Dr. Cohen is professor of medicine and public health, George Washington University, Washington, DC, and president emeritus, Association of American Medical Colleges, Washington, DC; (firstname.lastname@example.org).
Andrew Taylor Still, believing that human ailments were rooted in musculoskeletal dysfunction, opened the first school of osteopathic medicine in 1892. He elected to award graduates of his new school not the MD degree but, instead, a distinctive accolade: doctor of osteopathy. This decision led to a distinctly separate medical profession, one that was looked upon by the allopathic medical “establishment” with disdain. Had osteopathy remained slavishly obedient to Still’s quaint views of human biology, such disdain might be understandable. But it has evolved, just as allopathic medicine has, in response to the revolutionary scientific and technological advances that have occurred over the last several decades. As a consequence, today’s osteopathic medical profession looks an awful lot like its erstwhile rival.
Take, for example, osteopathic medical schools. The accreditation standards and the curricula of DO schools closely resemble those of MD schools. Indeed, in terms of curriculum, the single noteworthy exception is the time devoted to osteopathic manipulative medicine (OMM), reflecting a lingering belief among many osteopathic physicians that OMM is efficacious in some circumstances (as it may well be).
To be sure, the pedagogical model characteristic of DO schools, in contrast to their curricular content, differs in several respects from that employed by most MD schools. Osteopathic medical schools, in general, employ fewer faculty, conduct less research, and rely more heavily on community-based practitioners to implement the clinical portions of the curriculum. These differences, while characteristic, are not absolute. If the nation’s 152 Liaison Committee for Medical Education (LCME)- and American Osteopathic Association-accredited medical schools were arrayed on a spectrum from most research intensive at one end to most community based at the other, at no point could one draw a bright line to separate the institutions into two discrete groups. As a reflection of this overlap, the applicant pools from which entrants to MD and DO schools are selected contain a great many of the same students.
Those who wish to sustain the historic dichotomy between these two increasingly convergent medical professions point to the osteopathic profession’s avowed commitment to primary care and to patient-centered, “holistic” care. To my mind, this is a distinction without a difference. After all, the calls for more attention to primary care and to patient-centeredness are as loud in the halls of allopathic medicine as anywhere. Moreover, despite the rhetoric, more and more DO graduates, just like MD graduates, are electing to pursue non-primary-care residencies. In addition, the dwindling number of accredited osteopathic residencies available, coupled with the superabundance of Accreditation Council for Graduate Medical Education–accredited positions, means that the majority of DO graduates are now completing their medical education in allopathic training programs.
What, then, is the benefit of sustaining two separate educational pathways? Certainly not the notion that these two pathways are necessary to maintain heterogeneity and avoid a monolithic approach to the preparation of future physicians. That notion would imply that all allopathic and all osteopathic schools adhere, respectively, to separate and distinct educational paradigms. Nothing could be further from the truth, as noted above. Indeed, in recognition of the importance of adapting to changing realities of medical practice and, hence, of the need to embrace novel educational arrangements, LCME standards have for a long time not only permitted, but indeed encouraged, innovation. Working within those standards, the 130 MD schools currently in operation have developed a multiplicity of successful educational models, all of which pass muster by the accreditors. The same is undoubtedly true of the 28 accredited DO schools, including three branch campuses. And yet, despite the multiplicity of existing approaches, we all recognize that a great deal more innovation is needed if we are going to prepare future physicians adequately for the unprecedented challenges they will face in our rapidly changing health care system.
Those interested in finding more effective and efficient ways to educate future physicians to meet those challenges need, above all, to look “outside the box.” In doing so, they would do well to eschew outmoded stereotypic prejudices about osteopathic medicine and look objectively at the pluses and minuses of its educational model. Rather than remaining disengaged from our academic counterparts in schools of osteopathic medicine and sustaining separate educational pathways, a more certain path to improving the education of all our students would be to break down the remaining barriers and learn as much as we can from each other. Whatever benefits learners derive from the osteopathic educational pathway should be showered on all medical students, and vice versa. Isn’t it about time we got our acts together?
Jordan J. Cohen, MD