Alternative medicine and osteopathic medical education

by Tayson DeLengocky, DO

There has been a growing public interest in complementary and alternative medicine (CAM) in recent years. Osteopathic manipulative therapy, a form of physical manipulation of the body for improvement of health and body function, has been designated as complementary and alternative medicine (CAM) by the National Institutes of Health (NIH).

According to data reported in 2007 by the National Institutes of Health’s National Center for Complementary and Alternative Medicine, 38% of adults and 12% of children in the United States used some form of CAM that year. According to a 2007 report from the National Center for Statistics, Americans spent $33.9 billion out-of-pocket on CAM; of this figure, consumers spent $11.9 billion on an estimated 354.2 million visits to CAM practitioners.

Most allopathic medical schools have responded to this public interest by offering some elective instructions in CAM. Even a tentative proposal of core competencies in integrative medicine in undergraduate medical curriculum in allopathic schools was advanced in hope of instilling in graduating physicians the values, knowledge, attitudes and skills to improve physician-patient communication.

DOs are better positioned to respond to this public interest thanks to osteopathic medicine’s long tradition of a holistic and preventive philosophy to patient care.

Musculoskeletal conditions and injuries are among the most common reasons for visits to physicians in the United States. They accounted for more than 131 million patient visits in 1995 and cost $215 billion annually. According to the National Center for Health Statistics in 2003 and 2004, 21% of individuals aged 18 to 44, 59% of those aged 45 to 54 years, and 98% of those aged 55 to 64 years reported limitation of activity due to musculoskeletal conditions. According to a 1999 survey of the Steering Committee on Collaboration among Physician Providers Involved in Musculoskeletal Care, the percentages MDs who felt adequately prepared to physically assess problems of low back pain and foot pain were, respectively, 31% and 10%. By contrast, the percentages of DOs who felt adequately prepared to assess low back pain and hand problems were, respectively, 84% and 41%. Thus, osteopathic training appears to be at the forefront of addressing major healthcare issues and fulfilling public demands for patient-focused care.

Physicians who are exposed to osteopathic medicine are well-positioned to treat musculoskeletal injuries, an area that is often underemphasized in MD training programs. In the late 1990s, nine physician organizations (including the American Academy of Pediatrics, American Geriatrics Society, and the American Academy of Orthopaedic Surgeons, among others) decided to work together to improve the diagnosis and treatment of musculoskeletal injuries in a cost-effective way by sharing knowledge.

As part of their research, they surveyed physicians entering their residencies to see how these new physicians felt about their training in diagnosing musculoskeletal conditions. Thirty-one percent of MDs felt that their training to diagnose lower back pain was excellent or very good (compared to 82% of DOs).

Fewer DOs than MDs reported that they felt “poorly” or “very poorly” prepared to address foot pain and other categories of pain. The authors observed, “The fact that the osteopathic medical school graduates felt quite well prepared to assess these types of musculoskeletal problems indicates to us that it is possible to provide a musculoskeletal education in medical school that would improve the students’ confidence to assess musculoskeletal problems regardless of what specialties they intend to practice.”

The physicians’ organizations concluded that medical schools “should place more emphasis on these conditions so that young physicians entering their residencies will feel as well prepared to deal with such conditions as they are prepared to deal with problems found in other body systems… With appropriate reforms, all physicians who treat patients with musculoskeletal problems will know the appropriate diagnostic and treatment interventions and how to deliver them in a cost-effective manner. Their patients will benefit, and their health care burdens on society will decrease.”

A similar study (in 2005-06) among Harvard Medical School students found that musculoskeletal education was important (rated a 3.8 on a 5-point scale, with 1 meaning “no importance” and 5 meaning “critical importance”). At the same time, though, the students rated the amount of time spent on musculoskeletal education as poor (rated 2.1 on a 5-point scale, with 1 meaning “inadequate” and 5 meaning “excellent.”). On an exam of cognitive mastery of musculoskeletal medicine, fourth-year medical students had a passing rate of only 26%; the pass rate for third-year students (7%) was even worse. According to the study’s authors, “[R]ecent studies suggest that the discrepancy between the magnitude of musculoskeletal problems and physician competency in musculoskeletal medicine likely stems from educational deficiencies at the medical school level.”

Osteopathic medical education programs, are addressing this need every day.

Tayson DeLengocky is a vitreo-retinal surgeon who blogs at Eye Dr DeLengocky.

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  • Doctor J (MD)

    Osteopathic Medical Schools are superior to “allopathic” schools if your measure of quality stops at treating back pain and foot pain. I totally agree that I was poorly trained on how to manipulate spinal subluxation. I fail to see the point of this post. People want CAM does not make CAM real. I consider it unethical to sell snake oil even if people ask for it. It is my job to help educate then and get people to stop spending $10,000,000 per day on mostly useless treatments. If your point is MD’s need better training in musculo-skeletal ailments then I am with you 100%

    • gzuckier

      the trouble is that so much “conventional” medicine is as much superstitious hocus pocus as alternative medicine, as we continually discover; for instance, back surgery, ironically enough.

    • Dr. D. DDS

      If you check some reputable physician sites, either Quackwatch or Science-based Medicine, you will find that there is no such thing as “subluxation” and there never was. Chiropractors are now scrambling to restore some legitimacy to their quest for the magic bullet now that the spinal manipulation scam is about over. I think your comments on CAM are on the mark.

  • Dyck Dewid

    Throwing around terms like CMA and Integrative Medicine doesn’t seem meaningful considering the article aims to elevate the DO. The mind-body connection is at the heart of holistic view of the human, and the only legitimate, least-harmful aim of medicine.

    Other approaches are simply justification for what can be well-intentioned at best, but grossly ignorant and damaging at worst. Although musculoskeletal problems are not well served in allopathic practice and perhaps better served by a DO practitioner this doesn’t justify the arrogance or ignorance of our abysmal medical training and resultant practitioners.

  • anonymous

    You identified a potential deficiency in knowledge of musculoskeletal ailments in recent medical school graduates. You then identified that this deficiency may be less prevalent in graduates of DO schools than MD schools, the inference being that osteopathic medical education spends relatively more time on this specific topic. You’ve made the case that one way to increase mastery in a given area of study is to devote more time to education in that area. Furthermore, you’ve shown data suggesting that musculoskeletal ailments, in particular, are an important area for this increased emphasis. Fantastic. Great job. So, why did you take a hard left into ego land? A call for a greater emphasis on musculoskeletal conditions at MD schools, hopefully resulting in more prepared graduates, should have been the point of your piece. However, your opening mention of CAM and especially your choice of closing muddled what I hope was your main point, and likely left many readers to gauge the theme to be something more along the lines of the constant “which is greater” comparisons, from both sides of the useless MD/DO “debate”, that both dominate discussion and serve no one.

    • ninguem

      I think it’s fair to say the non-surgical orthopedics is not taught as well as it should be, in most training programs.

      Most anyone in a primary care practice, that’s such a massive portion of your day. Most primary care docs I know, MD or DO, they all wish they had more in training. They sure get plenty of it in practice.

  • Steven Reznick MD

    There really is little sense in putting down allopathic or osteopathic training if you received one or the other. They both have their strengths and weaknesses. Within each profession the different practitioners have different strengths and weaknesses as well. We would be best served to take the best of each training philosophy and make it available to all clinicians at the medical school level and at the post graduate level through CME courses. If it works and it is reproducible it is neither alternative or complimentary. Each physician from each school of training has something to learn and teach the other. We should be sharing this knowledge and experience to become better clinicians and healers

  • PCOM OMS-1

    Articles like this do a true disservice to those of us just entering the osteopathic medical field. Mired in Netters, Robbins, and BRS, one of the few things that keeps many of us afloat is the glowing beacon of residency that is years away. When I applied to D.O. schools, I did so with a full knowledge and appreciation of the osteopathic tradition. It was only after enduring countless sessions of flag-waving, mantra-spewing “History of Osteopathy” and “The TRUE Osteopathic Exam” lectures that I realized how much of a disadvantage I had put myself at.

    I WANT to learn manipulation, and I WANT to approach medicine with a holistic and healing perspective, but the allopathy-hostile attitudes of the died-in-the-wool Osteopaths place us all in an adversarial and compromised position. The osteopathic physicians who abhor those who call themselves “doctor” (vice John Smith, D.O.) and refer to M.D.’s as “drug-givers” send us all into an allopathic-dominated residency world where we’re automatically assumed to have chips on our shoulders.

    The D.O. stigma is perpetuated not by elitist M.D.’s, an uninformed public, or even sanctimonious pre-meds, but solely and specifically by D.O. zealots who refuse to abandon the already-outdated dying words of the profession’s founder.

    • pj

      Don’t lose heart my friend. Not sure if it is due to the PCOM culture, but I graduated from a different DO school and the “MD bashing” was ess. nonexistent.

      “I WANT to learn manipulation, and I WANT to approach medicine with a holistic and healing perspective”

      Excellent! Glad to have you in the profession! Hope you do find residency to be a beacon.

  • ninguem

    Glancing at my library. I have a primary care practice, babies to nursing homes, with some emphasis on medical pain management. Library has a little bit of everything.

    I have a book on manipulative medicine, written by Ombregt, Bisschop, ter Veer, and Van de Velde, who are MD’s in Belgium and the Netherlands.

    I have a few books by Cyriax, MD at St. Thomas Hospital London. He had been writing on manipulation since the 1940′s.

    Kirkaldy-Willis MD, orthopaedic surgeon in Canada, wrote a book on low back pain, with chapters on manipulation.

    Bourdillon (MD orthopaedic surgeon) and Day (MD physical med and rehab), also in Canada, wrote a book on spinal manipulation.

    Cyriax, in one of his books, shows an illustration of manipulative treatment for pain in 2000-year old Thai carvings, a Libyan bas-relief of a similar age, a medieval French book illustration showing spinal manipulation done in medieval Turkey. He shows a traction device for back pain from medieval Italy, another from ancient Greece, on and on.

    Spinal manipulation was not invented by osteopaths, chiropractors, or even Americans. It has existed all over the planet, for as long as people have had back pain and healers to address the problem.

    This “DO’s are better positioned” stuff is absolutely silly. And I am a DO, and I do spinal manipulation. People come to me for it, as part of a primary care practice.

    Most DO’s do not do spinal manipulation. If you’re a MD and you want to learn spinal manipulation, just go to the CME courses and learn it like any other new medical technique. There are several quality manipulation courses out there, and they welcome MD’s. I’ve been to them. Sometimes the MD’s outnumber the DO’s.

    It’s helpful, though hardly a miracle cure.

  • Dr. J

    The idea that a focus on ‘CAM therapies’ that are for the most part shams, and whose only function is to separate patients from their money somehow makes you a better listener, or a better doctor is one of the most outrageous things I have ever seen posted on kevinmd.
    The focus of any medical school, DO or MD, on therapies that have no basis in reality or science, because they are associated with buzzwords like ‘holistic’ or ‘integrative’ does a grave disservice to the doctors they are training and the patients those doctors will eventually serve.

  • gzuckier

    I think that, even more than a focus on the musculoskeletal system, what distinguishes osteopaths, naturopaths, and CAM in general is that they see their job, in general, in an opposite polarity to conventional medicine; rather than primarily treating illness and diseases, alternative practitioners view their job as maintaining a positive state of health in the patient; which happens to align with medical finance’s new focus on paying for keeping people healthy rather than paying for patching up sick folks.

  • VinceD

    The glaring fault that irks me about this article is that all the data it quotes refers only to how confident or prepared the respective doctors “felt”. It doesn’t address the actual effectiveness of these doctors’ assessments and treatments; it only states that the osteopathic doctors felt more comfortable dealing with the muskuloskeletal system. I’ve met several doctors who were very confident and comfortable in their abilities, but dead wrong an exceptional number of times.
    I’m not saying either camp creates better practitioners, simply that any of the facts supporting the viewpoint of this article are pure fluff and shouldn’t be confused with what matters: positive results for patients.

  • Tayson DeLengocky

    The article is an excerpt of a larger document about the state of osteopathic medicine. The title of the blog was given by KevinMD.
    It intends to point out some advantages of being a DO if embracing the blend of mainstream/conventional medicine and alternative medicines. It never claims its superiority to allopathic medicine.
    DO profession is a minority profession and some DOs try so hard to be only part of the mainstream. The DO profession is not going to fade away. It is true that most DOs dont do manipulation as most physicians dont do ob/gyn or other specialties during their medical training. Is it a waste of learning about other specialties? of course not.
    Dismissing other forms of alternative medicines is insulting the intelligence of patients/consummers and the world population not having access to modern medicine.
    It is interesting that prestigious institutions dont shy away from alternative medicines, they even offer instructions to their students and offer CME to their physicians. It should be noted that Traditional Chinese Medicine is still prevalent in China, it has good results in treating chronic conditions.
    Medicine is a lifetime learning process and an art. It is up to the physicians to choose how to practice. However, learning other forms of medicines can provide better understanding and serve better for the patients.
    It should be noted that acupuncture may be as efficacious or more than patching in the treatment of amblyopia. Do we know how those chinese meridians can have some efficacies.

  • Finn

    I find it alarming that medical schools seem to be increasing the amount of time they spend teaching CAM (none of which has been proven effective) and decreasing the already inadequatel amount of time they spend teaching nutrition, while the nation grows increasingly obese. What the hell good is all this CAM going to do for people with 35+ BMIs and the attendant diabetes, hypertension, hyperlipidemia, and atherosclerosis? Toss a few herbs at them while their blood sugars climb? Manipulate their spines while their arteries clog? Stroke the air a few inches above their skin when they’re in the ICU after their strokes? Tell them to meditate when they’re sitting there for hours on dialysis?

  • Dyck Dewid

    Twain’s quote, “…given a brain when a spinal cord would suffice” seems apt here.

  • Donna Carrillo Lopez

    Americans spend $33.9 billion dollars a year on alternative (complimentary) medicine. There are fundamental reasons why consumer dollars on allopathy are dwarfed by CAM. Here are just a few…Musculoskeletal symptoms are the number one reason health consumers seek help from physicians. Musculoskeletal disease is an orphan disease with no medical (non-surgical) specialty covering this entity. Most physicians have a need to go back to school and learn how to treat symptoms effectively, minimizing pharmacologic agents, especially in the quickly aging baby boomer generation (for the very reason of aging and senescent organs). Osteopathy, chiropractic practice, medical acupuncture and herbology offer many solutions that may still not have the RCT meta-analysis proofs…but perhaps this gold standard will have a paradigm shift and another more fitting gold standard will be found that provides more information on what demonstrates efficacy, effectiveness and safety. CMEs are not known to effectively change practitioner behavior and perhaps what is needed is intense practical seminars with certification based on performance and proven cognitive learning. Pain management is now center stage and also a common factor in musculoskeletal dysfunction. We have miles to go to get every primary care provider and every other specialty literate on how to care for pain, acute, chronic, nociceptive, neuropathic, somatic and visceral. Miles to go…

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