Osteopathic medical schools and hospital-based postgraduate programs have long constituted small but important sources of physicians and surgeons, particularly for traditionally underserved areas of the country. Though frequently marginalized in, or even left out of, standard histories and studies of U.S. medical education, these institutions have become much more difficult to ignore, given the rapid expansion of the overall number of osteopathic students in new and existing colleges. By 2019, upwards of 25% of all U.S. medical school graduates produced annually will be doctors of osteopathic medicine (DOs). In this article, I examine the process through which osteopathy was transformed into osteopathic medicine, how osteopathic medical schools achieved their present status as a significant source of U.S. graduates for residency training, and what changes osteopathic medical education now faces.
The First Osteopathic College
The first osteopathic college—the American School of Osteopathy (ASO)—was opened in 1892 by Andrew Taylor Still (1828–1917) in the small town of Kirksville, Missouri. Still was an apprentice-trained physician who in 1864, after the deaths of three children from meningitis, began to question the standard causal explanations for disease and the contemporary materia medica of orthodox medicine (labeled allopathic medicine by its critics). Still investigated homeopathy and eclecticism—the chief drug-based rivals of conventional medicine—but found them wanting. He also studied drugless systems and enjoyed clinical success, first with what was called magnetic healing and then, shortly afterwards, with bone setting. Both systems embodied physical manipulations. In 1874, he declared his independence from orthodox medicine, and during the next two decades he worked out the elements of his alternative approach.1–3
About 1880, an asthmatic woman came to see him for a pain in her shoulder. In examining her, he recalled, “She had a section of upper vertebrae out of line, and I stopped the pain by adjusting the spine and a few ribs. In about a month, she came back to see me without any pain or trace of asthma. This was my first case of asthma treated in the new way and it started me on a new train of thought.”4
Soon he was handling a variety of chronic ailments, all by manipulating vertebrae back into their “proper position.”4 In accounting for his good results, Still synthesized some of the theoretical arguments of magnetic healers and bonesetters into one unified doctrine. The effects of disease, as the former said, were due to the obstructions or imbalance of the body’s fluids, but this, in turn, was caused by misplaced bones, particularly of the spinal column, which interfered with nerve supply and, consequently, with the regulation of blood flow. Still called his distinctive system osteopathy.5 By the late 1880s, he established a permanent clinic in Kirksville. Because of the crowds of incoming patients, the town was referred to in one newspaper account as a “Missouri Mecca for invalids.”1
The first ASO course in osteopathy was brief, a matter of months. Dr. William Smith, a Scottish, university-trained physician who wished to learn Still’s methods, drilled students for several hours a day in anatomy.6 He was followed by Dr. Still, who lectured the class on his philosophy of medicine. Students then watched “the old doctor” examine and treat patients. Within five years, Still built a massive teaching facility, and his school enrolled 700 students. He soon expanded the curriculum to encompass two years of 20 months’ instruction and included lectures in all of the basic sciences found in a traditional medical school except pharmacology. The ASO also provided some instruction in surgery and obstetrics, although the only drugs that Still sanctioned were anesthetics, antiseptics, and antidotes. He argued that the body manufactures all the chemicals or drugs it needs when it is in health, and that the role of the osteopath was to mechanically remove all obstructions and impingements to these normal processes so that the body can then do its proper work without any further intervention. Still’s motto was “Find it, fix it, and leave it alone.”1,2,5 Upon graduation, each student was awarded a DO rather than a doctor of medicine (MD) degree.
By 1898, Still’s students opened several osteopathic schools across the United States, which led to the organization of the Associated Colleges of Osteopathy (decades later renamed the American Association of Colleges of Osteopathic Medicine). In 1901, the graduates of these institutions created the American Osteopathic Association (AOA), which established and enforced common minimum standards governing osteopathic education. The first AOA accreditation survey of osteopathic schools was carried out in 1903—three years before the American Medical Association (AMA) conducted its initial survey of MD-granting colleges. The AOA study pointed out several shortcomings in osteopathic training, and the most tangible outcome of this accreditation report was an agreement that all osteopathic schools immediately initiate a mandatory three-year curriculum. With baseline college standards in place, the DOs, despite great opposition from the MDs, were successful in getting state legislators to pass, and governors to sign, licensing acts to enable them to practice osteopathy.1
For the purpose of his Carnegie Foundation study published in 1910, Abraham Flexner treated osteopathic schools as medical colleges. However, in his report he emphasized that not one “of the eight osteopathic schools is in a position to give such training as osteopathy demands.” The teaching of anatomy, for example, he found “fatally defective.” Most of the students’ time during this course of study was spent listening to lectures. Too few cadavers were available to provide adequate laboratory dissection, and this pattern of meager laboratory resources characterized the other basic sciences as well. Flexner regarded clinical instruction as poor or nonexistent. “The osteopath,” he declared, “cannot learn his technique and when it is applicable except through experience with ailing individuals. And these for the most part he begins to see only … after receiving his DO degree.” In characterizing the entire osteopathic educational program, Flexner concluded that “granting all its champions claim, osteopathy is still in its incipiency. If sincere, its votaries would be engaged in critically building it up. They are doing nothing of the kind.”7
The Flexner Report reinforced efforts by the AMA to upgrade MD-granting institutions during the next quarter century. By 1935, dozens of weak MD schools either closed or consolidated, and state legislatures and universities, aided by institutional and private philanthropy, provided the necessary resources to improve college programs to a level of equivalency with, if not superiority to, the best European medical schools. On the postdoctoral level, internships for U.S. MDs became standard, and a variety of residency and fellowship programs increasingly became available in larger hospitals.8–9
In the same 25-year time span, the osteopathic educational system continued to lag behind that of its MD counterparts. The ranks of DO-granting colleges diminished from eight to seven. None of these osteopathic colleges were state supported, none were university affiliated, and they obtained little external philanthropy. Recognizing that the necessary resources for significant changes would not be forthcoming, the AOA pressed the colleges to make only modest improvements. In 1916, the AOA mandated that all accredited colleges expand their curriculum to four years—the same as MD-granting schools—but only required them to maintain as their base student entrance prerequisite a high school diploma—this compared with a minimum two-year preprofessional college requirement for MD students. Because of the small number of participating inpatient facilities, most osteopathic students received little hospital-based training in their third and fourth years. By the mid-1930s, only one in four graduates had the opportunity to complete an osteopathic internship.1,10
The most important change the DOs instituted during the quarter century following the Flexner Report was expanding the scope of the curriculum. The conservative political leadership of the AOA adamantly opposed the teaching of pharmacology and threatened to disapprove those schools that went beyond the list of subjects allowed in their accreditation standard. However, significant changes in the content of the orthodox materia medica, and the proven efficacy of vaccines, serums, and drugs such as digitalis, colchicine, and quinine, led DOs, who wanted their patients and the public to regard them as “complete physicians,” to incorporate these tools in their armamentarium. With their efforts to enlarge their scope of practice to encompass surgery and obstetrics stalled in some state legislatures because “pharmacology” per se was not taught, DOs brought increasing pressure on the AOA leadership to make the needed changes. Finally, the AOA board of trustees, after decades of professional strife, voted in 1929 to allow the teaching of pharmacology in osteopathic schools.1
This change in policy regarding the scope of the curriculum did not automatically lead to expansion of DOs’ legal scope of practice. State medical associations argued effectively that although osteopathic schools and postdoctoral training programs were now teaching medicine in its entirety, their educational standards continued to be grossly inferior to those maintained by MD-granting colleges and residency programs. Even in those states in which DOs had obtained the same eligibility as did MDs for an “unlimited” scope of practice, they still had to pass examinations given by PhD members of “basic science boards” before being examined by clinicians on state medical or state osteopathic boards. These basic science exams, championed by the AMA, were required of different classes of practitioners (MDs, DOs, and chiropractors, or DCs). Many DOs, who had little or no undergraduate college science prerequisites, did poorly compared with their MD counterparts.11 In many states, where DOs were legally eligible for a complete scope of practice, they were unable to obtain this privilege because of poor results on both basic science boards and on licensure tests administered before MD or composite (MD and DO) medical boards.1
Given this set of circumstances, the AOA and the colleges were forced to implement further educational reforms. In 1938, despite a fear that raising standards would dramatically lower the number of applicants and lead to the closure of several schools, the AOA changed its accreditation rules to enforce a one-year undergraduate college prerequisite for students and, in 1940, raised the standard to two years—the same as that of most MD colleges. The applicant pool soon declined more precipitously than expected. This was due in part to the great number of college-age men enlisting or being drafted into military service during World War II. After 1945, however, osteopathic school enrollment increased to attain prewar levels as returning veterans—a significant percentage of whom were not accepted into MD schools—sought admission to DO programs as an alternative way to become a “physician and surgeon.” An ongoing recruitment effort at liberal arts colleges also expanded the application pool, making acceptance into osteopathic colleges more competitive. By 1960, 71% of entering osteopathic students possessed a minimum of a bachelor’s degree.1
The United States’ entry into World War II affected osteopathic medical education in other ways. With tuition revenue dropping because of fewer enrolled students, the colleges needed added sources of revenue not only to help them survive but also to make essential improvements in their infrastructure. In 1943, the AOA launched the Osteopathic Progress Fund through which private-practice DOs contributed millions of dollars directly to their alma maters. As competition for college admittance intensified after the war, the schools were able to substantially increase their tuition and fees. In addition, this era marked the beginning of osteopathic eligibility for federal dollars. In 1951, the U.S. Public Health Service awarded all six osteopathic medical schools renewable teaching grants. As a result of these additional revenues, the colleges upgraded their laboratories and other facilities and hired more and better-qualified basic science faculty members.
Clinical training also significantly improved. During and after World War II, DOs established dozens of osteopathic hospitals across the country. Since the early 1920s, the AMA had officially branded DOs as “cultists,” and, as a consequence, the Joint Commission on the Accreditation of Hospitals specifically barred osteopathic physicians and surgeons from having staff privileges at member institutions. With more DOs seeking to practice as complete physicians and surgeons, it was essential for them to create alternative inpatient facilities. After the war, DOs secured federal Hill-Burton monies to support the construction and upgrading of osteopathic hospitals, both college operated and independent. Private insurers covered these patient costs in the same way as they did for patients hospitalized in MD-staffed institutions. This osteopathic hospital boom finally provided DO students with equivalent third- and fourth-year clinical experiences relative to their MD counterparts, and these osteopathic hospitals furnished all graduates with AOA-approved internship positions. In addition, the hospitals created a modest but increasing number of residency programs in a variety of medical and surgical specialties. By 1960, the AOA had established 11 osteopathic specialty boards that certified DOs in fields such as radiology, surgery, pediatrics, internal medicine, and anesthesiology. These institutional changes with respect to preprofessional requirements, basic science instruction, and clinical experiences were reflected in the steadily improving performance of osteopathic students and graduates on externally administered medical and composite board licensing examinations1 (see Table 1).
Why Two Medical Professions?
The growing similarity between allopathic and osteopathic colleges with respect to preprofessional requirements, curriculum, and standardized test performance posed an existential question for some DOs and MDs—namely, why have two separate medical professions? In the early 1940s, this question was raised by officials of California’s osteopathic and allopathic associations who met in private and quietly discussed how they could further an eventual national merger between the two professions. In 1951, they were instrumental in creating and furthering the AMA’s so-called “Cline committee,” whereby MDs would factually answer three questions: What is actually taught in osteopathic schools? What is the quality of instruction? Is the term “cultist” an appropriate label for osteopathic medicine? In 1955, after a series of negotiations with the AOA, an inspection committee, made up of deans and past deans of MD schools, visited five of the six osteopathic colleges. In their report to the AMA House of Delegates that same year, all but one of the committee members maintained that although there were some educational gaps in quality, the existing differences in content between the two types of medical schools (essentially osteopathic philosophy and manipulative medicine) “did not constitute the teaching of cultist healing.” However, after much debate, the AMA House of Delegates voted narrowly to reject the committee majority’s findings. As a result, the cultist designation remained, thereby continuing to prevent AMA members from ethically associating with DOs.1
The discarded Cline report nevertheless furthered the local interests of the leaders of both the California Medical Association and the California Osteopathic Associations. In 1961 and 1962, with no opposition from the AMA, they pushed through a statewide merger between MDs and DOs that resulted in the conversion of the Los Angeles osteopathic college into an MD-granting school (now the University of California, Irvine, School of Medicine), dozens of once-osteopathic hospitals becoming MD institutions, and approximately 2,000 of the state’s licensed DOs becoming licensed “MDs” (in California only) by paying a charge of $65 and surrendering their osteopathic diplomas. Many predicted the quick national amalgamation of all DOs and their institutions.1
These events forced DOs elsewhere in the country to consider whether they wished to maintain their own professional identity. Most responded affirmatively, and they acted quickly to secure their independent future. DOs used the California merger to convince those remaining state legislatures that had yet to give osteopathic practitioners full physician and surgeon licensing privileges to now do so, arguing that in California the only significant difference between being a DO or an MD was a paltry $65 fee. They also successfully pressed federal government agencies to provide them with all rights and privileges enjoyed by MDs, most notably equal opportunity to serve in the military medical corps.12
The DOs also lobbied some state governments to aid them in the process of replenishing their ranks. In the late 1960s, the Michigan legislature agreed to support a new osteopathic medical school at Michigan State University. In the 1970s, other state legislatures created osteopathic medical schools at the University of North Texas, Ohio University, the University of Medicine and Dentistry of New Jersey, Oklahoma State University, as well as the freestanding West Virginia School of Osteopathic Medicine. In 1974, a key provision of the California merger agreement that prevented future licensing of DOs in that state was ruled unconstitutional. Soon after, a new private osteopathic college was established in Pomona, California, that began the process of replenishing the ranks of DOs in the state.1
In the early 1960s, the AMA decided that the label of “cultism” should be left to the states to decide and encouraged its divisional medical associations to meet with their osteopathic counterparts to facilitate further mergers. State osteopathic associations insisted, however, that the MDs first had to drop the cultist designation as a precondition for meeting with them. After so doing, the state medical association representatives discovered, to their surprise, that the DOs then rebuffed any talk of “amalgamation.” To put pressure on osteopathic colleges to become MD schools or force them to close their doors, the AMA contacted enrolled DO students, urging them to transfer to MD colleges and thus deprive DO-granting schools of needed operating revenue. Not only was this effort unsuccessful, but it likely violated antitrust statutes.13
In the mid- to late 1960s, the AMA unveiled new tactics to lure DOs away from AOA affiliation. They opened up membership for DOs in their local, state, and national associations and encouraged them to enter internships and residency programs approved by the Accreditation Council for Graduate Medical Education (ACGME) where the respective specialty boards of the American Boards of Medical Specialties had agreed to examine and certify them at the completion of their training. The AOA and some of its state societies responded to this prospect of unfilled osteopathic graduate training positions by putting rules into place that required an internship in an AOA-approved program both for licensure and for AOA specialty board certification. The AOA also determined that, for osteopathic specialty board certification, DOs could enter an ACGME program, but only after completing a specified number of years of specialty training in an AOA residency. In part because of these restrictive rules, most DOs initially remained in osteopathic programs.1
In 1980, the first in a series of studies was published predicting a physician oversupply.14 Although these reports effectively ended efforts to establish new, state-supported osteopathic medical colleges, they did not deter groups from developing new private schools, nor did they prevent existing private osteopathic colleges from expanding their class sizes. The resulting growth in osteopathic graduates put an increasing strain on the ability of the profession’s associated hospitals to create sufficient numbers of AOA-approved internship and residency slots. In response to the shortage of AOA programs, and to retain the loyalty of osteopathic medical graduates, the AOA was forced to modify its rules regarding when and under what circumstances DOs could appropriately enter ACGME residencies. By 1995, more than 60% of DOs in internships and residencies were training in ACGME programs. The AOA has recently sought to increase the number of its own funded postdoctoral slots by developing a new means to organize and accredit internships and residencies through college and hospital consortia known as Osteopathic Postdoctoral Training Institutions (OPTIs), but, thus far, actual gains in positions have been outstripped by the increasing number of new DO graduates.1
A much-publicized 2002 workforce analysis arguing that there would soon be a looming physician shortage has provided a justification for an explosive growth in the development of new private osteopathic medical schools and an expansion of class size in not only private but public institutions.15 This trend, partially presented by Table 2, is continuing apace. In 2008–2009, there are 28 osteopathic medical colleges (including out-of-state “branch” campuses), with several more potential schools now in various stages of planning. Data suggest that, by 2019, DOs will constitute upwards of 25% of all new graduates of U.S. medical schools.
DO schools are currently expanding their class sizes much more quickly than are their MD counterparts. Unlike MD colleges, where it is widely known that academic faculty members—fearing dilution of quality as well as the prospect of an increased teaching workload—constitute a powerful inhibiting force to expand class size, osteopathic faculty at private osteopathic schools have traditionally had little or no input on such matters. Instead, these decisions are almost exclusively the responsibility of college administrators and their boards of trustees, who look at such expansion from an entrepreneurial as well as an educational perspective. Osteopathic medical schools can keep the cost of student body expansion relatively low compared with that of MD institutions. Although the standards of the Commission on Osteopathic College Accreditation ensure that there will be enough desks and lab spaces to accommodate all new students, they do not mandate that an osteopathic college must bear the expense of maintaining a high full-time-faculty:student ratio.16
Fortunately, the rapid expansion of osteopathic medical schools has not negatively affected the credentials of matriculants. Indeed, the present qualifications of DO students seem to be more than satisfactory, and performance indicators continue to improve. Osteopathic matriculants almost invariably enter with baccalaureate degrees, and a significant minority have advanced degrees. For the 2005–2006 entering class, the mean overall undergraduate GPA was 3.44, and the mean science GPA was 3.36 (each on a 4-point scale).17
Osteopathic medical college growth combined with the likely prospect of expansion in the number of MD-granting schools and MD students makes problematic the future ability of DOs to secure sufficient residency slots in either AOA or ACGME programs. In 1997, Congress passed the Balanced Budget Act, which restricted the number of Medicare-funded residency positions—this at a time of a perceived physician oversupply. MD and DO associations are currently pressuring members of each legislative branch to find a way to fund more residency slots to accommodate this growth in medical school graduates. However, getting Congress to act will be difficult, because both political parties seem more concerned with trying to limit overall Medicare expenditures.1
A final consideration with respect to the future of osteopathic medical education is the continuing existential question, Why have two separate academic programs—one MD and one DO? Osteopathic medicine is both a “profession” and a “social movement.” Given osteopathic medical schools’ considerable similarity with MD-granting colleges in terms of scope of curricula and the performance of graduates, the rationale for an autonomous existence and the granting of a distinctive DO degree (now signifying a doctor of osteopathic medicine rather than doctor of osteopathy) rests on the belief that there is something valuable about the osteopathic educational experience that translates into producing a distinctive type of competent physician serving the public interest.18,19
DO college students, unlike their MD school counterparts, spend a significant portion of their first two years being trained in the essentials of osteopathic manipulative medicine. Nevertheless, the use of palpatory diagnosis and manipulative treatment by DOs in AOA and ACGME residency programs or in private practice has diminished. Scientific research on the relative effectiveness of osteopathic manipulation is increasing, but it still lacks adequate funding and has yet to produce definitive results that an “osteopathic” approach makes a significant difference in patient care.20 As a group, DOs have somewhat different practice patterns than do MDs. A significantly larger percentage of DOs go into primary care, and a larger percentage of DOs practice in underserved, rural areas. Though these last two patterns are sociologically significant, they only weakly support an ideological justification for two types of degree-granting or residency programs.1
The osteopathic medical profession must continue to build up its academic infrastructure and find additional resources to ensure educational excellence, but, at the same time, the “social movement” aspect of osteopathic medicine also needs to be seriously addressed. If osteopathic medicine wishes to maintain its independence, it will need to strengthen its distinctive educational elements in its college and residency programs to produce physicians who believe they are (and are perceived by others to be) not only “qualified” but “different” in the way they practice medicine. Literally as well as figuratively, the future of osteopathic medicine may ultimately rest in the DOs’ own hands—and how they use them.