Special Communication  |   May 2014
The ‘little m.d.’ or the ‘Big D.O.’: The Path to the California Merger
Author Notes
  • Address correspondence to Norman Gevitz, PhD, Senior Vice President, Academic Affairs, A.T. Still University, 800 W Jefferson St, Kirksville, MO 63501-1443. E-mail:  
Article Information
Medical Education / Preventive Medicine / Professional Issues / Being a DO / Graduate Medical Education / Curriculum
Special Communication   |   May 2014
The ‘little m.d.’ or the ‘Big D.O.’: The Path to the California Merger
The Journal of the American Osteopathic Association, May 2014, Vol. 114, 390-402. doi:10.7556/jaoa.2014.076
The Journal of the American Osteopathic Association, May 2014, Vol. 114, 390-402. doi:10.7556/jaoa.2014.076

In the years following the American Osteopathic Association's sanctioning of the broad teaching of chemical and biological agents, osteopathic physicians moved closer to allopathic physicians with respect to diagnosis and treatment. In the 1930s, osteopathic colleges began to adopt standards and improve their basic science and clinical training, which allowed them to produce graduates who did substantially better in passing external examinations to become licensed as physicians and surgeons. Nevertheless, many state legislatures refused to grant DOs unlimited licenses and osteopathic physicians were unable to obtain medical commissions during the Second World War. In California, despite significant accomplishments on the social and legislative fronts, a growing number of osteopathic physicians believed that their DO degree and independent status as a separate medical profession was an impediment to achieving equality with their allopathic counterparts, and they worked toward a merger or amalgamation with their long-time opponents.

After years of pressure exerted by several college administrators and younger members of the profession, the American Osteopathic Association (AOA) House of Delegates formally voted in 1929 that the subject of pharmacology be fully integrated into the curricula of approved osteopathic schools. Although the House backtracked the following year and made this subject “permissible” rather than mandatory, the die had been cast and no longer would the AOA interfere with a given college's right to determine to what extent the teaching of chemical and biological agents subjects should be offered in its curriculum. Although a substantial number of older osteopathic physicians, or DOs, continued to be unhappy with younger practitioners who were determined to incorporate a wide range of materia medica into their practice, most DOs understood the need and desirability for these new colleagues to practice osteopathy consistent with their expanded range of knowledge and set of skills.1 
The osteopathic medical profession was also becoming more united in working to convince the public and particularly members of state legislatures that DOs should be granted a legal pathway to an unlimited scope of practice and that they should have the same rights, privileges, and opportunities that had been made available only to graduates of schools granting the MD degree. This was no easy challenge. The profession had to overcome a widespread, deeply rooted, and factually based belief that the osteopathic profession, by its own earlier self-definitions, was limited with respect to its range of diagnostic and therapeutic modalities, and therefore it could theoretically advance no further.2-4 
Just What Is a DO Anyway?
Pioneer DOs made a convincing case for their earlier narrow approach. Their theory and practice of osteopathy was internally consistent. Misplaced bones or osteopathic lesions, particularly along the spinal column, interfered with nerves, including those that regulated an adequate blood supply; the lack of an adequate blood supply resulted in disease. Thus, Still's most famous instructions to his students were, “Find it, fix it, and leave it alone.” Whatever one's attitude toward early osteopathy—as a system of practice—its chief merit was that it was an inclusive theory and was relatively easy to understand so that by 1910, it appeared that a large percentage of the US population had heard of osteopathy, associated it with physical manipulation, and conceived of its practitioners as offering a drugless and surgical alternative to the recommendations of MDs.1 
After 1910, even as more osteopathic physicians were incorporating physical diagnosis, laboratory tests, x-rays, drugs, vaccines, serums, and surgery, the public was slow to change its perception of what osteopathy was and what DOs did. In 1936, the AOA hired a public relations counselor who interviewed several randomly picked individuals in downtown Chicago and asked each the simple question “What is an osteopath?” A magazine writer answered, “An osteopath is a fellow who sets your spine, an MD who specializes in that method.” A postal clerk declared, “An osteopath has something to do with massage like a chiropractor.” A department store clerk exclaimed, “Oh I know, I went to one once…. The difference between a doctor and an osteopath is that an osteopath is drugless.” A stockbroker remarked, “A doctor can be an osteopath but an osteopath can't be a doctor.”5 
To address the problem of what appeared to be a fixed and unchanging perception of the terms osteopath and osteopathy, DOs increasingly sought to substitute adjectives for these nouns, preferring instead the terms osteopathic physician and osteopathic medicine. In 1926, Cyrus Gaddis, editor of The Journal of the American Osteopathic Association, declared, “Let no piece of literature be circulated or none go out with simply ‘osteopath’. Let it stand out ‘osteopathic physician’ and then be sure that we are ready to live up to that name…Times are changing. Are we willing to have the public consider us simple treatment givers?”6(p204) Nevertheless, the public's perception of who the DO was and how he or she should be classified was dependent upon the nature of his or her practice.7,8 That none of the Chicago respondents in 1936 associated an osteopath with the practice of medicine and surgery was largely a result of the fact that in Illinois, DOs were not eligible for a full scope of practice.5,9 Thus, if peoples' perception were to change, the law first had to be amended to allow the public to appreciate DOs as physicians in the full sense of the term. 
A Long, Difficult Slog
As DOs sought to enlarge their legal scope of practice, organized medicine intensified its opposition. The young editor of the Journal of the American Medical Association (JAMA), Morris Fishbein, had a particular interest in fighting “cults.” He authored a very accessible book for a general audience called The Medical Follies,10 in which he devoted a chapter to osteopathy for which he penned a humorous, scathing, and unbalanced account of Andrew Taylor Still and his beliefs. Fishbein maintained that osteopathy's modern exponents now recognized the system's fallacies and shortcomings and were trying to surreptitiously enter medicine “through the back door.” Fishbein argued that DOs were endangering their patients and had to be stopped. From 1923 through 1949, Fishbein used the pages of JAMA to oppose any expansion of DOs' scope of practice and encouraged state societies to marshal their forces and defeat osteopathic legislative campaigns.11,12 
Despite these formidable opponents, state osteopathic associations made some initial progress, but then their efforts all but completely stalled. In 1925, the number of unlimited license states and territories stood at 16; in 1930, the figure rose to 20; but by 1935 only 1 additional state had granted DOs a pathway to unlimited licensure.13 Furthermore, in some of these unlimited licensure states, a majority of DOs continued to be ineligible for a physician and surgeon certificate. Most osteopathic schools only required a high school diploma and 16 states mandated 1 or 2 years of pre-professional college work. Eight of these states stipulated a year-long internship following graduation.14 During the 1930s, only 20% to 25% of DO graduates were able to obtain such positions.15,16 Even when DOs met these requirements, they often faced additional hurdles in becoming licensed. In those jurisdictions where DOs and MDs took the exact same examinations before MD or composite (MD + DO) licensure boards, osteopathic graduates fared comparatively poorly. Between 1927 and 1931, for example, only 48% of DO candidates passed the examination compared with 95% of MDs candidates.1 Given this rate of failure, many DOs decided to avoid these particular jurisdictions, choosing instead to practice in an unlimited license state whose tests were devised and graded by an osteopathic board and where failures were negligible. This decision making led to a disproportionate geographical distribution of DOs throughout the country.17 
State medical associations also pursued a novel strategy of discouraging DOs from taking licensure board examinations through their legislative championing of independent “basic science boards.” The role of these boards was to examine all health care practitioners in the fundamental sciences of anatomy, physiology, biochemistry, and other subjects, and MDs, DOs, and doctors of chiropractic (DCs) had to first pass this special examination to be eligible for examination for professional licensure. In 1930, before 7 state basic science boards, the pass rate was 88% for MDs, 55% for DOs, and 22% for DCs.18 Eventually 23 states and the District of Columbia established basic science boards.19 Osteopathic physicians argued that their mediocre performance on medical and composite board licensure examinations as well as independent basic science board tests could be explained away as a form of discrimination. They argued that if such assessments contained a fair number of questions bearing on the mechanics of vertebral articulations or on the role of nerves in controlling physiological functions, the results would be different. This claim may have had some validity; however, it seems unlikely that these biases contributed substantially to the DOs' rate of failure. A more likely reason is that the MDs as a group had a superior overall background and that the schools from which they graduated offered superior laboratory and clinical experiences that more satisfactorily prepared them for such examinations. If DOs were to gain universal unlimited licensure and fare as well as MDs in passing preliminary and professional board examinations, they would need to increase their standards and upgrade their facilities.1,19 
One of the first reforms osteopathic colleges initiated was to raise admission requirements. By 1938, all accredited osteopathic colleges complied with an AOA requirement that every matriculant have a minimum of 1 year of prior college credit, and by 1940, all of the schools began enforcing a 2-year pre-professional requirement—the same minimum standard maintained by accredited MD-granting schools.20 Several osteopathic colleges also began making improvements to their basic science laboratories and established more clinical clerkships for their third- and fourth-year students. In 1936, the AOA Bureau of Hospitals undertook its first inspection of institutions offering internships. Because the primary objective was to provide a year-long postdoctoral position for all osteopathic graduates, requirements were initially set low to qualify as many hospitals and positions as possible.21 These changes may have contributed to achieving some progress on the legislative front. Between 1936 and 1940, 4 additional states—now 25 in all—provided a pathway for unlimited osteopathic practice rights.13 However during the same period, many more states were enacting or seriously considering basic science board legislation, which continued to make licensure difficult for osteopathic graduates.1,19 
The War From Without
In 1940, German aggression led to a wider war in Europe, and the US government began to ramp up its defense efforts in case this country was to be drawn into the conflict. As they did in the First World War, DOs began lobbying in Washington to become eligible for military medical appointments. The AOA believed that since their failed attempt 2 decades earlier, they had addressed several perceived deficiencies. Osteopathic colleges now required students to have the same minimum preprofessional requirements as did MD students, undergraduate professional instruction in both MD- and DO-granting schools was 4 years in length, and all osteopathic colleges provided instruction in a wide range of drugs, vaccines, serums, and biologicals. In addition, the DOs had already won important federal legislative victories. In 1929, Congress had passed a law making the MD and DO degrees equivalent for licensure purposes in the District of Columbia, and in 1938, Congress declared that DOs were to be designated as “physicians” within the provisions of the Federal Compensation Act.1,13,22,23 
In 1940, Congress passed legislation to allow DO students to be deferred—as were MD students—from possible military service until they graduated. In June 1941, members of the profession were elated when Congress passed and President Franklin D. Roosevelt signed the Military Appropriations Act, which provided for “the pay of interns (in the Army Medical Department) who are graduates of, or who have successfully completed at least four years of training in reputable schools of medicine or osteopathy.” In 1942, FDR signed an appropriations bill that provided funding for the commissioning of DOs as naval medical officers. However, despite the availability of funding, the surgeon-generals of the Army and Navy sided with the AMA's views of DOs and opposed the commissioning of DOs.22,24-26 
As shortages of military physicians and surgeons intensified, the AOA did not mount a public relations campaign to force the armed services to commission DOs. Instead, it continued to hold periodic meetings with Army and Navy officials to see how osteopathic physicians and surgeons could become qualified. This strategy of persuasion rather than coercion did not bear fruit. This rankled many DOs who would have preferred to marshal the newspapers and magazines and get their patients and supporters to write letters to their elected representatives, who in turn would seek to force the Army and Navy to accept DOs into the military medical corps. Some urged that DO-granting schools award the MD degree, but in 1941 the AOA House of Delegates unambiguously declared that the only professional diploma to be awarded by an AOA-accredited school would be the DO degree.22,27,28 Though angry and frustrated by their inability to become commissioned officers, DOs grudgingly accepted the fact that their service to the country would occur on the home front. Many found themselves busier than ever, as they now were increasingly responsible for the general health care needs of many patients of those MDs who were now elsewhere attending to the troops.29 
The Division From Within
The inability of the AOA to convince the Army and Navy to accept DOs as physicians and surgeons in their medical corps was especially felt in southern California. This situation was capitalized upon by a small but politically influential group of osteopathic physicians. They believed that a statewide merger with organized medicine wherein they would exchange their DO degrees for legal MD degrees provided the best pathway to removing a variety of obstacles to their personal professional needs. That this effort arose in southern California was no historical accident, as it reflected a particular—almost unique—development and growth of the profession that was not duplicated elsewhere in the country.1,30 
Between 1896 and 1905, 4 osteopathic schools were established in the Golden State—2 of them in San Francisco and 2 in the Los Angeles area. The San Francisco colleges were comparatively short lived and as a result, the profession did not progress substantially in the northern part of the state. The 2 southern California schools—the Pacific College of Osteopathy (PCO) established in 1896 and the Los Angeles College of Osteopathy founded in 1905, merged in 1914 as the College of Osteopathic Physicians & Surgeons (COP&S) in 1914, and it flourished in the decades ahead.1,3,31,32 
The PCO, originally located in Anaheim, was initially led by a DO—Audrey Moore—a graduate of Still's second class.3,33 Among the inaugural graduates of the PCO was Dain Tasker, who, after the osteopathic co-founder left, assumed the responsibility of teaching osteopathic diagnosis and treatment. In 1903, Tasker produced the first of 5 editions of his Principles of Osteopathy, which became the standard text of the PCO and which was used elsewhere as a reference.34 Tasker rejected a monistic theory of disease and challenged the premises of Still's “Our Platform”—a narrow set of party planks published in the Journal of Osteopathy.35,36 Tasker took the position that “There is no reason why each member of the profession should not feel free to develop and fit himself to aid humanity by…any… method which appeals to his best judgment.” Tasker declared that osteopathy had to be scientific and “In order to be truly scientific we must love truth better than we love our preconceived ideas of what truth is.”37(p3) Tasker was not an isolated voice in southern California—and his views of a “broad” osteopathy encompassing an extended and expanded curriculum quickly became a dominant view, one that Tasker furthered not only in the classroom and in his publications but as a leader in the state osteopathic association, as a legislative lobbyist, and as a member of the California State Board of Medical Examiners. 
In 1907, Tasker supported a revision of the medical practice act in which all MD and DO applicants took the same examination in fundamental medical subjects but not in therapeutic methods. On passing the examination, the candidate—whatever his or her degree—received an unlimited license to practice.38 In 1913, the California Legislature revised the medical practice act. It provided 2 types of licenses—one limited and the other unlimited. For candidates to be eligible for the examination to obtain an unlimited license, a school had to be “approved by the board” and adhere to certain minimum standards as to matriculation requirements, what it taught, and the length of the curriculum. The examination included questions on materia medica but not on osteopathic therapeutics.38-40 To meet the requirements of an approved school and to prepare students for the examination, the COP&S introduced a formal course in materia medica and obtained a temporary waiver from the AOA to allow them to do so until the state association could get the law changed.41 Over the next 8 years, the COP&S battled with the board over the eligibility of its graduates to take the unlimited license examination. Finally the state association was successful in its campaign to place an initiative on the 1922 statewide election ballot; voters passed the measure, allowing an independent osteopathic licensing board to judge the standards of DO-granting schools and examine DO graduates for licenses to practice as physicians and surgeons.30,42,43 
The osteopathic medical profession in California grew significantly, and by the mid-teens it had become the most populous osteopathic state.44 California DOs also gained in public estimation. When the American College of Surgeons in the late teens and beyond forced hospitals to exclude DOs from their staffs, the Los Angeles County Board of Supervisors took action to ensure that its residents would continue to have DOs provide inpatient as well as outpatient services to the community. In 1928, the County opened a separate DO-staffed wing of the Los Angeles County Hospital (Unit #2) right next to the much larger MD-staffed unit. For a 5-year period, the hospital issued annual reports, which allowed for direct comparison of the 2 units, and much to the surprise and the dismay of the MDs, who expected dismal osteopathic results, the DO-staffed unit consistently produced substantially better patient outcomes than the MD-staffed unit.45-49 
One of the great beneficiaries of Unit #2 was the COP&S. Shortly after opening, arrangements were made to place all senior students in the hospital as subinterns for 3 months, and as the hospital became busier, COP&S students spent more time at Unit #2.50,51 An analysis of the results of a college questionnaire sent to all accredited osteopathic schools covering the 1936-1937 school year showed that although it was the third largest osteopathic school in terms of enrollment, the COP&S provided its students with the most outpatient cases, clinic visits, obstetric cases, and total number of hospital cases.52 The COP&S also led all other colleges in terms of the length of preprofessional training of its matriculants as well as the percentage of its graduates who went on to take internships. In addition, Unit #2 and other California hospitals provided a number of opportunities for those completing internships to do formal residency training.30,53 
Some California DOs were coming to see themselves as a breed apart from osteopathic physicians elsewhere—being more broadly and thoroughly educated, having greater clinical opportunities, and possessing the most advanced practice rights. They enjoyed a good measure of public respect and were unique in securing county government taxpayer support for their primary teaching hospital. Nevertheless, many California DOs felt themselves disadvantaged by being a DO. Younger practitioners regarded the AOA leadership to be primarily composed of older and dogmatic osteopaths. The AOA had consistently opposed their efforts to expand their practice rights and teach and use all forms of proven diagnostic and therapeutic modalities. They also prevented the colleges from awarding the MD degree as well as the DO degree, which the Pacific College defiantly but quietly did to 12 graduates who had completed 4 years of training in 1913.54,55 
California DOs, though, had no love for their California MD counterparts, who belittled them as “little m.d.s”. The California Medical Association (CMA) opposed their efforts to gain legitimacy and had conspired to throw them out of the hospitals. But still, California DOs could only look with envy at the resources of allopathic schools and hospitals and the opportunities they provided for training and practice. Some younger California DOs had come to the conclusion that despite their legislative victories and their relatively high educational standards compared with other DO-granting schools, they would never attain parity with the MDs. Why not, they asked, find a way whereby they, like the homeopaths and eclectics did decades earlier, merge with allopathic medicine? Through this process they could obtain the MD degree and gain access to facilities and programs for which they were barred as DOs.30,56 
Beginning in 1938, informal and off-the-record conversations took place between some up-and-coming leaders of the California Osteopathic Association (COA) and influential members of the CMA. One of these DOs was Forest Grunigen, who became president of the COA in 1941 and soon after appointed a “Fact Finding Committee” whose purpose was to meet with the CMA and other groups to explore opportunities in which they might cooperate with one another.1,30,57 Those MDs who met with the Fact-Finding Committee wanted to find a way to finally resolve what they called “the osteopathic problem.” They believed that DOs were inferior practitioners who, despite their unrelenting opposition, had won legislative and political victory after victory and though thriving were doing so to the detriment of public health. These MDs thought if they could successfully amalgamate or absorb DOs into their ranks and prevent other DOs from subsequently being licensed, they could at long last put an end to this persistent thorn in their side.1,30,58 
At their first official meeting with the COA representatives, the CMA presented a proposal for amalgamation, which they had already discussed with the AMA Council on Medical Education and the Association of American Medical Colleges. Their plan called for the granting of the MD degree to all DOs who were already licensed as physicians and surgeons by one of the existing accredited California medical schools, the elimination of the independent osteopathic licensing board, and the conversion of COP&S into a medical college. In early 1944, the CMA Committee advised its osteopathic counterpart that both the AMA Council and the Association of American Medical Colleges had given tentative approval to the outline of the plan, but within a month, all unraveled. The Federation of State Medical Boards announced that it would not recognize the validity of this MD degree, and Fishbein, among other influential AMA political leaders, voiced his strong opposition to any society within organized medicine making an accommodation with “cultists.” At the spring 1944 COA Convention, the Fact Finding Committee reported to the society's leadership that there was no prospect in the foreseeable future of a merger with the MDs.1,59-61 
As no actual merger proposal was presented to the COA membership, the AOA did and said little. National osteopathic leaders outside of California believed that this now aborted attempt of some DOs in the state to merge with the MDs was a transitory phenomenon related to the profession's inability to get the Army and Navy surgeon-generals to accept DOs as commissioned medical officers. They believed that once the war was over, the desire for a merger on the part of some in the COA would abate. Indeed, in the late 1940s when a small group of California DOs established a paper school known as “Metropolitan University” for the sole purpose of awarding MD degrees, the COA blasted this effort. They brought the matter to the AOA House of Delegates, which in 1948 unanimously amended its code of ethics to prevent any DO from possessing or displaying any unaccredited degree. The following year, the state and national associations worked together to force this paper college and its alumni association to disband. Some AOA leaders may have believed that the COA position in this matter was strong evidence that the desire for merger had in fact dissipated in California, but if so, they were mistaken. The COA's actions were motivated by the belief that Metropolitan University and its “graduates” with their worthless degrees were embarrassing them and undermining their relationship and bargaining position with the CMA.1,30,62-64 
Catching Up
The United States' entry into the Second World War proved to be problematic to osteopathic medical schools. Although current students were given a deferment, many prospective applicants either volunteered or were drafted, which by 1943 reduced enrollment to historically its lowest levels. Since the financing of these colleges was almost completely dependent upon tuition, several were faced with the prospect of having to shut their doors. In response, the AOA in 1943 launched the Osteopathic Progress Fund, which vigorously solicited contributions from DOs in the field to support their alma mater and other schools in this time of financial peril. As a result millions of dollars were directly funneled into the coffers of the schools. The contributions not only compensated for lost tuition dollars but allowed the colleges to begin capital improvements.1,65,66 
Once the war ended, all of the osteopathic colleges, which were now boasting the same minimal preprofessional requirements as MD-granting schools, began sending recruiters to college campuses. They met directly with students and premedical advisors, touting the rising college standards and portraying the osteopathic profession as a viable alternative pathway to becoming a physician and surgeon. Not only did accredited osteopathic colleges meet their enrollment quotas, but by the early 1950s, matriculation became competitive, with 2 applicants for every available opening. By 1954, every osteopathic college felt comfortable adopting a 3-year standard for matriculation. In 1960, 71% of all new osteopathic medical students entered with a bachelor's degree or higher.1,67 
Many schools used Osteopathic Progress Fund monies to upgrade their laboratories and to hire more PhD instructors to improve their teaching in the basic sciences. On the clinical side, more than 100 osteopathic hospitals opened during the war as a consequence of DOs continuing to be excluded from existing institutions. Because MDs were called into serving the troops, DOs now had a larger and more diverse patient base, and they and their supporters were able to raise the needed capital to fund these hospitals. In 1946, Congress passed and President Harry S. Truman signed the Hill-Burton Act, which provided federal funding for the construction and upgrading of hospitals, including osteopathic institutions. The colleges not only upgraded or built new inpatient facilities but drew upon other— and sometimes larger—osteopathic hospitals elsewhere to provide clerkship opportunities for their students as well as internships and residencies for their graduates. By 1951, there were more available osteopathic internship positions than DO graduates.1,68-70 
The colleges' ability to enroll more highly qualified students, provide them with an enriched basic science training, and most importantly secure for them clerkship opportunities equivalent to those offered by MD-granting schools, had a significant impact upon osteopathic student performance on externally-administered examinations. Between 1942 and 1944 and 1951 and 1953, the gap in passage rate between MD and DO examinees went from a 33 percentage point difference to only a 7 percentage point difference. On examinations administered by medical and composite licensing boards, there was a similar pattern. In 1940 to 1944, DOs trailed MD graduates by 34 percentage points. Between 1955 and 1959, they trailed by 14 percentage points, though the DOs led international medical graduates by 21 percentage points. Certainly, progress in osteopathic standards and performance had been made, but more improvement was needed.1 
Many of the college curricular changes that led to better results on external examinations were made either at the expense of osteopathic manipulative medicine (OMM) or had an unanticipated consequence on its development. The number of clock hours in OMM during the first 2 years declined as more attention was given to pharmacology and other basic sciences. More severe was the cut in didactic OMM instruction during the third and fourth years as training moved from the school to hospital and outpatient sites. Leaders at the AOA and older DOs complained that structural examinations were not generally performed in these settings and comparatively little osteopathic manipulative treatment was provided to patients.71-73 
In 1954, the AOA sent out a questionnaire to all active DOs who had graduated between 1948 and 1953, and almost 60% responded. Only 44% of those answering the question, “What percentages of your patients receive manipulative treatment” said over half. There was considerable variation by school. Graduates of the Kirksville College led all schools with 53% reporting over half, whereas graduates from the Los Angeles College were at the bottom with only 16% saying the same.74 The COP&S continued to distance itself from the others in purposefully downplaying or reinterpreting those distinctive elements in osteopathic education, which defined their school as “osteopathic” and thus “deviant” in the eyes of the rest of the medical world.1,30 
The Push for Merger
In the early 1950s, leaders within both the COA and the CMA attained leadership positions within both the AOA and the AMA, respectively, and actively sought to maneuver their respective national associations to a rapprochement that would facilitate a merger agreement in California.1,30 The challenge for the Californians—both MD and DO—was to have the AMA House of Delegates and Judicial Council to remove the “cultist” designation of DOs. In 1952, AMA President John Cline from California declared that the issue of the relationship between “Medicine” and “Osteopathy” be revisited. The COA leaders urged the AOA Board of Trustees to agree to informal or formal meetings to discuss avenues of “inter-professional cooperation.” Upon leaving office, Cline was empowered to hold talks with designated AOA officials, and discussions between the AOA and AMA committees soon focused on removing the cultist label. As long as this designation remained, DOs across the country would be denied hospital privileges and consultations with their MD counterparts. Furthermore, medical society opposition to DOs obtaining unlimited practice rights and other privileges would continue.1,75,76 
Cline ingratiated himself to the AOA Board by seeking to overturn the 1923 AMA Judicial Council determination that DOs were “cultists.” He gathered all the college catalogs, printed materials, and other data that were available to him to present to the Judicial Council demonstrating that modern osteopathic schools were not engaged in the cultist teaching of medicine. However, Cline's findings and recommendations were met with skepticism by his AMA colleagues because his analysis was not based on independent and objective firsthand information.1,77 
Cline concluded and told his DO counterparts that only an on-site visitation by distinguished MD medical educators could convince the AMA Board, House, and Judicial Council as to the current state of osteopathic medical education. When first proposed to the AOA, this visitation was rejected because it was feared the proposal would be an opened-ended AMA accreditation survey that would rebound negatively on the schools and the AOA. Only when the AMA limited the purpose of the survey to answer the specific question as to whether osteopathic education was “cultist” and gather general information on the state of osteopathic medicine was there an AOA-AMA agreement that the survey should go forward. Five of the 6 colleges agreed—the Philadelphia College was unconvinced of the propriety or value of such a survey.1 
The college visitations eventually went forward, and the MD medical educators reported as to the strengths and weaknesses of osteopathic medical schools. They noted that distinctive osteopathic teachings had declined while the teaching of physical medicine had increased in accredited MD-granting schools. Whatever educational gaps existed between the 2 types of medical colleges, the committee was convinced that the teaching of medicine in osteopathic schools was not “cultist.” When the “Cline Report” came before a committee of the AMA House of Delegates, all of the Cline Committee's recommendations and findings were rejected with the proviso that no further talks be held with the AOA until it disavows “the osteopathic concept.”1,78 
In reaction to this unanticipated political decision, those California leaders who favored merger stepped up their efforts to change AOA policies, programs, literature, and teachings that they believed AMA opponents would interpret as “cultist.” The Californians were successful at altering the AOA Code of Ethics, completely taking out the tribute to Andrew Taylor Still.79 Tasker, who was long retired as a physician but was still active in osteopathic affairs, wrote a scathing article in the AOA's magazine The Forum of Osteopathy, in which he eviscerated the precepts of William Garner Sutherland and blasted the AOA for allowing one of its constituent societies—the Academy of Applied Osteopathy (which first met in 1938)—to affiliate with a group—the Cranial Academy—which championed Sutherland's “unscientific” theories and practices. Tasker's critique was adopted as the official position of the COA.80,81 For its part, COP&S leadership tried to place what distinctive osteopathic teaching it still offered under a more scientific-sounding nomenclature and rubric, changing the name of the Department of Osteopathic Principles and Practice to now begin with the more scientifically acceptable words “Physical Medicine.”30,82 
Secret discussions between representatives of the COA and the CMA continued apace throughout the 1950s, and at the AMA Convention in 1959, the California delegation announced that it was close to a deal with the COA whereupon the state's DOs would be amalgamated. Acceding to the California delegation's request, the AMA House of Delegates approved a resolution stating, “It shall not be considered contrary to the principles of medical ethics for doctors of medicine to teach students in an osteopathic college which is in the process of being converted into an approved medical school which is under the supervision of the AMA Council on Medical Education and Hospitals.”1,83(p1075) 
At the AOA Convention the next month, all eyes were on the California delegation. Outgoing AOA President George W. Northup gave a powerful speech demanding that the Californians explain themselves and asking the entire House membership 4 questions: (1) “Do we wish to maintain the independence of our colleges…?” (2) “Do we wish to [abandon] our intern and residency training programs, our approved and registered hospitals, our certification and recognition of our specialists and their certifying programs…?” (3) “Do we or do we not have a contribution to make to medicine not now being accomplished through the efforts of [the AMA or] any other organization?” and finally he asked, (4) “Do we wish to continue as an independent osteopathic profession, cooperative with all and subservient to none?”1(p131) Each of Northup's questions was answered with loud demonstrations of loyalty to the AOA and to the osteopathic profession. And when Northup finished, he was bathed in applause except from the COA delegation, which sat angry and silent and utterly refused to explain its position.1,84 The next largest delegation—Michigan—offered a resolution proclaiming that osteopathic medicine “shall maintain its status as a separate and complete school of medicine” and will work in the future with other groups “when that cooperation is on an equal basis granting full recognition to the autonomy and contribution of the osteopathic school of practice.” This resolution passed 95-22 with California delegates dissenting.1(p132),85 
Despite this vote, COA and CMA representatives continued to conduct secret negotiations. Months later when word leaked out, the AOA House of Delegates demanded at its annual meeting in July 1960 that the Californians explain themselves. Dorothy Marsh and Nicholas Oddo presented the position of the COA leadership. They reviewed past differences with the AOA over licensure and standard setting, noted the pervasive problem of obtaining postgraduate training, and noted the poor status of the DO degree. They argued that amalgamation with the MDs would settle these matters once and for all. However, delegates from other states challenged this rationale. They maintained that the various problems osteopathic medicine currently faced could be successfully addressed as an independent profession and that all the Californians wanted was a quick fix. The AOA House of Delegates thereupon passed a resolution that subjected any divisional organization “in the process of negotiation leading to unification and/or ‘amalgamation’ or merger…to the revocation of its charter.”1(p132),30,86 In November 1960, the COA House of Delegates voted 66-40 to ignore the directive, which led to its expulsion and the AOA's chartering of the Osteopathic Physicians and Surgeons of California, which sought to recruit dissenting COA members. However, only one-sixth of all practicing California DOs joined. The AOA's revocation of the COA charter only served to encourage a number of undecided DOs to stay unified with their long-time colleagues, whatever their reservations.1,30,87,88 
By late spring 1961, after clearing the provisions of the proposed contract with AMA leadership, it was presented to the delegates of the CMA and COA Houses. First, the COP&S would change its name to the California College of Medicine and offer all its living graduates and those DOs who held valid physician and surgeon licenses in the state an MD degree—which would be an “academic” rather than a “professional” degree. In California, statutory provision would be made to accept it for all purposes connected with the practice of medicine in the state but not elsewhere. Second, those DOs who chose to accept this MD degree would be required to cease identifying themselves as a DO or “osteopathic” physician. Third, the former COP&S would become a member of the Association of American Medical Colleges and end its teaching of osteopathy. Fourth, the CMA would absorb all DOs, segregating them into a separate divisional society until they could be integrated into existing geographically-based CMA units. Finally, the COA would support a new statewide initiative that if passed would prevent any new licensing of DOs within the state. When the number of those DOs who decided to remain DOs dropped to less than 40, the existing Osteopathic Licensing Board would be abolished and its functions would be taken over by the MD licensing board.1,30 
The CMA House of Delegates passed this agreement by a vote of 296-63 and the COA House voted 100-10 in the affirmative. The COP&S Board narrowly passed the resolution to convert itself into an MD-granting school 13-11, and in July, some 2000 DOs gathered in the Los Angeles County General Hospital to receive their academic MD degrees. Prominent among the recipients was 92-year-old Dain Tasker—whose presence symbolized both the beginning and end of osteopathy in California. The next year, Californians passed the ballot initiative, making it impossible in the future for any other DOs to be licensed in the state.1,30 
To many AMA leaders this victory made inevitable the soon-to-be amalgamation of all DOs—most of whom, they predicted, would be only too happy to exchange their poorly understood DO degree for the universally known MD. However, what the AMA did not count on was that the California merger would solidify DOs elsewhere around the country. Even if they were dissatisfied with the public's limited understanding of who they were, what they did, and the degree they actually earned, the merger strongly motivated them. Over the next several years they fought to win back their profession's rights and privileges in California, obtain unlimited licensure rights in other states that yet denied them, and secure the same federal recognition as MDs. They also worked to establish more osteopathic medical schools to produce graduates whom Northup called “the big DOs” to replace and supersede the number of what he disparagingly referred to as “the little mds.”1 The California merger, in fact, stimulated the osteopathic medical profession to chart a new path forward, but not without continuing debate as to the wisdom of maintaining the DO degree in the years ahead.1,89,90 
   Financial Disclosures: None reported.
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