Can-DO strategy: Osteopathic medicine survives, and thrives

The discipline has flourished since its 19th-century birth. Osteopathic physicians, now nearly 50,000 strong, say collegiality spurs their progress, and the future looks bright.

By Myrle Croasdale, AMNews staff. June 16, 2003.

Ed Stiles was pursuing his DO degree in Kirksville, Mo., in 1961 when he discovered his profession might be about to disappear.

The California Medical Assn. and the California Osteopathic Assn. were merging, and most of the state's DOs were becoming MDs. The osteopathic licensing board was abolished, and the state osteopathic college was taken over by the MDs. This was a major loss for the American Osteopathic Assn., and it was unclear if the trend would continue.

With this article

Making the grade

Long and winding road for recognition

"We didn't know if there'd be such a thing as a DO by the time we graduated," Dr. Stiles said.

Forty-two years later, the osteopathic medical profession has not just survived, it has thrived. In 1960 there were 13,708 DOs and five osteopathic medical schools. By 2002 there were 49,210 DOs and 19 schools. Experts predict that the number of DOs will grow to 95,400 by 2020, and the number of colleges is likely to increase as well.

Dr. Stiles is now a professor at Pikeville College School of Osteopathic Medicine in Kentucky, one of the AOA's newest schools. Prospects for Pikeville graduates are dramatically different from what they were when Dr. Stiles accepted his degree.

"I think our future is extremely bright," he said.

In 1960 there were 13,708 DOs and 5 osteopathic medical schools; in 2002, 49,210 DOs and 19 schools.

When he was starting out, DOs had yet to win full practice rights in all 50 states. Now they are leaders at prestigious institutions such as the Cleveland Clinic -- something Dr. Stiles never dreamed was possible in the '60s.

A combination of factors has contributed to such successes.

Even as allopathic medical schools have steered clear of expansion, keeping enrollment steady for 20 years, osteopathic schools have expanded. In 2001, there were 3,043 first-year students -- an increase of 881 from 1993.

The AOA also has moved to create new medical schools, securing development dollars by successfully selling the idea that building osteopathic schools in underserved areas will attract regional students who will be more inclined to practice there, as will DOs who train in regional resident programs. Another selling point for these schools is the focus on primary care. To date, 47.7% of practicing DOs are in family medicine, and 8.2% specialize in internal medicine.

Promises kept

If the Pikeville school is any example, the AOA is keeping its promises.

Seventy percent of the three classes that have graduated from Pikeville so far have stayed in the area, said Michael Murphy, DO, who helped create five residency programs in the region as executive director of the Appalachian Osteopathic Postgraduate Training Institutions Consortium.

A tuition-forgiveness program funded by the state of Kentucky ensures that more than 200 Pikeville graduates will stay in the state as primary care doctors over the next few years. That's precisely what Kentucky's politicians and coal industry leaders were counting on when they helped bankroll the school.

Pikeville is the latest of five medical schools the AOA has opened in the past 10 years. The 20th, the Edward Via Virginia College of Osteopathic Medicine in Blacksburg, Va., will welcome its first class of 150 students this fall. Campuses are being discussed in Florida and Nevada, and there's interest in Georgia, Colorado and Utah.

To be an MD or a DO?

DO schools are competing with MD programs for applicants. Students have a variety of reasons for picking the osteopathic path.

Older applicants are more likely to be accepted by osteopathic schools. Applicants who have DOs in their families want to stay loyal to the profession. For some, the added training in physical manipulation is the draw. But there's a sense of collegiality, of family, that may be equally appealing to applicants.

47.7% of practicing DOs are in family medicine, 8.2% in internal medicine.

"I applied to MD and DO programs to see what my options would be," said Andrew Farber, a third-year student at New York College of Osteopathic Medicine and 2003-04 chair of the Council of Osteopathic Student Government Presidents. "Had I not had the fortunate experience of visiting NYCOM, I might have made the wrong decision."

Farber said the program and facilities were on par with the MD schools he investigated. He knew of the osteopathic emphasis on the whole person. What might have cinched the deal, however, was his campus interview.

One of the deans happened to be free while Farber was visiting.

"He talked to me for a whole hour," Farber said.

Chris Yonts, president of the Student Osteopathic Medicine Assn. chapter at Pikeville, said such efforts are typical.

When Yonts had to miss class for an out-of-town trip, his stop by the professor's office to pick up the missed material turned into a private lecture.

A growing number of DOs have both allopathic and osteopathic board certification.

"You can't beat that," Yonts said. "We always have access to our professors. At [a large medical school], I wouldn't know where the professor's office was."

The sense of collegiality continues into the working world. It's not uncommon for DOs to know all of their colleagues within the same specialty. It's also not uncommon to have more than one DO in a family.

Martin Levine, DO, a family physician in New Jersey, has 19 in his. "At the Kirksville graduation, every year they take a picture of graduates with a mother or father or grandfather who is a DO," he said, "That's always 20 to 30 out of 100."

Improving the MD-DO relationship

While DOs cultivate a sense of community within their ranks, they've also developed better relationships with MDs.

According to data published in the Sept. 2, 2002, JAMA, the number of osteopathic graduates in ACGME-approved residencies rose 42% from 1996-97 to 2001-02.

There are several reasons for the influx. Osteopathic schools are graduating more doctors. Corporate mergers have resulted in the closing of some osteopathic hospitals and the loss of their residencies. Of the osteopathic residencies left, three-quarters are in just six states, so some graduates who want to practice elsewhere consider allopathic programs. Also, the migration of MDs into subspecialties has left family medicine residencies empty, and DOs are available to fill them.

Mitch Kasovac, DO, the AOA's director of osteopathic GME development, said AOA officials are seeking to expand the geographic reach of its residency programs by asking non-teaching hospitals to start programs. The AOA has also changed its accreditation standards so ACGME programs can win AOA approval with the addition of osteopathic oversight.

"During the '80s and early '90s, DOs weren't embraced by ACGME programs," Dr. Kasovac said. "[Now] I've had many inquiries from ACGME programs to become AOA-accredited."

He attributes this to the quality of graduating DOs. When MDs meet DO grads during clerkships, they end up asking their hospitals to open residencies to DOs. Some MDs even take advantage of the DO residents' osteopathic classes on manipulative treatment.

Howard Levine, DO, a past president of the AOA and father of Dr. Martin Levine, said that when he first started to practice in the late '50s, he had to threaten to sue before he was given hospital privileges. "The trick at that time was getting the opportunity," Dr. Howard Levine said. "Now they're only too glad to have most DOs, since they're family docs and they fill the beds."

For Niren Raval, DO, director of the dually accredited family medicine program at Arrowhead Regional Medical Center, Colton, Calif., training MDs and DOs together is a nonissue. "We've had dual accreditation for a while, so it doesn't even come up if you are a DO or MD," he said. Dr. Raval, like a growing number of DOs, holds allopathic and osteopathic board certifications.

Joint training programs raise the question of whether osteopathic physicians could eventually be absorbed by allopathic physicians, as they almost were in California in 1961. Dr. Howard Levine said that wouldn't happen now, because manipulation techniques give DOs something extra to offer, which is welcome at a time when more patients are seeking alternative medicine. The patients, he said, also have a deep loyalty to the profession.

Even as more DOs seek specialties outside of family medicine, the profession intends to stay united. In 2005, all specialists will meet in a joint conference, including surgeons and obstetricians, who previously have held separate meetings.

Dr. Stiles is confident that DOs will retain their distinctive skills and culture as their numbers grow. He's seeing this at Pikeville, where all the clinical instructors are MDs. Mutual respect between the professions is established from the outset.

"We've shown that [DOs] can work with the medical [MD] profession," he said. "In Pikeville, we have broken the mold."

ADDITIONAL INFORMATION:

Making the grade

Osteopathic physicians were once considered second-rate by allopathic physicians. But the professions' medical school curriculums are similar, covering the same basic sciences and core clinical studies. Over time, DOs have improved their ability to pass Step 2 and Step 3 of the U.S. Medical Licensing Examination on the first try.

Percentage who passed the U.S. Medical Licensing Examination the first time:

1997 2002

Step 1

MD degree 95% 92%

DO degree 78% 70%

Step 2

MD 95% 97%

DO 79% 89%

Step 3

MD 94% 95%

DO 92% 97%

	1997	2002
Step 1
MD degree	95%	92%
DO degree	78%	70%

Step 2
MD	95%	97%
DO	79%	89%

Step 3
MD	94%	95%
DO	92%	97%

Source: National Board of Medical Examiners

Data only for U.S. medical school graduates

Long and winding road for recognition

The osteopathic medical profession was birthed near the end of the 19th century, a time when many medical approaches to healing existed, though those espousing a nontraditional view were considered suspect.

Any physician could open a medical school to train doctors then. Quackery was commonly mixed with science. There was no federal oversight, and the public was left to sort out the good from the bad on its own.

Andrew Taylor Still, MD, had been developing his osteopathic manipulation techniques, and it was 1889 when he had gained enough of a reputation to open an infirmary in Kirksville, Mo., according to the AOA Yearbook: Historic Background of Osteopathic Medicine.

Dr. Still's concept was that the body was like a machine, and it should work well if it is mechanically sound. Based on this idea, he used manipulation to improve circulation and to correct altered body mechanics.

In 1892 the American School of Osteopathy was chartered, and the organization that was to become the American Osteopathic Assn. was formed in 1897.

Dr. Still's methods were greeted with skepticism by much of the medical community, and osteopathy was condemned by the emerging American Medical Association.

During the 1920s and '30s, DOs fought for compensation from federal health programs, according to the AOA Yearbook. Osteopathic hospitals were built, since DOs were denied privileges at their local hospitals. It wasn't until 1950 that DOs were able to get a foothold into the public hospital system, when a Missouri court became the first to grant them the right to practice in public hospitals as full physicians and surgeons.

During this time, DOs hit a critical juncture in California. In 1919, California's medical board had refused to examine DOs, and separate boards of examiners were created for the two medical branches.

By 1961 the California Medical Assn. and California Osteopathic Assn. agreed to merge, and the College of Osteopathic Physicians and Surgeons was converted to an allopathic medical school.

Many expected this to be the beginning of the end for the profession, since osteopathy lost its largest state group, one of its six colleges and many of its training hospitals.

Yet osteopaths persisted, and another milestone was reached in 1967 when DOs won the right to serve as physicians in the military.

By 1973, DOs had gained full practice rights in all 50 states.

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