A century ago, Abraham Flexner visited all 147 U.S. medical schools, including the 8 osteopathic schools of the time. Flexner’s 1910 report generally found U.S. schools to be poorly run producers of “uneducated and ill trained medical practitioners.”1 Following the Flexner Report, U.S. allopathic schools moved rapidly toward a more uniform system, significantly improving the quality and consistency of practitioners. In the process, allopathic institutions became increasingly tied to research universities and growingly complex and inflexible 20th-century academic medical centers (AMCs). Osteopathic schools followed a slower path to reform, in part due to an effort to hold on to their rural roots and traditional focus on general practice, and in part due to their limited sources of external funding. By the 1930s, however, states were setting professional requirements which osteopathic graduates were finding difficult to fulfill and limiting DO practice privileges.2 As a result, it was during this period that osteopathic schools pushed forward the reform that allopathic schools had achieved in the previous 25 years.
Today, osteopathic and allopathic medical education can be difficult to differentiate. Osteopathic medical schools are held to accreditation standards similar to those of allopathic schools, and increasing numbers of osteopathic graduates enter Accreditation Council for Graduate Medical Education residency and fellowship programs. However, the distinctive historical mission of osteopathy continues to yield substantial numbers of primary care physicians and practitioners working in underserved areas. Osteopathic medical education has also remained flexible enough to develop new models for the continuation of this mission.
The U.S. health care system has historically and persistently suffered from an insufficient number of primary care providers and a geographic maldistribution of physicians. Evidence shows that primary care is associated with better-quality care and systemic cost-savings. State-level reform efforts, as in Massachusetts, provide clear evidence that an increased number of primary care providers will be needed to improve health care access. In this time of a new administration, developing a consensus for heath care reform addressing the issues of primary care and the physician workforce in underserved areas will be critical to achieving a quality, cost-effective health care system for all Americans.
Unlike their allopathic counterparts, osteopathic schools generally have modest research portfolios and do not own hospitals. As a result, osteopathy has concentrated on education with a focus on primary care and rural practice. In 2005, 58% of DOs were generalists compared with only 35% of MDs, and 19% of DOs were practicing in rural areas compared with 11% of MDs.3 Unfortunately, recent trends indicate that osteopathic graduates are following the tendency of allopathic graduates to increasingly enter non-primary-care specialty-training programs.
However, the flexibility of osteopathic schools has allowed them to establish new schools in nontraditional locations and develop new models of education to continue their focus on primary care and practice in underserved areas. Of the nine new osteopathic schools opened since 2000, a majority have been located in smaller metropolitan areas or in urban, historically underserved areas. Many of these schools were established with the express mission to produce primary care physicians for the surrounding underserved communities. This mission and the decision to locate new schools in these areas not only reflect osteopathy’s historic focus on primary care and underserved practice but demonstrate a thoughtful effort to achieve a solution to these problems.
The flexibility of osteopathic medical education has also allowed schools to develop innovative curriculum models with the goal of producing physicians to provide primary care and practice in underserved areas. A.T. Still University in Mesa, Arizona, bases all clinical training in 10 community health centers around the country in an effort to prepare physicians for that mission from day one. The Lake Erie College of Osteopathic Medicine has developed an innovative primary care pathway that condenses four years of medical school into three, shortening the time and financial requirements for students pursuing primary care careers. Although these programs will need to be evaluated over time, their inventiveness and responsiveness to national problems are not generally seen in allopathic schools that are often tied to the demands of major medical centers and bound by constraining Liaison Committee for Medical Education requirements.
As we reconsider the U.S. health care system, the osteopathic educational tradition should be recognized for the contribution it has made and continues to make to the physician workforce in primary care and underserved areas. The structure of today’s osteopathic medical schools may be hard to distinguish from that of their allopathic counterparts, but the output of osteopathic schools remains clearly distinctive, and the nation’s health care system benefits as a result.
Candice Chen, MD, MPH
Dr. Chen is assistant professor of pediatrics, Department of General Pediatrics, Children’s National Medical Center, Washington, DC, and assistant professor of health policy, Department of Health Policy, George Washington University, Washington, DC; ([email protected]).
Fitzhugh Mullan, MD
Dr. Mullan is Murdock Head Professor of Medicine and Health Policy, Department of Health Policy, George Washington University, Washington, DC.
1 Flexner A. Medical Education in the United States and Canada. New York, NY: The Carnegie Foundation for the Advancement of Teaching; 1910.
2 Gevitz N. The D.O.’s: Osteopathic Medicine in America. Baltimore, Md: Johns Hopkins University Press; 1982.
3 Fordyce MA, Chen FM, Doescher MP, Hart LG. 2005 Physician Supply and Distribution in Rural Areas of the United States. Seattle, Wash: WWAMI Rural Health Research Center, University of Washington; 2007.