Although DOs practice in all 50 states and in every medical specialty,
6 the osteopathic medical profession is officially separate from the allopathic medical (ie, MD) profession. The distinction is based on the additional 200 hours of osteopathic coursework required of osteopathic medical students
7 with an otherwise complete overlap in the biomedical science and clinical curriculum shared by DO and MD programs. In fighting to convey osteopathic medicine as separate from allopathic medicine, DOs have not fully assimilated into the MD community.
Parallel systems of domestic licensure reinforce this individualism. Whereas MD schools are accredited by the Liaison Committee on Medical Education and their graduates are represented by the American Medical Association, osteopathic institutions are recognized by the AOA Commission on Osteopathic College Accreditation and the AOA is the central decision-making body for the osteopathic medical profession. However, both the osteopathic and allopathic professions agreed to a single accreditation system under the Accreditation Council for Graduate Medical Education.
8
The global spread of osteopathic medicine is promoted by several advocacy groups. Since 1986, the AOA Division of International Affairs (formerly combined into the Division of State Government and International Affairs) has been the established authority on negotiating international licensure. The AOA also charged the Bureau of International Osteopathic Medicine to “promote the highest standards of osteopathic medical education and practice throughout the world.”
9 In 2004, the Osteopathic International Alliance was formed to represent the global osteopathic profession including DOs and foreign-trained osteopaths.
10 The AOA works to maximize the scope of practice for DOs in other countries while recognizing the sovereignty of health care delivery systems in other nations.
9
In 2013, the AOA observed the following:
“[A] few countries have consistently refused to grant DOs full practice rights, often permitting them to perform only manipulation and sometimes refusing to grant them any type of practice. Other countries, however, are simply not educated on the qualifications of DOs and their equivalence in education, training and practice to MDs.”5
We are faced with a dual challenge of distinguishing our profession and validating its purpose. Foreign health officials tend to follow 1 of 3 heuristics when forming an opinion of osteopathic medicine. They may be (1) unacquainted with osteopathic medicine, (2) aware of osteopathic medicine only as a form of complementary manual medicine, or (3) aware of osteopathic medicine as being comparable to allopathic medicine. The AOA's goal is to shift health leaders to the third understanding by demonstrating that DOs have the same medical privileges as and hold equivalent jobs to MDs in the US health care system while still promoting the principles unique to the osteopathic medical profession.
9
Foreign leaders have historically assumed a very limited scope of practice (ie, manipulation) for osteopathic medicine,
11 and this misconception can be traced back to the first decades of osteopathic medicine. During the lifetime of Andrew Taylor Still, MD, DO, manipulation essentially was the only treatment taught to graduates from the 1890s to 1920s. Recalling his famous final plea, “Keep it pure, boys,”
12 there is clear evidence of Still's intention to preserve osteopathy as a separate entity from mainstream medicine.
In the decades to come, osteopathy evolved on 2 separate paths—1 American and 1 international. The first to spread osteopathy abroad was John Martin Littlejohn, a British citizen who was trained in Kirksville, Missouri, by Still in 1898. After a prominent career in the United States, Littlejohn returned to the United Kingdom and established the British School of Osteopathy in 1917.
13 When the AOA House of Delegates adopted
materia medica into education and practice in the United States in 1929, the British School of Osteopathy did not.
13 To this day, osteopaths graduate and practice in the United Kingdom and Europe and perform medical services limited to manipulation and some primary care coordination. When DOs sought practice rights in the United Kingdom, it was presumed that the degree was more manual than medical.
9 This false impression has seriously hindered DO practice in Europe, and it persists despite efforts by the World Health Organization and the Osteopathic International Alliance to outline definitions of osteopathic education levels.
14 Although DOs gained full practice rights in the United Kingdom in 2005 and under European legislation,
9 some European countries including France, Norway, and Ireland still do not officially recognize osteopathic medicine in national laws.
5
Outside of Europe and North America, the problem is more often that health care leaders are completely unacquainted with osteopathic medicine. In many developing nations without DO licensure, there have been numerous accounts of favorable reception to medical service trips. Medical practice regulations are typically softened for service trips because the providers are usually temporary volunteers. DOCARE International, a non-profit charitable organization that hosts service trips, has been in existence for 50 years, active primarily in the Caribbean, Africa, South America, and Central America.
13 Despite decades of visibility, few of the countries that have been visited have actually allowed DOs to practice permanently.
3