Paradox of Osteopathy

Discussion in 'Medical Students - DO' started by Dr. Nick, May 27, 2002.

  1. Dr. Nick

    Dr. Nick Senior Member
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    Hi Guys,

    Can someone with access to the New England Journal of Medicine post the editorial article:

    Howell, J. D. (1999). Editorial: The Paradox of Osteopathy. NEJM, 341(19).

    In my research of osteopathic practices I keep coming across references to the article but have yet to find a copy.

    Cheers,
    Dr. Nick
     
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  2. PainMan

    PainMan Senior Member
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    The New England Journal of Medicine November 4, 1999;341:1426-1431, 1465-1467.

    The Paradox Of Osteopathy
    In the spring of 1864, Andrew Taylor Still, a rural Kansas practitioner, watched helplessly as the best medications then available failed to save his three children from spinal meningitis. Bitterly disappointed, Still set out to devise an alternative healing practice. He eventually based his new system on the idea that manipulation of the spine could improve blood flow and thus improve health by allowing the body to heal itself. His philosophy included a healthy dose of moralism; patients were forbidden to consume any liquor and, as part of the break from existing practices, were also forbidden to take any medicine. Still founded a school to teach his new system of osteopathy in Kirksville, Missouri, in 1892.

    Osteopathy was not the only system of spinal manipulation to be created in the late 19th century. Chiropractic, established in 1895 by Daniel David Palmer, aimed to relieve obstruction in the nerves rather than in the blood vessels. Osteopathy and chiropractic initially shared several characteristics. Both were founded when Americans freely chose from many systems of healing. Both were homegrown American systems created at about the same time by messianic Midwesterners. Both systems were seen by many Midwesterners as preferable to the reductionist European model of laboratory-based medicine, which was established most firmly on the eastern seaboard and was fast becoming the standard.

    Over the course of the 20th century, medicine as practiced by M.D.'s (sometimes called allopathy) has come to dominate U.S. health care. Chiropractic and osteopathy, initially parts of a pluralistic medical system, have taken very different paths. Chiropractors have generally remained focused on spinal manipulation for a limited set of conditions, particularly those that are often resistant to allopathic therapy, such as back pain. Osteopaths, on the other hand, have worked hard to employ the entire therapeutic armamentarium of the modern physician, and in so doing they have moved closer to allopathy. )

    The move toward assimilation became explicit in California in the early 1960s, when the California Medical Association and the California Osteopathic Association merged in what has been called the osteopathic profession's darkest hour. By attending a short seminar and paying $65, a doctor of osteopathy (D.O.) could obtain an M.D. degree; 86 percent of the D.O.'s in the state (out of a total of about 2000) chose to do so. The College of Osteopathic Physicians and Surgeons became the University of California College of Medicine, Irvine. Many osteopaths feared that the California merger was the wave of the future and that the profession would not survive. But it did, and in so doing it may have become even stronger. D.O.'s are now licensed in all 50 states to prescribe drugs, deliver babies, and perform surgery -- in short, to do anything that M.D.'s can do. Despite national recognition, osteopathy is still a regional phenomenon in ways that mirror its historical origin. The ratio of D.O.'s to the population varies by a factor of almost 3, from a low of 7.7 per 100,000 population in the West to a high of 20.4 per 100,000 in the Midwest; the number is 8.5 per 100,000 in the South and 18.3 per 100,000 in the Northeast. M.D.'s are far more evenly distributed throughout the country.

    Osteopathy was originally created as a radical alternative to what was seen as a failing medical system. Its success at moving into the mainstream may have come at a cost -- the loss of identity. Most people -- including physicians -- know very little about the field (most people know more about chiropractic). Many people -- even osteopaths -- question what osteopathy has to offer that is distinctive.

    Those who claim that osteopathy remains a unique system usually base their argument on two tenets. One is the holistic or patient-centered approach, with a focus on preventive care that they say characterizes osteopathy. That claim to uniqueness is hard to defend in the light of the increasing interest paid to this approach within general internal medicine and other areas of allopathic medicine. The other, potentially more robust, claim to uniqueness is the use of osteopathic manipulation as part of the overall therapeutic approach. In osteopathic manipulation, the bones, muscles, and tendons are manipulated to promote blood flow through tissues and thus enhance the body's own healing powers. The technique, based on the idea of a myofascial continuity that links every part of the body with every other part, involves the "skillful and dexterous use of the hands" to treat what was once called the osteopathic lesion but is now referred to as somatic dysfunction. Osteopathic manipulation is not well known (or practiced) by allopathic physicians, but for decades it has stood as the core therapeutic method of osteopathic medicine.

    Some claim that osteopathic physicians are more parsimonious in their use of medical technology. Thus, they can provide more cost-effective medical care and reduce the need for medications, which, although effective, can have serious side effects. The specific mechanism that would account for any improvement in back pain directly related to osteopathic manipulation is unclear, but the most important studies will be those that test whether the technique works in clinical practice. Part of the success of osteopathic manipulation for patients with back pain may come from the fact that physicians who use osteopathic manipulation touch their patients.

    Osteopathic manual therapy is claimed to be useful for treating a wide range of conditions, from pancreatitis to Parkinson's disease, sinusitis, and asthma. Some leading osteopaths say that manual therapy should be part of almost every visit to an osteopathic physician. A recent president of the American Osteopathic Association claimed that he "almost always turned to [osteopathic manipulation] before considering any other modality," and he asserted that 90 percent of his patients got better with osteopathic manipulation alone. Such claims underscore a raging debate within osteopathy and a disconnection between its theories and its practice. A 1995 survey of 1055 osteopathic family physicians found that they used manual therapy only occasionally; only 6.2 percent used osteopathic manipulation for more than half of their patients, and almost a third used it for fewer than 5 percent. The more recent their graduation from medical school, the less likely practitioners were to use osteopathic manipulation, a finding consistent with the view that osteopathic practice is moving closer to allopathic practice. A decreasing interest in osteopathic manipulation may also indicate that more physicians enter osteopathic medical school not as a result of a deeply held belief in the osteopathic philosophy but after failing to be admitted to allopathic medical schools. The osteopathic physicians who are more committed to osteopathic manipulation tend to be more likely than their colleagues to have a fundamentalist religious orientation.

    With or without manipulation therapy, osteopathic medicine seems to be undergoing resurgence. Although the number of allopathic medical schools in the United States has remained stable since 1980, at about 125, the number of osteopathic medical schools has increased from 14 to 19. The number of graduates each year has increased at an even more disproportionate rate. The number of graduates of allopathic medical schools has increased only slightly, from 15,135 in 1980 to 15,923 in 1997, whereas the number of graduates of osteopathic medical schools has almost doubled, from 1059 to 2009, over the same period. Osteopathic medical schools have not done as well as allopathic medical schools in recruiting underrepresented minorities and women, and students entering osteopathic medical schools have somewhat lower grade-point averages and lower scores on the Medical College Admission Test. On the other hand, the ratio of applicants to those admitted is higher for osteopathic medical schools, 3.5 applicants for each person admitted, as compared with 2.4 for allopathic medical schools.

    Overall, osteopathic medical schools have come to resemble allopathic medical schools in most respects; some students even share classes. Graduates of osteopathic medical schools more often than not go on to residency training in allopathic programs. An evaluation of performance on the certifying examination of the American Board of Internal Medicine in the 1980s noted that although physicians from osteopathic medical schools did not do as well as those from allopathic programs, overall they "did well" and could be an "untapped reservoir of talented physicians" for internal medicine.

    Although they constitute only about 5 percent of U.S. physicians, osteopaths may be disproportionately important for the health care system by virtue of their distribution in terms of specialty and location: 60 percent of graduates of osteopathic medical schools select generalist fields. Because osteopathic education is more community-based than allopathic education, and because osteopathic schools are smaller, osteopathic education may be able to adapt more quickly to new approaches to health care delivery. Many more osteopaths than allopaths (18.1 percent vs. 11.5 percent) select rural areas in which to practice. One osteopathic medical school found that 20 percent of its graduates were practicing in underserved communities.

    At the end of the century, osteopathy continues its uneasy dance with allopathy, but only one partner is really paying attention. The resurgence in the numbers of osteopaths should not mask the precarious position of osteopathy. At its birth, osteopathy was a radical concept, rejecting much of what allopathic medicine claimed was new and useful. Today, osteopathic medicine has moved close to the mainstream -- close enough that in general it is no longer considered alternative medicine. The long-term survival of osteopathic medicine will depend on its ability to define itself as distinct from and yet still equivalent to allopathic medicine. That argument may best be articulated not in theoretical terms, but by demonstrating treatment outcomes. The paradox is this: 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 or other techniques -- why should its use be limited to osteopaths?

    Joel D. Howell, M.D., Ph.D. University of Michigan Ann Arbor, MI 48109-0604

    The New England Journal of Medicine November 4, 1999;341:1426-1431, 1465-1467.

    [Editors Comment]
    COMMENT: I rarely print an entire article; but this one is a rare exception. I am an osteopathic physician and I have never read a more eloquent and accurate assessment of osteopathic medicine. This is a classic. I believe I will reprint this article and hand it out to patients who wish to know what an osteopathic physician really is. I have mixed feelings about having chosen to be a D.O. as I chose it for its natural philosophical orientation. In reality however, as Dr. Howell so beautifully describes, there is essentially little difference between a D.O. and an M.D. I did find it interesting that it is actually harder to get into a D.O. school than an M.D. school. One of my friends could not get accepted into an osteopathic medical school and had to go to a regular medical school. Patients frequently ask for a physician who practices medicine like I do and mistakenly believe that all D.O.'s practice natural medicine. I have to regrettably tell them that this is not so and that they are better off contacting ACAM for a referral (800-532-3688) as most ACAM physicians are at least oriented towards natural medicine and more open to those alternatives. I do believe that the selection process for osteopathic schools is oriented to identifying other variables than grades and test scores, which tends to produce more empathic physicians.
     
  3. DOcjoshua

    DOcjoshua Member
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    Thanks for the reference to the article and for posting it. I found the article to be very informative and also agree with the editor's comments. I am not sure I agree with the idea of the paradox. Yes there is a gradual migration of DOs to more mainstream medicine, but I feel that it it is not only the OMM that makes a DO. There is an entire philosophy that is taught. Granted this could be taught at any medical school, osteo or allo, and the students could also take what they wanted from it. But, this teaching is what Osteopathic Medicine was founded on, and should continue to be founded upon. In fact all schools could take this philosophy and teach it, but when it comes down to it, this is the Osteopathic Philosophy and this is what they teach to students who are conferred with the degree of DO. So, MD and DO are one in the same, but should there be only one distinction? If you ask me I don't think so, but that is a whole other discusssion.

    JOSH
     
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  4. Dr. G. to be

    Dr. G. to be Junior Member

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    They can keep debating this as much as they want, but they will never be able to prove a very basic concept: there's just something special about people who want to be D.O.s!
     
  5. Dr JPH

    Dr JPH Membership Revoked
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    I would be interested in seeing a recent comment or study from the American Board of Internal Medicine evaluating the "certifying examination."

    I'm thinking that DO students preparing for the COMLEX would have a lesser amount of time to prepare for the USMLE that their MD counterparts, though I am unaware of the differences between these two sets of exams. This may be a large factor if DO students do, indeed, score disproportionately lower on the USMLE.

    I have heard recent talk of one single exam that is to be given that will encompass ALL DO and MD students, with a separate section given to DO students only.

    Would this type of examination work in favor of dispelling some of the myths that "you don't have to be as smart to get into a DO school".

    I have also looked at published numbers for many of the DO schools and find that their GPA and MCAT requirements parallel those of several MD schools in all parts of the country.

    Overall, I thought this was an interesting article to read. It didn't stand up for the fact that osteopathy is different, but I look at that as a positive.

    Many current DOs and leaders in the osteopathic profession want to remain as a "unique" medical identity. I find this difficult when there is only so much room in the medical school curriculum for OMM. I also find it difficult, and it will become more difficult in the future as the article stated, to remain unique when fewer and fewer DOs are using OMM in their everyday practices.

    At this point I think many in the medical field view osteopathy as a backup. Easiers schools to get into and subpar residencies as compared to the allopathic counterparts.

    Well, as a future DO student, my biggest question is concerning the quality of the osteopathic residencies. I have heard much good, and unfortunately, much bad spoken about them.

    In order for osteopathy to remain unique it will take a strong movement by the current DO students. We, the class of 2006 and others similar in time frame, will need to work at this issue if osteopathy is to remain unique.

    We, too, will be the group that will make the decision to let the "uniquness" drift away, should that be the collective decision.

    I applaud the AOA for recent advertising schemes that I have heard about, but I myself have yet to see any of them in use. I hope that they concentrate their efforts towards educating the public about DOs and improving osteopathic graduate education.
     
  6. Dr. Nick

    Dr. Nick Senior Member
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    Pain Man:

    The comments that you identified as [Editors Comment], are these comments from the editor of the New England Journal of Medicine??

    Please clarify so as not to confuse.

    Cheers
     
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  7. PainMan

    PainMan Senior Member
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    No..Sorry for any confusion. I put that in there so no one would think it was my comment. I got this from the website of Dr. Mercola (a D.O.). Here is the link <a href="http://www.mercola.com/1999/nov/7/paradox_of_osteopathy.htm" target="_blank">http://www.mercola.com/1999/nov/7/paradox_of_osteopathy.htm</a>
     
  8. Stillfocused

    Stillfocused Senior Member
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    This is an equally interesting. Its a speech by James Jealous, DO.

    THE DEATH OF OSTEOPATHY
    AOA Annual Convention in San Francisco
    November 1999

    <a href="http://hammer.prohosting.com/~ostium/Articles/1-THE%20DEATH%20OF%20OSTEOPATHY.doc" target="_blank">http://hammer.prohosting.com/~ostium/Articles/1-THE%20DEATH%20OF%20OSTEOPATHY.doc</a>
     
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  9. mddo2b

    mddo2b STOP PAGING ME....PLEASE!
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    I read the article by Dr. Jealous and must admit that I was moved by the passion of this physician. I am a recent graduate of NYCOM, and will be entering into an allopathic residency in surgery. I refuse to believe that osteopathy had "died", instead I believe that osteopathy has evolved. It has taken the best of two systems and made something new, unique and much, much better. My training at NYCOM has made me a better physician and in turn, I will be able to traet my patients more efficiently, and most importantly more effectively.
    Just my 2 cents
     
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