Letters to the Editor  |   September 2010
Author Affiliations
  • Eric E. Shore, DO, JD, MBA
    Healthcare law attorney, internist, and founding partner, Kane, Shore, & Witcher, LLC, Philadelphia, Pennsylvania
Article Information
Cardiovascular Disorders / Evidence-Based Medicine / Medical Education / Neuromusculoskeletal Disorders / Osteopathic Manipulative Treatment
Letters to the Editor   |   September 2010
The Journal of the American Osteopathic Association, September 2010, Vol. 110, 552-553. doi:10.7556/jaoa.2010.110.9.552
The Journal of the American Osteopathic Association, September 2010, Vol. 110, 552-553. doi:10.7556/jaoa.2010.110.9.552
I'd like to thank JAOA—The Journal of the American Osteopathic Association for the opportunity to respond to the comments by Drs Fredricks and Comeaux. Although I clearly do not agree with some of what they write, their concerns certainly need to be addressed. 
In his letter, Dr Fredricks, who is obviously a staunch advocate of the “separate-but-equal” doctrine for osteopathic and allopathic medicine, makes several assumptions for which he provides no foundation. First, he asserts that “federal funding of medical schools in the future will have nothing to do with degrees”—yet he provides no insight as to how he arrived at this opinion. 
Federal dollars are at a premium and will be more so as a result of the Patient Protection and Affordable Care Act,1 signed by President Barack Obama in March 2010. Moreover, among the provisions of the act is the formation of a panel to apply the principles of both evidence-based medicine and “value-based” medicine to determine which procedures will be reimbursed.2 Certainly, we can expect the same principles to be applied to medical education. 
In addition, Dr Fredricks' own arguments regarding reimbursement and continuing medical education (CME) lend credence to my call for unification of the osteopathic and allopathic medical professions. He bemoans being mandated to attend 20 hours of American Osteopathic Association (AOA)-approved Category 1-A CME instead of any Category 1 CME. However, he neglects the obvious—that without such a requirement, most of these mandated, solely AOA-approved programs would fail to fill available positions. Thus, as a result of our professional separation, these programs would not be economically viable. 
Dr Fredricks also makes much of the fact that multiple medical degrees are issued by various countries. Many of these medical degrees—similar to the LLB degree that used to be awarded to graduates of law schools in the United States—are anachronistic. Even those remaining medical degrees with diverse designations uniformly symbolize the same type of training around the world—unlike the training of a DO, which is substantially different outside of the United States than within the United States. 
Such points, however, are irrelevant because had Dr Fredricks read my original letter3 carefully, he would have noted that I actually advocate the awarding of both MD and DO degrees at graduation. Such a combination of degrees would provide both the recognition and acceptance of an MD degree, along with the ability to maintain osteopathic professional distinctiveness where it exists. Moreover, with an MD, DO degree combination, the display of a particular professional designation would be an individual's choice. Dr Fredricks would not have to display his MD if he chose not to, and if most graduates of osteopathic medical schools are happy with their DO degrees, they too could choose not to display their MDs. If that is the case, so be it. 
Dr Comeaux makes some valid points in his letter. I agree with him that every nation has a right to extract from Dr Still's teachings whatever it desires and to apply those teachings as it wishes. However, we live in the United States, where nearly a century was spent fighting for full licensure for DOs in every state and at the federal level. I differ with Dr Comeaux in regard to his feeling that the fight has been won in any but a strictly legal sense. His own descriptions of the “criticisms of the 1960s through the 1980s” and the “collapse of the osteopathic hospital system” are symptoms of a fight that is already lost both internally and externally. 
What Dr Comeaux views as a “medicine-by-algorithm” approach is what most medical authorities today call evidence-based medicine. Surely, Dr Comeaux is not advocating a system in which patients are exposed to medical procedures based on anecdotal reports rather than peer-reviewed studies. 
Few of us doubt that osteopathic manipulative treatment (OMT) has a place in managing musculoskeletal disease. Perhaps the problem with the patient that Dr Comeaux describes as having back pain is that the patient should not have had those serial laminectomies in the first place. However, to base an entire profession on a single therapeutic modality, such as OMT, defies logic. Instead, let's help physicians who do not use OMT see the value of incorporating this manipulative therapy into patient care when and where appropriate, thereby adopting it throughout the wider medical profession. Imagine how many more patients would benefit from that approach. 
Regarding Dr Comeaux's emphasis on philosophy and reform, I'd like to point out that if reform is our goal, then bringing the benefits of OMT into the mainstream of medicine should be our method. Only then will larger numbers of patients in the United States and around the world gain access to, and benefits from, this valuable treatment modality. Surely this would be the goal of Dr Still if he were alive today. 
I have heard “osteopathic philosophy” described in many ways by many people throughout the years. Even in the July issue of the JAOA, Felix J. Rogers, DO,4 alludes to the fact that the distinctiveness of osteopathic medicine is difficult to define. Mostly, descriptions of osteopathic philosophy seem to involve a holistic approach to patient care. I'm sure that Dr Comeaux has not failed to note the increasingly holistic approach being taught in most medical schools, at least in the United States. The failure of physicians to use a hands-on approach is usually the result of instruction in this approach becoming buried by other clinical teachings during the postdoctoral training years. We can best effect positive change in this matter by increasing the roles of osteopathic physicians as teachers in hospitals throughout the country. 
Finally, I find it ironic that the individual who taught me the most about patient-centric medical care and a hands-on approach was not a DO. I spent some time studying cardiology with William Likoff, MD, during my early training. Dr Likoff was a world-renowned cardiologist, yet I never recall him entering patients' rooms without fluffing their pillows, holding their hands, sitting and talking with them, and carefully examining them. In fact, on rounds, Dr Likoff rarely allowed us to see patients' test results until we had given patients this kind of attention and arrived at our own conclusions by analyzing their medical histories and physical examination results. Neither did Dr Likoff allow us to consider only the cardiovascular system in our diagnoses and treatment. Rather, he insisted that we treat patients as people, not as organ systems, with the same degree of humanity as he did. 
I wish that all physicians—no matter the types of degrees they have—were as dedicated, knowledgeable, and holistic as Dr Likoff. I urge those of us who practice a patient-centric, hands-on approach to medicine—regardless of our specialties—to use the greater acceptance and recognition of the proposed MD, DO, designation to spread that approach and philosophy throughout the medical profession. 
Patient Protection and Affordable Care Act, 42 USC 18001 (2010). Accessed August 9, 2010.
Patient Protection and Affordable Care Act, 42 USC 18001 § 4105 (2010). Accessed August 9, 2010.
Shore EE. The anachronistic fight for osteopathic distinctiveness [letter]. J Am Osteopath Assoc. 2010;110(5):299-300. Accessed August 9, 2010.
Rogers FJ. Defining osteopathic medicine: can you put your finger on it [editorial]? J Am Osteopath Assoc. 2010;110(7):362-363. Accessed August 12, 2010.