The strange history of osteopathic medicine

And its implications for our healthcare system today

Donald Trump and Joe Biden will happily tell voters, the media, and really anyone who will listen, about their differences.

I’d like to share something they have in common: Both of their primary care doctors hail from a style of medical practice that was once derided by the mainstream medical community as a cult.

They're called Doctors of Osteopathy (DOs), and they offer a holistic treatment approach that emphasizes preventive care, the musculoskeletal system, and the overall “mind, body, and spirit” of the patient. Despite the approach’s ostracized 19th-century origins, DOs are now commonplace in hospitals across the country. They receive equal training and have the same practice rights as medical doctors (MDs).¹

Our last two presidents aren’t alone in turning to DOs for treatment.

Buffalo Bill was an early supporter of the practice. Nelson Rockefeller saw an osteopath twice a week. Pope John Paul II, Michael J. Fox, and Muhammad Ali have all been treated by DOs.

Even if you don’t know it, there’s a possibility that you’ve either been treated by a DO or will in the near future. DOs currently represent 11% of all physicians in the United States and 25% of current medical students.

The story of osteopathic medicine’s shift from the medical fringe to an integral part of modern medicine is not widely known. But it's a fascinating tale with implications for our contemporary public healthcare system.

The father of osteopathic medicine

The field of osteopathic medicine was born out of tragedy. Dr. Andrew Taylor Still, a former Kansas state legislator and Union soldier, lost three of his children to spinal meningitis. In his profound grief, he went looking for something to blame.

What he found has surprising resonance with medical debates today.

Dr. Still believed that allopathic medicine (the treatment practiced by mainstream medical doctors) was far too focused on treating symptoms, usually with drugs, rather than the underlying conditions that led to illness.

This was a bit more rational than swapping Advil with turmeric. Dr. Still was practicing medicine in Kansas during the 1870’s, a time where sore throats were treated with mercury and chapped lips with lead nitrate. He wanted to deemphasize these harsh and, at times, deadly forms of medicine, and treat patients more holistically.

Did Dr. Still wander into strange medical experiments of his own? Absolutely. The father of osteopathy tried treating pain with magnets and disease with herbs. He was, by our modern definition, a bit of a kook. And perhaps, a bit of a megalomaniac, once claiming that he could “shake a child and stop scarlet fever, croup, diphtheria, and cure whooping cough in three days by a wring of its neck.”

However, much of his work remains foundational to the practice. Most notably, he invented Osteopathic Manipulative Treatment (OMT), a hands-on technique used to treat and prevent everything from knee pain to chronic migraines. This practice, along with his philosophical approach to treating the patients’ “mind, body, and spirit” are taught as core elements of the osteopathic educational curriculum today.

The slow road to acceptance

When Dr. Still first began preaching the virtues of osteopathic medicine, his local church denounced him as sacrilegious. His brothers openly called him crazy. Baker University, the educational institution his family had helped establish a few decades prior, flatly refused to let him present his ideas.

By all accounts, it was a stunning fall from grace for a once-respected community leader. And it took moving to several towns and a decade of travel before he eventually found a receptive community in Kirksville, Missouri, where he founded the first functioning osteopathic school. He soon transformed the town into a Midwest medical destination; by the late 1890s, around 400 people journeyed to see Dr. Still or one of his newly credentialed students each day.

That local recognition failed to resonate with the mainstream medical community. In 1910, the famed medical education reformist, Abraham Flexner, issued the eponymously named Flexner Report. In it, he recommended a litany of reforms for the medical community, the most significant of which was the outright end of osteopathic medicine. Ten years later, the American Medical Association furthered osteopathic ostracism, releasing a resolution that essentially called all practitioners cultists.

While the name-calling might’ve been a bit heavy-handed, the substance of these critiques had some merit. Early 20th-century osteopaths eschewed mainstream pharmacological treatments and invasive surgery. The schools had comparatively lower admissions standards, and certified practitioners were able to practice on patients without significant clinical training.

If the osteopathic field hadn’t internalized those critiques, it might’ve gone the way of phrenology—just another quackery footnote in medical history. But the field began to incorporate mainstream medical practices, including many of the breakthroughs that occurred from the mid 19th through the 20th century. This meant expanding treatments that involved pharmacology and invasive surgery, practices that would’ve abhorred the deceased Dr. Still, but were essential to the modernization of the field.

Eventually, DOs began learning the same curriculum as MDs, along with their holistic approach and the requirement that all practitioners learn OMT treatments. The AMA soon recognized the modernization of the DO field, and started certifying DOs as equivalent to medical practitioners in the early 1960s.

Today, in addition to the standard osteopathic exam, DOs take the exact same credentialed test as MDs. And as recently as 2020, the osteopathic field integrated into the singular accreditation system for graduate medical education, meaning DOs and MDs now complete their residency training at the same schools.

Modern osteopathic medicine is effective

Outside of its applications for bar trivia and stimulating dinner party conversation, this history matters because osteopathic medicine has evolved to become an important practice in today’s healthcare system.

Consider some of contemporary America’s biggest public health crises.

The Opioid Epidemic has already killed 600,000 Americans and is expected to claim 1.22 million lives this decade. Two of the leading causes of death are hypertension and heart disease, both of which are linked to obesity. A staggering one in five Americans is currently living with chronic pain.

There is, obviously, no silver bullet to treat any of these healthcare issues. But it’s worth considering the philosophical and practical differences that separate DOs from MDs, and subsequently, their capacity to treat these public health problems.

A study by PRECISION Pain Research Registry found that doctors of osteopathy are less likely than medical doctors to prescribe opioids and other non-steroidal medicines. And “patients of osteopathic physicians reported lower levels of pain catastrophizing and were more resilient and better able to cope with their pain.”

Why were DOs predisposed to prescribe less opioids, and how were they able to still leave their patients with a greater capacity to deal with pain? One possible reason dates back to the same philosophical practices that grounded osteopathic medicine 150 years ago. DOs are trained to treat the patient holistically, and while they still absolutely prescribe prescription medicine, they do so at a comparatively lower rate than medical doctors.

OMT, the manipulative bone therapy technique that is exclusively practiced by osteopaths, has been shown in multiple comprehensive studies to be effective against some of the most prevalent forms of chronic pain. Most notably, it’s been proven to reduce the amount of work days missed due to lower back pain. It was demonstrated to be more effective than medication in treating chronic migraines, and even reduced the length of hospital stay and the chances of both respiratory failure and death for elderly patients suffering from pneumonia.²

A clinical trial has also demonstrated that osteopathic treatment is associated with an improvement in high blood pressure, as well as an improved intima-media (essentially a proxy for artery health).

This doesn't suggest you should forsake your MD for a DO, nor does it imply that a medical doctor is incapable of treating these conditions effectively. Notably, the most extensive study available, conducted by UCLA Health on nearly 330,000 senior Americans, found virtually identical outcomes in patient mortality, hospital readmission, and Medicare spending between DOs and MDs.

It is fascinating that doctors of osteopathy transitioned from their cult-like reputation to perhaps outperforming medical doctors in treating some of the most pressing public health issues in contemporary America.

But that history matters for another more troubling reason: Despite its increasing prevalence and demonstrated effectiveness, osteopathic medicine is still plagued by the remnants of historical bias.

The lingering bias against DOs

Last year, a bipartisan group of Congress members introduced the Fair Access in Residency Act. The legislation’s purpose was twofold:

1. It forced all residency programs receiving federal funding to report the number of osteopathic students it admitted each year, with the hope that the added transparency would reduce bias against prospective osteopathic students in the residency application process.

2. Each school also had to affirm that they accept the respective licensing exams for both practices — the USMLE for allopathic licensure and COMLEX for osteopathic licensure.

The problem they were trying to solve is a very real one.

According to the National Residency Match Program, 32% of residency program directors report never or seldom interviewing an osteopathic medical student. And of the programs that do consider DOs, 56% require the students to take the MD licensing exam. In effect, this forces DO students to take two tests, while MD students take just one.

The good news for DO students is that the match rate into residency programs is basically the same as MD students, meaning they’re equally likely to continue their education and ultimately become practicing doctors. But these facts still reveal a lingering bias against DOs that excludes them from certain residency programs and adds additional obstacles to continuing their medical education.

Now, it’s natural to ask whether MD students simply perform better academically, and are thus more qualified to gain access to certain elite residencies.

And the answer to that is complicated.

DO programs have a historical reputation, dating back to the infamous Flexner report, for having lower standards for admitted students. Today, that narrative is still somewhat accurate, but less so. Admitted MD students have an average GPA of 3.77, while the DO GPA sits at 3.61. The average MD MCAT score is also slightly higher (511.7) compared to DO students (504.8).

But are those slight differences enough to justify the 32% of residency programs that basically ignore all qualified osteopathic doctors?

To answer this question, I think it’s worth returning to the actual performance of osteopaths in the field. Are MDs outperforming DOs in actual hospital performance? The largest study we have demonstrates no difference between the performance between the two medical professions. Other research suggests that osteopathic medicine outperforms allopathic medicine in treating certain conditions, including chronic pain and hypertension.

That lingering bias should probably be buried right next to A.T. Still and his neck-wringing cure for scarlet fever.

More practitioners, more public awareness

Doctors of osteopathy now play an incredibly useful role in our healthcare system, filling gaps in field that face significant supply shortages.

Fifty-six percent of all graduating DOs ultimately pursue a career in primary care, a specialty that could face the largest physician shortage by 2034. By contrast, two-thirds of MDs work in other medical specialties. DOs are also more likely to work in rural areas and in communities that are under-serviced by healthcare.

It’s difficult to say whether this is due to nature of their education, the innate desires of the students, or the geographic placement of the schools (DO schools are more likely to be in rural areas), but it does underscore the valuable role practitioners of osteopathic medicine play in our modern healthcare system.

The fact that DOs now represent 25% of all current medical students is a promising development for patients seeking primary care doctors and for millions of Americans living in rural America.

I do think we would benefit from a broader awareness of osteopathic medicine, though. Everyone knows the function of a medical doctor. But according to the American Osteopathic Association, 1 in 5 Americans don’t know DOs exist. And depending on the age group, 37% to 46% of adults would not consider osteopathic treatment.

These aren’t terrible public opinion numbers for a practice that was practically considered a cult a mere century ago. But the deadly crisis of overprescription continues to decimate communities. Chronic pain afflicts 20% of Americans and is substantially more common than depression and diabetes.

That means millions of Americans who are dealing with pain might benefit from knowing more about osteopathic medical practices like OMT. The historic number of younger patients looking for alternative forms of treatment should know that osteopathic medicine is far more reputable and effective than advice they might get on social media. And people looking to avoid opioid prescriptions should know that DOs are far less likely to prescribe them.

Century-old bias should not undermine the standing of this growing medical practice.

1. My sister is currently studying to become a DO, which triggered my interest in the topic.

2. Notably, 56% of DOs report to not use OMT on patients.