The merging of MDs and DOs: A unification of training standards

More than a century of American medical history was turned on its ear recently by the announcement that the groups that accredit medical residencies will unify their standards. Don’t be too hard on yourself if you failed to understand the significance (or notice at all). But this should be viewed as good news across the land. As someone who trains doctors from both traditions, I certainly welcome a more level playing field.

First, a little background.

Osteopathic physicians (those with a D.O., or doctor of osteopathy degree) have a history dating back to the 1800s. They comprise slightly more than 10% of practicing doctors in the United States. Currently, there are 35 osteopathic medical schools, compared with 135 allopathic institutions, the kind that confer the M.D. (doctor of medicine) degree.

Though historically the two educational paths varied in principles and practice, there aren’t many remaining differences. Both disciplines now use biomedical science as their core. Originally, osteopathy relied on manipulation of bones and joints to diagnose and treat illness. This tradition, known as osteopathic manipulative treatment (OMT), lives on in the osteopathic curriculum, though it’s now mostly used as an adjunct for treatment of chronic musculoskeletal conditions. Today, most D.O.s leave OMT behind after they finish their training.

Throughout the 20th century, as allopathic medicine became the dominant model, its practitioners and leaders sought to discredit osteopathy. Attempts to unite the fields have come in sporadic fits and starts. The warring sides reached a detente of sorts in 1969, when the American Medical Association granted full and unrestricted membership to D.O.s.

Osteopathic doctors play a vital role in U.S. health care, as about 60% of D.O.s practice primary care, a far higher percentage than M.D.s, who mostly subspecialize. Osteopathic education also emphasizes rural health and community care. In states with strong osteopathic schools, like Oklahoma (where I practice), Iowa, and Michigan, D.O.s constitute about 20% of the physician population.

The announcement about unification of accreditation standards only applies to graduate medical training, or what is commonly known as residency, the three-to-seven year period of training after medical school that leads to licensure and certification. The agreement will be phased in between 2015 and 2020, as the governing bodies for the osteopathic movement align their training standards with those of the Accreditation Council of Graduate Medical Education (ACGME), the large Chicago-based non-profit that accredits more than 9200 residency programs across the U.S.

The agreement brings competency standards into alignment for all physicians, which in the long run will allow those of us involved in training the nation’s physicians to speak with a more unified voice. This will help foremost with question of funding for residency programs, which for decades have been funded almost exclusively by the federal Medicare program. At an annual cost of nearly $10 billion, members of Congress have been threatening to put this funding on the chopping block.

One thing I wonder is whether the unification of training standards will do anything to address the perceived shortage of primary care doctors.

Speaking in a conference call about the historic agreement, American Osteopathic Association President Norman Vinn noted that the osteopathic focus on primary care would not change. Further, he stated, “Future growth would include primary care, community-based hospitals, and rural and underserved communities.”

John Schumann is an internal medicine physician who blogs at GlassHospital.

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  • Kristy Sokoloski

    Why is Medicare involved as it is in the training of student doctors whether they become an M.D. or a D.O.? And how did that come about to begin with?

    • Dr. Drake Ramoray

      The payment of medical residents started at essentially the same time as the introduction of Medicare. Prior to Medicare, many physicians didn’t even do post-graduate training. If they did they were given room and board only (thus the term “resident”. The instruction for post graduate education was part of the institution of Medicare in the initial stages.

      “educational activities enhance the quality of care in an institution, and it is intended, until the community undertakes to bear such education cost in some other way, that a part of the net cost of such activities (including stipends of trainees, as well as compensation of teachers and other costs) should be borne to an appropriate extent by the hospital insurance program.”

      The above quote is pulled from “Committee on Ways and Means. U.S. House of Representatives, 89th Congress, 1st Session, House Report, No. 213 (Washington, DC: 1965)”

      Currently hospitals receive funding for residents in part in proportion to the percentage of Medicare and Medicaid patients that the facility treats.

      Here is a good primer on the “current” issues and history of residency funding. Note the article is over 10 years old but should answer some of your questions.

      • Patient Kit

        Thank you. That is very interesting. I knew that Medicare largely funds residency programs in the US. But I had no idea that, prior to 1965, many doctors did not do any post-graduate training after medical school and that residency programs started when Medicare was created. If that fact was a Jeopardy answer, I bet most Americans would get that question wrong. I learn so much here at KevinMD.

        • ninguem

          Used to be an internship and out to practice.

          A surgeon I knew for example, trained in the 1950′s, he worked as a GP for years and saved up money so that he could go back for the specialty training he wanted, and live off his savings, as there would be no income from the training.

  • morebuzzkills

    Does this “unification” mean that allopathic physicians will now be able to train at osteopathic residency programs or did they really mean unification*?

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