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The Doctors Without MDs: What Makes Osteopathic Medicine Different?

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When Dr. Jerry McQuain walks the wards of Sentara Norfolk General Hospital in Norfolk, Virginia, he dons the garb typical of a doctor — a long white coat covering his scrubs, a stethoscope hanging on his neck, and a badge telling his specialty.

But you won’t find an "MD" behind this physician’s name.

McQuain is a doctor of osteopathic medicine, or DO, the other type of medical doctor in the United States. And while osteopathic physicians are fully licensed doctors with the same prescribing privileges as MDs, the American Osteopathic Association says 1 in 5 Americans don’t know DOs exist.

DOs receive conventional medical training, but also learn osteopathic medicine, which focuses on holistic approaches to care that sometimes involve hands-on treatment. The philosophy was developed by a controversial 19th-century doctor who, at the time, was shunned by the medical establishment.

Since 1973, though, DOs have been fully recognized as doctors in all 50 states. Today, DOs practice side-by-side with MDs. While some embrace the differences of their osteopathic medical training, many in the growing profession just want equal footing.

The number of DOs in the U.S. has more than tripled since 1990, with osteopathic physicians now accounting for around 10 percent of doctors in America. That figure is expected to double by 2030, largely due to rising enrollment in a growing number of osteopathic medical schools. One in 4 medical students is currently training to become a DO.

The number of DOs practicing in each state, as well as locations of America's 34 osteopathic medical schools (Courtesy American Osteopathic Association)
The number of DOs practicing in each state, as well as locations of America's 34 osteopathic medical schools (Courtesy American Osteopathic Association)

As to the stigma once tied to osteopathy, “I actually don’t think it exists much anymore,” says Maria Jones, a second-year medical student at the University of New England College of Osteopathic Medicine and the school’s student government president. She says that since its founding nearly 150 years ago, the profession has “developed into … a modern practice of medicine.”

Training for DOs and MDs is nearly identical. Both require four years of medical school, an internship year and a residency in order to practice medicine. The line dividing the two sects will fade further in 2020, when long-separate accreditation systems for DO and MD residencies will officially merge. This effort is intended to improve accountability and simplify the processes of graduate medical education.

So what exactly are the defining features that distinguish some DOs from MDs?

Treating The Whole Patient

When practicing medicine, osteopathic physicians are expected to uphold a unique philosophy called the “Tenets of Osteopathic Medicine.”

Put simply, “we as DOs were holistic before holistic became cool,” says William Mayo, president of the American Osteopathic Association. DOs are trained to look at the patient’s mind, body and spirit, he says. “You don't just look at the particular illness, you look at the patient behind the illness and approach it that way.”

Mayo, a board-certified eye surgeon, gives an example from his own practice:

"When I’m talking to my glaucoma patients about their medications, [it’s important] knowing the background, knowing that they may have issues coming up with their copays, knowing that they may have to heat their home with a fireplace instead of central electric, [which] may make their eyes tear more … approaching the patient as a whole and not just focusing on the disease, that’s what we do.”

In one study comparing clinical interactions of MDs and DOs, those with osteopathic training were more likely to call patients by their first names, explain the sources of disease to patients, and discuss the social and emotional impacts an illness can bring. However, a larger study found the two types of doctors spent equal time with patients, and there was “little evidence to support a distinctive approach” by osteopathic doctors. Researchers are continuing to explore potential differences in empathy between DO and MD students.

An Extra Touchy Subject

The biggest area of difference between MDs and DOs remains the use of osteopathic manipulative treatment, often referred to as OMT or OMM.

“You could think of [OMT] as being somewhat like physical therapy techniques, but they're used to get the body back into homeostasis,” says Mayo. He says OMT is often utilized to treat muscular or skeletal injuries, and can help when diagnosing systemic problems and pinpointing the origins of referred pain, like when a stomach injury makes your back hurt.

According to the American Osteopathic Association, there are well over 200 OMT techniques.

A DO demonstrates an osteopathic manipulative treatment. (Courtesy American Osteopathic Association)
A DO demonstrates an osteopathic manipulative treatment. (Courtesy American Osteopathic Association)

McQuain, the Virginia osteopathic physician, says he uses OMT with patients on a daily basis. As a hospitalist who is board-certified in internal medicine, he often employs a therapy called myofascial release, said to “relieve restrictions in the fascia,” a layer of connective tissue above the muscle. Generally, his patients “love it and often request more,” he says, but some are surprised when it’s not a relaxing, massage-like experience. He says some soreness after treatment is expected.

Medical student Jones says that students at the University of New England College of Osteopathic Medicine start learning OMT in their first week of school, and practice for hundreds of hours before graduating. The hands-on techniques can be a useful tool in the healing process, she says, adding, “you don’t always have to revert to a position of pushing meds.”

For a variety of reasons, research backing up many OMT techniques is still lacking. There is evidence OMT can further relieve lower back pain when added to usual care, and patient surveys find many report it helps with pain management. But some critics claim the manual manipulations remain nothing more than pseudoscience. A representative for the American Medical Association, the largest physician organization in the U.S., declined to discuss OMT, saying the organization has no official position on the practices.

And while some DOs still swear by OMT, predominantly those in primary care, its use is declining. In surveys of osteopathic physicians, most say they employ OMT rarely, if ever.

"My sub-specialty is so highly focused on vascular diseases that I’ve never used it in my clinical practice,” says Michael Jaff, DO, president of Newton Wellesley Hospital in Massachusetts, and professor of medicine at Harvard Medical School. He is one of just 30 DOs at his medical center, which has more than 1,000 MDs on staff.

A Degree Of Discrimination? 

Jaff says he is proud of his accomplishments. But he admits that at times, his DO degree has left some patients, and even colleagues, questioning his skills as a physician.

He tells of an experience from the early 1990s, while training in vascular medicine at the Cleveland Clinic:

“I went to see a patient for a consultation … about a complex vascular disorder," he recalls. After taking her history and doing a physical, he brought in his boss, “who, by the way, was the only other DO … on the [vascular medicine] staff.” The patient raved about Jaff's performance. She’d come to Cleveland Clinic for another opinion because, according to the patient, every doctor she’d seen elsewhere was a DO, and "they didn’t know what they were doing.”

When his boss revealed they too were osteopathic physicians, “you can imagine her teeth almost fell out of her head.”

Jaff says his non-MD degree also came up while he was being recruited to work at Massachusetts General Hospital in Boston. After his arrival, he found out that his osteopathic medical education was an issue "raised by several” on the hiring committee. Ultimately, he says, his performance quieted fears that his medical training was sub-par.

While opposition to osteopathic physicians may be a defining part of the profession’s past, today DOs face less adversity.

"There are plenty of very well-known MD programs that now routinely seek out and accept DO trainees and members," says Jaff. He adds that DOs landing residencies in top hospitals was not nearly as common when he was training as it is today.

As to the future of osteopathic medicine, all eyes are on the 2020 residency merger.

Mayo, with the American Osteopathic Association, says the move will “[codify] osteopathic medicine into all of medicine.” McQuain, the hospitalist from Virginia, expects it will result in a “stronger physician workforce.” Jaff, the hospital president, suspects the line between MDs and DOs "will blur even more."

And Jones, the doctor-in-training, says she hopes it will help unify medicine. “We’re all working toward a common goal."

Related:

Justin Kaplan CommonHealth Fellow
Justin Kaplan is a summer fellow at WBUR, covering science and health for CommonHealth.

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