"The D.O.", the AOA, and What They Don't Get.

[It'sElectric]

Your logic would work perfectly were it not for the new DO schools opening on a yearly basis forcing the admissions committees to accept students they maybe wouldn't have a few years back due to needing to fill the seats.

Does anyone honestly think any DO school is going to allow vacant seats in their class when there are applicants willing to come drop in their $30,000 a year + the money the government pays the school for each student?

I completely agree w/ your 2nd statement, but my response was primarily in regards to the more established schools (i.e. Open for more than ~5 years).

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[drusso]

JP and drusso,
I understand what you guys are saying, and it makes sense in terms of the whole application process.

My contention is this: how does an interviewer (per JPs example) try to truly understand an applicant's dedication to the osteopathic profession when--other than OMT--pre med students aren't going to see any genuine difference in DO medicine during their shadowing?

I mean, how do applicants truly experience osteopathic medicine from a pre-med standpoint, other than personal opinions a DO may tell them?

Personally, I'd take an applicant that had a burning desire to learn applied A&P over an applicant that for whatever reason thinks DO school is going to make him a better physician, they like "holistic medicine," etc...

Very interesting questions. There is a validated survey instrument to measure these things...someone should do a study!

J Am Osteopath Assoc. 2003 Sep;103(9):429-34.
Development of the Attitudes Toward Osteopathic Principles and Practice Scale (ATOPPS): preliminary results.

Russo DP, Stoll ST, Shores JH.
Department of Osteopathic Manipulative Medicine, University of North Texas Health Science Center at Fort Worth-Texas College of Osteopathic Medicine, USA.

Little empirical work has been done to examine how osteopathic medical students' attitudes toward osteopathic principles and practice (OPP) develop and evolve over the course of their medical education. A major obstacle to conducting this research is the absence of reliable and sensitive instruments to measure students' attitudes toward OPP. The purpose of this project is to develop a sensitive and reliable instrument to measure students' attitudes toward OPP. Face-to-face and telephone interviews were conducted with osteopathic medical students, osteopathic manipulative medicine (OMM) residents, OMM undergraduate fellows, and three board-certified OMM specialists. These interviews were summarized in a 39-item instrument administered to 127 students at the completion of their core OMM rotation at the University of North Texas Health Science Center at Fort Worth-Texas College of Osteopathic Medicine. Factor analysis of student responses to the 39 candidate items yielded two interpretable factors. Factor 1 contained 24 items and accounted for 33% of the item response variance, and factor 2 contained four items and accounted for 5.6% of the item response variance. Based on these results, 14 of the original 39 statements were eliminated and the smaller second factor was dropped. Factor 1 contained items reflecting both positive and negative attitudes toward the application of OPP in patient care, the importance of OPP in medical education, and professional distinctiveness. One of the original 39 candidate items was returned to factor 1 because it was judged by the investigators to be consistent with the underlying construct of the scale and helped balance the number of forward-scored and reversed-scored items in the final instrument. Two internal consistency estimates of reliability were computed for the revised 25-item Attitudes Toward Osteopathic Principles and Practice Scale (ATOPPS): the Spearman-Brown unequal-length corrected coefficient alpha and the split-half reliability coefficients. Estimates for the split-half coefficients were .89 for part 1 and .87 for part 2. The Spearman-Brown coefficient alpha was .93, indicating substantial internal consistency. The 25-item ATOPPS seems to reflect a continuum of positive and negative attitudes toward OPP. This preliminary report documents reliability for the 25-item ATOPPS. With continued support for its construct validity, ATOPPS provides investigators with a reliable tool to assess the development of attitudes toward OPP.

 

[DropkickMurphy]

$515 for a "biopsy" on a nail fungus...wow!

I'm going to biopsy everything that walks through the door! j/k

Don't laugh, it might just work......

 

[McDoctor]

I dont want to get too far into this because people have blasted me in the past for being "money hungry" when I talk about billing for OMT and making money while treating with OMT. (Funny that these are the same people who covet high end specialties).

Anyway, OMT pays very well.

1. Insurance does cover it
2. You can not only bill for a higher level visit but there are codes to specifically bill for OMT based on # of areas treated
3. There is a large number of docs who bill cash for OMT services (going rate is about 75% of what a chiropractor in the same area charges)

So OMT can net you more than $100/month as someone above said. It can net you $100 per DAY or more if it is billed correctly.

BUT, in order to do that you need to:
- Be good at it...patients wont pay for and wont return if you hurt them or dont help them
- Be efficient. You only lose money if it takes a 15 minute visit and turns it into a 50 minute visit
- Know how to bill for it. We teach it here at PCOM to an extent but you need to see how its done in a real life practice.

Any way you break it down becoming a physician is a CAREER choice. There is no ethical qualms about billing for OMT unless you dont believe it to be an efficacious treatment modality...and thats your own personal opinion.

There is research to back it up.
There are clinical trials to back it up.
There are patients to back it up.

And yes, it is covered by most major insurance plans as well as covered by Medicare.

I have quote the financial numbers somewhere else (all while taking heat from future Dermatologists and Radiologists saying that I am "money hungry") ...anyway, a family doc who uses OMT only a few times/day on only a few patients/day can make upwards of $40,000 more per year than their partner who doesnt do OMT.

Again...not feasible if you arent good at it or cant keep it under a few minutes.

So OMT can pay the mortgage while your other medical practice can cover everything else.

Thats all I have to say about that.

I need to get back to stacking my gold coins now.

Bah humbug.

Alot of family doctors tell me they run into problems when they bill for an E&M (i.e. 99213) and then bill the OMT using a modifier 25 and appropriate procedure code i.e. 98926 with corresponding osteopathic diagnosis. They say they end up getting paid for either the E&M, or the procedure (OMT), but not both. And, of course, the insurance pays whichever fee is lower.

So for a patient who comes in with a headache, you evaluate, examine, determine he/she has tension headache, and decide to treat with OMT and perhaps an NSAID. Lets say you find osteopathic lesions at OA, cervicals, and thoracics and treat appropriately. You would bill this as a 99213 with ICD-9 code for tension headache. And then you would attach a modifier 25 and bill for a 98926 (OMT 3-4 regions) with ICD-9 code for cervical and thoracic somatic dysfunction (739.1 or something like that). I'm told by doctors in my area that in this scenario, most insurances won't pay for both in one visit. That you would need a seperate appointment and submit a seperate bill for the OMT alone in order to be properly reimbursed.

Has this been the case in your experience?
(BTW, sorry to sidetrack).

 

[Nasrudin]

Having said that, I will say that after spending a lot of time in allopathic environments interacting with and teaching MD students and residents, they don't complain about this stuff. I rarely hear MD students vent about "the big bad ACGME" or the "big bad LCME." I know most of them don't agree with all of these organization's policies ("brainwashing disguised as professionalism" or "ivory tower idealism") but they don't have the same degree of disdain that so many DO students express toward their organizations. Maybe it's easier to be apathetic or anonymous when you're in the majority group.

Returning to your OP: I think the real question you ask is, "Why, given all the resources available to various COM's, is the 'packaging' of osteopathic ideas so poor?" If your undergraduate college can make you a fan of their athletic teams in less than four years, why can't a DO school make you a 'fan' of the osteopathic approach to patient care in the same amount of time?

I think that the answer comes down to applicant selection---the three groups you mentioned. Medical school admission is a high stakes endeavor. Pre-meds are smart and there exists ample resources out there to "game the system." I know many, many, many MD students who got accepted to their state's primary-care medical school with no real intention of ever doing primary care. That's the way the game is played.

Similarly, most people willing to put out an ounce of effort can shadow a D.O., get a letter of rec, and tweak up their AMCAS essay for AACOMAS. That's fine. We've all been there.

But, osteopathic admission committees could probably get a little more sophisticated about who they select. There is a sub-set of students, I think that we all know them, who really struggle to adapt to their circumstances. They may excel academically, but they dislike primary care, they dislike OMM, they dislike the whole osteopathic professional culture, etc. Is it any wonder that they disengage? Duh...they never engaged in the first place![/QUOTE]

Interesting ideas. I'm a pre-med in Homeboy's category 2)--and applying both, am geniuinely interested in OMM, and alternative approaches particularly those that pertain to physical medicine.

I think regardless of what filtering process you put on your applicants that they are not the problem with osteopathic medicine. Osteopathic medicine fails them because it maintains a level of hypocrisy and is fastly becoming fossilized in its development. A.T. Still was a potent and relevant reformer of medicine. The problem arises much as it does for cults and religions who seek to maintain a rigid and unevolving structure in the face of a changing environment. How can a philosophy of primary care development maintain itself when the average tuition is skyrocketing. That's insane to think that that idea is sustainable. I have a hard time imaging some old mid-western dude rambling on about such rubbish to medical students who carry the burden of a quarter million in debt and still keep a straight face. It is hypocrisy and grandiose unreality. If Osteopathic medicine sought to accomplish what it professes to seek with competence and with real, well-planned strategies, I would be a willing disciple.

As it stands I want to be a physician more than it would bother me to accomodate the nonsense. I will "game" the process to do so. If somebody sees the initials D.O. and approves of my work and desire to serve humbly then the deal struck with the osteopathic adcomm's will be paid in full in my opinion. They don't exist without us number 2's. If it was all #3's Osteopathic medicine would have been extinct some time ago, in my opinion.

 

[Nasrudin]

JP and drusso,
I understand what you guys are saying, and it makes sense in terms of the whole application process.

My contention is this: how does an interviewer (per JPs example) try to truly understand an applicant's dedication to the osteopathic profession when--other than OMT--pre med students aren't going to see any genuine difference in DO medicine during their shadowing?

I mean, how do applicants truly experience osteopathic medicine from a pre-med standpoint, other than personal opinions a DO may tell them?

Personally, I'd take an applicant that had a burning desire to learn applied A&P over an applicant that for whatever reason thinks DO school is going to make him a better physician, they like "holistic medicine," etc...

This is potent logic. I have tried to make this point as a premed and someone who works in healthcare--there is no discernible professional difference.

What I will get from an osteopathic school is generally high tuition and a harder road towards residency....that's reality. What I will gain is the chance to practice medicine first and secondly some satisfaction in my ability to treat with OMM and perhaps my increased knowledge of anatomy and physical medicine. By default I will also gain from being in the company of those who come from very diverse backgrounds who are willing to risk obstacles in the pursuit of their dreams.

I have yet to hear any cogent argument or shred of evidence that would suggest that this assesment is incorrect or that there is some hidden art to the practice of osteopathic medicine that cannot be discerned by the uninitiated. Until the hierarchy of osteopathic medicine reconciles itself with me--the majority consumer--it will continue to face the threat of extinction and absorbtion back into the fold of mainstream medicine. This is not a bad thing in my opinion either. We're hungry for the chance to be physicians--we're looking for opportunities. We don't have any respect for the peddling of dogma. We look for the bottom line deal that will be struck. We are in the majority. It would be prudent to deal with us as the source and bloodline of your existence and not your malignancy.

 

[drusso]

Alot of family doctors tell me they run into problems when they bill for an E&M (i.e. 99213) and then bill the OMT using a modifier 25 and appropriate procedure code i.e. 98926 with corresponding osteopathic diagnosis. They say they end up getting paid for either the E&M, or the procedure (OMT), but not both. And, of course, the insurance pays whichever fee is lower.

So for a patient who comes in with a headache, you evaluate, examine, determine he/she has tension headache, and decide to treat with OMT and perhaps an NSAID. Lets say you find osteopathic lesions at OA, cervicals, and thoracics and treat appropriately. You would bill this as a 99213 with ICD-9 code for tension headache. And then you would attach a modifier 25 and bill for a 98926 (OMT 3-4 regions) with ICD-9 code for cervical and thoracic somatic dysfunction (739.1 or something like that). I'm told by doctors in my area that in this scenario, most insurances won't pay for both in one visit. That you would need a seperate appointment and submit a seperate bill for the OMT alone in order to be properly reimbursed.

Has this been the case in your experience?
(BTW, sorry to sidetrack).

This is a common game that the third-party payors play some physicians. They would *NEVER* think of doing this do a dermatologist who diagnoses (E&M) a wart and then freezes it off (CPT). You have to appeal and right some angry letters. It eventually gets reversed because they know its illegal.

 

[drusso]

This is potent logic. I have tried to make this point as a premed and someone who works in healthcare--there is no discernible professional difference.

What I will get from an osteopathic school is generally high tuition and a harder road towards residency....that's reality. What I will gain is the chance to practice medicine first and secondly some satisfaction in my ability to treat with OMM and perhaps my increased knowledge of anatomy and physical medicine. By default I will also gain from being in the company of those who come from very diverse backgrounds who are willing to risk obstacles in the pursuit of their dreams.

I have yet to hear any cogent argument or shred of evidence that would suggest that this assesment is incorrect or that there is some hidden art to the practice of osteopathic medicine that cannot be discerned by the uninitiated. Until the hierarchy of osteopathic medicine reconciles itself with me--the majority consumer--it will continue to face the threat of extinction and absorbtion back into the fold of mainstream medicine. This is not a bad thing in my opinion either. We're hungry for the chance to be physicians--we're looking for opportunities. We don't have any respect for the peddling of dogma. We look for the bottom line deal that will be struck. We are in the majority. It would be prudent to deal with us as the source and bloodline of your existence and not your malignancy.

Of course there is no "hidden art." But, it is interesting to me that few applicants to DO school really get invested in the idea of joining a unique social movement in health care---they only see it as another means to an end---not that there's anything wrong with that, but it creates difficulties in maintaining internal cohesion that is a requirement for minority groups to be successful. Only the USA has two historically separate branches of medicine and two fully recognized medical degrees; its early practitioners faced a lot hardships and overcame adversity; it re-invented itself (at least 3 times) as larger needs required. It's an archetypally American endeavor in that way. I think that those subtleties are appreciated later.

BTW, your road won't be significantly harder in the residency/career path. It's not like all DO's are doomed to primary care medicine. There is certainly still regional variation, but I've encountered DO's literally in every specialty.

 

[group_theory]

What I will get from an osteopathic school is generally high tuition and a harder road towards residency....that's reality

Osteopathic schools are not more expensive than their allopathic counterpart ... there is just a higher percentage of private osteopathic schools compare to allopathic schools. A private DO school and a private MD school will have comparable tuition

And since you are not paying tuition based on the average of all DO schools but to one particular schools, look at the tuition at that one school instead of DO schools in general.

*I've seen some posts on SDN where premeds have said they're not applying to DO schools due to high tuition price, yet have applied to NYMC, BU, GWU, etc

 

[bla_3x]

I love the OP! I would sign that in a heartbeat.

There are a lot of core problems in our profession...I don't want to restate the OP.

This "identity crisis" that the AOA is going through is so annoying to me as a future DO. I feel so embarrassed at times that our governing body acts more like a high school student council than a professional medical organization.

Regarding the GPA/MCAT/OPP issue and admissions, it is clear that in reality these cant "really" predict academic aptitude/future ability as a physician/etc. Many of my friends from my class and others have told me their scores/grades and they are among the top performers in med school. Schools know that regardless of taking the highest scores they are likely to turn out good docs (taking all the other parts of the application into mind). A lot has to do with perception. A big aspect to why "going DO" is thought of as a second chance route is that they are seen as taking the people with scores not "worthy" of the allo route (at least at my undergrad). So in routinely accepting students with lower #s but who "seem" to be really in tune with osteopathy (and this is REALLY easy to fake with just very little prep!) that perception will continue. I am just pointing that out, if that is what the body as a whole are cool with than great...I could give a rats !@!@ about other peoples ignorant perceptions!

How to increase the competitiveness of admissions? maybe not opening up schools like 7-11s and lowering the class sizes to under infinity! 150-200+/class...come on! Although, I am a realist and its is just about the $$...another well known black dot on our governing body! Yes, all organizations will be found corrupt at some level, but the AOA is just so good at it!

I know I am not saying anything novel...I just wanted to vent a bit. Ahhh better....wait...

 

[bla_3x]

...just a couple more points that bug me:

COMLEX:
What a poor excuse for an exam!! I took both the USMLE and COMLEX and good lord what a difference in quality of questioning and question relevance! Has there been an objective third party review of both of these exams? B/c after taking them I can't see how the comlex is allowed to be in existence. I had to actually think a bit on a lot of the USMLE Q's but literally breezed through the comlex stuff..except for the way over the head legal crap and redundant opp questions!

Osteopathic residencies:
At least here in the west...what a difference, in a bad way! In general (i have rotated at only three in different specialties, but they are so much alike it must be a rule to be this way) didactics, if existent, are at a level so far below the allo one's I have rotated it's disgusting. Rounds/teaching is very ramshackle and the use of true evidence based medicine is VERY poor...to the point of being dangerous to pts at some points! And the overall organization is less and the level of
"drama" withing the programs makes them seem so childish.

I don't want to make generalizations, since I have heard good things from people about our programs in the Midwest/east. But seriously, these three were so alike it is scary!

 

[San_Juan_Sun]

Osteopathic residencies:
At least here in the west...what a difference, in a bad way! In general (i have rotated at only three in different specialties, but they are so much alike it must be a rule to be this way) didactics, if existent, are at a level so far below the allo one's I have rotated it's disgusting. Rounds/teaching is very ramshackle and the use of true evidence based medicine is VERY poor...to the point of being dangerous to pts at some points! And the overall organization is less and the level of
"drama" withing the programs makes them seem so childish.

Hey bla, hope things are well with you.

I know you totally put a disclaimer on the DO residenies comment. Like you, I've been exposed to the less than stellar osteopathic education out west.

However, I was definately impessed with my rotations in Ohio and Michigan. Osteopathy is much, much more developed back east.

It of course highlights what a poor job the AOA is doing to support the osteopathic communities growth. For starters, I would require each new school to financially support residencies (and more than just FP, I'm talking IM, OB, Surg, ER, etc.... hospital based stuff). I would also require private schools to annually publish the financial assets of the school.

 

[bla_3x]

Hey SJS
All is well here, just finishing up the interviews. I hope things are good with you as well!
I know, I am sure my whole educational experience would be different if I went to school in the "fertile lands" I just find it amazing that the AOA or any body for that matter would allow such lack luster efforts out here.

I am so with you on your thoughts, these schools are bringin' in some serious green. And although most of our schools are private, and the whole capitalist argument, yadda, yadda, yadda, there should be some required commitment to graduate medical education other than putting your name on an OPTI. They can afford to do that AND get the president a new 7 series BMW

And diddo on the specialty thing!!

Hey bla, hope things are well with you.

I know you totally put a disclaimer on the DO residenies comment. Like you, I've been exposed to the less than stellar osteopathic education out west.

However, I was definately impessed with my rotations in Ohio and Michigan. Osteopathy is much, much more developed back east.



It of course highlights what a poor job the AOA is doing to support the osteopathic communities growth. For starters, I would require each new school to financially support residencies (and more than just FP, I'm talking IM, OB, Surg, ER, etc.... hospital based stuff). I would also require private schools to annually publish the financial assets of the school.

 

[San_Juan_Sun]

Hey SJS
All is well here, just finishing up the interviews. I hope things are good with you as well!
I know, I am sure my whole educational experience would be different if I went to school in the "fertile lands" I just find it amazing that the AOA or any body for that matter would allow such lack luster efforts out here.

I am so with you on your thoughts, these schools are bringin' in some serious green. And although most of our schools are private, and the whole capitalist argument, yadda, yadda, yadda, there should be some required commitment to graduate medical education other than putting your name on an OPTI. They can afford to do that AND get the president a new 7 series BMW

And diddo on the specialty thing!!

Things are good for me. All interviews are finished, just waiting to graduate now. Completely agree that private schools ought to make money, I'd just like to more of an effort that the transparent garbage some schools put up.

And don't forget the presidents new jet.

 

[jhug]

SJS, glad to hear things are going well for you!
i think i'm off to st.v's after speding a month in the 250 square foot call room for a month
i would add to your request for new programs to have residencies that they be QUALITY residencies...none of this community hospital with 60 beds in a rural town with an ICU the size of our biggest bathroom and no dedicated faculty to oversee teaching (or lack thereof)...

 

[San_Juan_Sun]

SJS, glad to hear things are going well for you!
i think i'm off to st.v's after speding a month in the 250 square foot call room for a month
i would add to your request for new programs to have residencies that they be QUALITY residencies...none of this community hospital with 60 beds in a rural town with an ICU the size of our biggest bathroom and no dedicated faculty to oversee teaching (or lack thereof)...

I completely agree.

Sounds great about St. V's. Nice hospital, strong residents, great city.

How was the month in the call room for you? Were you in the one without the TV or anything? You can tell which one I was in, I scratched "God will give me justice" on the back of the door.

 

[jhug]

i didn't have a tv...but i didn't notice your little plea scratched into the door either. What is that all about?
i loved the city, hospital, people, pathology...it seems like a good fit. (i'm just going through the similar dating feeling of once you get the girl you wonder if you really like her/is she the best one out there type thing)...make any sense?
oh, and the AOA sucks

 

[drlisa0318]

I love the OP! I would sign that in a heartbeat.

There are a lot of core problems in our profession...I don't want to restate the OP.

This "identity crisis" that the AOA is going through is so annoying to me as a future DO. I feel so embarrassed at times that our governing body acts more like a high school student council than a professional medical organization.

Regarding the GPA/MCAT/OPP issue and admissions, it is clear that in reality these cant "really" predict academic aptitude/future ability as a physician/etc. Many of my friends from my class and others have told me their scores/grades and they are among the top performers in med school. Schools know that regardless of taking the highest scores they are likely to turn out good docs (taking all the other parts of the application into mind). A lot has to do with perception. A big aspect to why "going DO" is thought of as a second chance route is that they are seen as taking the people with scores not "worthy" of the allo route (at least at my undergrad). So in routinely accepting students with lower #s but who "seem" to be really in tune with osteopathy (and this is REALLY easy to fake with just very little prep!) that perception will continue. I am just pointing that out, if that is what the body as a whole are cool with than great...I could give a rats !@!@ about other peoples ignorant perceptions!

How to increase the competitiveness of admissions? maybe not opening up schools like 7-11s and lowering the class sizes to under infinity! 150-200+/class...come on! Although, I am a realist and its is just about the $$...another well known black dot on our governing body! Yes, all organizations will be found corrupt at some level, but the AOA is just so good at it!

I know I am not saying anything novel...I just wanted to vent a bit. Ahhh better....wait...

This thread has been fascinating reading. Just to throw a different perspective on things, read the 2001 President's Address to the Association of American Medical Colleges. Some of the points that have been made in this thread are touched on in it, as well as quite a few others that haven't been addressed here at SDN.
http://www.aamc.org/newsroom/pressrel/2001/011104a.htm

 

[homeboy]

This thread has been fascinating reading. Just to throw a different perspective on things, read the 2001 President's Address to the Association of American Colleges. Some of the points that have been made in this thread are touched on in it, as well as quite a few others that haven't been addressed here at SDN.
http://www.aamc.org/newsroom/pressrel/2001/011104a.htm

Thanks for the link--good speech!