*Note: This paper was written before the implementation of health care reform by the Obama administration in 2010. However, this does not in any way lessen the importance or timeliness of the claims being made.
Atul Gawande, endocrine surgeon and author of Better: A Surgeon’s Notes on Performance, has said that it takes a certain ingenuity and innovation to excel in health care. Advances, he argues, are not made by meeting standards, but by finding new ways to rise above them. The current US health care system is in need of reform. Approximately 47 million people are lacking insurance (Chirayath 2008), and over 78% of physicians believe there is currently a shortage of primary care doctors in the United States (Durand 2008). Amid a suffering economy and a health care system deficient of primary care physicians, Osteopathic Manipulative Treatment (OMT) shows promise as an efficient and cost-effective way of treating visceral disease. This physical approach to patient treatment relies on Osteopathic Medical principles of the body’s ability to heal itself, restricting prescription drug use and invasive procedures to an absolute minimum, therefore reducing the cost of treatment in comparison to an allopathic counterpart (Kornhauser 2007). Osteopathic Medicine—considered separate from conventional M.D. practice—encompasses a traditional medical foundation coupled with additional diagnostic tools and treatments to yield highly trained Doctors of Osteopathy (D.O.’s). Though faced with skepticism and rivalry by their M.D. counterparts, the population of D.O.’s has been on the rise in the past decade. With hopes of gaining a solid establishment and acclaim among the medical society, Osteopathic Medical practices, such as OMT, can be incorporated into insurance plans to provide millions of Americans with an affordable and alternative treatment option. Given the proper support, D.O.’s will uniquely address the nation’s health care needs by meeting the demand for primary care physicians and providing a cost-effective adjunct to traditional medical therapies.
Osteopathic medicine traces its origins to late nineteenth century midwestern America. Andrew Taylor Still, a disgruntled, apprentice-trained physician, began to experiment with homeopathy after seeing poor outcomes in the treatment of meningitis with conventional (i.e. allopathic) medicine. Still experimented with eclecticism, magnetic healing, and bone setting until experiencing clinical success (the last two methods embody physical manipulation). He was able to treat asthma and a variety of other diseases by finding that many ailments were caused by an obstruction/improper nerve supply and blood flow in the body due to misplaced bones (Gevitz 2009). If those bones could be realigned (most commonly in the spine), then many diseases could be treated, drug-free. After receiving an overwhelming influx of patients, Still decided to open the American School of Osteopathy (ASO) to teach his techniques to medical students. The school enrolled 700 students and within a matter of years was teaching everything offered in an M.D. curriculum except for pharmacology. Osteopathic institutions opened across the country—the American Osteopathic Association (AOA) and the American Association of Colleges of Osteopathic Medicine (AACOM) were soon formed. Osteopathy began to thrive.
In 1910, Abraham Flexner, a professional educator, conducted a thorough investigation of 147 medical institutions throughout the country, eventually going on to deem them “poorly run producers of uneducated and ill-trained medical practitioners” (Chen 2009). The Flexner Report caused a major upheaval in U.S. health care, serving as part of the driving force towards modifying medical institutions into contemporary and complex research-based academic institutions. Osteopathic medical schools, however, lagged behind because of limited state funding and restrictions on the types of treatment that could be practiced (due to growing guidelines and restrictions by medical communities). As a result, osteopathic institutions pushed forward for a separate reform that would dictate their own accreditation centers and committees, as well as their own guidelines for practice. Osteopathy gradually developed into its own distinct branch of medicine, causing concern among the American Medical Association (AMA). As such, many M.D. practitioners regarded osteopathy as cult-like, believing it to be an obsolete and unapproved form of treatment in the place of newer drugs and therapies. The AOA began to make changes to improve the stance of osteopathic institutions among state governments and M.D.-granting institutions by expanding their curriculum to include pharmacology. They additionally mandated 4 years of medical training to acquire a D.O. degree, and required at least two years of prior undergraduate college education in the sciences. Osteopathic medical schools ultimately gained a competitive applicant pool, some state funding, and their own hospitals to practice and provide residencies for their medical students. Despite resistance from the AMA, osteopathic institutions and allopathic institutions offer the same fundamental science and health curricula, as well as administer the same medical licensing exams. D.O. schools, however, have managed to maintain their independence through distinctive educational elements like OMT.
Osteopathy is a philosophy of medical care that places special emphasis on the relationship between structure and function, promoting the body’s ability to heal itself. Osteopathic physicians draw from current practices and specialties of medicine and combine them with Osteopathic Manipulative Treatment (OMT), a manual application of forces on the body so as to restore maximal, pain-free movement of the musculoskeletal system. Osteopathic Manipulative Treatment is a hands-on approach to medicine that uses ‘somatic dysfunction’—problem areas such as inflammation, regional asymmetry, and restricted motion/changes in tissue texture—to detect visceral disease. This technique is particularly effective in diagnosing patients with hypertension, coronary artery disease, and a number of other visceral diseases.
The human spine is of great importance to OMT practitioners. It is meticulously examined during treatment and is strongly linked to visceral organs of the body so that “any sensory, motor, or vasomotor disturbances will present themselves in different segments of the spine to display a kidney infection, a gastrointestinal lesion or a cardiac malfunction, etc.” (Kornhauser 2007). In addition to being an effective diagnostic tool, OMT is also used to realign vertebrae or other bones and release vasomuscular obstructions in order to maximize pain-relief and function. This reduces the need for invasive treatment and pain-killers. A study by Anderson et al has found osteopathic treatment to be more cost-effective than standard medical care due to less reliance on prescription drugs and physical therapy. In another study conducted by Von Korff et al, two patient groups were compared, one treated under conventional medical practice and the other under OMT. The latter group reported fewer prescription drugs, lower financial costs, and higher patient satisfaction than the former. The widespread practice of osteopathic medicine has implications in better patient care and less expensive treatment, thereby making it accessible to more people in need.
With so much potential and promise in serving the public, it is baffling that osteopathic medicine is neither as renowned nor as prevalent as conventional medicine. According to the Cecil Textbook of Medicine, “other than teaching manipulation, medical training for an osteopathic degree (D.O.) is now virtually indistinguishable from that which leads to the M.D. degree”. Osteopathic physicians complete conventional residencies in hospitals and training programs, are licensed in all states, and have rights and responsibilities, such as military service, that are identical to M.D. qualified physicians and surgeons. The discrepancy between the professions, then, can be explained by looking at the history of each branch of medicine. At the start of the 1900s, osteopathic medicine was thriving; spreading rapidly throughout the country and posing a threat to many M.D.-granting institutions. Then, in 1910, the release of the Flexner Report created a pivotal moment for the future of medicine, both conventional and osteopathic. For M.D. institutions, this meant shutting down low-quality institutions and replacing them with better, stronger research-based universities. State governments heeded the report and responded by allocating large funds to the reform cause. For D.O. institutions, however, the report proved to be both eye-opening and detrimental to their growth and development. Because the report was issued early into the birth of osteopathy, the D.O. movement had not gained enough momentum to warrant funding from state governments. Osteopathic medical schools fell behind with little research or financial support to keep them afloat. For 25 years, the AOA garnered support and made necessary changes to its medical school requirements and curricula in order to receive private (and some state) funding. The lag in development explains several things: the subordination of osteopathic medical professions, the stigma surrounding D.O.’s as being underdeveloped or outdated, and the formation of academic-based and tuition-driven osteopathic medical institutions.
To this day, D.O.’s receive little attention or credit from the national health care system. Unique D.O. practices, such as OMT, are not covered by insurance for fear (arising from the stigma) that they may be risky or harmful, without any proven added benefit to the patient. As such, “over 65% of osteopathic physicians reported an identity crisis…struggl[ing] to achieve the same level of respect and authority as allopathic medicine while trying to hold on to the traditional practices like OMT that make them unique” (Johnson 2002). In an effort to refute these stereotypes many medical societies have funded studies and research that compare allopathic to osteopathic treatment. One such study, funded by the Massachusetts Medical Society, selected 155 patients to be treated for lower back pain: 83 patients treated with D.O. manual therapy and 72 patients treated with standard M.D. care. Patients were chosen based on similarity and severity of their lesions and were treated over a 12-week period. When the treatment results were assessed, both treatment groups showed improvement over the 12 weeks, with little discrepancies between the primary outcome measures. However, the D.O.-treated group “required significantly less medication (analgesics, anti inflammatory agents, muscle relaxants) and less physical therapy than the M.D. group; 0.2% in comparison to 2.6%” (Andersson 2003). Although over 90% of both patient care groups were satisfied with their treatment, osteopathic care proved to be as efficient but less costly/reliant on drug therapy than conventional medical care. Further studies have confirmed these results in an effort to break down the stereotypes and misconceptions that surround the profession.
In spite of the obstacles that face osteopathic institutions, they continue to enroll increasing numbers of graduate students amid a growing deficiency of physicians in the US. In 2006, osteopathic schools reported 15 percent of all medical school enrollment. Since 1980, M.D. schools, however, have experienced a plateau in the number of physicians they produce annually despite the rapid increases in US health care spending and population size. Reports show that “approximately 15,000 M.D. physicians are produced each year, while the D.O. population of 3,079 physicians is steadily rising and is projected to reach 5,020 graduates by 2016.” (Hilsenrath 2008). There are several explanations for the surge in enrollment in osteopathic schools, one of which may be the stigma itself. Because of the competition and criticism generated by M.D.-granting institutions, D.O. schools offer a less-cutthroat admission process. Although they maintain high standards for their entering students (National Avg GPA: 3.45, National Avg MCAT score: 28), osteopathic schools are able to accept more students who meet these averages than M.D. institutions because they are less sought after, and therefore, less crowded. This has become an appealing alternative for many qualified premedical students who are seeking medical training but are denied entry into highly-impacted M.D. schools. Another explanation for the surge is the fact that osteopathic schools are tuition-driven, relying much more on school fees (approx. 76% of school revenue) than allopathic medical schools, who report 2-3% of their revenue from student tuition and the whopping majority from grants and research funds. Because of this, osteopathic schools are reportedly more student-centered and provide a more responsive, efficient medical education than institutions whose primary funding goes into research. Consequently, D.O. enrollment has increased and the number of graduating D.O.’s continues to rise.
Competition between D.O.’s and M.D.’s has also had a positive impact on the number of osteopathic physicians choosing primary care specialties. As noted earlier, there is a great demand for primary care physicians in the U.S. Many graduating M.D.’s are choosing to specialize in surgery or different fields of medicine over family medicine because of higher income levels and preferred career locales (urban and suburban environments). Osteopathic physicians, however, are drawn to primary care specialties because of the suitability of the profession to their own medical philosophy of a holistic approach and non-invasive treatments. Additionally, D.O.’s are more likely to secure practices in rural areas than in most competitive urban regions. Because rural communities draw upon primary care, “over 58% of D.O.’s will enter primary care as opposed to the allopathic national average (35%)” (Chen 2009). If D.O.’s are better incorporated into the health care system through insurance plans, hospital recruitment and otherwise, the number of D.O.-certified primary care physicians is likely to sky-rocket and help the nation meet its demand for physicians.
A shortage of doctors is not the only issue that needs to be addressed; US health care must also solve the problem of the medically indigent—those who are uninsured or covered by Medicaid. According to the Journal of Healthcare for Poor and Underserved, “since 2006, the number [of uninsured Americans] is steadily rising by one million per year”. Governmental attempts to pass universal health care bills have failed in the past, and new budget acts and policies continually reduce coverage to thousands of US-born children and poverty-stricken populations. Physicians limit their treatment of uninsured/Medicaid patients due to low reimbursement rates or little to no payment for services. Doctors have cited accrued medical debt as the number one reason to limit such patient care, and studies have shown that a number of factors (i.e. location, specialty, practice) also affect the number of treated medically indigent patients (Teitelbaum 2009). Today, osteopathic physicians yield substantial numbers of primary care physicians and practitioners working in underserved areas. Because osteopathy was able to develop separately to allopathic medicine, it retains flexibility in developing new models for treating the medically indigent. For example, the Lake Eerie COM three-year program condenses medical school to three years and reduces student debt and time in exchange for pursuing a primary-care career. Osteopathic medical schools also ingrain service of the medically indigent into their students by employing disciplinary programs. The A.T. Still University of Arizona, which bases its medical training in ten community health centers around the country, familiarizes its students with public service early in their career. These examples display the inventiveness, responsiveness, and flexibility of D.O. schools in addressing the nation’s biggest problem: providing health care to all Americans, regardless of economic status or insurance.
However, D.O.’s are cheap alternative that many hospitals resort to in placing nurse practitioners into primary care offices. These practitioners limit the type of care that a patient receives to a strict convention. This means that “less and less patients are aware of osteopathic alternatives to treatment, such as lymphatic release and rib raising, manipulative techniques which are used to alleviate chest congestion for flu patients” (Wagner 2009). Not only does this threaten the identity of osteopathic physicians but also limits the type of care most patients are currently receiving. Incorporating osteopathic treatments into health insurance plans would make them accessible to millions of patients, providing them with an extra option of care. And perhaps most significantly, lowering insurance costs for osteopathic physicians would encourage entry into primary care specialties and service to rural communities and medically indigent populations.
An investment into osteopathic medicine is an investment into the US health care system. If D.O. schools are better-financed by state governments, they can increase their resources and the number of students accepted every year as well as financial aid funding for students-in-need. A rise in the number of osteopathic physicians will help reduce health care costs by focusing on more holistic methods of treatment in the place of prescription drug usage and invasive therapies. More importantly, D.O.’s will be able to meet the public need for primary care specialty physicians. Though osteopathic medicine faces resistance from the AMA and uncertainty from the government, there is plenty of hope that stigmas, ideologies, and misconceptions will become a thing of the past. By putting aside differences between osteopathy and allopathy, new and alternative options can be afforded to patients, and the practice of medicine can ultimately become what matters.
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