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Special Communication  |   June 2014
From “Doctor of Osteopathy” to “Doctor of Osteopathic Medicine”: A Title Change in the Push for Equality
Norman Gevitz, PhD
Author Notes
  • Address correspondence to Norman Gevitz, PhD, Senior Vice President, Academic Affairs, A.T. Still University, 800 W Jefferson St, Kirksville, MO 63501-1443. E-mail: ngevitz@atsu.edu  
Article Information
Medical Education / Being a DO
Special Communication   |   June 2014
From “Doctor of Osteopathy” to “Doctor of Osteopathic Medicine”: A Title Change in the Push for Equality
The Journal of the American Osteopathic Association, June 2014, Vol. 114, 486-497. doi:https://doi.org/10.7556/jaoa.2014.099
The Journal of the American Osteopathic Association, June 2014, Vol. 114, 486-497. doi:https://doi.org/10.7556/jaoa.2014.099
Abstract

Nationally, the California merger created great solidarity among osteopathic members of state and national osteopathic associations. They rebuffed further efforts at amalgamation and championed the continuation of the DO degree. Even after the American Medical Association (AMA) opened its doors to DOs to join local and state medical associations as well as the AMA itself and gave its blessing to them entering allopathic residency programs and becoming MD board certified, the DOs stood fast for their independence. Yet some across the country wanted to become known as MDs. A few osteopathic physicians even went to federal court to claim—unsuccessfully—that state medical boards' refusal to license them or allow them to identify themselves as MDs violated their constitutional rights under the 1st and 14th Amendments. In the mid-1990s, the American Osteopathic Association (AOA) gave individual osteopathic medical colleges the option of indicating on their diplomas that the DO degree signified “Doctor of Osteopathic Medicine” rather than “Doctor of Osteopathy,” a change that paralleled previous AOA policy changes regarding appropriate professional language. Nevertheless, some DOs and particularly a sizable number of osteopathic medical students continued to write of their desire for a change in the degree osteopathic medical colleges awarded. However, in July 2008 the AOA House of Delegates unanimously reaffirmed its commitment to continuing the traditional DO degree.

The title of Time magazine's story read “Dr. Osteopath, MD,” and the writer, like many other external observers of the California merger and its after-math, thought it probable that osteopathy would soon merge into the medical mainstream.1 Indeed, medical reform movements like homeopathy, Thomsonianism, hydropathy, eclecticism, and physio-medicalism, which produced “physicians and surgeons,” have come and gone. Their life cycle followed a similar pattern: They emerged in a time of therapeutic crisis and uncertainty, their formative period was marked by a broadening of what initially were narrow ideas, and their decline occurred when whatever distinctive approach they had to patient treatment had been either coopted by “mainstream” practitioners or left to wither. These movements died from within because their practitioners lost the will to fight and allowed themselves to be absorbed into the mainstream.2 
The osteopathic medical profession, however, did not die, much to the surprise of outside observers and particularly to the leaders of the American Medical Association (AMA). The medical establishment believed that after the events in California in the early 1960s, other state mergers would quickly follow. They believed that the American Osteopathic Association (AOA)—whatever its official position on remaining independent—would soon become irrelevant. Sapped of members, it would no longer effectively represent osteopathic physicians—the great majority of whom, they believed, would be all too eager to trade their odd and poorly understood DO degree for the universally recognized MD designation.2 
Instead, the California merger created a high degree of solidarity within the membership of the national and state osteopathic medical societies, which together forged a united front against the AMA's efforts to destroy the profession. Part of this unity reflected a shared antipathy for the AMA and its leaders' categorization of what they privately and sometimes publically called the “osteopathic problem.” Furthermore, many DOs could not help but notice that the AMA, in its official publications, used the term physicians to refer to MDs to differentiate them from osteopaths.3 
In 1961, the AMA Judicial Council was again asked by leadership to rule on “voluntary” relations of its members with “osteopaths.” The Council declared, “there cannot be two sciences of medicine or two different yet equally valid systems of medical practice.” As such the test should now be, “Does the individual doctor of osteopathy practice osteopathy or does he in fact practice a method of healing founded on a scientific basis?” The Council continued, “If he practices osteopathy, he practices a cult system of healing.” As to what constitutes the “principles of scientific medicine,” the Council declared, they are those principles “adhered to by members of the American Medical Association.”4(p775) In response, the AOA Board of Trustees acknowledged that while there may well be one science of medicine, “It is unrealistic to hold that the practice of medicine is pure science. It is equally unrealistic to insist that only one system of medical practice, that system officially approved by a political body, can be valid.”5(p3) 
Encouraged by the Judicial Council's ruling that the issue of “cultism” and “ethical” interprofessional association with “osteopaths” was to be decided locally, several state medical societies sought to meet with their state osteopathic medical society counterparts for the expressed purpose of facilitating a merger. Osteopathic groups were quite willing to meet with the MDs, but insisted they would not do so until the state medical associations officially removed the cultist label to describe them and their practice of medicine. However, when MD associations did so, they found that while their osteopathic counterparts wanted to talk about many things—joint practices, referrals, malpractice insurance, and barriers to getting hospital privileges—they had no interest in discussing a merger.6 While there were certainly DOs in the field who were interested in obtaining MD degrees, most of them were either not members of or not active in their state associations, thus they had no organizational voice with which to speak or to negotiate. 
The one exception occurred in the state of Washington. In 1962, a faction of DOs established their own group. They negotiated directly with the state medical association, which encouraged them to create a “paper medical school” to award “academic” medical degrees, which the state legislature would make valid for the purpose of licensure within Washington. The Washington Board of Medical Examiners, after getting the blessing of leaders of both the AMA and the Association of American Medical Colleges (AAMC) to the plan, voted to recognize this paper institution as a legitimate medical school. However, all was for naught as the Washington State Supreme Court declared in a unanimous ruling that this action was “subterfuge, was palpably arbitrary and capricious, and it was void in all respects.”7-9,10(p1) 
In California, the merger between DOs and MDs had worked for some ex-DOs but not for others. The great majority were clearly happy with having the MD initials behind their names. However, many osteopathic specialists were negatively impacted. Their AOA board certification was not accepted by what became known by the ex-DOs as “congenital” MD hospitals. Furthermore, the ex-DO general practitioners were given admitting privileges to these institutions and thus were now more likely to refer patients to board-certified MD specialists. This caused financial problems for ex-DO specialists as well as for former osteopathic hospitals with now diminishing patient censuses.2,11-15 
When those practitioners who had exchanged their “professional” DO degree for an “academic” MD degree tried to use their new diploma for the purpose of licensure outside of California, they discovered that their piece of parchment was worthless. State medical or composite licensing boards would not examine these candidates because they were not graduates of an accredited MD-granting school. Some ex-DOs brought this matter to state courts, but the latter invariably sided with their boards of licensure and registration.2 
As the AMA's efforts to replicate California-style mergers elsewhere stalled, national and state osteopathic lobbying efforts to achieve legal equality ramped up and succeeded in large part as a result of what happened in California. For decades, many state legislatures refused to grant DOs the same rights and privileges as MDs because they believed the AMA and the state medical associations when they argued that osteopathic medical education was vastly inferior. However, DOs dramatically improved their standards, and their performance on basic science examinations as well as medical and composite board examinations greatly improved. Now, with California DOs becoming licensed MDs by merely paying a nominal fee of $65 with no further educational qualification necessary, the MDs' long-standing argument was insupportable.2 
Between 1960 and 1969, 10 states passed unlimited practice acts for DOs, bringing the total number of states and the District of Columbia who had done so to 47.16 On the federal level, in 1963, the US Civil Service Commission, citing the California merger agreement, announced that for its purposes the MD and DO were henceforth to be deemed equivalent degrees.17 In 1966, the AOA was accepted as an accrediting agency over osteopathic hospitals for participation in the newly passed Medicare program;18 in that same year, after a 5-decade struggle, DOs were finally permitted to serve as physicians and surgeons in the military medical corps.19 Thus, DOs were increasingly obtaining on their own some of the benefits that the AMA and state medical associations argued could only be achieved through amalgamation. 
In reaction, the AMA crafted additional policies to break apart the osteopathic profession. In 1967, the AMA Board of Trustees began negotiations with all DO schools to have them convert to MD-granting institutions. In addition, the AMA Council of Medical Education was authorized to establish a process by which students already enrolled in osteopathic medical colleges would be directly encouraged to transfer to MD schools and receive full academic credit for courses completed.20,21 In the judgment of the AOA leaders, the AMA was now on record as supporting the raiding of osteopathic medical colleges and stealing their medical students.22 In 1968, the AMA House of Delegates voted to encourage county and state medical associations to accept “qualified osteopaths” as members so they could join the AMA. In addition, the House urged all medical specialty certifying boards to change their rules to allow for board certification of DOs. Once each board did so, DOs would be allowed to enter allopathic residency programs in that specialty.2,23,24 
These efforts did not produce the results the AMA expected. Few DO students transferred, all but a single osteopathic medical college totally rebuffed “conversion,” and the leaders of the college who entertained such thoughts were soon forced to resign. Through the mid-1970s, comparatively few DOs became AMA members, though more joined local medical societies. Although 12% of 1970 osteopathic graduates went directly into allopathic graduate medical education programs, only 3% followed this route in 1975 and 1976.2 
New Colleges of Osteopathic Medicine
With more than 2000 California DOs (or approximately 20% of all practitioners nationally) lost to the profession, state osteopathic medical associations saw the desirability of replenishing and then greatly expanding their ranks by establishing new osteopathic medical schools. The first sustained effort came in Michigan, which now had more DOs than any other state. In 1963, the Michigan Association of Osteopathic Physicians and Surgeons' House of Delegates unanimously supported the development of a new school, and in 1965, a charter was obtained and architects were hired to build the college in Pontiac.25 
Many proponents argued it should be a state-supported school, and in their efforts to gain the backing of legislators and the public, they dispensed with the term osteopathy in the title and provisionally named it the Michigan College of Osteopathic Medicine following the example of the Des Moines college, which changed its name to the College of Osteopathic Medicine in 1958. The promoters of the new college believed that the incorporation of the word medicine would make it easier for them to convince lawmakers that DO educators taught the breadth of pharmacologic knowledge and that DOs were fully trained “physicians and surgeons.” By 1971, all DO-granting colleges had incorporated the word medicine in their official names.16 
Michigan DOs battled a well-funded Michigan State Medical Society campaign to deny state support. In 1966, the president of the Michigan State Medical Society testified before a legislative committee that a state-financed medical school “just for osteopaths” was absurd, since at least 75% of Michigan DOs favored merger. This testimony stalled plans until DOs in the field could be surveyed as to their actual desires. To the question, “Do you believe amalgamation of allopathy and osteopathy would be in the best interest of the state?” 87.3% of DO respondents said “no.” On the question, “Should the state give state support to the osteopathic school?” 93.3% of DO respondents said “yes.” Despite these survey results, the state medical society used its influence to postpone a definitive vote.2(p151),26(p1) Finally in 1969, osteopathic advocates overcame opposition and saw their bill to create a state osteopathic medical school—the first ever—pass both houses and secure the governor's signature. The school that had already opened in Pontiac was moved in 1970 to the campus of Michigan State University. It would exist side by side with the MD-granting College of Human Medicine—thus also making MSU-COM the first-ever university-based osteopathic medical school.27,28 
On the heels of the Michigan school was the Texas school, which started inauspiciously in part in an old bowling alley as a private institution. By 1971 the Texas College of Osteopathic Medicine was receiving state aid, and by 1975 it became a public institution under the control of the University of North Texas State Board of Regents.29 Four other new osteopathic medical schools opened their doors between 1974 and 1977 that became state supported; 1 was a free-standing institution (West Virginia School of Osteopathic Medicine), and the other 3 were components of large state institutions (Oklahoma State University, Ohio University, and the University of Medicine and Dentistry of New Jersey).2 In 1977, a wave of private osteopathic medical schools began with the New York College of Osteopathic Medicine. In 1963, there were 5 osteopathic medical colleges, and by 1979, there were 14. During that same period, enrollment in osteopathic medical schools tripled from approximately 1400 to 4200, and the number of new graduates rose from 362 to 1004.30 
The opening of the College of Osteopathic Medicine of the Pacific in 1978 signaled a physical as well as symbolic renewal in California.2,13 In 1974, the California Supreme Court ruled that the section of the merger agreement that outlawed any new licensing of DOs in the state was unconstitutional. Osteopathic physicians across the country who had supported those California DOs who had fought the long battle for the restoration of their rights and privileges filled out paperwork, took examinations if necessary, and became licensed in California. They did so not to practice in California but to show professional solidarity with their osteopathic brethren.2,13,31 
By 1973, the number of DOs in the nation surpassed the total before the merger, and by the end of the 1980s, the number of practicing DOs in California exceeded the number of practicing ex-DOs. Osteopathic medicine was moving forward as an independent medical profession irrespective of the vocal opposition and policies of the AMA and various state medical associations across the country.2 
Social Invisibility and Status Inconsistency
Organizationally, the osteopathic medical profession was in lock-step moving forward; however, a substantial minority of DOs and osteopathic medical students were dissatisfied. They complained that comparatively few in the public knew what a DO was, what a ‘Doctor of Osteopathy’ degree entailed in terms of a course of study, what the degree represented, or that DOs were trained as full-fledged physicians and surgeons. Others believed that the AOA official publications gave a biased or one-sided account of the effects of the California merger or were not objective in analyzing various AMA policy initiatives. George W. Northup, AOA editor in chief from 1961 to 1987, had served as AOA president when the California merger was unfolding. Northup made it absolutely clear in his editorials that he was staunchly committed to furthering a “separate but equal” medical profession and was unwilling to open the pages of AOA publications to those DOs who either complained about their DO degree or sought further state amalgamations.32 
This editorial stance provided an opportunity for the independent journal The Osteopathic Physician (OP), edited by J. Dudley Chapman, a specialist in obstetrics and gynecology, to make inroads in osteopathic readership.33 Chapman's magazine published various—including heretical—viewpoints and encouraged meaningful debate. During the 1970s, the OP often surveyed DOs in the field and students in the osteopathic medical schools as to what they thought about AOA policies and their social status and identity. These surveys demonstrated that although the profession was united with respect to maintaining its independence, there was great variability within the ranks as to the status of osteopathic medicine and what degree or degrees its schools should offer. 
In April 1971, under the title, “Should our schools alter their DO degree policy?” the OP published the results of a questionnaire sent to DOs randomly selected in 9 states and military installations. Of 497 questionnaires mailed out, 302 (60.8%) were returned. The DOs in the field were asked to answer “yes” or “no” to 4 questions and were encouraged to write narrative responses supporting their choices. The survey's first question was, “Do you favor the change in our schools from conferring the DO degree to the granting of a DO-MD degree?” Of those DOs who answered this question, a substantial minority—41%—said “yes.” The second query read, “Do you favor the complete change in degree programs by our schools to allow the granting of a degree by the choice of the student—ie, a degree of DO to one student and an MD to another according to his choice?” This proposal drew scant support. Of those DOs who answered this question, less than 15% answered affirmatively. The third question read, “Do you prefer no change in degree designation and that all schools grant the degree DO?” Fifty-six percent of those answering said “yes.” On the fourth query, “Do you prefer we abandon all current programs in our schools and acquire approval to grant the MD only?” 25% answering replied “yes.”34 
Although the phrasing of some of these questions was not optimal, the selected published commentary demonstrated that DOs were conflicted over the issue of identity, public awareness, and distinctiveness. One physician who opposed the awarding of a DO-MD degree nevertheless noted of the 2 types of medical schools, “there is no difference in instruction on basic science and clinical courses. We use the standard MD textbooks…The practice of medicine—DO vs. MD—is essentially identical.”34(p20) A DO who thought the profession was going “medical” argued,
 

We have DOs who don't give a treatment year in and year out. In my practice, I continually hear patients say that it is almost impossible to find a manipulator. There are a few real manipulators in our profession—orphans all. Why not call us what we are—medical physicians—and confer the MD degree?34(p21)

Some DOs who returned the questionnaire but did not check boxes thought the issue of what degree osteopathic medical schools issue was unimportant. One physician observed that…
 

…the vast majority of DOs are not talking about their degree either positively or negatively. They are simply too busy taking care of a practice which is extremely active, time-consuming, and in most cases, satisfying.34(p21)

 
In January 1972, the OP published the answers of a separate survey asking the same questions to randomly selected students of 6 osteopathic medical schools. The response rate was higher, as was the number of commentaries. Of those answering each question, 68% favored the schools awarding a DO-MD degree, 40% favored students choosing either a DO or an MD degree, 22% favored no change in degree designation, and 25% favored granting the MD degree solely. Most students believed that the DO degree itself was not the problem per se. It was public misunderstanding. If the MD degree was attached to the traditional designation, the problem would significantly diminish and they would enter the workforce recognized as true physicians and surgeons. Nevertheless, more students in the poll favored osteopathic medical colleges granting MD rather than DO as the sole degree to be awarded, and these data did not fail to trouble, if not alarm, AOA leaders.35 
Advocates of the DO, MD, and DO-MD degrees appear to have been in basic agreement that osteopathic physicians were “socially invisible.” The author of the OP articles, Jack Leahy, noted, “Students as well as doctors feel that the osteopathic profession needs a vast public relations effort to educate the man-in-the-street about the DO's role in medicine.”35(p50) One student observed, “The AOA has done a fine job in working for practice rights. Now more emphasis should be placed into educating the public as to who and what we are.”35(p51) Other students were less complimentary. One college senior declared, “It is a shame that AOA public relations has not done much to change our public image. The AMA has done more to promote a public acceptance of DOs.”35(p50) More bitterly, one student declared, “If the AOA wants to take in our money, but does not put out efforts comparable to the AMA's public relations department, then I'm not getting my money's worth.”35(p50) 
The issue of poor perception of the profession was highlighted in the wide distribution of a 1974 study conducted by researchers at the University of Chicago who asked MDs, hospital patients, and graduate students of their school of business to rate the prestige of various health care professionals. Prestige was defined as “how much do you look up to each occupation?” Of 41 occupational titles, both the MDs and the allopathic hospital patients ranked the category “osteopath” 37th.36 Chapman noted, “The only ones lower than us (in descending order) were practical nurses, nurses' aides, podiatrists, and, at the end, chiropractors. In short, our image is miserable.”37(p23) 
Chapman lashed out at both those who favored the retention of the DO degree and those who favored the MD. With respect to the first group, the…
 

…fundamentalists would say that, as long as we are busy, nuts to them. These loyalists measure success by dollars and political recognition. They say, “what more do you want? We have full rights in all 50 states and the federal government.”

As to the second faction, Chapman opined,
 

There are others among us that would say “why worry, let's get a merger, an MD degree” or some such thing. Those radicals forget that a membership in a club does not mean you are respected. These mergerists forget we are not loved, admired, or respected by the medical world in general.37(p23)

 
In the January 1975 issue of the OP, Chapman declared his degree preference:
 

The new year reminds us again of our deplorable image as a profession. The poor “DO” degree is still a public enigma, a misunderstanding, and misnomer. We have “Osteopathic Medical Societies” and “Colleges of Osteopathic Medicine”; why then can we not overcome the logorrhea of our leaders and adopt the DO-MD title?

Chapman gave 4 reasons for the change. “It would solve the street corner problem. It would please the ‘country club set’ among us and be in keeping with the new names for our state and college titles, as well as our education and manner of practice.” He added, “It would also bug the hell out of the bigot MDs and the allopathic politicos who cut us down daily.”38(p23) 
Enter the Courts
Neither Northup nor other leaders of the AOA thought it advisable to enter into editorial warfare with Chapman. The AOA's leaders had no interest in giving greater attention to him or the issues he highlighted or championed. Their interest lay in uniting the profession rather than identifying and magnifying small fractures that could widen and weaken their overall resolve or ability to fight AMA and state society policies, which were to them of a more pressing concern. Nevertheless, the AOA and state osteopathic medical associations became concerned when a handful of DOs went to court challenging the decisions of licensing boards to deny them the opportunity of identifying themselves or being licensed as MDs. 
Richard Oliver, a 1960 graduate of the Kansas City osteopathic medical school, was one of the first DOs to serve in the military medical corps. He practiced medicine in Texas and New Jersey before entering and completing an allopathic residency program in obstetrics and gynecology in Georgia. In 1971, he took and passed an examination administered by the composite medical board of that state and was issued a “license to practice medicine.” He moved to a rural part of the state to practice as an obstetrician-gynecologist and used the designation “MD” rather than “DO” after his name on his stationary, in prescription blanks, and in public listings. Within months, the Composite Medical Board took action and informed Oliver that by not identifying himself by the diploma of the school from which he graduated, he was violating the law. He was ordered to cease and desist employing the MD designation to identify himself. Oliver immediately filed a lawsuit in federal court claiming that the Georgia statutes and Board rules in question deprived him of his constitutional rights of freedom of speech, due process, and equal protection under the law. The case was decided in July 1973.39 
The District Court seriously considered 2 of Oliver's arguments based on the Equal Protection Clause of the 14th Amendment. First, Oliver maintained that “there is no rational basis for the differentiation between D.O.'s and M.D.'s in that the two terms are functional equivalents.” His second argument was that…
 

…the statute is unconstitutionally applied to him in that foreign doctors, many of whom do not have the degree of Doctor of Medicine, or M.D., are nonetheless designated ‘M.D.’ on their licenses and are permitted to use the initials ‘M.D.’ in all their professional correspondence and listings.39

On the first, and what in time would be the most important precedent, the Court found “there are meaningful distinctions between D.O.'s and M.D.'s,” specifically citing osteopathic manipulative “therapy.” It found the state of Georgia's role in “the recognition and perpetuation of the classifications” withstood 14th Amendment scrutiny and that the existing “statutory scheme” does “bear a reasonable relation to a legitimate state purpose.” In concluding its analysis of Oliver's first argument, the Court declared,
 

In sum, while osteopaths and allopaths are both fully licensed and competent physicians, there are differences between them which make it rational for the State to require physicians to hold themselves out to the public and to be licensed with the letters of the degree which they have been awarded.

Speaking directly to Oliver's complaint that few people knew what DOs were or the breadth and quality of their training, the Court noted, “we believe that his remedy lies chiefly in a concerted effort by him and other osteopaths to educate the public.”39 
The court, however, sided with Oliver in the second aspect of his 14th Amendment “equal protection” argument. The court noted that the state arbitrarily differentiated between Oliver and licensed foreign-trained physicians who did not graduate with the MD degree “in its original language or as translated” or who instead of a degree held a certificate giving them “a license to practice medicine” in their home country. The Composite Board had not satisfactorily explained why these individuals were allowed to identify themselves as MDs. The District Court concluded that the state failed to show…
 

…any reasonable basis for its differing treatment of foreign-trained physicians and D.O.'s. The two are similarly situated; without a rational basis for the distinction, the State's differing treatment of foreign-trained physicians and D.O.'s is arbitrary and in violation of the Equal Protection Clause.39

Although the Court sided with Oliver and allowed him to use the MD designation for the time being, the ruling provided the Composite Board and the Georgia legislature with a simple and long-term solution that they subsequently employed. Through statute and rules they satisfactorily addressed the issue of why international medical graduates and not DOs were legally entitled to use and display the MD designation. Oliver's victory was thus short-lived.39 
The year after the Oliver decision, the AMA House of Delegates debated “Report D,” a policy proposal that called on state medical societies to have lawmakers introduce legislation at the state level to allow DOs to use the initials “MD” after their names. The AMA report carefully noted that no DO would actually “receive” the MD degree and that the initials would be an “occupational” designation. However, under the plan, any DO availing him- or herself of this MD title would no longer be permitted to use the DO title. The House of Delegates sent the report to a reference committee, which had serious concerns that this suggested course of action would undermine the legitimacy of the MD degree and recommended that it not be passed. Nevertheless, some in the House continued to enthusiastically endorse the report, arguing that the AMA owed it to DOs who took part in AMA training programs. However, in the end the resolution supporting Report D was narrowly defeated.40,41 
In subsequent years, federal courts of appeal handed down 3 decisions in cases originating in the states of Texas (1982),42 New Jersey (1982),43 and California (1983)44 in which osteopathic medical graduates, all of whom had completed allopathic residency programs and were allopathically board certified, sued to be licensed as or permitted to advertise themselves as MDs.45 Attorneys for these practitioners employed variations of the same constitutional arguments as found in Oliver's original lawsuit and challenged as discriminatory particular state statutes and regulatory board rules. Unlike the Oliver decision, appellants lost on each and every constitutional argument. Each federal court noted that there is a different philosophical basis underlying osteopathic medicine, that DOs, unlike MDs, mandatorily received instruction in their schools in manipulative medicine and that these differences were legally important. It did not matter to the courts whether individual DOs employed manipulative treatment or not. Each court also concluded that the state was not discriminating against DOs and that rules created to ensure that physicians employ the degree designation on their license passed what is called the “rational relation” test. Finally, all 3 courts, unlike in the Oliver decision, held that the practice of regulatory boards designating international medical graduates as “MDs” on their license and not allowing DOs to do so was “rationally related” to the purpose of allowing the public to make an informed choice among physicians. The 3rd Circuit Court in Eatough v Albano43—citing the 5th Circuit Court in Maceluch v Wysong42—noted,
 

Since there are no [foreign medical graduates] eligible to practice in New Jersey that come from a school identified with osteopathy, rather than allopathy, the distinction between MDs and DOs is rational in light of the previously mentioned purpose to inform patients of those physicians with osteopathic training.

In June 1982, the US Supreme Court let stand the 3rd Circuit Court decision in Eatough v Albano, and after a 1983 California case (Brandwein v California Board of Osteopathic Examiners) was decided in favor of the defendant, there were no further legal appeals by DOs to force regulatory bodies to license or permit them to advertise themselves as MDs solely on the basis of their possession of a DO diploma.46,47 In more recent years, medical boards have taken legal action against some DOs who possess foreign medical degrees and advertise themselves as MDs when this credential does not constitute the basis upon which they have been licensed in the United States as physicians and surgeons. 
A New Title or a New Degree
In 1960, the AOA House of Delegates voted that the AOA “both officially in publications and individually on a conversational basis, use the terms osteopathic medicine in place of the word osteopathy and osteopathic physician and surgeon in place of osteopath; the words osteopathy and osteopath being reserved for historical, sentimental, and informal discussions only.”48(p884) Indeed, since that resolution was adopted, The Journal of the American Osteopathic Association and The DO magazine as well as other AOA publications have consistently used the updated terminology to describe the profession and its physicians. Nevertheless, the degree awarded by osteopathic medical colleges continued to read “Doctor of Osteopathy.” 
Many DOs thought this continuation of the degree title was inconsistent with the profession's goal to get the public to understand that DOs were fully trained and qualified physicians and surgeons and not limited practitioners. Others, particularly members of the American Academy of Osteopathy, were opposed to changing the degree in any form. As members of this group were primarily or exclusively dedicated to employing their distinctive manipulative approach, they viewed the terms osteopathy and osteopath as perfectly appropriate in informing their patients and colleagues who they were and what they did. Although the members of the American Academy of Osteopathy represented a small fraction of the membership of the AOA, they were joined by prominent DOs whose practices were more broad based. These physicians were not comfortable with changing the title of the degree for “historical” or “sentimental” reasons. Although the title had changed before, in 1900 from “Diplomate in Osteopathy” to “Doctor of Osteopathy,” many DOs continued to believe that the term Doctor of Osteopathy was symbolic and vital in tying different generations of osteopathic physicians together. 
However, at the AOA House of Delegates' 1993 meeting, the Maine delegation submitted a resolution that would leave the initials “DO” intact but would permit each accredited osteopathic medical school to change the DO designation on the diploma to read “Doctor of Osteopathic Medicine.” This resolution met with little resistance and the next year came before the AOA's Bureau of Professional Education, which approved the measure and forwarded it to the Board of Trustees.49 Some colleges, as a result of this new policy option, immediately changed the wording of the degree, while others kept “Osteopathy” in the title. The long-time dean of the New York college—himself a well-known physician who practiced osteopathic manipulative medicine—resisted any change of language. It was not until he retired that a new dean endorsed the new terminology—effective for the class of 2003. 
Still, some members of each new class of osteopathic medical students were not satisfied with the “Doctor of Osteopathic Medicine” diploma and persisted in lobbying for a change in the letters of the degree. New social media outlets were used to both promote thoughtful dialog and stimulate intemperate rants as to the advisability of maintaining the DO letters as representing the osteopathic physician and surgeon. In 2006, a brief remark by a reader of the “AOA Daily Report” blog began a 2-year online and in-print discussion on the topic. Rather than ignoring or burying the concerns of some dissatisfied students and physicians, AOA leaders encouraged them—as well as defenders of the DO degree—to publically express themselves and argue for their point of view in official AOA publications. Hundreds of comments either were posted online or made their way into traditional print outlets.50 
In a balanced article titled “Letter Perfect?: Can a New Degree Lead to More Respect, Recognition for DOs?” published in The DO in February 2008, AOA Special Correspondent Barbara Greenwald concisely identified the arguments behind a plethora of degree designations for graduates of osteopathic medical schools—MDO, DOM, OMD, DO-MD, MD-DO, as well as the rationale for maintaining the current DO designation. Proponents of a new degree in place of or added to the DO designation noted the comparative lack of public awareness of the osteopathic medical profession and its traditional degree and maintained they were motivated by the perceived or actual negative social and economic consequences that might exist with respect to their practice or personal lives. Those who defended the DO degree argued that either they suffered no significant discrimination or economic loss as a consequence of their DO diploma or, if they had, they were proud of their role in fighting for their individual rights and the rights and reputation of the profession at large.51 
Perhaps the most significant new arguments for the retention of the traditional DO designation were based on legal and political considerations. According to the AOA's General Counsel, Josh Prober, Greenwald noted, “Transmuting DO to MDO, OMD or DMO” would require “changes anywhere DO is mentioned in more than a century of statutes and regulations of 50 states, the District of Columbia, US territories and the federal government.”51(p32) The legal process to implement a change in degree could take years. As described in the article,
 

Even if all state legislatures placed degree-change legislation on their agendas, the bills would face a tough road to reaching a vote [and] there is no guarantee that the bills would pass or that governors would sign them.51(p33)

The AOA's Manager of State Government Affairs Tom McElligott argued that “reopening state medical practice acts is like taking the lid off Pandora's box” and noted, “Some of the state medical boards are reluctant to open up the practice acts because of the potential for negative changes in the amended statutes.”51(p33) 
Greenwald's article was met with great interest on the part of the osteopathic medical community. In the next several months, it was downloaded 15,000 times, more than thrice any other previous article in The DO.50 Comments continued to appear online and in the “Letters to the Editor” section of The DO magazine. This included the thought-provoking argument in support of a switch to the OMD degree by Anthony J. Silvagni.52 
At various colleges, students held meetings to discuss the issue and voted on supporting or changing the DO designation. This extended discussion came to a head at the AOA House of Delegates meeting in July 2008 when the Ohio delegation put forward Resolution 306, a proposal to reaffirm the DO degree as the sole professional degree to be awarded to graduates of accredited osteopathic medical schools. Students attending the House of Delegates and consisting of Student Osteopathic Medical Association members and the American Association of Colleges of Osteopathic Medicine's Council of Osteopathic Student Government Presidents were divided, but in their report to the AOA Board of Trustees, they voted to recommend that the resolution to support the DO degree be passed. After coming out of reference committee, the amended resolution was voted upon by the members of the House. In his story on the proceedings of the House meeting for The DO magazine, Managing Editor Patrick Sinco noted,
 

With a hush, the AOA House loudly pronounced its unanimous support for DO as the letters that designate the profession's educational degree, cinching up more than a century of tradition and quieting months of quarrel that played out online, on campuses, in caucuses and in the pages of this magazine.50(p38)

 
Some House members may have believed that this unanimous voice vote would finally convince those who preferred another degree to at last move past this issue, and while perhaps some advocates for a different degree did, many osteopathic medical students and some osteopathic physicians continue to press their case that a new degree designation is warranted. Indeed, each new class of osteopathic medical school matriculants since the 2008 House of Delegates vote contains a varying proportion of students, by school, who believe that the profession's social invisibility can only be addressed by adding an “M” to their degree. Indeed, it is likely that as long as the perceived or actual underlying fundamental problem of poor public knowledge and appreciation of osteopathic physicians as a class of health care professionals is not satisfactorily addressed, this chronic yearning on the part of some for a different designation will persist. 
In the final installment of this 6-part history of the DO degree,53 I will examine how this underlying problem might be solved and consider the future of the DO degree itself. 
   Financial Disclosures: None reported.
 
   Support: None reported.
 
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