Letters to the Editor  |   December 2010
Osteopathic Medicine's Holistic Approach Is More Important Than Ever
Author Affiliations
  • Paul M. Goldberg, DO
    Alexandria, Virginia
Article Information
Medical Education / Osteopathic Manipulative Treatment / Being a DO / Graduate Medical Education
Letters to the Editor   |   December 2010
Osteopathic Medicine's Holistic Approach Is More Important Than Ever
The Journal of the American Osteopathic Association, December 2010, Vol. 110, 741-743. doi:10.7556/jaoa.2010.110.12.741
The Journal of the American Osteopathic Association, December 2010, Vol. 110, 741-743. doi:10.7556/jaoa.2010.110.12.741
To the Editor:  
Who would have imagined just a few years ago that certain major corporations would be out of business, bankrupt, or just remnants of what they once were? Yet, this is my concern for the future of osteopathic medicine. Although our profession has undergone unprecedented growth, the growth alone will not guarantee future success. The main strengths of osteopathic medicine are our philosophy and training, which provide a more holistic and comprehensive approach to treating patients than does allopathic medicine. However, we currently seem to be swept up in a tide to emulate allopathic medicine, and we are eroding the principles that it truly takes to be the most well-rounded and educated physicians. 
A tremendous amount of information is learned in medical school, but the vast amount of our clinical knowledge and expertise is acquired after graduation. Regardless of specialty or expertise, a physician needs to have a solid and well-rounded knowledge of medicine and surgery. The traditional osteopathic rotating internship helps to foster our philosophy and to promote this solid foundation. Unfortunately, the “deregulation” of this traditional rotating internship by the American Osteopathic Association (AOA) to allow specialty-tract internships1,2 is a grievous mistake. These specialty-tract internships will not provide the comprehensive exposure and knowledge that a physician should possess to provide the best possible patient care. 
As an allergy specialist, I believe that now—more than ever—a holistic philosophy and approach as developed in the traditional osteopathic rotating internship is invaluable. 
Many patients are referred to me by primary care physicians or specialists for allergy treatment. In some cases, I find that these patients have been misdiagnosed as a result of failure by the referring physicians to use a holistic approach. For example, I commonly see patients who have been diagnosed as having chronic allergic cough, but who in reality have asymptomatic gastroesophageal reflux disease—a condition that can also be exacerbated by certain medications. One of my patients had been diagnosed by her cardiologist as having an exacerbation of asthma, but she actually had congestive heart failure. 
Only a small number of osteopathic physicians use osteopathic manipulative treatment (OMT).3 Nevertheless, the vast majority of osteopathic physicians should at least incorporate basic palpatory skills to improve their diagnostic acumen. I frequently see patients who were diagnosed as having “sinus headaches” that I find, upon palpation, resulted from musculoskeletal causes. One of my patients with chest discomfort had been incorrectly diagnosed by her primary care physician as having costochondritis. After performing a complete physical examination of the patient, including palpation, I concluded that a chest radiograph was warranted. The radiograph revealed a pneumothorax. 
I have a longtime friend who writes business-oriented books and tours the country as a highly paid speaker and business consultant. In his work, he always stresses the critical importance of having one's own niche, so one does not need to compete with others. This advice is especially important during these increasingly difficult times. The osteopathic medical profession already has its perfect niche carved out—yet we are squandering our great potential by trying to emulate our allopathic colleagues. In fact, some members of the osteopathic medical profession are even promoting a change of our DO degree to be more like the MD degree.4,5 
High-quality evidence-based studies, as Felix J. Rogers, DO,6 has promoted, could help propel us to the preferred physician status in the United States. Such studies could be the center-piece of an effective public marketing campaign, which has been sorely lacking, to introduce and promote the superiority of osteopathic medicine. In addition, Norman Gevitz, PhD,7 has stressed that for the osteopathic medical profession to thrive, young osteopathic physicians need to practice distinctive osteopathic medicine and to dedicate themselves to conducting research on osteopathic principles and practice and fighting for professional autonomy. 
A number of published studies have indicated benefits from osteopathic medicine for a variety of conditions. For example, a study by Licciardone et al8 in the January 2010 issue of the American Journal of Obstetrics and Gynecology presented evidence that OMT may ease late-pregnancy back pain, though the authors called for further investigations. In another example, Guiney et al9 found statistically significant improvements in peak expiratory flow rates in pediatric patients with asthma after OMT. 
At the AOA's Annual Convention and Scientific Seminar in Las Vegas, Nevada, in October 2008, one presented abstract10 described a small pilot study designed to assess whether OMT could reduce the need for cesarean sections. If beneficial results of OMT for such cases are demonstrated in larger, controlled studies, OMT may not only help patients, but it may also help reduce medical and surgical costs. Furthermore, results of such studies would increase patient demand for osteopathic medical services. 
We currently find ourselves at what may be the dawning of monumental changes in the US healthcare system. With the ballooning deficits of the federal government, healthcare dollars will most likely dwindle in the future. Residency positions that are funded by the Medicare program may also decrease, creating keen competition for the remaining spots. Allopathic residency slots in many fields are still plentiful, but in certain fields, such as dermatology, competition for these slots is already extremely competitive. Moreover, according to Michael E. Whitcomb, MD,11 the availability of allopathic graduate medical education programs will cease to exist for osteopathic medical students in the foreseeable future. 
In addition, slots that remain unfilled in the AOA Intern/Resident Registration Program (ie, AOA “Match”) may disappear with decreased funding,12 creating the “perfect storm” of fewer slots and more competition. Residency program directors will have their pick of the top medical students in the country. By surrendering our unique osteopathic medical training, we would force residency program directors to consider other information about candidates, such as medical school attended, college grades, and Medical College Admission Test (MCAT) scores. This development would place us at a greater disadvantage. According to 2009 statistics from the Association of American Medical Colleges13 and the American Association of Colleges of Osteopathic Medicine,14 allopathic matriculants have higher grade point averages (GPAs) and higher MCAT scores than do osteopathic matriculants (allopathic GPA=3.66 and MCAT=30.8, osteopathic GPA=3.48 and MCAT=26.19). 
Further denigrating our profession are those applicants who wish to become physicians and have no interest in osteopathic medicine, but whose grades and board scores were not competitive enough for admission to allopathic medical schools. Upon graduation from osteopathic medical schools, such students will simply skip the rotating internship and enter the allopathic “Match” and then blend into the allopathic medical profession. 
The second-rate image of osteopathic medicine was fostered by a New York Times article in February 201015 that discussed the keen competition for admission into allopathic medical schools. According to the article, an individual who was rejected from 28 of 30 medical schools was told by his pre-med adviser that, with his 3.3 GPA, he should apply only to osteopathic medical schools. 
What is our goal for excellence? If an individual is truly committed to becoming an osteopathic physician, he or she should be willing to commit to completing a rotating internship and then be free to pursue any residency. One additional year of training over a life-time of practice is little sacrifice and will result in an immense payoff in terms of both personal and professional satisfaction. 
Another problem that we face involves lack of the holistic approach in coordination of care between physicians and patients. This deficiency is becoming a major obstacle in delivering quality medical care. A letter in the July 2009 issue of JAOA—The Journal of the American Osteopathic Association by David Stuart Tabby, DO,16 illustrated this problem. Dr Tabby's father, a retired osteopathic family physician, was hospitalized in the intensive care unit at a Philadelphia hospital. Dr Tabby described his frustration regarding the lack of communication between his family and his father's physicians. The letter16 revealed that even in an intensive care setting where both the patient and his son are physicians, there is no continuity of care, and no one seems to be in charge. Unfortunately, this situation appears to be a growing epidemic that is exacerbated when physicians know nothing outside their realm of expertise, resulting in a “medical Tower of Babel.” 
In summary, it is critical in these changing times that the osteopathic medical profession not be embarrassed by our history and embrace what has brought us as far as we have come—a holistic approach to patient care and a comprehensive osteopathic training program. We must also demonstrate through evidence-based studies that we practice thorough and sound medicine. If we continue along our new path of following allopathic colleagues, I fear that our prognosis is guarded. 
Obradovic JL, Winslow-Falbo P. Osteopathic graduate medical education. J Am Osteopath Assoc. 2007;107(2):57-66. Accessed November 5, 2010.
Freeman E, Lischka TA. Osteopathic graduate medical education. J Am Osteopath Assoc. 2009;109(3):135-145. Accessed November 5, 2010.
Spaeth DG, Pheley AM. Use of osteopathic manipulative treatment by Ohio osteopathic physicians in various specialties. J Am Osteopathic Assoc. 2003;103(1):16-26. Accessed November 5, 2010.
Greenwald B. A rose is still a rose... or is it? Can a new degree lead to more respect, recognition for DOs? The DO. 2008;49(2):30-34.
Bates BR, Mazer JP, Ledbetter AM, Norander S. The DO difference: an analysis of causal relationships affecting the degree-change debate. J Am Osteopath Assoc. 2009;109(7):359-369. Accessed November 5, 2010.
Rogers FJ. Defining osteopathic medicine: can you put your finger on it [editorial]? J Am Osteopath Assoc. 2010;110(7):362-363. Accessed November 5, 2010.
Gevitz N. Center or periphery? The future of osteopathic principles and practices [editorial]. J Am Osteopath Assoc. 2006;106(3):121-129. Accessed November 5, 2010.
Licciardone JC, Buchanan S, Hensel KL, King HH, Fulda KG, Stoll ST. Osteopathic manipulative treatment of back pain and related symptoms during pregnancy: a randomized controlled trial [published online ahead of print September 20, 2009]. Am J Obstet Gynecol. 2010;202(1):43 .e1-e8.
Guiney PA, Chou R, Vianna A, Lovenheim J. Effects of osteopathic manipulative treatment on pediatric patients with asthma: a randomized controlled trial. J Am Osteopath Assoc. 2005;105(1):7-12. Accessed November 5, 2010.
Keurentjes AE. Relationship of Osteopathic Manipulative Treatment During Labor and Delivery on Selected Maternal Morbidity Outcomes: A Randomized Control Trial [PhD dissertation]. Blacksburg, VA: Virginia Polytechnic Institute and State University;2009 .
Whitcomb ME. Physician supply revisited. Acad Med. 2007;82(9):825-826.
Freeman E, Duffy T, Lischka TA. Osteopathic graduate medical education 2010. J Am Osteopath Assoc. 2010;110(3):150-159. Accessed November 5, 2010.
Table 17: MCAT scores and GPAs for applicants and matriculants to U.S. medical schools 1998-2009. Association of American Medical Colleges Web site. Accessed November 5, 2010.
AACOMAS matriculant profile, 2009 entering class. American Association of Colleges of Osteopathic Medicine Web site. Accessed November 5, 2010.
Hartocollis A. Expecting a surge in US medical schools. New York Times. February 15, 2010:A1. Accessed November 5, 2010.
Tabby DS. Where is the “captain of the ship” [letter]? J Am Osteopath Assoc. 2009;109(7):386-387. Accessed November 5, 2010.