Topic: Osteopathic Medicine

[sakuma]

There were a couple other threads on this topic but I really wanted to start a discussion concentrated on whether or not there should be "Osteopathic Medicine." I should preface that this only refers to the American definition of DO.

This isn't designed to be the place to discuss whether DOs are quacks or if they are comparable to MDs. It has been discussed many times in this forum, on science-based medicine, on wikipedia, and on many other sources.

Osteopathic Medicine is like Alternative/Complimentary/Integrative Medicine in the sense that the modifier to the word "Medicine" suggests that it is another form of medicine, but medicine is a broad category that refers to all scientific healing and anything that is non-scientific can't be medicine. If their are components of osteopathy that are not used by allopathic medicine but they are scientific they should be adopted. If there are components osteopathy that don't work they should be rejected from the discipline. If both of those points are true, then the professions are the same and there should only be one discipline of medicine and only one type of medical doctor.

Thoughts? Disagreements?

[Xptical]

If both of those points are true, then the professions are the same and there should only be one discipline of medicine and only one type of medical doctor.

Thoughts? Disagreements?

I agree with this statement *so* much.  If you want to practice medicine, then go to medical school.  A "real" medical school.  I really don't understand how homeopaths get away with what it is they do.  Arrest the bastards and throw their asses in jail for practicing without a license.

Same for chiropractic, Chinese medicine, faith healing, and all those other things.  Hell, if a preacher tells members to pray for someone's health, throw his ass in the slammer.

[drizz]

You say you don't want to talk about whether osteopaths are quacks but that argument is key to the rest of your post. If they are quacks, they should be treated as such. If not, their practices should be integrated into the body of knowledge that we call medicine and there should never be such a thing as an osteopathic doctor.

As it stands, they are quacks, performing unscientific treatments. Any scientifically legitimate treatments they administer are by accident and not through any devotion to logic and evidence.

[Chew]

Very recent news: Amputee patient sues osteopath who provided holistic treatment

[drizz]

Very recent news: Amputee patient sues osteopath who provided holistic treatment

So I guess "go home and take a nap" is not one of the osteopathic practices that should be integrated into real medicine?

[sakuma]

Thanks guys for your comments. That story of the osteopath being sued because of amputations is sad. The problem is that this is that this looks like a basic malpractice lawsuit. If the osteopath had the incorrect diagnosis because he was basing his analysis on something unscientific then he was in the wrong but they didn't list anything in the article that his osteopathic training is what led him to the wrong conclusion.

You say you don't want to talk about whether osteopaths are quacks but that argument is key to the rest of your post. If they are quacks, they should be treated as such. If not, their practices should be integrated into the body of knowledge that we call medicine and there should never be such a thing as an osteopathic doctor.

So I said discuss DO quackery because my analysis of the previous discussions of this issue on this forum suggested there was some sort of consensus that the profession is not currently quackery but has it's origins in pseudoscience. Steve said on Science-based Medicine that he knows many great DOs and many others have echoed the same sentiment. It seems clear that they receive thorough enough education to be good doctors (not that all are). If that is not established enough I guess we should discuss it.

If it is established that DOs can be great doctors I am basically echoing the same sentiment as drizz: integrate proven modalities into medicine and disband the DO brand.

[drizz]

I think it's a bit more complicated though. A couple of questions for you:

1) If there is effectively little/no difference, why are DO and MD different designations?

2) What are some scientifically valid practices/treatments that osteopaths use that are not already integrated into standard medical practice?

[AQB24712]

I don't know where all of you are, though it's important to note that sakuma wanted to discussion "only the American definition of DO."

In the United States, DOs are doctors.  They're not "medical doctors" because the degree is Doctor of Osteopathy, not Medical Doctor.  But they are licensed physicians, and can do anything that an MD can do.  In other countries, the title "osteopath" carries no such legitimacy.  Also please note that osteopathic physicians practice osteopathic medicine, not osteopathy. 

Yes, Andrew Taylor Still's original philosophy focused on "treating the body by improving its natural functions" and "included manipulation designed to improve circulation and to correct altered mechanics," and he went on to disavow the use of drugs, which smells very much like contemporary chiropractic, this is not what osteopathic medicine is now. 

Osteopathic physicians receive the same training as allopathic physicians—residencies, internships, board certification, etc.  They can specialize.  They have hospital privileges.  They are additionally trained in osteopathic manipulative treatment, which, yes, again, smells a little chiropractic.  But it's related to the osteopathic philosophy of considering the body as a whole, and how the various systems work together.  And it's not the DOs' only tool, as it is for DCs. 

Here's an overview of osteopathic medicine, from the American Association of Colleges of Osteopathic Medicine.

I should perhaps stop here to note that I'm all up in this bidness because my mother, a PhD physiologist, was a founding faculty member of the West Virginia School of Osteopathic Medicine.  I've been learning about all of this for 40 years.  I've seen the DOs' struggle to be accepted as physicians, not quacks, and not chiropractors.  Almost all of my doctors throughout my life have been DOs; I've sought them out because I appreciate their philosophy.  I've had OMT for chronic muscle spasms.  My current doctor is an MD in a group practice with DOs.  One of my mother's former students did her knee replacement surgeries.

WVSOM epitomizes another aspect of osteopathic medicine:  its emphasis on family/general practice and on placing physicians in rural and other underserved communities.  From the AACOM page linked above:

The osteopathic medical profession has a proud heritage of producing primary care practitioners. In fact, the mission statements of the majority of osteopathic medical schools state plainly that their purpose is the production of primary care physicians. Osteopathic medical tradition preaches that a strong foundation in primary care makes one a better physician, regardless of what specialty they may eventually practice.

Today, when the challenge of ensuring an adequate number of primary care physicians extends to osteopathic medicine, the majority of most osteopathic medical school graduates choose careers in primary care. Osteopathic medicine also has a special focus on providing care in rural and urban underserved areas, allowing DOs to have a greater impact on the U.S. population's health and well-being than their numbers would suggest. While DOs constitute 7 percent of all U.S. physicians, they are responsible for 16 percent of patient visits in communities with populations of fewer than 2,500.

I think it's a bit more complicated though. A couple of questions for you:

1) If there is effectively little/no difference, why are DO and MD different designations?

Because MDs would not have it.  They would not recognize DOs as physicians.  They would not admit them to the AMA (hence the formation of the AOA).  They would not give them hospital privileges.  The two schools work together much more collegially now, but I don't know what the prevailing wisdom is about possibly merging the two associations.

2) What are some scientifically valid practices/treatments that osteopaths use that are not already integrated into standard medical practice?

Osteopathic manipulative treatment is the difference, along with the emphasis on primary care, the holistic approach, and the focus on community service.  It seems to me that OMT is less emphasized than it used to be, and I suspect that the philosophical differences are the reason for the continued presence of the AOA. 

I'll ask my mother about that this weekend.  She is retired (professor emerita, boo-yah), but she is a member of the West Virginia Board of Osteopathy, so she knows the current buzz.

Very recent news: Amputee patient sues osteopath who provided holistic treatment

It appears that this person was not an osteopathic physician.  But definitely a dangerous quack.

[sakuma]

Thanks for your thoughtful and thorough reply AQB24712

Regarding the possibility of merging MD and DO:

Because MDs would not have it.  They would not recognize DOs as physicians.  They would not admit them to the AMA (hence the formation of the AOA).  They would not give them hospital privileges.  The two schools work together much more collegially now, but I don't know what the prevailing wisdom is about possibly merging the two associations.

I understand that this was not possible in the past because of contention but is it possible now and should we do it? I think answering these questions in this discussion would be spectacular.

Osteopathic manipulative treatment is the difference, along with the emphasis on primary care, the holistic approach, and the focus on community service. 

OMT:
I am going to be a little intellectually lazy and ask you to provide some evidence. From a cursory examination of the research I think that there are some positive effects (size? application?) of OMT and there are definitely some dis-proven uses of OMT. Regardless of the proven and dis-proven uses of OMT, it is important to determine if these methods (along with others) are being taught from a scientific background. Are they teaching their students OMT broadly or are they clearly outlining what does and does not work?

Another point on OMT:
How difficult is OMT to learn? If it is really efficacious it should should be integrated into allopathic medicine. If it is difficult it can be a specialty. If it is easy then it should be standard medical school curriculum.

Holistic approach:
By holistic do you mean (stolen from Wikipedia) "a concept in medical practice upholding that all aspects of people's needs, psychological, physical and social should be taken into account and seen as a whole?" I feel like we should all be careful using words like holistic that have many varied definitions. It is known that psychological and social (a part of psychological?) factors effect well-being but this is something that should definitely be integrated into allopathic medicine.

Commmunity service:
My personal experience is that both DO and MD programs have a heavy emphasis on community service. All of the medical students I know (DO or MD) are and have been involved in community service. Dartmouth did a survey that shows 81% of their students are doing community service. This isn't proof but I definitely don't think you can make an argument that allopathic medical schools don't place a heavy emphasis on community service.

On a more mundane note:
I know Wikipedia isn't proof but their article on osteopathy suggests that it is a completely interchangeable term for osteopathic medicine. And your own usage of the terms within the profession agree:

Also please note that osteopathic physicians practice osteopathic medicine, not osteopathy.
...
West Virginia Board of Osteopathy

Sorry that was so long...

[hfleming]

Osteopathic medicine and allopathic medicine are both nonsense/crank words. Osteopathic, allopathic and medicine are three completely different models of illness and treatment. Allopathic is the complement of homeopathic - treating the symptom with something that causes an opposite symptom (rather than the same symptom). Medicine does not use allopathic therapies. [Homeopathic and allopathic were both named by an idiot/quack who claimed that he cured a deaf man with a spinal adjustment btw.]

I don't know how other countries operate, but American osteopaths are taught both osteopathic and medicine, and these are fundamentally contradictory therapies - there is no such thing as "osteopathic medicine". Some osteopaths  practice more medicine and some practice more nonsense. Unlike other quacks like chiropracitors and naturopaths, osteopaths are taught a considerable amount of medicine. In principle, they should actually know something.

Should there be doctorates in osteopathy? No. Their training is strictly worse than that of a medical doctor's, who is, in principle, only trained in therapies with proven efficacy. If "holistic" woo therapy gave better outcomes, then it would be medicine.

[AQB24712]

DOs' training covers the same material as medical doctors (MDs).  They are physicians.  They graduate from accredited medical schools.  In principle and in practice, they actually do "know something."  It is true that some practices employ OMT more than others.  Do you live in the United States, hfleming?

[drizz]

DOs' training covers the same material as medical doctors (MDs).  They are physicians.  They graduate from accredited medical schools.  In principle and in practice, they actually do "know something."  It is true that some practices employ OMT more than others.  Do you live in the United States, hfleming?

Stephen Barrett pretty much nails it in his article (as usual):
http://www.quackwatch.com/04ConsumerEducation/QA/osteo.html

The dispute is not that they are untrained or that everything they do is useless. Chiropractors, by analogy, often provide legitimate physiotherapeutic treatments that are scientifically based. The underlying philosophy however is unscientific; modalities used are basically a grab bag of legitimate treatments and quack remedies and there is no consistent scientific basis on which these treatments are chosen.

As qualified as they may be, I would never go to a DO because I disagree with their worldview. This is the same reason I choose not to see MD's who integrate complementary and alternative medicine into their practices, regardless of how qualified they are.

[hfleming]

DOs' training covers the same material as medical doctors (MDs).  They are physicians.  They graduate from accredited medical schools.  In principle and in practice, they actually do "know something."  It is true that some practices employ OMT more than others.  Do you live in the United States, hfleming?

I do live in the U.S. DO's are taught both medicine and nonsense here. Medical doctors are taught only medicine (a strictly superior education, even if it is the same school). The fact that the state recognizes them as physicians is not necessarily meaningful. Some of their schools are good and many of their residencies are good. But the standard of entry is generally lower than regular medical school. E.g., their average undergraduate GPA is lower than that of MD's. That isn't to say that there are no good DO's. Some are very medicine oriented, even to the point of being hesitant and embarrassed to show you any osteopathic stuff they learned in school.

[AQB24712]

I had an interesting talk with my mother (EKB24741) this morning.  All my notes are at home, and I'm now at work.  More later.

[AQB24712]

Thanks for your thoughtful and thorough reply AQB24712

You're welcome.

Regarding the possibility of merging MD and DO:

Because MDs would not have it.  They would not recognize DOs as physicians.  They would not admit them to the AMA (hence the formation of the AOA).  They would not give them hospital privileges.  The two schools work together much more collegially now, but I don't know what the prevailing wisdom is about possibly merging the two associations.

I understand that this was not possible in the past because of contention but is it possible now and should we do it? I think answering these questions in this discussion would be spectacular.

I don't think "we" can accomplish this merger.    Mom's take on this idea is that it won't happen because the AOA sees no benefit in merging with the AMA.  A notable attempt at such a merger took place in California in the middle of the last century, and was a spectacular failure that left much distrust on both sides in its wake.  Reminds me of Christianity's many campaigns of forced conversion.

I'm not especially sure that a merger is needed, although I understand the arguments that've been made in this thread.  It's interesting to me to see how MDs and DOs work together more than they used to.  In the early days of WVSOM, the faculty had some trouble finding locations for their students to do clinical rotations.  I think I might have mentioned that my current primary care doctor is an MD in a mixed practice of primary care MDs, DOs, and PAs.  Mom noted that Michigan State has three schools of medicine: osteopathic, veterinary, and "human" (MSU's term). 

Osteopathic manipulative treatment is the difference, along with the emphasis on primary care, the holistic approach, and the focus on community service. 

OMT:
I am going to be a little intellectually lazy and ask you to provide some evidence. From a cursory examination of the research I think that there are some positive effects (size? application?) of OMT and there are definitely some dis-proven uses of OMT. Regardless of the proven and dis-proven uses of OMT, it is important to determine if these methods (along with others) are being taught from a scientific background. Are they teaching their students OMT broadly or are they clearly outlining what does and does not work?

Another point on OMT:
How difficult is OMT to learn? If it is really efficacious it should should be integrated into allopathic medicine. If it is difficult it can be a specialty. If it is easy then it should be standard medical school curriculum.

Well, I'm going to be a little intellectually lazy in return and not provide any evidence!    I'll just tell you some more about my conversation with my mother, a.k.a. EKB24741, a.k.a. Dr. Betty.  I told her that it seemed to me that OMT was not so much emphasized anymore; it doesn't have a big presence on the Web sites of the AOA, AACOM, or WVSOM.

She said that OMT (also sometimes called OMM, osteopathic manipulative medicine) does work quite well in somewhat limited applications, specifically musculoskeletal issues, and most especially back pain.  (When I've had OMT, it was for treatment of the chronic muscle spasms in my back that've plagued me my entire adult life.)  That some treatments work without knowledge of the specific mechanisms involved.  (I noticed a near-complete cessation of chronic muscle tensions headaches when I started taking a low dose of paroxetine, a selective serotonin reuptake inhibitor.  Not what it was prescribed for.  I read some time later, perhaps in Harvard Women's Health Watch, that this was a noted result with no explanation to date.)

All DOs are taught OMT in medical school, but not all of them integrate it into their practice to any significant degree, and some don't use it at all.  Dr. Betty says this is for many reasons:  Sometimes they're not very good at it.  Sometimes it's not terribly useful in the specialty they've chosen (She had an awful car crash last summer, and when she went to see her alumnus orthopedic surgeon, Dr. Morgan, to see how her bionic knees had done in the accident, she said she'd really gotten beaten up and could maybe use some OMT.  He told her that he didn't practice it anymore, really. 

I didn't realize that OMT is a board-certifiable specialty, which EKB says it is.  She says there's a married pair of DOs on the WVSOM faculty whose practice consists pretty much solely of OMT.  It's a time-intensive treatment, that is, typically a series of manipulations is prescribed, but because "reimbursement schemes" (insurances, etc.) aren't favorable toward that sort of plan (as anyone who's tried to get coverage for continuing mental health counseling might know), it's not so economically feasible for DOs to give it much emphasis in their practices.  Thinking back on my own medical history, I had OMT only for acute spasms, and was given programs of physical therapy and exercises to continue on my own. 

I understand why people give OMT the side-eye, and I can see clear differences between it and chiropractic.  It's not the only tool in the physician's arsenal, and the physician doesn't claim it'll cure everything.

Dr. Betty and I also had a nice talk about the history of osteopathic medicine.  As I said before, Dr. Still's philosophy and methods might not pass a 21st century sniff test.  Mom noted that he had his training during the Civil War, when all kinds of wacky shit abounded in the name of medicine, and when one could proclaim oneself a doctor after serving an apprenticeship of indeterminate length with another doctor whose training might have been...anything.  Pharmacology was a hairy buffalo mess of unstandardized formulations and dosages. 

Okay, now, my mom is so cool.  She told me about the Flexner Report of 1910, a study of medical education commissioned by the Carnegie Foundation (Andrew Carnegie was a fascinating guy [/tangent]) that led to the closure of many schools of quackery and the standardization of admissions and curricula.  (The report had the unfortunate effect of keeping women and minorities largely out of medical school, due to the resultant increased cost.)  It's an interesting article; it's so much fun to learn about these bits of history that I knew nothing about.

When Flexner researched his report, "modern" medicine faced vigorous competition from several quarters, including osteopathic medicine, chiropractic medicine, eclectic medicine, naturopathy and homeopathy. Flexner clearly doubted the scientific validity of all forms of medicine other than that based on scientific research, deeming any approach to medicine that did not advocate the use of treatments such as vaccines to prevent and cure illness as tantamount to quackery and charlatanism. Medical schools that offered training in various disciplines including eclectic medicine, physiomedicalism, naturopathy, and homeopathy, were told either to drop these courses from their curriculum or lose their accreditation and underwriting support. A few schools resisted for a time, but eventually all complied with the Report or shut their doors.

Holistic approach:
By holistic do you mean (stolen from Wikipedia) "a concept in medical practice upholding that all aspects of people's needs, psychological, physical and social should be taken into account and seen as a whole?" I feel like we should all be careful using words like holistic that have many varied definitions. It is known that psychological and social (a part of psychological?) factors effect well-being but this is something that should definitely be integrated into allopathic medicine.

Yeah, that's a fuzzy word, all right.  This is what the AOA's Web site says:

You are more than just the sum of your body parts. That’s why doctors of osteopathic medicine (DOs) practice a “whole person” approach to health care. Instead of just treating specific symptoms, osteopathic physicians concentrate on treating you as a whole. 

Osteopathic physicians understand how all the body’s systems are interconnected and how each one affects the others. They focus special attention on the musculoskeletal system, which reflects and influences the condition of all other body systems. 

This system of bones and muscles makes up about two-thirds of the body’s mass, and a routine part of the examination DOs give patients is a careful evaluation of these important structures. DOs know that the body’s structure plays a critical role in its ability to function. They can use their eyes and hands to identify structural problems and to support the body’s natural tendency toward health and self-healing. 

Osteopathic physicians also use their ears to listen to you and your health concerns. DOs help patients develop attitudes and lifestyles that don’t just fight illness but also help prevent disease. Millions of Americans prefer this concerned and compassionate care and have made DOs their physicians for life. 

Heh, I can see some forum members' eyes rolling.

Commmunity service:
My personal experience is that both DO and MD programs have a heavy emphasis on community service. All of the medical students I know (DO or MD) are and have been involved in community service. Dartmouth did a survey that shows 81% of their students are doing community service. This isn't proof but I definitely don't think you can make an argument that allopathic medical schools don't place a heavy emphasis on community service.

Hmm, I suspect I might've been mostly thinking about WVSOM:

The mission of the West Virginia School of Osteopathic Medicine (WVSOM) is to educate students from diverse backgrounds as lifelong learners in osteopathic medicine and complementary health related programs; to advance scientific knowledge through academic, clinical and basic science research; and to promote patient-centered, evidence based medicine.

WVSOM is dedicated to serve, first and foremost, the state of West Virginia and the special health care needs of its residents, emphasizing primary care in rural areas.

Now, this is a big fat hairy dope deal, as physicians and proper health care have historically been in short supply throughout Appalachia.  All WVSOM students' first clinical rotation "is an eight week preceptorship with a rural, family medicine osteopathic physician."  (West Virginia has allopathic schools at WVU and Marshall; I don't know offhand anything about their missions.  ETA:  WVU's dental school has a mobile clinic that tours the rural areas providing free or low-cost dental care, which is awesome.  I've seen that giant bus out on the road; I don't know how they drive that sucker on some of those roads.)) 

(If by chance anyone's interest in rural medicine and the history of WVSOM has inexplicably been piqued, I recommend Roland Sharp, Country Doctor: Memories of a Life Well Lived, a memoir by the 103-year-old DO who led the team that founded WVSOM, after many years as a coal company doctor and rural physician.)

On a more mundane note:
I know Wikipedia isn't proof but their article on osteopathy suggests that it is a completely interchangeable term for osteopathic medicine. And your own usage of the terms within the profession agree:

Also please note that osteopathic physicians practice osteopathic medicine, not osteopathy.
...
West Virginia Board of Osteopathy

I know!!  Screwy, huh?  Coincidentally enough, the West Virginia state association has recently changed the name of the board to the West Virginia Board of Osteopathic Medicine.  The AOA and AACOM Web sites confirm that the full title of the degree (DO) is Doctor of Osteopathic Medicine, which I didn't know.  I'm sure this is to continue to strengthen the differentiation between licensed physicians in the United States and the dubious practitioners elsewhere who call themselves osteopaths.

Sorry that was so long...

Hur hur hur.  I mean, no problem!  I really enjoyed revisiting all this stuff with my mother.

As qualified as they may be, I would never go to a DO because I disagree with their worldview. This is the same reason I choose not to see MD's who integrate complementary and alternative medicine into their practices, regardless of how qualified they are.

I understand that.  And I have sought out DOs as primary care physicians because I agree with their philosophy/worldview.  I don't think any of us would argue with Dr. Betty's contention that there are more and less capable physicians of all sorts.  I ditched my previous primary care physician, a DO, because the quality of care I was getting from him had markedly declined to the point at which he dismissed symptoms of gallbladder disease (unrelievable, recurrent bouts of intense nausea) as a sign of perimenopause without further exploration.  I had an emergency cholecystectomy and never looked back.  And of course, Andrew Weil is an MD.