Letters to the Editor  |   February 2008
OMM Education vs “Real World” Medicine
Author Affiliations
  • Stephen M. Davidson, DO, C-SPOMM
    Phoenix, Ariz
Article Information
Medical Education / Neuromusculoskeletal Disorders / Osteopathic Manipulative Treatment
Letters to the Editor   |   February 2008
OMM Education vs “Real World” Medicine
The Journal of the American Osteopathic Association, February 2008, Vol. 108, 87-89. doi:10.7556/jaoa.2008.108.2.87
The Journal of the American Osteopathic Association, February 2008, Vol. 108, 87-89. doi:10.7556/jaoa.2008.108.2.87
Web of Science® Times Cited: 22
To the Editor: I was compelled to write this letter after reading the many articles on the state of osteopathic medical education in the February (2007;107:47-92) and March (2007;107:93-136) issues of JAOA—The Journal of the American Osteopathic Association. I am well aware of the current state of training of our osteopathic medical students, and I am saddened and confused by one aspect of that training in particular. Why is it that education at colleges of osteopathic medicine (COMs) in all specialty areas except osteopathic manipulative medicine (OMM) prepares undergraduate students to analyze clinical problems as they would in the “real world”—that is, the way successful specialists in those areas approach the problems of patients? 
I have observed that, in OMM training, students are typically taught a “regional” approach (ie, focusing on specific body regions) to diagnosis and treatment, along with a few techniques of osteopathic manipulative treatment (OMT)—but not how to analyze the total body's musculoskeletal fascial strain pattern, as any skilled OMM specialist would do when working with a structural problem presented by a patient. What is the rationale for teaching OMM using a regional musculoskeletal approach? 
Because a subset of patients will have musculoskeletal findings amenable to a regional analysis, COM students applying their OMM training in the clinical setting will doubtless experience a limited degree of success. With no other analytic skills at their disposal, many osteopathic medical students and osteopathic physicians simply give up believing that OMT works—or they come to believe that it works only in certain select cases. Other osteopathic physicians may spend the next 10 or 15 years using their limited manual skills to “wander around” their patients' myofascial planes until stumbling upon a structural analytical model that is clinically effective for them. 
How far ahead might our students be if we trained them from the beginning of their medical education to approach patients' problems osteopathically—with a total-body approach—as long used by the profession's most successful OMM specialists? 
I would like to use this letter to analyze an example of an osteopathic medical student's encounter with a patient that illustrates the failure of the regional method of OMM training to adequately prepare the student for real-life clinical challenges. 
During my almost 30 years of training and clinical experience in the osteopathic medical profession, I have had the privilege of studying with many highly accomplished osteopathic physicians who are known for their clinical acumen and successful results with patients. I observed these DOs treating patients during a hands-on preceptorship, and I have also personally experienced their application of osteopathic manipulative techniques. I have had numerous lengthy discussions with many of these masters aimed at elucidating their analytic methods. 
The osteopathic physicians who trained me during my undergraduate years at Kirksville (Mo) College of Osteopathic Medicine of A.T. Still University of Health Sciences (KCOM; now A.T. Still University-Kirksville College of Osteopathic Medicine) shared their knowledge regarding a variety of osteopathic manipulative (OM) techniques (ie, their osteopathic paradigms), including articulatory treatment system, counterstrain, high velocity/low amplitude technique, low velocity/low amplitude technique, lymphatic pump, muscle energy, myofascial release, Osteopathy in the Cranial Field, and the percussion vibrator technique. 
Although the dominant osteopathic paradigms and treatment approaches used by each of my mentors in undergraduate school varied widely, each of them first analyzed the patient's entire musculoskeletal system before determining the most important body area in which to begin treatment. They each would sequence the patient's treatment until they were satisfied that the body had received all the manipulation it could handle or until the job was done for whatever technique was being used. 
Many of my friends and colleagues in the osteopathic medical profession have served as faculty in, and chairs of, departments of OMM or osteopathic principles and practice (OPP) at COMs. Many of them have told me that they are instructed by the administration at their COMs to “teach to the test” (ie, the Comprehensive Osteopathic Medical Licensing Examination [COMLEXUSA]). They tell me that they are required to teach a regional musculoskeletal approach to analysis, including four or five basic OM techniques that could be used to correct somatic dysfunction discovered in any particular region. During their own practice careers, however, none of these faculty members analyzed or treated patients using a regional approach. 
When I have asked them why they don't teach students the type of total-body analysis and treatment sequencing that they used in their own practices, they all have given me similar responses—a shrug of the shoulders, a knowing sad smile, and the statement that OMM faculty must follow the dictates of the COM administration. 
The only radiant exception to this regional approach I have found at the COMs in recent years was the OMM program developed by Edward G. Stiles, DO, who served as chairman of the Department of OPP at the Pikeville (Ky) College School of Osteopathic Medicine (PCSOM) from 1997 to 2005. Dr Stiles trained his students to analyze patients osteopathically—exactly as he did when he was in private practice. His OMM program was also integrated with other specialty disciplines of osteopathic medicine. At the American Academy of Osteopathy (AAO) annual convocations during those years, I always thought that the PCSOM students seemed to be light-years ahead of the students from other COMs in their ability to analyze, manage, and solve musculoskeletal problems. As I recall, the PCSOM students often had jobs waiting for them in the offices of local MDs, who were likely hungry for the kind of whole-body contribution to neuromusculoskeletal medicine that these new graduates could provide to their patients' care. Unfortunately, with a changing of the guard at PCSOM, the OMM program there is now back to training students with the regional approach (E.G. Stiles, DO, written communication, December 2007). 
Through my extensive and varied experiences with osteopathic medical students, I have been able to evaluate the effectiveness of their learned methods at solving the clinical problems of patients. In the past 10 years or so, I have visited at least six COMs to perform weekend training sessions in the neurofascial release paradigm for hundreds of osteopathic medical students as part of the AAO's Visiting Clinician Program funded by the American Osteopathic Foundation. In addition, I have personally trained more than 200 students from many different COMs in my office. I have also spent many hours with students at the AAO annual convocations listening to their views about the education they receive at the COMs. Thus, I believe I have sufficient experience with osteopathic medical student education to have formulated a knowledgeable opinion regarding its effectiveness. 
Almost three decades of experience regarding the education of osteopathic medical students have led me to believe that though osteopathic medical student training may be referred to by different names at different times, the training tends to impart the same narrow outlook to students. 
Generally, the student is taught to analyze only the area of the patient's chief complaint and to correct that local problem. After this task is completed, the student then manually wanders around the rest of the patient's body, treating this and that, until the designated treatment time runs out. As a result of this type of education, the student's knowledge of living human anatomic features is weak. In addition, his or her ability to integrate OMM and OPP with other medical disciplines is virtually nonexistent. 
When I ask osteopathic medical students what methods they use to think through a patient's medical problem, they typically answer that they don't have a method—except to “find it, fix it, then leave it alone.” 
The successful OMM specialists I have known understand this osteopathic medical nostrum a little differently. 
The idea behind “find it” is to identify which somatic dysfunction needs to be corrected first. One determines where to begin only after analyzing the entire musculoskeletal fascial strain pattern according to a selected treatment paradigm. It is only through such a total-body approach that the osteopathic physician functions—in the words of A.T. Still, MD, DO,1—as a “master mechanic.” 
Osteopathic medical students can surely help some patients using the skills they have learned from the regional approach of their training—because the medical problems of some patients will be regional in nature. For example, sometimes somatic dysfunction in the shoulder is simply that. However, when students find themselves confronting situations involving more widespread musculoskeletal problems, their training fails them. Thus, the regional approach to training misses the clinical mark and does not meet a major tenet of osteopathic medicine—namely that “the body is a unit.”2 
Now, I'd like to present a typical clinical example of a patient–student doctor encounter, based on my office experience with students of osteopathic medicine. A patient has suboccipital pain and a headache. The student examines the patient's head, neck, and upper thoracic area. He finds that the relationship between the atlas and occiput is amiss, according to whatever paradigm he uses. He corrects the somatic dysfunction locally using one of the four or five OM techniques he was taught. If the somatic dysfunction involving the atlas and occiput is a local phenomenon, this regional approach will be effective, and the somatic dysfunction may be removed along with the patient's complaint. 
However, when the somatic dysfunction involving the atlas and occiput is part of a more widespread myofascial strain pattern, the regional approach will fail. Then, when the patient's condition does not improve, the student does not have the training to figure out what to do next, and the underlying cause of the patient's problem will remain a mystery. 
Recently, a student and I were treating a patient with this kind of atlas and occiput problem. The student performed a regional evaluation, correcting the atlas and occiput somatic dysfunction. Upon re-evaluation, the patient's somatic dysfunction was just as it was before the correction. It was as though nothing at all had been done with the patient. The student was left not knowing what to do next or why to take any particular action, because his training had not provided him with a method for finding the answer to this patient's functional problem. 
After this student and I together performed a total-body myofascial strain evaluation of the patient, we came upon the left flexed talus—an old ankle strain—which was the cause of the myofascial strain pattern leading to the cervical somatic dysfunction. When we corrected the talus (the cause), the atlas and occiput somatic dysfunction (the effect) immediately and spontaneously resolved. No further action to the atlas was needed on our part. 
This case clearly demonstrates a real-world example of how “the body is a unit” and supports this tenet of osteopathic medicine.2 Specialists in OMM analyze the entire body's musculoskeletal strain pattern. Their analyses tell them why to begin a certain course of action in patient treatment, which is essential knowledge before deciding what osteopathic paradigm to apply in the treatment. Our current crop of osteopathic medical students knows “five ways to fix a lesion” (ie, somatic dysfunction) based on only a regional analysis that does not allow them to properly determine why or where to begin treatment. 
I return to my previous question: Why is it that education at COMs in all specialty areas except OMM prepares osteopathic medical students to analyze clinical problems the way the most successful specialists do? 
For example, in the study of neurology, an undergraduate osteopathic medical student is taught to perform a neurologic examination of a patient that is similar to the way a practicing neurologist would. If a patient has a numb first big toe, the osteopathic medical student, following standard neurologic guidelines, would be taught to carefully examine the patient's nervous system, including areas (eg, lumbar spine) that are some distance from the toe. The student would not be trained to examine only the big toe, foot, ankle, and calf. 
The osteopathic medical tenet that the body operates as a unit2 holds just as well for OMM as it does for neurology. Thus, the osteopathic medical student learning about OMM needs the same kind of real-world training at as the student learning about neurology. 
In conclusion, the current training received by osteopathic medical students at does not accurately reflect how osteopathic physicians specializing in OMM actually practice. Therefore, the student's application of OMM is not—and cannot be—as clinically effective as treatment methods used by osteopathic physicians specializing in OMM. This lack of clinical effectiveness leads osteopathic medical students and new osteopathic physicians to become discouraged with OMT. Later, they abandon it altogether because, in their hands, it just doesn't work. 
I call on administrators at COMs to allow our OMM and OPP professors, seasoned by years of clinical experience and successful musculoskeletal analyses, to teach what they know about OMM and treatment sequencing to their students. It is time we give our students the real stuff—both for their professional satisfaction and for their patients' well-being. 
Still AT. Philosophy of Osteopathy. Kirksville, Mo: AT Still; 1899:220. Available at: Accessed December 13, 2007.
Rogers FJ, D'Alonzo GE Jr, Glover JC, Korr IM, Osborn GG, Patterson MM, et al. Proposed tenets of osteopathic medicine and principles for patient care. J Am Osteopath Assoc. 2002;102:63-65. Available at: Accessed December 10, 2007.