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Osteopathic medicine's growing pains

A boom in numbers is leading to criticism—and an identity crisis

From the November 1997 ACP Observer, copyright 1997 by the American College of Physicians.

By Jennifer Fisher Wilson

When medical educators in Arizona were planning to open a new school of osteopathic medicine, they faced passionate opposition from the local medical community. There was already a residency agreement in place with an out-of-state osteopathic medical school, and many medical educators and physicians felt that the area simply didn't need another medical school producing more doctors.

Despite those concerns, however, the University of Arizona College of Osteopathic Medicine opened its doors to students this fall. It was the third new U.S. osteopathic medical school to open this year.

At a time when much of the medical profession is facing the prospect of downsizing, osteopathy is experiencing explosive growth. In the last decade alone, the number of osteopaths in this country has grown by 50%, their popularity due in large part to their focus on primary care. By the turn of the century, about 45,000 osteopaths are expected to be practicing in the United States. Each year, the nation's 19 osteopathic medical schools—14 of which have opened since 1968—enroll roughly 2,000 new students.

But that growth is causing something of a schism between osteopaths and their allopathic counterparts. Like those opposed to the new school in Arizona, many in the medical community question whether any specialty, even one like osteopathy that focuses on primary care, should be opening new schools to train new doctors. And despite osteopaths' growing popularity among patients and health plans, many in the allopathic community still have questions about the quality of osteopathic education and training, especially since so many graduates go on to specialize in internal medicine.

And even within the osteopathic community, the growth is drawing attention to the identity crisis faced by the specialty. While osteopathic leaders emphasize osteopaths' unique identity, many osteopaths would rather not draw attention to their uniqueness. Many actually complete their training in allopathic residency programs, in effect turning away from osteopathic principles.

Nonetheless, osteopathy's boom in numbers is good news for the profession. A decade ago, many thought osteopathy was an also-ran specialty. But today, as the American Osteopathic Association celebrates its 100th anniversary, the specialty has been buoyed by smart maneuvering that has given osteopaths the same privileges as allopaths. More students are applying to osteopathic schools and more patients are choosing to see doctors of osteopathic medicine (DOs).

Identity crisis

The cornerstone of osteopathic education is osteopathic manipulative treatment (OMT), a technique that osteopaths use to assess and treat conditions like low back pain, asthma, carpal tunnel syndrome, sinus problems and migraines. It is part of osteopath's training that teaches students to look at patients' overall health, not just their individual diseases.

Such skills may be in demand, but many osteopathic leaders lament that too many osteopaths downplay their training. In a recent editorial for the Pennsylvania Journal of the American Osteopathic Association, Leonard Finkelstein, DO, the president and CEO of the Philadelphia College of Osteopathic Medicine, wrote that for too long too many osteopaths have thought of themselves as second-class citizens. For years, he wrote, "Too many hid the fact that they were osteopathic physicians by putting 'Dr.' in front of their name instead of 'DO' behind it."

But the truth is that many practicing osteopaths really don't want patients to distinguish between the two specialties. Many choose an allopathic residency with the hope that it will improve their prospects in the job market and help them fit in with the medical field in general. "Real or imagined, the perception has always been that some of the allopathic programs are better so students want to go to those," Dr. Finkelstein said.

Yet while many osteopaths are ambivalent toward their specialty, nearly 60% belong to the American Osteopathic Association (AOA). Osteopathic leaders view those numbers as a mandate, and they have decided to emphasize their distinctiveness from other specialties. When the AMA invited the AOA to send voting members to its House of Delegates recently, for example, the AOA declined. "Now is the time to emphasize the DO after our name, and to market ourselves as such," Dr. Finkelstein said.

Despite that kind of official bravado, osteopathic leaders are concerned about their future. Cases like that of Catherine A. Pesek, ACP Associate, have them worried that the ranks of osteopathy are slowly being diluted.

While Dr. Pesek entered osteopathic medical school, she chose an allopathic internal medicine residency, and later entered an allopathic cardiology fellowship, both at the University of Iowa. Dr. Pesek, who is still in her cardiology fellowship, believes that osteopathic medical school has made her a more well-rounded physician. But she said the best residency she could find, was in allopathic, not osteopathic, medicine.

Even as the specialty grows and opens up more schools, 65% of osteopaths still opt to finish their training in an allopathic residency program. That's despite the fact that there are 150 AOA-approved osteopathic training programs, enough to accommodate most osteopathic medical school graduates.

"A fair number of these students do not come back into the profession," said Douglas Wood, DO, PhD, president for the American Association of Colleges of Osteopathic Medicine. "They stay where they've done their training."

Dr. Pesek, for example, said that she is proud of her DO background, but added that she does not currently practice osteopathic techniques like OMT because it is not called for in her training program. In fact, she said that during her residency, her clinical care was so similar to that of the allopathic doctors that patients didn't seem to notice a difference, except to occasionally compliment her on her excellent bedside manner.

Training issues

This identity crisis has only helped perpetuate debate on whether DOs measure up to MDs. Off the record, allopathic physicians have said that many of their allopathic colleagues still think that osteopaths are people who couldn't get into medical school.

Until osteopathic medicine standardized its admissions and modified its curriculum and philosophies to be more like allopathic requirements, the specialty did in fact suffer a perception of quackery. But after extensive efforts to gain respectability, osteopaths now hold the same legal authority to practice as allopaths. By the 1960s, all 50 states had granted DOs the right to practice medicine. In 1966, the U.S. government ordered the armed forces to accept DOs for military service.

The science prerequisites at osteopathic medicine schools now match those at many allopathic medical schools: two courses in general chemistry, two in organic chemistry, two in physics and three in biology. Four years of osteopathic medical school includes courses commonly found in allopathic medical school courses, but with an emphasis on osteopathic philosophies. All osteopathic graduates complete a one-year internship—usually in an osteopathic program—rotating through the primary care fields.

"I think that osteopaths have gotten bad press from people who don't understand them," said Herbert S. Waxman, FACP, the College's Senior Vice President for Education. "Once you're at the top level of an osteopathic class, the students are pretty much interchangeable with allopathic students." Dr. Waxman added, however, that the number of high-quality students may not go as deep in an osteopathic class.

Some say that may be due to the depth of the osteopathic education itself. The new school in Arizona has hired just eight full-time faculty—far fewer proportionately than the number at most allopathic medical schools. "They seem to have a tremendous lack of depth when it comes to clinical teaching, no evidence of an animal laboratory, and no hospital, so their microbiology is lacking," said Michael Grossman, FACP, ACP's Governor for Arizona and president and CEO of the Phoenix Area Medical Education Consortium associated with the University of Arizona College of Medicine, an organization that coordinates residency programs in the Phoenix area. "They're basically learning from textbooks." The clinical training for students in the new school occurs mainly through community-based rotations, he said.

There may also be some significant differences in training. When Marvin Kirschner, FACP, visited an osteopathic medical school to learn more about osteopathic training in preparation for accepting osteopathic residents into his program for the first time, he found some significant differences between allopathic and osteopathic education—particularly in the training facilities where osteopath students do their clerkships.

"There are a number of quite good hospitals and a number of not so good hospitals," explained Dr. Kirschner, who is emeritus chairman of the internal medicine program at Newark Beth Israel Hospital in Newark, N.J. "If osteopathic students get assigned for their entire clerkship to one of these no-name places, their education could be very spotty."

Filling a need

Despite concerns about training and education, osteopathic medicine has been able to expand largely because it fills a need for primary care physicians. More than 60% of osteopathic graduates ultimately practice primary care, and osteopathic medicine's philosophies translate well to rural and low-income areas, where general medicine practitioners are needed—but few allopathic physicians choose to go.

Although osteopaths account for only 6% of the total physician population, almost 10% of the nation's primary care physicians are osteopaths.

Osteopath's primary care leanings helped garner support for the Pikeville College School of Osteopathic Medicine in Pikeville, Ken., which welcomed its first class of 60 this fall. "The mission here is to produce primary care physicians who will stay in Kentucky and Appalachia," said John A. Strosnider, DO, the dean of the College. "There were no physicians coming to eastern Kentucky and the community support was here to start its own school."

And at the San Francisco School of Osteopathic Medicine, which also accepted its first class of 60 this fall, the justification for the new school is similar. "The Northwest is an area that is in need of general practitioners," said the school's dean, Bernard Zeliger, DO. "We're trying to get students from those areas that will return to those areas."

Health care policy may play in osteopathic medicine's favor. If Congress mandates cuts in how many IMGs can enter U.S. residencies, experts say, osteopathic graduates may find that more residencies accept DOs than had before, Dr. Kirschner said.

Even the economic barriers that led many osteopaths to downplay their training are disappearing. Until recently, osteopaths worried that managed care favored MDs over DOs when offering contracts. But according to John Crosby, JD, the new president of the AOA, this is no longer the case. "I think we've turned the corner and have a bright future in terms of relations between managed care organizations and osteopathic medicine," he said.

Officials at Oxford Health Plans, based in Norfolk, Va., for instance, said that they don't discriminate between MDs and DOs when creating physician panels. And like many managed care plans, SummaCare Health Plan, based in Akron, Ohio, bases contracting decisions on board certification, not the type of degree a physician has. The HMO even has a specific billing code for OMT, although officials said it is not used very often.

When practiced, osteopathic medicine's philosophies—incorporating prevention and low-cost interventions like OMT with a focus on primary care—fit right into managed care's cost-efficient health care strategies. A study by the Center for HealthCare Performance in Toledo, Ohio, has demonstrated that osteopathic-centered medical care can lead to fewer average bed-days, lower average payment per patient and lower average related expenses.

A new bond?

Finally, there are signs that osteopathic medicine's general acceptance by the medical community may lead to better relations with allopathic physicians. Some are even predicting that allopathic and osteopathic primary care physicians may benefit from closer association.

"While our training philosophies are different, there's a natural alliance in terms of speaking with one voice on issues of primary care versus specialists," said William J. Hall, FACP, Chair of ACP's Board of Governors. "I think there's a lot of reason to think that the two camps will come together here."

Even in Arizona, where the new school has many allopathic physicians up in arms, critics go to great pains to explain that they are not anti-osteopaths. After all, they point out, there are five osteopathic hospitals in the state, in addition to the osteopathic medical school.

So despite their concerns about producing too many physicians, the critics realize that ultimately a partnership between the two schools is inevitable. "At some point, we're going to have to come to grips with this," said ACP's Governor for Arizona Dr. Grossman. "Right now, it's still an emotional issue."

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