Osteopathic medicine and the growth of D.O. graduates as physicians

by Tayson DeLengocky, DO

The landscape of healthcare delivery has changed so drastically over the past three decades with the proliferation of allied health professions, increased in medical specialization, managed health care, and technology advancement.

The direct doctor-patient relations have been relegated to the relations between healthcare providers and patients, in which doctors are only participants among other healthcare givers. A healthcare consumer, patient, can be easily further confused when visiting medical offices or hospitals as there is no dress code, i.e., any employee can wear any scrubs or white coats. Moreover, allied health professions have upgraded their degrees to doctorate levels such as Doctor of Pharmacy, Doctor of Physical Therapy, Doctor of Audiology, and Doctor of Nursing Practice, which can further confuse patients from distinguishing these doctors with their physicians, whom they normally used to know as doctors. M.D.s, doctors of medicine, are widely-known as physicians.

Have you ever heard of D.O.s, doctor of osteopathic medicine, as your physicians?

How to become a practicing physician in the US?

There are two types of complete physicians, M.D.s and D.O.s, who are fully-licensed to prescribe medication and practice in all specialties of medicine and surgery. In 2008, there were about 780,000 practicing physicians in the United States, of which 68% were graduates from a US M.D. school, 25% were graduates from a foreign medical school, and 7% were graduates from a D.O. school. All these graduates must pass the medical licensing board examinations and complete internships and residencies before being licensed to practice medicine.

What is osteopathic medicine?

D.O.s are fully licensed physicians and are recognized as equals to M.D.s at every level of government in all 50 states. There are more similarities than differences between M.D.s and D.O.s. The medical education and training of D.O.s follow the exact rigorous curriculum of M.D.s training. The main difference lies in the osteopathic philosophy of the preventive and holistic approach of these tenets:

  • The body is a unit, and the person represents a combination of body, mind and spirit.
  • The body is capable of self-regulation, self-healing and health maintenance.
  • Structure and function are reciprocally interrelated.
  • Rational treatment is based on understanding the body unity, self-regulation and the interrelationship of structure and function.

With the concept that diseases of internal organs can manifest externally as referred pain to different musculoskeletal regions and vice versa,  D.O.s are trained at least 200 hours extra in osteopathic manual medicine (OMM), a hands-on technique for diagnosis and treatment. OMM incorporates aspects of traditional manual therapy, soft-tissue massage therapy, and other body-based modalities to relieve pain from strained muscles, tendons, and joints and improve motion and function of blood circulation, lymphatic and respiratory systems.  Another important educational difference in the D.O. schools is the emphasis placed on primary care specialties such as internal medicine, family medicine, pediatrics, and obstetrics/gynecology during the clinical years. Therefore, approximately 60% D.O.s practice in the primary care specialties in contrast with 35% of M.D.s. Furthermore, osteopathic schools focus on providing care to rural and urban underserved areas by recruiting students from these areas, promoting rural medicine, and even establishing new schools in the underserved areas. While D.O.s 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.

Recently, the Annals of Internal Medicine released a new national study that ranks medical schools based on their contributions to meeting the nation’s health care needs, “social mission” scale, based on an analysis of graduates who practice primary care, work in medically underserved communities or are themselves minorities. The discussion section of the study praises osteopathic medical schools’ achievements in their “social mission.” Six osteopathic schools ranked in the top 50 overall. In contrast, some prestigious institutions such as Columbia, Johns Hopkins, Northwestern, Duke, University of Pennsylvania and Stanford all ranked in the bottom twenty.

Relevance of osteopathic medicine

First, there has been a growing public interest in complementary and alternative medicine (CAM) recent years. 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 the National Center for Statistics’ 2007, Americans spent $33.9 billion out-of-pocket on CAM, of which $11.9 billion were spent 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 graduating physicians with the values, knowledge, attitudes and skills to improve the physician-patient communication.

D.O.s are better positioned to respond to this public interest thanks to its long tradition of a holistic and preventive philosophy to patient care.

Second, 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 M.D.s 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 D.O.s 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.

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 educational programs are addressing this every day.

Growth of osteopathic medicine: An answer to physician shortage

Osteopathic medicine has enjoyed the exponential growth over the past three decades while M.D. schools decided to remain stagnant. In 1980, there were 17,620 practicing D.O.s and 1,059 D.O. graduates. In 2010, there are 63,000 practicing D.O.s and 3,845 D.O. graduates. The number of colleges of osteopathic medicine has increased from 15 to 26 colleges and 5 branch campuses. At least three schools and two branch campuses are being planned. Marian University in Indianapolis, IN, Campbell University at Buies Creek, NC, and Southeast Alabama Medical Center in Dothan are applying for accreditation. Interestingly, because of the continuous growth, one in five medical students in the United States is currently enrolled in an osteopathic medical school. 32% of the D.O. student body is made up by minority groups. By 2020, there will be 100,000 D.O.s practicing in the U.S., more than 6,000 D.O.s will graduate yearly, and one in four medical students will be D.O. students.

The looming forecast of physician shortage in 2030 estimated to be from 160-250,000 physicians as the population will grow to 350 million, the number of people over 65 will double, a third of current physician work force will retire, and the new healthcare law providing more coverage to 32 million persons. In 2006, Association of American Medical Colleges called for increased of 30% M.D. student enrollment by 2020, i.e., additional 5,000 students. Despite this expansion, shortage of physicians can not be prevented. The continuous growth of osteopathic medicine will somewhat alleviate the future physician shortage, and its unique blending characteristic of holistic and conventional medicine makes it a special and leading force responding to the healthcare needs of the nation.

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

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  • ninguem

    The growth has been irresponsible. They don’t have the postgraduate training positions to match the number of new graduates.

    There’s going to be a collision soon.

    • richard scottr

      Cannot agree more. The concepts and goals are good. Many D.O. students are eager to specialize…Even if the goals change and primary care becomes more sexy, the increasing graduates without places for training seems wrong. Do we need a new model for primary care training, outside of hospitals. Osler would not be happy.

      • john

        messrs ninguem and scottr, Huh? None of this makes any sense.

        I respectfully disagree, the number of osteopathic students who graduate each year corresponds with the number of osteopathic residency programs available, including fields such as orthopedics.

        Finally, and perhaps most important, there has been for several years now a significant number of vacancies in the allopathic primary care residency slots that were being taken up by FMGs (non-carribbean). Even then, there were openings that were then closed due to unfilled slots.

        I’m not sure why you made the comments you did.

        • richard scottr

          John
          I have not seen current statistics and would be pleased if the number of Osteopathic residencies increases with the increasing number of graduates. I will stand corrected. Certainly the newer move towards more home grown physicians will increase “spots” for training.

          • http://jessicasideways.com Jessica Sideways

            Well, I would like to see the number of Osteopathic residency positions increase too – and some to come to urban areas like Denver (we have no AOA internships here), but if worse comes to worse – we can all be happy that Resolution 42 exists…

          • http://www.eyedrd.org eyedrd

            not all new DO schools are supported by DOs. The proposed DO school in Saint Louis is vehemently opposed by the osteopathic community. Here is the latest progress of the planned DO schools.
            http://www.eyedrd.org/2011/04/progress-of-planned-osteopathic-medical-schools.html

        • ninguem

          There has been abundant concern among academics in the osteopathic programs themselves. The concerns show up in the Journal of the American Osteopathic Association, look it up for yourself.

          If you want doctors in primary care, make the field attractive. Don’t force the doctors into the field by closing off everything else. I do not want a primary care doctor who was forced into the field.

          • richard scottr

            I can only presume John has new statistics.

          • pj

            Ninguem and Scottr are right. John is flat out wrong.

  • Viking

    Ninguem:

    There are plenty of positions, just not in what people want to do. There are plenty of family medicine positions available.

    Just because you graduate from medical school doesn’t mean you cab become an ophthalmologist. The US needs primary care, badly.

    • ningem

      Yep, just what you need. A family doc who was forced into the field.

      • john

        And you are suggesting that the majority of family doctors who went to allopathic schools did so out of choice? That is also simply not true. And you should know better. If you don’t, you are most likely not a doctor.

  • http://fertilityfile.com IVF-MD

    Dr. TD, I’m guessing a lot of DO students will gain some optimism from your own example as a successful DO specialist. This year alone, I got over half a dozen emails and comments on my blog from DO students asking how easy is it for a DO student to enter the subspeciality field of Reproductive Endocrinology. I got the impression that DO students felt that while they had no problem pursing the primary care field of their choice, they were a little uncertain about their chances should they wish to pursue a specialty. My reply to them is that while there may be fewer DO residency programs for specialists, the top DO students can and have been accepted to MD residencies, so it’s definitely possible, albeit more challenging.

    By the way, my lectures are interactive and I call on students and ask them questions throughout the talk and I find no overall difference in the quality of responses regardless of which variant of medical student I’m speaking to, whether MD or DO,

    The practical differences with regard to finding residency positions lies not in the different philosophical approaches between the two schools of training, but more on the perceived difficulty of getting accepted into each type of medical school.

  • PAULMD

    I worked with a DO during my transitional internship in Chicago when DOs could easily have worn a scarlet letter(s).

    Very competitive crowd of 11 of us. All going into eyes, and rays etc. The DO was great. Competitive and competent hard working and good guy. He was going into an allopathic ER residency and I am sure has done well.

  • anonymous

    I was surprised to read that a quarter of practicing physicians in the US are graduates of foreign medical schools. I have no doubt that these physicians are well qualified, but (for a variety of reasons) I believe that we, as a country, have a duty to educate of own physician workforce. Therefore, I agree with the assertion that medical school enrollment should increase to meet current and future needs. What doesn’t matter to me is whether that increase is in MD students or DO students. The posturing for “market share” is petty politics.

  • http://www.eyedrd.org eyedrd

    IVF-MD…you are being so kind. I am just an average person thriving to do my best. There are better physicians and DOs. As being part of a minority profession, there are a lot of uncharted territories that why there are always questions if DOs can be competitive in this or that field.
    Here is a small list of prominent DOs that i compiled
    http://www.eyedrd.org/2010/11/prominent-doctors-of-osteopathic.html

  • http://www.eyedrd.org eyedrd

    John

    I believe that osteopathic growth due to the business-driven motivation has unintended consequences. I am an optimist. In 1990s, the forecast of a huge physician surplus was totally wrong and now we are doing the catching ups over the past few years. The exponential growth of osteopathic profession has helped to alleviate or blunt the physician shortage effects.

    I have to respectfully disagree with your statement about osteopaths need to take remedial testing or training. 2/3 of DO graduates serve ACGME residencies. Being in a minority profession, there are rules and regulations for self-preservation, which makes DOs life harder as you can see in this link
    http://www.eyedrd.org/2011/02/the-pathways-to-become-a-do-or-an-md-subtle-differences.html

    • ninguem

      Contrary to some assertions here, I am indeed a doctor, and have been a doctor for more than half my life. In younger days, I could not justify having a completely parallel organization (osteopathic-DO and allopathic-MD).

      As the years go by, I see the advantage of having two organizations that can run the entire process of creating physicians with unrestricted license. From the medical school through the residencies, certification process, licensure, hospital certification, etc.

      The MD organizations get too full of themselves. I’m actually happy that the DO’s are expanding. I’m concerned it’s too much, too fast.

      I wasn’t aware that they were starting dental schools. An interesting development.

      John Russell: “…….But even, today, I don’t think allopathic residency training programs accept osteopaths without some remedial testing or training……”

      My only Osteopathic postgraduate training was my rotating internship. All my residency training was at University medical centers. I’m double-boarded, fellowship trained, and taught at Assistant Professor level at an Ivy program.

      You think wrong. That’s OK, just saying it’s just plain not true.

  • MassachusettsPCP

    What is unsaid is the growth of the D.O. schools and their origins. Most all M.D. schools are associate with large medical centers and institutions; consequently, the student is exposed to rotations largely within such centers and their affiliates with specialty care glorified and often primary care belittled. As has been stated, it is alarming that many M.D.’s are not as comfortable managing common musculoskeletal problems (25% of outpatient PCP visits) but then again most M.D.’s don’t go into primary care. Not a justification, just a notation. My problem with D.O. schools is that many — and virtually all new ones — are opening independent of large academic medical centers, in small/medium sized communities, perhaps associated with a community hospital, and many D.O. students do rotations with community preceptors, not in the world of tertiary care. Bad? Maybe not. Only 3% of patient care needs to be delivered in tertiary centers. But a broad exposure is needed in the formative and residency years. Perhaps some D.O. graduates get this in allopathic residencies (just ilke the M.D. graduates have to brush up to speed) or in highly specialized D.O. medical centers. Summarized, it’s the difference between the top law schools (all university associated) and the independent community law school. Either prepare you for the law, you can get in the bar after passing the exam with either one, and your practice can be successful either way. Most M.D. schools don’t open in small towns. But look at the latest D.O. schools – many in small towns with Catholic or Baptist universities (Indiana, Mississippi) … with no affiliated major academic center as the anchor. Some are “branch campuses” of others in FL, AZ, etc .. with the same name. Costs for the D.O. degree from these places aren’t any cheaper. The owner of one off-shore Caribbean M.D. school opened a stateside for-profit D.O. school (Rocky Vista, in Colorado). Never heard of a for-profit, unanchored to major medical center/university American M.D. school. I will look at quality of graduates in future, but while this post is not meant to belittle D.O.’s, the phenomenal growth of the D.O. schools in just about any place where community preceptors can be found for rotations is sorta concerning. But such an environment will produce more PCPs, if not the promise of a less expensive education.

    • richard scottr

      My mom attended her first year of Osteopathic Medical school in Boston. The school closed and she finished in Philadelphia.
      The drive for increasing medical schools now is huge. There are a number opening here in Michigan, where there is difficulty keeping graduates in state after training.
      There is a complementary blog on KevinMD on cost of medical school. The threads are quite fascinating from those who comment that entering medical school, despite the huge debt, is a financial decision offset by known or expected financial rewards. That many, including D.O.’s , who might be expected to enter into primary care can not because of the large debt they carry is also recognized.
      There will be a rude awakening for those who think our health care system will afford the life style suggested.