Doctors must undergo extensive training to be able to properly diagnose and treat illness and injury. Years of schooling followed by many more years of intensive residency, internship and fellowship training enable most doctors to perform well when treating the vast range of problems that can afflict the human body. As a stamp of that authority, doctors typically use initials after their name that specify which degree they’ve completed and other earned distinctions.
While most doctors you encounter are likely to have the initials MD, meaning “doctor of medicine,” after their name, there is another, equally well-regarded set of initials you might see: DO, which stands for “doctor of osteopathic medicine.” That refers to a specific approach to medical education that began in the mid-19th century.
Dr. Andrew Taylor Still was an MD “who pioneered the concept of ‘wellness’ and recognized the importance of treating illness within the context of the whole body,” beginning in 1874, the American Association of Colleges of Osteopathic Medicine reports. The idea for this new approach came to Still after three of his children died of spinal meningitis in 1864. “Dr. Still concluded that the orthodox medical practices of his day were frequently ineffective, and sometimes harmful,” the AACOM reports.
His dissatisfaction with the typical medical approach led Still to research other ways to treat diseases. “He did a lot of study of anatomy and anatomical structure and he developed different kinds of techniques that could be used in treatment,” says Dr. Stephen C. Shannon, president of AACOM. “At that time, Still was shunned by the MD community as being different, or not operating in the exact same way (as MDs), so he formed his own school,” thus founding the separate system of osteopathic medicine.
That school employed a slightly different philosophy of medicine, one that considered the musculoskeletal system’s role in overall health and wellness. “The body has an innate ability to heal itself if it is structurally sound,” Shannon explains. Still developed manual techniques, which are referred to as osteopathic manipulative medicine or osteopathic manipulative treatments, to resolve structural problems he believed would hinder overall good health. Today, some DOs use these manual techniques to help patients get better.
Dr. William Mayo, a board-certified ophthalmologist and president of the American Osteopathic Association, the primary certifying body for DOs and accrediting agency for osteopathic medical schools, adds that the underlying philosophy of osteopathic medicine seems like simple common sense today. “If you cut yourself, the body heals itself. But we also know that if you keep that cut clean and dry, you will promote healing. If you keep dragging it through the mud, you’re not going to heal — you’re likely to get an infection and have a worse outcome.” In practice, this translates into “working with the patient to make sure they understand what they need to do, whether it’s a simple example like that of cleaning the wound or whether it’s promoting proper exercise and diet to make your body function at its peak efficiency.”
This approach also includes a philosophy of prevention, rather than simple intervention after a problem develops, Shannon says. “Many chronic diseases can be prevented by paying attention to proper nutrition and proper exercise, proper lifestyle, dealing with stress and the issues that are related with adverse health outcomes.”
But there’s more to people than just skin, bones, infection and illness, and this concept of the patient as a whole individual with a spirit and mind is also a core component of osteopathic medicine, Shannon says. “We focus our medical students and residents on not only the body, but also the mind and spirit of the patient and that includes the family and the community.” It’s a concept that’s gained traction over the years.
Where once DOs were less common, they are growing in numbers. The AOA reports there are currently 34 osteopathic medical schools in the United States and that the number of practicing DOs has more than tripled over the past 30 years. The AACOM reports that more than 100,000 osteopathic physicians practice in the United States, and that one in four medical students is enrolled in an osteopathic medical school. Shannon says about 6,500 students are expected to graduate in 2019, a number that’s expected to grow to about 8,500 annually over the next four to five years.
Mayo notes that “about 56 percent of DOs practice in either family medicine, internal medicine, or pediatrics.” If you add obstetrics and gynecology to the list, “because that’s who a lot of female patients get their primary care from,” and emergency physicians who practice primary care in an emergency setting, “then about 70 percent of our DOs are actually in primary care.”
There’s a strong tendency for DOs to build practices in family medicine, primary care, general internal medicine and pediatrics, and yet all other specialty fields are open to DO school graduates who want to pursue them. “I’m an ophthalmologist. I’m not in that 70 percent,” Mayo notes, adding that “whether you want to be a family physician or an ophthalmologist, a neurosurgeon or a pediatric cardiologist, all specialties are open. We practice across all specialties.”
However, he says that underlying concept of treating patients holistically still shows up in sometimes subtle but important ways. “For example, sometimes I’ll walk into an exam room and pick up a faint odor of smoke, and I think, ‘well, maybe this patient heats their home with a wood burning stove.’ And if they’re a glaucoma patient, that’s going to make their eyes tear more, so I need to make sure I talk with them and tell them to blot their eyes well before they use the eye drops (used to treat the disease) to get the full benefit of the medication,” he explains.
In addition to often gravitating towards primary care fields, DOs also are more commonly found practicing in rural areas where they may be working with underserved populations. Because of this, Shannon says they could play a big role in helping to alleviate the coming shortage in primary care physicians, which Shannon says will be somewhere between 50,000 and 150,000 doctors across the United States in 2030, with much of that shortfall occurring in rural areas. “Osteopathic physicians are fundamentally engaged in the delivery of primary care especially in rural areas, and many of our schools are located in places of need. That’s intentional.” Many of these schools state right in their mission that they’re aiming to train physicians to serve in the community in which they’re based.
Shannon says much of this training occurs in community-based settings such as community hospitals, clinics and specialty practice groups. “There’s that connection with the community and there’s a lot of research that shows that if you want to develop physicians for a particular geographic area, if they go to school there and do a residency there, they’re much more likely to stay there.”
In his case, Shannon was an older student who “decided when I was 30 that I wanted a career change,” and was interested in becoming a doctor. He enrolled at the University of New England College of Osteopathic Medical School in Biddeford, Maine, for a few reasons, not least of which was because “I was really enticed by going to school in an institution that was focused on providing care in a state where there was a clear need for physicians,” he says. And because “osteopathic medical schools have been traditionally more open to older students and students with other diverse backgrounds,” he was able to become a doctor.
This valuing of diversity has long been part of the osteopathic approach, Mayo says, noting that Still admitted women to his medical school right from the beginning. Of the 21 students in the inaugural class at his American School of Osteopathy in Kirksville, Missouri, six were women. “That was pretty progressive at the time.” (That school is now called A.T. Still University.)
In the United States, doctors must be licensed by a state licensure board in order to practice any type of medicine, and although there once were entirely separate organizations that handled licensure for DOs and MDs, today, they are frequently administered by the same entity. Even as recently as about 50 years ago, Shannon says “we had separate schools, separate licensing boards, separate residency programs and osteopathic hospitals. We had specialty groups that were specifically just osteopathic,” and in some regions of the country, you’d be more likely to find osteopathic doctors than medical doctors, and vice versa. “In other places, there was a blending of the two” approaches, he says. Over the years, allopathic (MD) and osteopathic (DO) approaches have integrated and “few osteopathic hospitals still exist because DOs are engaged in virtually all the hospitals in the country,” Shannon says. That same integration has occurred with residency training programs and licensing boards, which are state-based entities.
Today, it largely doesn’t matter whether a specific doctor is a DO or an MD — you’re likely to get good care from either type. “In many respects MDs and DOs practice medicine in identical ways today,” the Indiana University Bloomington, which offers MD degrees, reports. This also means that DOs and MDs can expect the same salary ranges and reimbursement levels from insurers, so the difference is largely in the underpinnings of training and philosophy rather than in daily practice.
Osteopathic medical school students receive the same clinical and biomedical sciences training as students working toward an MD degree, Shannon says, with one clear distinction — the manipulative medicine piece. These manual techniques can be used to diagnose and treat conditions related to musculoskeletal problems, such as pain conditions like headache or chronic issues like asthma. The idea is that these hands-on techniques can sometimes remove the need to use medications, but in instances where manipulative techniques can’t treat the problem, DOs also have the same medication and surgical options that MDs can offer.
As an overall approach to medicine, the concept of holistic, patient-centered care that looks to prevention rather than jumping right to medication or surgery has gained traction over the past few decades as patients have begun asking to be more involved in decision-making surrounding their care and to be considered as whole individuals. The concept of treating people in context is right in line with the philosophy of osteopathic medicine, Mayo says, adding that “DOs were holistic before holistic became cool.” Particularly as the trend across all levels of health care is to look at patients as more than just their disease or condition, the distinction between MD and DO is blurring as the best elements of both approaches are being put forward in schools and doctors’ offices across the country.
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Correction 11/09/18: A previous version of this story misstated the number of osteopathic physicians practicing in the U.S.