to the recent "Scientific Convention" in FL, claimed p-values that were laughable.

Yes, there are ongoing attempts at improving osteopathic research ,which I applaud! However, from my perspective, the leaders of this movement still have a bit to learn before they go teaching others...this is just my opinion.

Addressing "the sharing of our manipulative medicine" with the MDs...I completely and fully support that! In fact, I believe the AOA should reciprocate the ACGME's generosity and make our internships & residencies open to MD-graduates.

AT Still is not famous for finding the panacea-of-all-ills in OMM. However, he is to be revered for his courage in saying there's got to be a better way. Also, from the beginning, he was not elitist or exclusionistic in who he taught his then novel treatment modalities...he taught anyone who cared to learn, among earliest DO-school graduates were female and African-american physicians...virtually unheard of at that time. In the spirit of AT...we should be, and should have been all along, teaching our MD colleagues what we have learned about OMM. After all, the primary goal of all physicians should be to provide the best care possible for their patients...irregardless of the alphabet-soup behind your sig!

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David W. Kelley, MS-2
'Old Man Dave'
KCOM, Class of '03

Nothing Risked, Nothing Gained!!