I just came upon this article while searching through Slow Boring's archives for something different. Thank you for writing about this issue. My husband is a DO because--basically--he screwed around in college and had a low GPA. His MCAT score was stellar, but that wasn't enough for him to get into any MD programs in the states. He chose a DO school in Florida because we were newly married and I was working as an attorney in Orlando. His school was great and his fellow students were smart, driven, and hardworking.
Still, back then (12 years ago), the residency bias against DO students was strong. The hospital where my father-in-law had worked for decades and had held leadership roles in for many years flat-out refused to interview my husband because he was in DO school (despite the fact that he had taken the USMLE). Ultimately, my husband matched into an MD residency in radiology. Now, as a working radiologist, his DO degree is rarely remarked upon. I'm glad to hear that the younger generation has it better than he had, and I wish all the best for your sister!
I’m a DO and have been in practice for several years as a nephrologist. I did my residency and fellowship at allopathic institutions, and have not used OMT since medical school but found it interesting at the time. As a nephrologist, it would not be part of what I do to treat patients with kidney disease, but it could be useful in primary care, particularly as an alternative to traditional pain medications, namely opioids.
In my area where I practice there are several DOs and even more MDs of course, and I have not encountered any biases against DOs recently.
Nice piece Ben. I come to Slow Boring as an escape from medicine and to pique my interest in policy/politics. But it was a pleasant surprise to read about my own world, including the comments.
Please, all medicine in the 1800s had its share of 'cultists'. Just gp tp the AMA medical device museum in Chicago! Disease-focused medicine wasn't consolidated by the AMA until the second decade in the 20th century. A lot of the holistic and preventive care priorities of osteopathic medicine was lost. In fact, the difference in approach to patients centered around the rapid industrialization of that period. One faction of those practicing medicine poured resources into finding treatments for limbs mutilated in the course of factory or extraction work, the other focused on the immediate environments workers were exposed to during their work days. My father got his medical degree in the 1920s. Every year he and my mother would attend the AMA convention and tack a holiday vacation onto the end. We grew up thinking Kirksville, MO was the home of quacks. Your analysis gives the AMA too much credit: it took decades from the 1960s on for the AMA to accept the credentials of DOs and later of nurse practitioners, PAs and midwives. When I moved to a new city I had two physicians recommended to me. Both turned out to be DOs ( I discovered after treatment).I think your starting point (introducing DOs to your readers) is a bit behind the times.
Okay, but how does it...work? What's the One Weird Trick? What I'm coming away with is - here's this odd duck breed of doctor which might be better for commonplace ailments that we know are frequently psychosomatic* and respond well to a wide variety of gazebo-effect treatments like massage therapy, etc. Some placebo must be done -> this is a placebo -> let's do it. Sure, whatever works (if efficacy is on par, at least it's no *worse*, First Do No Harm), and maybe it's even worth diverting some VA dollars or whatever for the cost savings(?). Way cheaper to prescribe chiropracty or acupuncture than back surgey. But I'm not convinced that outside such frustratingly subjective ailments, DOs have some particular special sauce worth elevating. You can hide a lot of shenanigans in aggregate statistics like all-cause mortality. And more generally, the research seems clear that the main benefit of "holistic" care is the provision of, well, human caring, which seems to promote healing along many axes. (Do you know how many people get basically no human touch outside of medical settings?) The systematic incentives towards both cold clinical efficiency and pills-first treatment that prevent such human connections are much bigger than osteopathy. Good on them if they punch above weight class in that regard, but let's call a bandaid a bandaid.
*not to be confused with "isn't real"! As anyone who's ever had a migraine or thrown out back can attest, the pain's very real! Just because there's no clear mechanistic explanation doesn't invalidate the actual suffering, which still needs treatment somehow...the same way you can't logically argue someone out of chronic Lyme disease.
I see a lot of "mays" and "mights" in this article, along with the straight fact that DOs have lower GPAs.
If osteopaths get better results with different pain management techniques, that's an argument that standard physicians should adopt those techniques, in particular, prescribing fewer opioids.
Do DOs go into primary care because they don't qualify for more competitive and lucrative specialties?
I've practiced with DOs who were fine, competent physicians.
But this is a terrible, uneven essay. Endorsements by non-physicians, whether in the 19th century or the 21st, is a terribly unreliable way to evaluate an entire profession. And citing the (seeming) brilliance of founders, only to note they saw the error of their ways after Flexner, is contradictory to say the least. Had osteopathy not changed, I suspect it would have gone the way of naturopaths. Equating the training DOs go through might be a bit misleading to laypeople. Post-graduate training is the same, yes, but education is not- hence the difference in degrees.
And " promising evidence suggests the possible effectiveness of OMT for musculoskeletal disorders" from https://pubmed.ncbi.nlm.nih.gov/35414546/ is as about as hesitant as one can get. Not the proof one might hope for from a technique practiced for over 100 years.
I personally thing medical practice should be under a single degree, but it's clear that allopathic schools need a more efficient and useful curriculum as well as more admissions.
Maybe this is just my training, but the topic here seems to me straightforward: professionalization in medical practice. Professionalization as a process has two strands: 1) status cultivation; 2) efficacy or capacity-building to deliver service/expertise. There's a huge historical & sociological literature on this topic generally, and specifically with regard to the medical field (which is, in fact, a case study in "cartel" behavior).
The scientistic dudes in here talking about studies not being legit unless they are RCT's are kinda laughable. Spend some time in the science & technology studies stacks learning about how actual science and proof points are stabilized institutionally, materially and socially (see: Latour). Taking a beat to review Cochrane studies & other meta-analyses is a better word of hueristic caution.
But honestly, I just want to say, "Thanks Ben. I didn't know about this & enjoyed learning more about DO's." ...and, generally, my sense from having spent some academic time on this topic in my graduate training is that MD's/medical training would benefit tremendously from a more holistic approach to patient care. The specialization/fragmentation of fields coupled with a reductionist approach to diagnostic care (that in turn is more driven by insurance codes than any would like to believe) is a pretty substantial blindspot.
I read the post and I still don't understand how osteopathy is different from regular doctors. It seems like they're medical doctors plus, as in they take all the MD curriculum plus the OMT treatments?
I'd be interested to know how many students of osteopathy just regard this as another way to get into medical school that avoids competing for limited regular MD slots. How many of them continue to use OMT and how many toss it out and never bother with it again after they get their medical license?
The article sounds to me like a pr pitch for osteopathy and does things like cherry picks a few articles like the one on opioids in an osteopathic journal done by osteopaths and concludes that the findings are universal.
In medicine, on most given topics there is evidence for various outcomes, and I wouldn't source a decision on one study, but on a consensus evaluation. There is varying data on whether spinal manipulation has any benefit. And as the article mentioned, most DOs do not do spinal manipulation, anyway.
The opioid issue is rather complex. I trained in the paleolithic days where you didn't prescribe opioids for chronic pain. What made this more common practice, is not the villainous Sacklers, but the humanistic doctors who felt we were too strict and people were suffering. This started with hospice, but then gained popularity throughout medical care, and then in the 90s there were the birth of pain clinics, which varied enormously on how liberal they were in dispensing narcotics. In my area I knew which pain clinics were strict and which Rx'd Fentanyl and Dilaudid like it was a vitamin. And of course, medicine being a commercial enterprise, there was lots of money to be made Rx'ing narcotics being that the patients didn't want to spend any more time than to get their Rx and run.
I feel it was more of the pendulum being formerly too strict and then becoming too loose, than any malfeasance in organized medicine, though individual doctors and pharmacists may have profited from the more liberal standards of narcotic use to make big bucks with pill mills. In the last ten years it has gone back to a much stricter standard.
I saw an osteopath once after experience years of chronic neck pain resulting from bad work posture. I lied on the table and he gently poked me with his fingers in a few spots, and a half hour later I paid him $200. It felt like a scam. But maybe if I'd stuck with it that osteopathic manipulation would have actually done something? Hard to believe, but I'm open to it.
FWIW, I also don't think massage does a whole lot, but at least it's cheaper and more enjoyable! Nor did I even think physical therapy did anything to help the neck issue, and he included some chiropractic manipulation in that as well. What ultimately fixed it was me simply fixing my posture. Perhaps I'm asking too much of these other practices to fix something that I'm constantly reinjuring through the same problematic behavior? That seems reasonable, but I also wish these practitioners had said that to me.
You're second note is of extreme importance. I spent 30 years as a hospital administrator. I had both DOs and MDs on medical staffs. Doctors were not distinguished by their primary medical training but by their residency training and their demonstrated competency. The states that I worked in did not discriminate in licensure. The MD and DO licences were functionally equivalent. No one spoke openly about spinal manipulation.
I’m a little gobsmacked by some of the hostility in these comments (canceling your subscription seems a bit much) because I found this an interesting explanation of something I was curious about and while it makes the case that DOs have value it isn’t exactly a strong rallying cry for them. As the parent of someone who aspires to attend medical school I found this post informative and useful. Thanks Ben.
Canceling your subscription over this would be ridiculous, but the article really misleadingly friendly to DO claims. The mainstream establishment treated them like quacks because they were quacks. Modern DO's are fine because they're basically MD's who are also taught some random quackery that most of them are smart enough to ignore.
Journalism needs places for younger writers to hone their skills that aren’t centered on advocacy, as James Bennnet described about his time at NYT. Standards should be the same, but I try to be more constructive in my comments.
When I moved and had to find a new Cardiologist, the one I found through Yale Medicine was a DO who had done their residence at another Ivy hospital. I was kind of excited to become part of their practice, I figured anyone able to get into both those programs despite the lingering skepticism of DOs in top programs had to be exceptionally sharp. So far my assumption seems pretty sound.
I am married to an MD, and we've had DOs as our Primary Care docs on and off over the years. Her view was that their training as PC practitioners was probably superior to a run of the mill MD, and especially 20-30 years ago they were more likely to have gone into school wanting to be Family physicians.
I just came upon this article while searching through Slow Boring's archives for something different. Thank you for writing about this issue. My husband is a DO because--basically--he screwed around in college and had a low GPA. His MCAT score was stellar, but that wasn't enough for him to get into any MD programs in the states. He chose a DO school in Florida because we were newly married and I was working as an attorney in Orlando. His school was great and his fellow students were smart, driven, and hardworking.
Still, back then (12 years ago), the residency bias against DO students was strong. The hospital where my father-in-law had worked for decades and had held leadership roles in for many years flat-out refused to interview my husband because he was in DO school (despite the fact that he had taken the USMLE). Ultimately, my husband matched into an MD residency in radiology. Now, as a working radiologist, his DO degree is rarely remarked upon. I'm glad to hear that the younger generation has it better than he had, and I wish all the best for your sister!
I have chronic migraines and I didn’t know OMT was a potential treatment. Thanks for writing this!
I’m a DO and have been in practice for several years as a nephrologist. I did my residency and fellowship at allopathic institutions, and have not used OMT since medical school but found it interesting at the time. As a nephrologist, it would not be part of what I do to treat patients with kidney disease, but it could be useful in primary care, particularly as an alternative to traditional pain medications, namely opioids.
In my area where I practice there are several DOs and even more MDs of course, and I have not encountered any biases against DOs recently.
Nice piece Ben. I come to Slow Boring as an escape from medicine and to pique my interest in policy/politics. But it was a pleasant surprise to read about my own world, including the comments.
Please, all medicine in the 1800s had its share of 'cultists'. Just gp tp the AMA medical device museum in Chicago! Disease-focused medicine wasn't consolidated by the AMA until the second decade in the 20th century. A lot of the holistic and preventive care priorities of osteopathic medicine was lost. In fact, the difference in approach to patients centered around the rapid industrialization of that period. One faction of those practicing medicine poured resources into finding treatments for limbs mutilated in the course of factory or extraction work, the other focused on the immediate environments workers were exposed to during their work days. My father got his medical degree in the 1920s. Every year he and my mother would attend the AMA convention and tack a holiday vacation onto the end. We grew up thinking Kirksville, MO was the home of quacks. Your analysis gives the AMA too much credit: it took decades from the 1960s on for the AMA to accept the credentials of DOs and later of nurse practitioners, PAs and midwives. When I moved to a new city I had two physicians recommended to me. Both turned out to be DOs ( I discovered after treatment).I think your starting point (introducing DOs to your readers) is a bit behind the times.
Okay, but how does it...work? What's the One Weird Trick? What I'm coming away with is - here's this odd duck breed of doctor which might be better for commonplace ailments that we know are frequently psychosomatic* and respond well to a wide variety of gazebo-effect treatments like massage therapy, etc. Some placebo must be done -> this is a placebo -> let's do it. Sure, whatever works (if efficacy is on par, at least it's no *worse*, First Do No Harm), and maybe it's even worth diverting some VA dollars or whatever for the cost savings(?). Way cheaper to prescribe chiropracty or acupuncture than back surgey. But I'm not convinced that outside such frustratingly subjective ailments, DOs have some particular special sauce worth elevating. You can hide a lot of shenanigans in aggregate statistics like all-cause mortality. And more generally, the research seems clear that the main benefit of "holistic" care is the provision of, well, human caring, which seems to promote healing along many axes. (Do you know how many people get basically no human touch outside of medical settings?) The systematic incentives towards both cold clinical efficiency and pills-first treatment that prevent such human connections are much bigger than osteopathy. Good on them if they punch above weight class in that regard, but let's call a bandaid a bandaid.
*not to be confused with "isn't real"! As anyone who's ever had a migraine or thrown out back can attest, the pain's very real! Just because there's no clear mechanistic explanation doesn't invalidate the actual suffering, which still needs treatment somehow...the same way you can't logically argue someone out of chronic Lyme disease.
I see a lot of "mays" and "mights" in this article, along with the straight fact that DOs have lower GPAs.
If osteopaths get better results with different pain management techniques, that's an argument that standard physicians should adopt those techniques, in particular, prescribing fewer opioids.
Do DOs go into primary care because they don't qualify for more competitive and lucrative specialties?
I've practiced with DOs who were fine, competent physicians.
But this is a terrible, uneven essay. Endorsements by non-physicians, whether in the 19th century or the 21st, is a terribly unreliable way to evaluate an entire profession. And citing the (seeming) brilliance of founders, only to note they saw the error of their ways after Flexner, is contradictory to say the least. Had osteopathy not changed, I suspect it would have gone the way of naturopaths. Equating the training DOs go through might be a bit misleading to laypeople. Post-graduate training is the same, yes, but education is not- hence the difference in degrees.
And " promising evidence suggests the possible effectiveness of OMT for musculoskeletal disorders" from https://pubmed.ncbi.nlm.nih.gov/35414546/ is as about as hesitant as one can get. Not the proof one might hope for from a technique practiced for over 100 years.
I personally thing medical practice should be under a single degree, but it's clear that allopathic schools need a more efficient and useful curriculum as well as more admissions.
Maybe this is just my training, but the topic here seems to me straightforward: professionalization in medical practice. Professionalization as a process has two strands: 1) status cultivation; 2) efficacy or capacity-building to deliver service/expertise. There's a huge historical & sociological literature on this topic generally, and specifically with regard to the medical field (which is, in fact, a case study in "cartel" behavior).
The scientistic dudes in here talking about studies not being legit unless they are RCT's are kinda laughable. Spend some time in the science & technology studies stacks learning about how actual science and proof points are stabilized institutionally, materially and socially (see: Latour). Taking a beat to review Cochrane studies & other meta-analyses is a better word of hueristic caution.
But honestly, I just want to say, "Thanks Ben. I didn't know about this & enjoyed learning more about DO's." ...and, generally, my sense from having spent some academic time on this topic in my graduate training is that MD's/medical training would benefit tremendously from a more holistic approach to patient care. The specialization/fragmentation of fields coupled with a reductionist approach to diagnostic care (that in turn is more driven by insurance codes than any would like to believe) is a pretty substantial blindspot.
Whenever I here osteopath I think of Larry David's, sorry "Todd's", uncle.
I read the post and I still don't understand how osteopathy is different from regular doctors. It seems like they're medical doctors plus, as in they take all the MD curriculum plus the OMT treatments?
I'd be interested to know how many students of osteopathy just regard this as another way to get into medical school that avoids competing for limited regular MD slots. How many of them continue to use OMT and how many toss it out and never bother with it again after they get their medical license?
The article sounds to me like a pr pitch for osteopathy and does things like cherry picks a few articles like the one on opioids in an osteopathic journal done by osteopaths and concludes that the findings are universal.
In medicine, on most given topics there is evidence for various outcomes, and I wouldn't source a decision on one study, but on a consensus evaluation. There is varying data on whether spinal manipulation has any benefit. And as the article mentioned, most DOs do not do spinal manipulation, anyway.
The opioid issue is rather complex. I trained in the paleolithic days where you didn't prescribe opioids for chronic pain. What made this more common practice, is not the villainous Sacklers, but the humanistic doctors who felt we were too strict and people were suffering. This started with hospice, but then gained popularity throughout medical care, and then in the 90s there were the birth of pain clinics, which varied enormously on how liberal they were in dispensing narcotics. In my area I knew which pain clinics were strict and which Rx'd Fentanyl and Dilaudid like it was a vitamin. And of course, medicine being a commercial enterprise, there was lots of money to be made Rx'ing narcotics being that the patients didn't want to spend any more time than to get their Rx and run.
I feel it was more of the pendulum being formerly too strict and then becoming too loose, than any malfeasance in organized medicine, though individual doctors and pharmacists may have profited from the more liberal standards of narcotic use to make big bucks with pill mills. In the last ten years it has gone back to a much stricter standard.
I saw an osteopath once after experience years of chronic neck pain resulting from bad work posture. I lied on the table and he gently poked me with his fingers in a few spots, and a half hour later I paid him $200. It felt like a scam. But maybe if I'd stuck with it that osteopathic manipulation would have actually done something? Hard to believe, but I'm open to it.
FWIW, I also don't think massage does a whole lot, but at least it's cheaper and more enjoyable! Nor did I even think physical therapy did anything to help the neck issue, and he included some chiropractic manipulation in that as well. What ultimately fixed it was me simply fixing my posture. Perhaps I'm asking too much of these other practices to fix something that I'm constantly reinjuring through the same problematic behavior? That seems reasonable, but I also wish these practitioners had said that to me.
You're second note is of extreme importance. I spent 30 years as a hospital administrator. I had both DOs and MDs on medical staffs. Doctors were not distinguished by their primary medical training but by their residency training and their demonstrated competency. The states that I worked in did not discriminate in licensure. The MD and DO licences were functionally equivalent. No one spoke openly about spinal manipulation.
I wonder whether Naturopathic medicine, which truly is quackery, will eventually reform itself as osteopathic medicine has.
I’m a little gobsmacked by some of the hostility in these comments (canceling your subscription seems a bit much) because I found this an interesting explanation of something I was curious about and while it makes the case that DOs have value it isn’t exactly a strong rallying cry for them. As the parent of someone who aspires to attend medical school I found this post informative and useful. Thanks Ben.
Canceling your subscription over this would be ridiculous, but the article really misleadingly friendly to DO claims. The mainstream establishment treated them like quacks because they were quacks. Modern DO's are fine because they're basically MD's who are also taught some random quackery that most of them are smart enough to ignore.
I agree.
Journalism needs places for younger writers to hone their skills that aren’t centered on advocacy, as James Bennnet described about his time at NYT. Standards should be the same, but I try to be more constructive in my comments.
When I moved and had to find a new Cardiologist, the one I found through Yale Medicine was a DO who had done their residence at another Ivy hospital. I was kind of excited to become part of their practice, I figured anyone able to get into both those programs despite the lingering skepticism of DOs in top programs had to be exceptionally sharp. So far my assumption seems pretty sound.
I am married to an MD, and we've had DOs as our Primary Care docs on and off over the years. Her view was that their training as PC practitioners was probably superior to a run of the mill MD, and especially 20-30 years ago they were more likely to have gone into school wanting to be Family physicians.