Letters to the Editor  |   February 2015
Research in the Osteopathic Medical Profession: Roadmap to Recovery—Conundrums in Osteopathic Research Require Consensus and Collaboration
Article Information
Osteopathic Manipulative Treatment / OMT in the Laboratory
Letters to the Editor   |   February 2015
Research in the Osteopathic Medical Profession: Roadmap to Recovery—Conundrums in Osteopathic Research Require Consensus and Collaboration
The Journal of the American Osteopathic Association, February 2015, Vol. 115, 70-71. doi:10.7556/jaoa.2015.016
The Journal of the American Osteopathic Association, February 2015, Vol. 115, 70-71. doi:10.7556/jaoa.2015.016
To the Editor: 
This letter is in response to an article in the August 2014 issue of The Journal of the American Osteopathic Association.1 The crux of the article, written by Brian Clark, PhD, and Jack Blazyk, PhD, accurately describes the paucity of research in osteopathic medical institutions and also asserts that unless we reverse that trend, it will be the death knell of the osteopathic medical profession. We fundamentally agree that the osteopathic medical profession must produce more research and that greater use of clinical researchers and collaboration with basic science must occur. We disagree, however, on 3 cogent points. 
One of the main arguments the authors make is illustrated in a diagram identifying the National Institutes of Health (NIH) research dollars as seemingly going everywhere but to colleges of osteopathic medicine. Besides implying that all valuable research is exclusively funded by the NIH, an important piece of comparative data that was omitted might serve to put that diagram in perspective but may not be available. Given that research at colleges of osteopathic medicine has always been uniquely secondary to the training of future osteopathic physicians, should the comparison with NIH funding be full-time osteopathic physicians who are principally researchers? The focus of colleges of osteopathic medicine has always been service, but the focus of almost all other academic institutions is research-generated extramural funding.2 Some of our schools have robust research, but others less so. Therefore, we believe the authors should have compared apples to apples, a fundamental concept in any data analysis. 
With respect to the second point we disagreed with, in the middle of the article, the authors described “unsubstantiated” treatments still being taught or practiced, and implied that the practice of osteopathic manipulative medicine (OMM) does not stand the test of evidence. Regrettably, there are examples demonstrating that the profession sometimes espouses unsubstantiated medical practices (eg, certain applications of osteopathic manipulation), and there are other practices codified in osteopathic medicine that do not yet have an adequate evidence base and require additional study. 
Evidence-based medicine (EBM) has been held as the criterion standard since the 2009 Institute of Medicine roundtable set the goal that 90% of clinical decisions will be based on the best evidence.3 Since that time, the realities and limitations of EBM have been recognized clinically. However, specialties such as plastic surgery have been shown to be almost exclusively based on case studies.4 Orthopedic surgery, which prides itself on its research acumen, self-identifies that nearly half of its data are level 4, the lowest level of evidence.5 Are plastic and reconstructive surgery and orthopedic surgery therefore delegitimized as professions? Are they teaching “codified” medicine or “unsubstantiated medical practices?” If so, where is the authors' commensurate outrage? Why is OMM being held to a different standard? 
The authors adroitly illustrate the divide that exists in medicine today between the bench-honed basic science researcher and the physician who is fortunate enough to practice in the world of uncertainties and gray zones, where individual human lives occur. Evidence-based medicine, which dominates our basic science thought and funding rationale, may have failed us already. A recent review of the state of EBM suggests that most interventional studies are industry funded, and so “EBM's indiscriminate acceptance of industry-generated ‘evidence’ is akin to letting politicians count their own votes.”6 
This is not to say that OMM falls outside the need for continuing research and evidence or that we should not question our assumptions. We have journals, domestic and international, that routinely publish data on diagnosis and treatment measures. Texts documenting the scientific underpinnings of treatment7 as well as direct evidence-based data8 have also been published. 
Last, the authors engage in a circular argument regarding research in osteopathic principles and practice (OPP). We are told in one section of the article that we should not focus our research efforts on OPP because of its narrow and limited funding ability. Next, we are told that its practices are unsubstantiated and its teaching is based on mere oral history and, therefore, research is necessary. In a classic “damned if you do, damned if you don't” argument, the authors' ambivalence leaves the reader perplexed as to their final recommendations, but it also leaves the reader with the feeling that OPP research is ultimately being devalued. 
We believe the apparent shortsightedness of the authors of this article1 is a perfect example of the challenge that exists at all colleges of osteopathic medicine to a greater or lesser degree. We are first osteopathic, and it is that quality that serves to primarily employ and support our basic science faculty. To that end, it is the job of each researcher in our colleges to support the philosophy and the practice of osteopathic medicine by actively designing and engaging in studies that support or refute the current science around that practice. We need more research, yes, but we can no longer be engaged in the kind of “tail wagging the dog” relationship with basic science, where the direction of scientific research operates in a vacuum with an exclusive superiority and primacy around its direction. Intellectual curiosity about osteopathic medicine must supplant generations-old uninformed and prejudicial assumptions about our clinical practice. Osteopathic manipulative medicine works.9-11 It is up to the amicable collaboration between our clinicians and our basic science researchers to elucidate and refine the ever-emerging details of that efficacy, perhaps not by focusing on the holy grail of EBM but by looking to the new paradigm of patient-centered care, outcomes research,12 and complex physiologic system interfaces. We welcome a spirited dialog about this issue and, ultimately, hope for more consensus and mutual support rather than the divisive territoriality which has for so long marked our profession. 
   Editor's Note: The JAOA declined to publish the response submitted by Drs Clark and Blazyk.  Editor's Note: An additional letter from Boyd R. Buser, DO, regarding the single graduate medical education accreditation system is published online at
Clark BC, Blazyk J. Research in the osteopathic medical profession: roadmap to recovery [In My View]. J Am Osteopath Assoc. 2014;114(8):608-614. doi:10.7556/jaoa.2014.124. [CrossRef] [PubMed]
The crisis in extramural funding. American Association of University Professors website. Accessed November 4, 2014.
Charter and vision statement. In: Olsen L, Goolsby WA, McGinnis JM. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: Institute of Medicine of the National Academies; 2009:ix.
Burns PB, Rohrich RJ, Chung KC. The levels of evidence and their role in evidence-based medicine. Plast Reconstr Surg. 2011;128(1):305-310. doi:10.1097/PRS.0b013e318219c171. [CrossRef] [PubMed]
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Every-Palmer S, Howick J. How evidence-based medicine is failing due to biased trials and selective publication [published online May 12, 2014]. J Eval Clin Pract. 2014. doi:10.1111/jep.12147.
King HH, Janig W, Patterson M, eds. The Science and Clinical Application of Manual Therapy. Philadelphia, PA: Elsevier; 2011.
Seffinger MA, Hruby RJ, eds. Evidence-Based Manual Medicine: A Problem-Oriented Approach. Philadelphia, PA: Saunders/Elsevier; 2007.
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Rolle G, Tremolizzo L, Somalvico F, Ferrarese C, Bressan LC. Pilot trial of osteopathic manipulative therapy for patients with frequent episodic tension-type headache. J Am Osteopath Assoc. 2014;114(9):678-685. doi:10.7556/jaoa.2014.136. [PubMed]
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