Good morning and thank you for the kind introduction. I am very honored to be here to deliver the A.T. Still Memorial Lecture today.
As part of the osteopathic family, I have had the opportunity to represent the American Osteopathic Association (AOA) in many different ways, but serving as this year's speaker for this memorial lecture is one of the biggest highlights in my career. Today, I am very privileged to be able to serve the osteopathic community in this fashion.
In preparing for my remarks, I spent a good deal of time contemplating the life of Andrew Taylor Still, MD, DO, and considering what he would be like and act like if he were alive today. Yes, a century and a half separates his time from ours. But so little about the human condition has changed.
Today, we face many of the same concerns A.T. Still did, only with a modern twist. There are 5 ways in which I believe A.T. Still would distinguish himself and osteopathic medicine if he were practicing medicine in 2012. I will provide a few examples of how we, as DOs, carry on his work. And by the end of my talk, I think you will agree that Dr Still's spirit lives on through all of us.
If A.T. Still were here today,
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He would be an outspoken advocate for patients.
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His practice would be on the leading edge of technology.
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He would conduct research—gathering and analyzing evidence and data for the good of his patients.
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He would fight for social justice and change.
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He would be a champion for osteopathic medicine.
Now, let me expound on these 5 points, starting with A.T. Still as an outspoken patient advocate.
Patient Advocate
If we know anything about A.T. Still—based upon what we've read about him and stories we've been told about him—it's that he was outspoken. He was not shy about voicing his views about the state of physicians and medicine during his time. He pointed his most intense criticism at physicians who did not keep the interest of the patient first. He once said, “If a patient had one foot in the grave and a half-pint of whisky in a bottle, the doctor would work as hard to get the whisky out of the bottle as to keep the foot from the grave.”
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A.T. Still was critical of how many physicians overused drugs, for example. Today, I'm sure he would be critical of a sometimes impersonal and complex medical system that can make a patient feel like a small cog in a very large machine.
For all of the talk today surrounding the buzzwords of patient-centered quality care, A.T. Still would see a lonely patient—perhaps separated by miles from family and friends—surrounded by beeping monitoring equipment in a large hospital. He would want to bring humanity into the situation.
You see, A.T. Still was a very practical man. He was able to cut to the chase of what was really important. When he saw a patient standing before him, all he wanted to do was make him or her feel better, and that's what led to his revolutionary manipulative techniques. He had a very simple maxim that he followed—“find it, fix it and leave it alone.”
2(p428)
Throughout my term as AOA president several years ago, I often spoke about quality. I defined quality very practically in a way I thought A.T. Still would—as doing the right thing, at the right time, in the right way, to the right person, for the right reason.
I think Dr Still would agree with this definition of quality because it summarizes how he would deal with a patient standing before him. He would call upon his experience and judgment to do his best for the patient at that point of time—it's as simple as that.
Brian F. Degenhardt, DO, summed up the relationship between quality, patient-centered care, and osteopathic medicine quite aptly when he delivered the George Northup Memorial Lecture in 2011.
3 He said,
Osteopathy was founded upon an intimate relationship with promoting individual patient health, and now osteopathic medicine has a legacy of patient advocacy and patient empowerment to promote health.3
A.T. Still's legacy of patient advocacy is still very apparent in 2012.
Technology
Now to the second distinguishing characteristic of A.T. Still. If he were alive today, I just know his practice would be on the leading edge of technology. He would embrace technology and use it for the benefit of his patients. I know this because Dr Still loved to tinker, and he was an inventor at heart. He was always coming up with better ways to do things, both inside and outside of medicine.
He patented an improved butter churn
4 and a smokeless furnace burner.
5(p228) He made improvements to a mowing machine designed to make harvesting grain easier, but his ideas were stolen before he could get the patent.
4 During the Civil War, he saved a soldier from leg amputation by building a wooden trough and arranging a draining system using quills, rope, and a keg of water.
4 In a few weeks, the soldier was walking with crutches.
Today, I'm sure he would be among the first to earn incentive payments as a meaningful user of electronic health records. Dr Still would be intrigued by electronic health records because he so intently observed his patients, noting changes in their conditions and the effect various treatments would have on them. Electronic health records would help him to keep track of his patients' unique characteristics.
A.T. Still also would be delighted with AOA-CAP—our Clinical Assessment Program—which analyzes data abstracted directly from patient medical records to measure clinical performance. Dr Still would be eager to compare his clinical practice and his patients' outcomes to those of his peers and to national measures.
And he would be encouraged by the new pay-for-performance models, such as AOA-CAP for PQRS (Physician Quality Reporting System), that reward physicians who use evidence-based processes and outcome measures. For Dr Still knew then, as we know now, that the best measure of quality is patient outcomes.
Research
This brings us to our third characteristic of A.T. Still. He would gather and analyze evidence and data through research for the good of his patients.
The meningitis epidemic that took the lives of 3 of his children made a huge and lasting impression on A.T. Still. He asked himself, “In sickness has God left man in a world of guessing? Guess what is the matter? What to give, and guess the results?”
1(p88) Rather than becoming despondent, he, like Columbus, “trimmed [his] sail and launched [his] craft as an explorer.”
1(p88)
Dr Still sought answers to these perplexing questions and began to develop a systematic method of treatment that would eliminate guesswork and bring health without the disastrous results of many therapies of his day. He studied bones and their relationship to one another. He studied muscles and nerves and the circulation of blood—which he called the “river of life.”
4 He found that all bodily systems were interconnected—that an infection in one part could affect another. He understood the benefits of cleanliness, exercise, fresh air, and good nutrition. Most importantly, he began to understand that a physician must treat the whole person, not just the symptom.
His view was that the body was a machine, and the osteopathic physician was the mechanic who could keep it running smoothly. At the heart of his osteopathic philosophy was his belief in the body's ability to cure itself of many pathological conditions. Hippocrates expressed a similar philosophy more than 2000 years ago when he said: “Our natures are the physicians of our diseases.”
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Dr Still did his own kind of outcomes research—traveling from town to town, treating patients and observing the results he used to fuel further discoveries. He never settled. He always searched for a better way. As he stated,
An absolute demand for reformation is before us at this day and time, a demand for a progressive step in the line of treating disease. … For a number of days I have been haunted by the feeling that we are in danger of getting in a rut. … Let us not be governed to-day by what we did yesterday, nor to-morrow by what we do to-day, for day by day we must show progress. … At the head of our column, we carry the flag of progress, and should honor it with greater results by better application of the principles of osteopathy. We must avoid the dust of habit.1(p201-202)
A.T. Still persisted through many trials and tribulations. After many treatments on many patients, he developed his philosophy of osteopathy. He continued his systematic observation, his reasoning, and the treatments that resulted in good patient outcomes.
Today, I'm sure he would be a leader in comparative effectiveness research because it is so very similar to how he operated his own practice and formed his own decision-making process. He was always looking for evidence of the effectiveness, benefits, and harms of different treatment options.
In addition to conducting his own studies, I'm sure he would be interested in collecting evidence from clinical trials and through systematic reviews of research studies.
A.T. Still would be a proponent of comparative effectiveness research because it requires the development, expansion, and use of a variety of data sources and methods, all in the effort to conduct timely and relevant research toward identifying new and improved clinical interventions.
He would like it because the knowledge gained from it is quickly usable by clinicians, patients, policymakers, and payers. And perhaps most importantly, he would support comparative effectiveness research because it empowers patients. He understood that patients could not make good decisions about their health if they didn't get good information about their choices.
Social Justice and Change
The fourth characteristic of A.T. Still that has great relevance to us today is his great dedication to social justice and change. To A.T. Still, the Kansas-Missouri border conflicts during the Civil War were up close and personal.
On the day confederate Colonel William Quantrill raided Lawrence, Kansas, and left 150 dead, A.T. Still saw smoke rising from the town. He grabbed his gun and hurried off to join the Kansas militia. A staunch abolitionist, A.T Still was willing to put his life on the line for his beliefs, serving as a surgeon during the war and eventually reaching rank of major.
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After the war, he thought about returning to medical school in Kansas City, although his prior experience in medical school was neither pleasant nor educational. A visit to Kansas City reinforced this experience—teachers were still stressing empirical medicine with little deviation and no innovation. A.T. Still expressed his strong opinions about the indiscriminate prescribing of dangerous drugs and tonics, but his concerns fell on physicians' deaf ears.
In addition to advocating for abolition and more responsible medical practices, A.T. Still also fought for civil rights and suffrage, showing compassion and generosity to the poor.
In 1892, he admitted 6 women to the first class at his School of Osteopathy, firmly believing they could do as well as men.
7 He also wanted to have African-Americans in the first class, but none applied and he felt bad about it.
7
He often took no pay or discounted his fee for patient care, believing that it was his duty to “help the needy, and deal justly with all.”
8(p5) He visited charity clinics. When parting, he would shake hands with patients, often leaving a bill or coin in their hands.
One time, after a patient remarked she would have to first find work before she could pay his $10 fee, Dr Still pulled a $10 bill out of his pocket, gave it to the woman and said, “The bill is paid, go home and be happy.”
2(p33) His son Henry wrote the following:
People came from great distances to see him, the wonderful faith cure healer. … It looked like an old-fashioned camp meeting, as everybody who was treated went off happy and shouting. … My father treated all classes of people who were not afraid to come to him. … The poor always got their treatment free, and if they did not have car fare or board they got it from my father, if he had it.4(p15)
These people spread the word about Dr Still's “never give up on the patient” attitude that helped him attain results other physicians could not.
Today, he would be pleased to see that this commitment to both the underserved and the enrollment of female and minority students remains a strong presence within the profession. More than 20% of DOs practice in a designated medically underserved area in the United States.
9 Among students, ethnic minorities accounted for more than 25% of student enrollment during the 2010-2011 academic year and women represented 47% during that same school year.
10
Dr Still organized a system that was a precursor to today's preventive and managed care programs. Patients would sign up for 3-times-per-week treatments for 1 month. The first examination was free, like a Medicare wellness visit; then, patients would pay by the month. Patients needed to refrain from alcohol and drugs and adhere to other rules, or they wouldn't be treated. Dr Still put into place a delivery system and payment structure that worked for the profession.
Today, I believe he would see the need, as we do, for newer models. He would tout patient-centered medical homes and applaud the profession's involvement in bringing more attention to it as well as to accountable care organizations. He would be disheartened to witness the pitfalls of the Sustainable Growth Rate formula and the impact it has on our practices and, most importantly, on our patients. And he would be among our staunchest advocates demanding its repeal.
Champion for Osteopathic Medicine
The last of the 5 characteristics of A.T. Still that would be very relevant today is that he would continue to be a champion for osteopathic medicine and, thereby, the patient.
Dr Still's passion for the profession was so strong, even its name evoked his conviction for it. When his son, Charles, asked what this new profession would be called, Dr Still replied, “osteopathy.” Charles objected, stating it wasn't a word that could be found in the dictionary. Dr Still simply answered, “I know it, but we are going to put it there.”
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In his day, Dr Still had to prove his treatments daily while carrying a heavy patient load so that he could pave the road for DOs to follow. When he “flung to the breeze the banner of osteopathy,”
1(p94-95) he challenged the medical establishment of his day, against the popular tide of mediocrity and resistance to change.
In addition to proving the benefits of osteopathy to his patients, he won over prominent individuals such as George Bernard Shaw, Buffalo Bill, Helen Keller, Theodore Roosevelt, and Mark Twain, who was instrumental in helping DOs gain legislative rights in New York State.
4(p23) Dr Still continually advocated for high standards within the profession.
Today, there is a movement toward making health care a high-reliability, zero-defect industry, and A.T. Still would want to have the profession leading the way toward that goal. If a student in his school did not make 90% in anatomy, the student did not work in the clinic, and the student failed. He understood that adherence to a high standard rewards the patient.
To the graduating class of 1894, Dr Still said, “You are indeed to be congratulated upon the splendid grades attained at the close of the recent examinations—for an average of 98.7 per cent for the entire session is not to be excelled or even equaled by any institution of learning of whatever nature on the American continent.”
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When Dr Still sent his newly graduated DOs out to develop their own practices, he urged them to have confidence and to advocate the merits of osteopathy to legislators. This kind of grassroots advocacy is now a part of our heritage, gaining for us our present-day stature and continuing among the osteopathic family today.
Through the likes of our Grassroots Osteopathic Advocacy Link, or GOAL network, and DO Day on the Hill, we advocate for continued graduate medical education funding, the repeal of the Sustainable Growth Rate formula, and other issues important to us and our patients.
In my role as chair of the AOA Bureau of Federal Health Programs, I see how active the osteopathic family is when it comes to advocacy. At this year's DO Day, more than 1100 DOs, osteopathic medical students, and supporters took time out of their busy schedules to travel to Washington, DC, to participate in the event.
12 Membership in GOAL continues to increase every year, standing at nearly 18,000 today (Leann Fox, e-mail communication, October 16, 2012).
A. T. Still would have supported these programs just as he supported the AOA when it was founded in 1897. It was no secret that he wanted the AOA to set the standards for the schools. He founded the entity that served as the precursor to the AOA Commission on Osteopathic College Accreditation. He encouraged DOs to record their observations and conclusions, and their successes and difficulties, in the AOA's journal for the benefit of others. He saw these organizations and activities as essential toward continual learning—not just among medical students, but lifelong learning among all in the profession.
He told one of his students,
Don't hesitate to trust your own judgment and reason, and remember you are just as apt to make valuable discoveries as any one else. … Go to a small town, live on cornbread and sow belly if you have to, but sleep with your anatomy [book] under your pillow and don't forget that you are supposed to have a brain inside your skull.13(p248)
Not only was Dr Still adamant about continued learning, he persisted when it came to proving his philosophy, despite many trials and tribulations.
An itinerant physician living in the wilderness of the Midwest, he never stopped observing, learning, and advancing his theory of osteopathic principles. His practice-based research with clinical observation—learning through patient outcomes—crystallized the practice of osteopathic medicine.
The Spirit Lives on
It remains for the osteopathic medical profession to determine what needs to be done in the future to preserve our role in providing distinct, patient-centered quality care. I see the potential for growth, but we must take Dr Still's advice, that we strap on enthusiasm and “Dig On.”
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We must constantly self-examine to assure that we are meeting the societal needs that osteopathic medicine was created to meet. To meet these needs, we must continue to focus on education as the lifeblood of our profession—education within our schools, through internships and residencies and through lifelong learning. We must continue to emphasize the uniqueness of osteopathic medicine and how it can improve patient care.
Many of us believe that while DOs and MDs are similar in many ways, there are some qualities that make us different and, in some respects, better. These qualities not only help us to provide holistic and personal care incorporating osteopathic principles and practices, but they also enable us to maintain an independent professional existence.
Our challenges are to provide convincing scientific evidence that our distinctive characteristics do indeed make a positive impact in patient care and to have this impact recognized by federal and state government entities, health insurers, and the public. Achieving these aims could begin a new chapter in the profession's history. We can make the leap from being regarded as a “medical minority” to becoming broadly recognized as a special and esteemed group of health care providers.
As Norman Gevitz, PhD, stated in his book,
The DOs: Osteopathic Medicine in America,
Osteopathic medicine was founded … on the idea that a new type of practitioner—the DO—could make a significant difference and improvement in health care. … The future of osteopathic medicine may ultimately rest in our own hands—and how we use them.14(p190-191)
Over the years, I've met many DOs who exemplify how osteopathic medicine should be practiced. They volunteer in DOCARE clinics, participate in AOA-CAP, and lend their voices to grassroots advocacy. They are active in social causes. They rely on osteopathic principles and practice, including the use of osteopathic manipulative treatment, participate in comparative effectiveness research, and follow the examples set by A.T. Still in other ways. For example, President Levine's theme for his 2011-2012 presidential year, “Thinking Osteopathically,” inspired us all to embrace that philosophy.
If you took these and other outstanding qualities our DOs have and created a composite person possessing these traits, that's what A.T. Still would be like if he were alive today.
Dr Still said,
I do not want to go back to God with less knowledge than when I was born. I want my footprint to make an impress on the field of reason. I have no desire to be a cat, which walks so lightly that it never creates a disturbance. I want my footprints to be plainly seen by all readers.1(p251)
Today, Dr Still's wishes have surely been granted, as it's clear that we're still following in his footprints nearly 140 years after he founded our profession. A.T. Still remains with us today because his qualities are instilled within all of us.
This article is based on the A.T. Still Memorial Lecture, which Dr Thomas delivered on July 21, 2012, to the House of Delegates during the 2012 Annual Business Meeting of the American Osteopathic Association, which was held in Chicago, Illinois.
Financial Disclosures: None reported.
References
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