Abstract
In the early 1960s, Dorothy Marsh, DO, then president of the California Osteopathic Association, ardently promoted an amalgamation with the California Medical Association that would eliminate the doctorate of osteopathy (ie, DO) degree and grant medical doctor (MD) degrees to DO holders. Marsh traveled extensively throughout California in an effort to gain support for the merger, which passed in spring 1961. The osteopathic medical community tends to view the California merger as a dark period in history of the profession, a devastating loss of members and facilities. Yet, on the day it was signed, Marsh called the event a “historic achievement in the field of osteopathy.” Using primary documents from the Dorothy Marsh Collection at the University of California, Los Angeles, the author attempts to understand the reasons why an osteopathic physician would fight so passionately to abandon her own professional identity. These documents shed light on Marsh's motivations and the perspectives of merger supporters and opponents during this period.
In April 1961, Dorothy Marsh, DO, received a letter from Evelyn Pendleton, the patient of a California osteopathic physician for 26 years. Pendleton wrote,
1
Pendleton's letter was 1 of hundreds that Marsh received during her term as president of the California Osteopathic Association (COA) imploring her to end merger negotiations and preserve osteopathic identity. Despite these letters, on May 17, 1961, Marsh signed an agreement with the California Medical Association (CMA) to merge the professions. The merger and its associated propositions (notably the people's proposition 22, approved by the state's voters in 1962) prevented California's osteopathic medical licensing board from providing new doctor of osteopathy (DO) degrees. Existing osteopathic physicians (ie, DOs) and new osteopathic medical graduates received medical doctor (MD) degrees, and the identity of the osteopathic physician formally disappeared under Marsh's new agreement.
While many DOs and patients around the country shared Pendleton's sentiments, Marsh proclaimed the merger a triumph, the end of a century-long battle for equality in the medical profession. She believed that osteopathic physicians would no longer be segregated in their own schools and hospitals and that the financial and social burdens of maintaining a separate profession would be lifted.
2 In the years leading up to the merger, Marsh, a respected obstetrician and gynecologist, attempted to convince California DOs that amalgamation with MDs would afford them unlimited practice rights and the universal respect they deserved. Her humorous speeches and persuasive arguments won the merger a majority vote in California—296 to 63.
3 Marsh hoped the rest of the states and the American Osteopathic Association would follow suit.
Marsh's dream of a national merger never came to fruition. In 1974, the Supreme Court overturned the component of proposition 22 that limited the autonomy of California's osteopathic medical licensing board, thus reinstating the board's full power to provide new DO degrees. Those physicians who had refused to undergo a degree change began the process of rebuilding a distinct osteopathic identity in California. Having already shed the title of osteopathic physician, Marsh and most other former DOs held onto their converted MD degrees. Many became faculty at the California College of Medicine, which soon thereafter became affiliated with the University of California, Irvine.
The conviction with which Marsh promoted the elimination of the DO degree is puzzling. If she simply wanted to be an MD, as many merger dissidents believed, why would Marsh have exerted such effort to convince her colleagues that merging was necessary for the longevity of osteopathic medicine? Why call it a victory in equality, a way to legitimize the teachings of Andrew Taylor Still, MD, DO, if she had no interest in the profession's survival? Were these convictions part of a flashy campaign to gain support for the merger, or were they honest beliefs that osteopathic medicine would benefit from this move?
In an attempt to answer these questions, I turned primarily to the Dorothy Marsh Collection in the archives of the Charles E. Young Research Library at the University of California, Los Angeles. The collection contains Marsh's COA-related correspondence during the years of her presidency as well as numerous speech drafts, newspaper clippings, and other primary documents regarding the 1961 merger. The collection offers valuable insight into the psychology of Marsh and other merger supporters; these documents, to my knowledge, have not yet been analyzed in a historical publication.
Other valuable sources for the present article on the California merger were
The D.O.'s: Osteopathic Medicine in America4 by Norman A. Gevitz, DO, and
The Merger: M.D.s and D.O.s in California,5 by Sibylle Reinsch, PhD, and colleagues. The latter work includes oral interviews with individuals involved in the merger, many of whom knew Marsh, and material collected from California College of Medicine archives at the University of California, Irvine, and the Western University of Health Sciences College of Osteopathic Medicine of the Pacific.
“The further we get from A.T. Still”
Gevitz describes the COA in the 1950s as a “progressive wing,” a “stronghold for broad osteopaths,” who practiced the full scope of medicine in addition to osteopathy.
4 Prior to 1961, California had more DOs in practice than any other state and made up 10% of the state's physicians.
4 The College of Osteopathic Physicians and Surgeons (COP&S) in Los Angeles, California, was the first osteopathic medical school to require previous college work to matriculate, and thus, many California DOs believed they were the most “scientific” osteopathic physicians in the country.
4 This self-identification set them apart from DOs in other regions and brought them closer in scope of practice to California MDs.
By the middle of the twentieth century, California DOs had made significant progress in obtaining equal licensing to MDs. Though they were confined to osteopathic hospitals (plus 1 wing of Los Angeles County Hospital), and prohibited from consulting with MDs on patient cases, DOs were caring for approximately 15% of the state's population.
4 Yet, the American Medical Association (AMA) still designated osteopathy as a “cultist” practice in their formal literature.
4 In 1955, John Cline, MD, chairman of the AMA's Committee on Osteopathy, proposed removing the cultist label from AMA documents.
4 He conducted an on-campus survey of 5 of the 6 existing osteopathic medical schools (the Philadelphia College of Osteopathic Medicine refused to participate), which showed that students received adequate training in basic and clinical sciences.
4 The AMA House of Delegates rejected Cline's proposal, stating that unless osteopathic medical schools abandoned the “osteopathic concept,” removing the term osteopathy and the mention of Still from their courses, the cultist label would remain.
4 While these conditions angered most state delegations, California delegates were willing to comply with the AMA on the issue of cultism. The COP&S removed several osteopathic references from the school literature and changed the name of the Osteopathic Therapeutics Department to the Department of Physical Medicine and Rehabilitation.
4
By the late 1950's, DOs in California were caught between an identity that felt distant and the temptation to redefine themselves as mainstream physicians. Months before the merger became official, Myrtle P. Cochran, DO, wrote to Marsh, “The further we get from A.T. Still, the further we get from Osteopathy,”
6 referencing the physical distance between California and Kirksville, Missouri, where osteopathic medicine was founded and where Cochran had graduated in 1908. She meant this letter to be a criticism of Marsh's actions, but in fact the “distance” Californians felt from the teachings of Still worked to Marsh's advantage as she promoted the merger. Marsh delivered her arguments for amalgamation in a climate of insecurity about the future of the osteopathic medical profession and a profound desire for equal treatment under the law and in the community.
Seth Hufstedler, LLB, attorney for the COA during the merger proceedings, described Marsh as a “very bright and vigorous person.”
5(p129) Hufstedler accompanied Marsh to osteopathic meetings throughout the state, spreading information about the merger through what he says Marsh referred to as their “dog and pony show.”
5(p140) According to Hufstedler, Marsh approached these meetings with an elaborate presentational style, which proved to be quite persuasive. She was funny (she offered Hufstedler free gynecologic care for life if they were successful), blunt, and conversational in her speeches, addressing her osteopathic colleagues, for instance, as her “boys.”
5
Marsh's main emphasis, apart from the presentational elements, was the financial necessity of the merger.
7 Given the increasing price of medical education, she felt that funding COP&S was becoming an insurmountable challenge.
7 At the AOA convention in 1960, Marsh delivered a spirited response to the extremely negative reception the merger was receiving nationally. She drew links between financial deficits, educational breakdown, and the eventual demise of the profession, and she asked how osteopathic medical schools could “keep competent faculty,” without adequate compensation: “We believe that if our educational front collapses, our protective legislature front will be unable to protect members' practice privileges.”
7
Marsh argued that the merger was primarily an effort to protect the practice rights of its members. She did not see how the AOA could oppose this protective measure, and she hoped to eventually convince them to alter their stance. When the AOA president publicly denounced the merger and threatened to remove California from the AOA, Marsh called his speech “rumor perverted to have the ring of fact.”
7 Regarding these dramatic AOA conferences, Hufstedler expressed relief in being outside of the heated discussions, saying, “Fortunately I was just a lawyer.”
5(p125)
Marsh clearly enjoyed delivering passionate performances, but beneath the “dog and pony show,” her personal motivations are open for interpretation. A glance at the correspondence she received in the month before the merger reveals a variety of opinions. R.C. Blackwell, DO, wrote the following to Marsh
8:
W. Fuller Robinson, DO, compared Marsh to Judas Iscariot in the betrayal of Jesus Christ, saying, “He too sold out to a stronger group.”
9 Robinson also presumed her naïveté in negotiating with the California Medical Association, writing the following:
Those who knew Marsh, however, say she understood exactly what she was doing. Dolores Grunigen, wife of California merger pioneer Forest Grunigen, MD, explained it as follows5(p127):
The most prominent evidence of Marsh's feelings toward the merger comes from speeches she gave at the COA convention on May 17, 1961, the day the merger was signed. She assured colleagues, “United we (COA-CMA) can better serve the vital health needs of California.”
2 At a banquet in her honor, she rewrote the words to the Gettysburg Address, with “apologies to Abraham Lincoln,”
10 to reflect the story of the osteopathic medicine and the merger
10:
She described the merger negotiations as a great “Civil War,” and concluded the following
10:
Marsh's decision to present this speech speaks to her quirky sense of humor, but it also demonstrates how significant an achievement the merger was in her eyes. A comparison to the Civil War cannot be made lightly, even in the context of a celebratory dinner. Marsh clearly felt this was a historic event, worthy of a major historical association. By signing this merger, she maintained, the CMA had formally accepted osteopathic medicine as a legitimate form of medical practice.
While Marsh was celebrating the “elevation” of her profession to the status of an MD, other DOs were questioning the CMA's motives for signing a merger. Many believed MDs supported the merger as a way to obliterate the DOs, envelop the profession as they had with homeopathy. Was Marsh aware of this possible motive? Marsh's archives contain a few letters from MDs, praising her work on the merger. “The unification of our groups is many years overdue,” wrote Wilbur D. Currier, MD.
11 Another letter proclaimed that the “trend of the 60's is amalgamation,” and the “existing inequalities” built on “a faint line of demarcation between the two college degrees” needed to be eliminated.
12 These documents alone might suggest that the positive reception she received from some CMA politicians had convinced Marsh that she had the support of most California MDs.
However, Marsh's archive also contains several copies of the San Fernando Valley District of the Los Angeles County Medical Association Newsletter, published April 15, 1961.
13 This particular issue of the newsletter was devoted to criticizing the merger. In one article, “At What Price Merger,” Robert Hood, MD, discussed his objection to the merger's “assertion that the concept and quality of medical and osteopathic practice are identical.”
13 He felt it inappropriate to grant MD degrees without a review of the physicians' qualifications. He also argued that because the merger was not supported by DOs nationwide, the objective to “terminate the practice of osteopathy,” would not be achieved.
13 Allyn McDowell, president of this chapter of the CMA, signed his message, “MD (Not DO),” and wrote the following: “Some of our CMA politicians who so readily admit they are no better than osteopaths, seem bent on forcing a similar evaluation upon the rest of us.”
13 He continued to explain that the he did not feel threatened by the existence of osteopaths, writing, “Their's is a second rate group. They know that, we know it, and we have gone to considerable effort in the past to let the public know it.”
13
The extreme opinions and powerful language in these articles could not have gone unnoticed. Despite her assurance that the merger would foster equality and acceptance, Marsh must have been aware that a sizable percentage of California MDs were opposed to the change and would continue to treat DOs as a second-rate group after the merger. Perhaps Marsh chose to ignore these viewpoints, or maybe she felt the degree change would eventually make osteopathic and allopathic physicians indistinguishable and therefore equal. This state of equality would require either the complete obliteration of osteopathic philosophy and techniques or the seamless integration of osteopathic medicine into allopathic medicine. Marsh was undoubtedly hoping for the latter scenario, but to achieve that level of equality with the majority, she was willing to risk sacrificing the identity of the osteopathic minority.
At 5:30
am on April 7, 1961, after a sleepless night of agonizing over the COA-CMA merger, Frank E. MacCracken, DO, typed a letter
14 to his friend and colleague J. Frank Holt, DO. He later sent a copy of the letter to Marsh. MacCracken was the primary author of the AOA-approved Osteopathic Oath, which has been recited by all graduates at osteopathic medical schools during graduation ceremonies since 1954.
15 He had previously opposed the merger but was now changing his mind:
The letter was fraught with emotion, reflective of a physician in a minority profession, an original student of Still at the American School of Osteopathy (now the A.T. Still University of Health Sciences-Kirksville College of Osteopathic Medicine), and a DO who had spent 48 years fighting to bring osteopathic medicine to the forefront of medical practice. “I believed in Dr. Still's theories,” he wrote.
14 Yet, instead of celebrating a century of survival, with numerous osteopathic hospitals and the nearly unlimited practice rights of their physicians, MacCracken, Marsh, and a majority of California DOs lamented the enduring social and financial inequalities. Marsh believed these disparities would never fully disappear if the professions remained separate. Osteopathic physicians in California were beginning to define themselves by what they were not. Rather than proud DOs, they were “not MDs,” and the social ramifications of being something other than a mainstream physician cultivated a profound minority complex in these individuals.
Minority complex refers to the sense of relentless comparison that a smaller, less prominent group may feel toward the majority in a given population. This psychological state can breed tremendous success among minority populations, motivating them to succeed as underdogs and surpass the majority. However, a minority complex can also be hazardous to the identity of that minority. Members of the minority group may begin to feel hopeless, trapped in an inferior position unless they can assimilate into the majority population. Marsh was at this point in 1961. California DOs were tired of minority status. They were presented with a rare opportunity to assimilate, and most of them took it. Even though it wasn't clear how MDs would respond, or how complete this assimilation would be, these osteopathic physicians made the complicated and, for some, agonizing decision to abandon their professional identity.
Marsh could not have foreseen today's flourishing osteopathic medical profession: financial security, graduates entering every specialty, open collaboration with MDs, and the continued practice of OMT. Yet even with these successes, modern osteopathic physicians should be weary of the same minority complex that drove Marsh and other California DOs toward amalgamation 50 years ago. In her analysis of the evolution of osteopathic identity, Katherine Miller accurately describes a professional “identity tightrope,” on which we must be “true to some philosophical roots and responsive to a complex health care environment.”
16 When describing the profession, osteopathic physicians too often employ the defensive phrase, “We're just like MDs, except....” Our focus must shift away from “exception,” which is a definition based on comparison to the MD majority. Instead, DOs should concentrate on cultivating an independent definition on the basis of exemplary patient care. To close her 1961 letter,
6 Cochran advised Marsh, “If you are going to be an Osteopath, be an Osteopath. If you are going to be an MD, be an MD. Whatever you are, be a good one.” Her advice resonates today as we strive to preserve the identity of osteopathic physicians and ensure the future of this unique profession.
I would like to thank Alexander S. Nicholas, DO, for his commitment to teaching the history of osteopathic medicine and for his guidance in crafting this essay.