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