Special Report  |   October 2014
Gray Zone: Why a Delayed Acceptance of Osteopathic Medicine Persists in the International Community
Author Notes
  • From the Department of Osteopathic Manipulative Medicine at the Georgia Campus-Philadelphia College of Osteopathic Medicine in Suwanee. Dr Berkowitz holds master's degrees in education and science 
  • Address correspondence to Murray R. Berkowitz, DO, MA, MS, MPH, Georgia Campus-Philadelphia College of Osteopathic Medicine, 625 Old Peachtree Rd NW, Suwanee, GA 30024-2937. E-mail:  
Article Information
Medical Education / Being a DO
Special Report   |   October 2014
Gray Zone: Why a Delayed Acceptance of Osteopathic Medicine Persists in the International Community
The Journal of the American Osteopathic Association, October 2014, Vol. 114, 754-760. doi:10.7556/jaoa.2014.145
The Journal of the American Osteopathic Association, October 2014, Vol. 114, 754-760. doi:10.7556/jaoa.2014.145

“ Osteopathy, as little as is known of it now, bids fair in a very few years to penetrate the minds of the philosophers of the whole earth.”


—Andrew Taylor Still, MD, DO1

The St Hélène Orphanage, located in the mountains outside Port-au-Prince, is home to more than 500 indigent Haitian children. Rev Leo R. “Rick” Frechette, DO, has compassionately helped foster youth at the orphanage for nearly 25 years, first as a Roman Catholic priest and later as medical director after earning his doctor of osteopathic medicine degree at the New York Institute of Technology College of Osteopathic Medicine in 1998.2 As the founder of the St Luke Foundation for Haiti, Dr Frechette established Haiti's only free pediatric hospital, the 120-bed St Damien Pediatric Hospital in Port-au-Prince in 2006. In 2012, he received the Opus Prize of $1 million to invest into the St Luke Foundation for Haiti for his efforts in addressing the nation's poverty and social problems.3 
Considering Dr Frechette's humanitarian work, Haiti benefits greatly from allowing US-trained osteopathic physicians (ie, DOs) to practice within its borders. Yet it wasn't until late in 2013 that DOs were officially accepted in Haiti as physicians with full practice rights.4 
While the osteopathic community can now celebrate Haiti and other incremental victories in recognition of the profession around the world, approximately two-thirds of all countries are still considered off limits to the osteopathic profession (Figure 1). In this report, we describe the historical evolution of DO international practice rights, address the barriers to such rights, and profile success stories of DOs who have settled abroad. Because the greatest unified efforts for increasing international practice rights have come directly from the American Osteopathic Association (AOA),5 we also review AOA documents and analyze trends in successful licensing requests by country. 
Figure 1.
International licensure map of countries in which osteopathic physicians currently have unlimited practice rights. American Osteopathic Association, 2013.4
Figure 1.
International licensure map of countries in which osteopathic physicians currently have unlimited practice rights. American Osteopathic Association, 2013.4
Barriers to International Recognition
Although DOs practice in all 50 states and in every medical specialty,6 the osteopathic medical profession is officially separate from the allopathic medical (ie, MD) profession. The distinction is based on the additional 200 hours of osteopathic coursework required of osteopathic medical students7 with an otherwise complete overlap in the biomedical science and clinical curriculum shared by DO and MD programs. In fighting to convey osteopathic medicine as separate from allopathic medicine, DOs have not fully assimilated into the MD community. 
Parallel systems of domestic licensure reinforce this individualism. Whereas MD schools are accredited by the Liaison Committee on Medical Education and their graduates are represented by the American Medical Association, osteopathic institutions are recognized by the AOA Commission on Osteopathic College Accreditation and the AOA is the central decision-making body for the osteopathic medical profession. However, both the osteopathic and allopathic professions agreed to a single accreditation system under the Accreditation Council for Graduate Medical Education.8 
The global spread of osteopathic medicine is promoted by several advocacy groups. Since 1986, the AOA Division of International Affairs (formerly combined into the Division of State Government and International Affairs) has been the established authority on negotiating international licensure. The AOA also charged the Bureau of International Osteopathic Medicine to “promote the highest standards of osteopathic medical education and practice throughout the world.”9 In 2004, the Osteopathic International Alliance was formed to represent the global osteopathic profession including DOs and foreign-trained osteopaths.10 The AOA works to maximize the scope of practice for DOs in other countries while recognizing the sovereignty of health care delivery systems in other nations.9 
In 2013, the AOA observed the following:

“[A] few countries have consistently refused to grant DOs full practice rights, often permitting them to perform only manipulation and sometimes refusing to grant them any type of practice. Other countries, however, are simply not educated on the qualifications of DOs and their equivalence in education, training and practice to MDs.”5

We are faced with a dual challenge of distinguishing our profession and validating its purpose. Foreign health officials tend to follow 1 of 3 heuristics when forming an opinion of osteopathic medicine. They may be (1) unacquainted with osteopathic medicine, (2) aware of osteopathic medicine only as a form of complementary manual medicine, or (3) aware of osteopathic medicine as being comparable to allopathic medicine. The AOA's goal is to shift health leaders to the third understanding by demonstrating that DOs have the same medical privileges as and hold equivalent jobs to MDs in the US health care system while still promoting the principles unique to the osteopathic medical profession.9 
Foreign leaders have historically assumed a very limited scope of practice (ie, manipulation) for osteopathic medicine,11 and this misconception can be traced back to the first decades of osteopathic medicine. During the lifetime of Andrew Taylor Still, MD, DO, manipulation essentially was the only treatment taught to graduates from the 1890s to 1920s. Recalling his famous final plea, “Keep it pure, boys,”12 there is clear evidence of Still's intention to preserve osteopathy as a separate entity from mainstream medicine. 
In the decades to come, osteopathy evolved on 2 separate paths—1 American and 1 international. The first to spread osteopathy abroad was John Martin Littlejohn, a British citizen who was trained in Kirksville, Missouri, by Still in 1898. After a prominent career in the United States, Littlejohn returned to the United Kingdom and established the British School of Osteopathy in 1917.13 When the AOA House of Delegates adopted materia medica into education and practice in the United States in 1929, the British School of Osteopathy did not.13 To this day, osteopaths graduate and practice in the United Kingdom and Europe and perform medical services limited to manipulation and some primary care coordination. When DOs sought practice rights in the United Kingdom, it was presumed that the degree was more manual than medical.9 This false impression has seriously hindered DO practice in Europe, and it persists despite efforts by the World Health Organization and the Osteopathic International Alliance to outline definitions of osteopathic education levels.14 Although DOs gained full practice rights in the United Kingdom in 2005 and under European legislation,9 some European countries including France, Norway, and Ireland still do not officially recognize osteopathic medicine in national laws.5 
Outside of Europe and North America, the problem is more often that health care leaders are completely unacquainted with osteopathic medicine. In many developing nations without DO licensure, there have been numerous accounts of favorable reception to medical service trips. Medical practice regulations are typically softened for service trips because the providers are usually temporary volunteers. DOCARE International, a non-profit charitable organization that hosts service trips, has been in existence for 50 years, active primarily in the Caribbean, Africa, South America, and Central America.13 Despite decades of visibility, few of the countries that have been visited have actually allowed DOs to practice permanently.3 
Reputation and Growth of the Profession
The first DO to practice in a country has the potential to make a lasting impression on behalf of all future representatives. Therefore, entering new territory with a strong professional reputation is imperative to gaining acceptance. This sentiment was clear in a 1988 article, as Shadday et al15 noted,

“Gaining the appropriate licensure to practice medicine and surgery has been the greatest barrier for DOs in foreign countries. Overall, osteopathic physicians have gained acceptance based on their ability. … Personal interaction with the medical community has provided the basis for understanding and subsequent acceptance of the osteopathic profession abroad.”

Strong personality and leadership ability are essential for any DO innovator. 
Professional reputation is certainly a factor in premedical students deciding to apply to osteopathic medical school over other health care programs such as domestic MD, foreign MD, physician assistant studies, or chiropractic studies. Many prospective students are apprehensive and “desire assurance that their earned degree will prepare them for the future implications of globalization,”9 perhaps implicitly believing that a DO degree carries less professional capital than an MD degree. Decades of progress in gaining practice rights have helped to dispel this illusion. However, to assume that an MD degree from a US medical school is the worldwide criterion standard is another falsehood, as evidenced by the fact that neither US-trained MDs nor DOs are permitted to practice in countries such as Switzerland and Morocco.5 
The improved perception is evidenced by the sheer growth of the profession in the United States. When the AOA began concerted efforts toward international licensure in 1986, the number of DOs was approximately 23,000.16 Since then, the number of DOs in practice has grown exponentially, and it is estimated that more than 100,000 DOs will be in active medical practice by the year 20206 (Figure 2). 
Figure 2.
The number of osteopathic physicians has grown exponentially between 1935 and 2012. American Osteopathic Association, 2012.6
Figure 2.
The number of osteopathic physicians has grown exponentially between 1935 and 2012. American Osteopathic Association, 2012.6
Simply put, the DO degree is much less marginalized today after a dramatic increase in the numbers of osteopathic medical schools and osteopathic medical students. The potential cumulative service of thousands of talented DOs who desire to practice abroad may be an undeniable driving force toward further international recognition. 
Review of International Licensure Progress
Currently, there are more countries without explicit DO licensing laws than countries where DOs have full practice rights.4 The AOA is tasked with championing DOs who wish to practice internationally and helping them overcome the legal paperwork to guarantee foreign licensure. 
In several former British colonies where osteopaths practice, the pervasive misconception of DO skill level has held back progress. The Bureau of International Osteopathic Medicine has been pivotal in promoting and distinguishing DOs from osteopaths in these countries.9 In the last decade, advancement toward recognition has been made in New Zealand, Australia, and the United Kingdom.6 In 2005, the General Medical Council of Great Britain allowed DOs to have full medical practice rights in the United Kingdom.5 In New Zealand, a DO was granted full licensure in 2008 to work as a general practitioner with a specialty of musculoskeletal medicine.5 As of April 2013, the Medical Board of Australia also recognizes the DO degree.5 Still, progress remains to be seen across much of Europe. For example, the Irish government has repeatedly declined to recognize DOs as physicians.6 
Progress has also been made elsewhere. Guyana's first DO was granted a physician license by the health ministry in 1996 because his credentials were considered as MD equivalent.5 In 1997, the Bahamian Medical Council issued a license to a DO to practice cardiac and vascular surgery.5 In 2000 in St Lucia, a “U.S.-educated DO was granted an unlimited license to practice medicine based on his credentials.”5 In 2009, 2 DOs gained practice rights in the United Arab Emirates, working with the country's health minister and Dubai's health minister.5 In October 2012, South Africa approved a DO for full medical licensure.17 Lobbying efforts by osteopathic medical students have also brought about change. For example, in 2007, the AOA assisted an osteopathic medical student to bring about policy change to secure full rights for DOs in Venezuela.5 
Other cases demonstrate that achieving DO rights can take some patience, as exemplified by the labor-intensive process that brought change in Chile.5 The first DO gained practice rights in 2008 after a 4-year process that required him to take examinations. The delay was due in part to the Chilean medical council's mandate that “all transcripts, course descriptions and entire medical school catalog [be] translated officially into Spanish.”5 
Practice rights in Jamaica took even longer. In the former British colony and largest English-speaking island in the Caribbean, the first AOA request for DO recognition and full practice rights was denied in 1994.5 Since then, specific medical service trips have been permitted by the minister of health, including recent trips with DO medical direction by Nova Southeastern University College of Osteopathic Medicine,18 Lake Erie College of Osteopathic Medicine-Bradenton,19 and Rowan University School of Osteopathic Medicine.20 In 2013, the Jamaican medical council agreed to license DOs (Joshua Kerr, e-mail communication, September 23, 2013). This course of events in Jamaica is encouraging because it shows that DO familiarity reversed the initial decision in less than 20 years. 
But perhaps the experiences in Mexico could guide future international licensing requests. Licensure for DOs is not allowed in most of Mexico except through the association of a short-term service project, such as through DOCARE.5 Recent medical service trips to Mexico have served as the spring-board for changing that rule. The Institute of International Health at the Michigan State University College of Osteopathic Medicine (MSUCOM) manages an international health elective training site in Mérida, Yucatán, in Mexico. In a joint effort, the AOA and MSUCOM worked to secure medical licensing rights for DOs, making Yucatán the first Mexican state to recognize DOs.21 The AOA plans to develop the Mérida site into a permanent osteopathic medical clinic and to allow international rotations for MSUCOM students while permanently serving the health care needs of Yucatán citizens.21 If this international health elective is successful, it will be a landmark moment in international osteopathic education and could serve as model for developing similar clinics in other countries around the world.21 
Despite the widespread progress of licensing DOs in foreign countries, many AOA requests remain unrequited simply because of bureaucratic oversight or delayed legal correspondence.5 In countries on every continent—Thailand, Uruguay, Denmark, Ukraine, Ghana, Egypt—there are AOA files with official responses unresolved.5 It is even a problem in Guatemala, where despite established DOCARE sites in the country, the country has failed to respond to the AOA's 2009 request regarding licensure for DOs.5 In neighboring Nicaragua, where in 1994 budget constraints prevented the government from accepting foreign clinicians, no progress has been made in the 20 years since.5 
Additionally, there remain many nations that have not been approached regarding DO practice rights. The precedent for licensure requests tends to be on a case-by-case basis. If an interested DO wishes to practice in a country, the AOA will support the venture. In that way, licensure has been achieved in more than one-third of countries around the world. However, the AOA has not put efforts into countries without demonstrated interest from a practicing DO. 
Whether politically recognized or not, DOs think globally, cross borders, and provide health care around the world.22 On January 12, 2010, a catastrophic magnitude 7.0 Mw earthquake devastated Haiti. Dr Frechette was featured on the homepage of ABC news23 as St Damien Hospital continued to admit hundreds of injured children and adults. In his interview, Dr Frechette spoke of treating crush injuries, reuniting missing relatives, and providing shelter for the newly homeless. He described how St Damien Hospital had shared all it could with other relief groups and had completely run out of basic medical supplies. While ABC provided excellent coverage of the compassionate deeds of Dr Frechette, there was no question of his credentials to practice and no mention of his DO title. 
As the number of osteopathic physicians multiplies, as the AOA and ACGME embark on a single graduate medical education system, and as globalization accelerates, the acceptance of osteopathic medicine will truly reach that “whole earth” as predicted by Still.1 If past progress is any indication of future success, the opportunity gap between USeducated DOs and US-educated MDs will soon be history. 
Special thanks to Joshua Kerr, director of the AOA Division of International Affairs, for his help in editing and for providing a current international practice map and statistics about osteopathic physicians. Many thanks also to Evan Altman, OMS III, for helping to research the international practice rights of DOs. 
   Financial Disclosures: None reported.
   Support: None reported.
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Shadday GJ, Papadeas GG, Smith LL. The progression of osteopathic medicine internationally: a survey of America-trained DOs practicing abroad. J Am Osteopath Assoc. 1988;88(9):1095-1098.
History. DOCARE International website. Accessed July 27, 2013.
Raymond R. Hero next door: DO broke ground in education, South Africa. The DO. July 11 , 2014. Accessed September 8, 2014.
Medical mission to Jamaica. Nova Southeastern University College of Osteopathic Medicine website. Accessed July 31, 2013.
LECOM's medical missions. Herald Tribune. September 13 , 2009. Accessed September 9, 2014.
UMDNJ physician makes house calls to Jamaica's poorest. Rowan University School of Osteopathic Medicine website. Accessed August 26, 2014.
Coupet S. Response [letter]. J Am Osteopath Assoc. 2013:113(6);448-449.
Carreiro JE. A global snapshot of osteopathic medicine. Osteopathic Family Physician News. 2006;6(5):14-16.
Hagan K, Escherirch K. After earthquake, fight to save Haiti's children. ABC News. January 15 , 2010. Accessed July 28, 2013.
Figure 1.
International licensure map of countries in which osteopathic physicians currently have unlimited practice rights. American Osteopathic Association, 2013.4
Figure 1.
International licensure map of countries in which osteopathic physicians currently have unlimited practice rights. American Osteopathic Association, 2013.4
Figure 2.
The number of osteopathic physicians has grown exponentially between 1935 and 2012. American Osteopathic Association, 2012.6
Figure 2.
The number of osteopathic physicians has grown exponentially between 1935 and 2012. American Osteopathic Association, 2012.6