Osteopathy Then and Now

When the President’s doctor, Sean Conley, came down the front steps of Walter Reed Army Medical Center to brief the nation on the President’s health, it caused consternation in some quarters. His name was followed by the letters DO rather than MD. Some people questioned “why the president was being seen by someone that wasn’t even a doctor.” Some knew that licensed doctors in the US came in two flavors (MD and DO) but would be hard pressed to explain the difference. Some were being treated by DOs but had never realized they weren’t MDs. Some equated osteopathy with quackery; others confused it with chiropractic. 

Some people simply asked for information: “What is osteopathy?” Good question. 

Origins of chiropractic and osteopathy

In the early days of the 20th century, chiropractic and osteopathy had much in common.  Both were based on a vitalistic philosophy and on spinal manipulations.

Chiropractic was invented in a single day by D. D. Palmer, a grocer and magnetic healer with no scientific or medical training. The day was September 18,1895, when he manipulated the spine of a deaf janitor and allegedly restored his hearing. Palmer thought that 95% of all disease was due to mythical subluxations of the spine that interfered with the functions of nerves and of the vitalistic Innate and could be corrected with spinal adjustments. He was a spiritualist who claimed to have received his knowledge of chiropractic from the other world, from a doctor who had been dead for 50 years. He later admitted to having taken a course in osteopathy (presumably from instructors who were still alive). He thought of chiropractic as a sort of religion and he opposed vaccines (which most chiropractors still do). 

Chiropractic has not shown any signs of progress. The so-called “straights” still follow Palmer’s principles closely. Other chiropractors called “mixers” have added other treatments (from massage to acupuncture) and some “reformers” have rejected the subluxation concept and are essentially treating a limited scope of musculoskeletal conditions. Chiropractors’ main raison d’être is spinal manipulation therapy (SMT), which is somewhat effective for low back pain; but studies have shown that it is not significantly more effective than other treatments for low back pain. Physical therapists also offer SMT, and chiropractors have never shown that chiropractic care is superior to physical therapy; so there is little justification for chiropractic’s continued existence. Some chiropractors have tried to re-invent themselves as family physicians, but their training does not prepare them for that role. 

The father of osteopathy was an MD, Andrew Still, who became disillusioned by the medical care of the day after losing his wife and daughters to meningitis. He founded the American School of Osteopathy in 1892. Still’s autobiography states that he caused a bald-headed man to grow hair three inches long in one week and that he could “shake a child and stop scarlet fever, croup, diphtheria, and cure whooping cough in three days by a wring of its neck.” He claimed to have invented preventive medicine and the concept of holistic medicine, but neither is true. MDs are responsible for most of the developments of preventive medicine, and good clinicians have always considered the whole patient rather than simply treating symptoms. Today’s medical students are taught the biopsychosocial model of medicine which considers every factor in the patient’s life that might have some impact on their health or might affect their treatment. 

After the 1910 Flexner report recommended that medical schools adopt high standards of science, many schools of osteopathy closed; but a few of them heeded Flexner, and by the middle of the 20th century DOs had become accepted as equivalent to MDs. Their curriculum is the same, except that they get additional training in manual techniques (Osteopathic Manipulative Treatment, or OMT). They take the same exams, are licensed in all 50 states to practice medicine and surgery and to prescribe drugs, and they take the same residencies to become specialists. Osteopathy accepted modern science and evolved, but chiropractic remained mired in prescientific superstition. 

Important note: DOs trained in the US are doctors of osteopathic medicine and are legally equivalent to medical doctors (MDs). They must be distinguished from “osteopaths,” members of a less regulated or unregulated profession that is practiced in many countries. Osteopaths get inferior training that can’t be compared to that of DOs. 

The tenets of osteopathy, as formulated by the American Osteopathic Association, are:

  1. The body is a unit; the person is a unit of body, mind, and spirit.
  2. The body is capable of self-regulation, self-healing, and health maintenance.
  3. Structure and function are reciprocally interrelated.
  4. Rational treatment is based upon an understanding of the basic principles of body unity, self-regulation, and the interrelationship of structure and function.

That’s a bit vague, and these tenets are not really different from what MDs believe. Indeed, medical educators have endorsed them as broad medical principles. 

According to the website of a  school of osteopathic medicine,  

“Still’s basic idea [was] that the human body was much like a machine, one that would function well if all its parts were in proper mechanical relationship.” 

It goes on to explain that the osteopathic physician’s goals are to:

  • Seek out and address the root cause(s) of disease using available evidence-based approaches
  • Optimize the patient’s self-regulating and self-healing capacities
  • Provide an individualized patient management plan that includes emphasis on health promotion and disease prevention
  • Include palpatory diagnosis and osteopathic manipulative treatment to address the somatic component of disease to the extent that it influences the well-being of the patient.

Osteopathic students increasingly demand evidence, and often reject some of what they are taught, including vitalistic and metaphysical concepts and specific treatments like cranial therapy.

Cranial therapy, or craniosacral therapy, is a pseudoscientific method of diagnosis and treatment. It is not only scientifically implausible but has been tested and shown not to work. Quackwatch’s Stephen Barrett says, “I believe that most practitioners of craniosacral therapy have such poor judgment that they should be delicensed.” Yet all US ostepathic schools continue to teach it.

Some DOs stop practicing OMT after graduation, and a 1998 study found that over half used it on fewer than 5% of their patients and 30% used it on 5-25% of patients. Recent graduates were less likely to use OMT, and specialists were less likely to use it than family physicians. 37.5% of the specialists never used OMT on their patients, whereas 7.9% of family physicians never used it. 

My personal experience (anecdote alert!)

I first met a DO during my internship at an Air Force hospital. He stood out from the other interns who were MDs because of his people skills and his practical knowledge. I was impressed when he confidently placed a posterior nasal pack to control a nosebleed. I didn’t know how to do that; I had never even seen it done. 

I worked with many DOs during my 20-year career in the Air Force Medical Corps. None of them did osteopathic manipulations or followed osteopathic principles. With one exception, they were excellent clinicians. The one exception was the worst doctor I ever worked with, not because he was a DO but because he was cognitively impaired and incompetent. When asked to give a briefing on osteopathy to the staff, his lecture was incoherent and uninformative. I was told that he was the oldest physician in the Air Force at the time and had entered active duty as a full colonel directly from private practice – a big mistake. The rules were soon changed; now doctors in the Air Force Medical Corps start at the rank of Captain or Major.

Since my retirement, I have been treated by a number of specialists who were DOs, both civilian and military. They all provided excellent care that was indistinguishable from the care provided by MDs.

Why do students choose a DO school?

Common reasons given for choosing osteopathic medicine: 

  1. “My grades weren’t good enough for medical school.” Some applicants had applied to multiple medical schools first and were rejected. Some didn’t even try applying to a medical school because they assumed they wouldn’t be accepted. That assumption may not be valid: Grades and scores on the Medical College Admission Test (MCAT) do average a bit lower for osteopathic than for medical students, but not much lower.
  2. “I like the osteopathic philosophy of prevention.”
  3. “I like the holistic approach of osteopathy.”

It has been pointed out that their choices of specialty are inconsistent with reasons 2 and 3. If they really believed in osteopathy’s core values, they wouldn’t go into surgery, anesthesia, dermatology, radiology, emergency medicine, or any other specialty that doesn’t allow them to use OMT to its fullest potential.

The bottom line

On Quackwatch, Stephen Barrett says, “I believe that osteopathic organizations and many of the DO schools and their graduates are acting improperly by exaggerating the value of manipulative therapy, falsely claiming that osteopathic medical care is inherently superior to standard medical care, and failing to denounce cranial therapy. However, there are many competent DOs. If you wish to select a DO as your primary-care provider or for specialty care, your best bet is one who: (a) has undergone residency training in a medically accredited program; (b) does not assert that osteopaths have a unique philosophy or that manipulation offers general health benefits; (c) either does not use manipulation or uses it primarily to treat back pain; and (d) does not practice cranial therapy.” 

Should the DO degree be abolished? It has been proposed that DOs and MDs could be merged into a single science-based profession. In my opinion, that’s not a bad idea.

This article was originally published as a SkepDoc column in Skeptic magazine.

Dr. Hall is a contributing editor to both Skeptic magazine and the Skeptical Inquirer. She is a weekly contributor to the Science-Based Medicine Blog and is one of its editors. She has also contributed to Quackwatch and to a number of other respected journals and publications. She is the author of Women Aren’t Supposed to Fly: The Memoirs of a Female Flight Surgeon and co-author of the textbook, Consumer Health: A Guide to Intelligent Decisions.

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