What's Up, Docs?

Here’s how I’ll know when we’re serious about reforming the U.S. healthcare system: we’ll no longer have both M.D.s and D.O.s.

Now, I’m not saying that this change alone will bring about a new and better healthcare system; I’m just saying that until such change, our healthcare system will remain too rooted in the past, not focused enough on the science, and – most importantly – not really about patients’ best interests.

Let me make it clear from the outset that I have no dog in this hunt.  I’ve had physicians who have been M.D.s and others who have been D.O.s, and I have no indication that there have been any differences in the care due to those training differences.  That’s sort of the point: if there are no meaningful differences, why have both? 

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Chances are, your physician is an M.D.; M.D.s make up around 85% of all U.S. physicians.  You don’t see many D.O.s on television shows either; it wasn’t Marcus Welby, D.O. for example.  Gregory House was an M.D., as is Meredith Grey.  However, the number and percentage of D.O.s is increasing; 25% of U.S. medical students are in osteopathic medical schools. 

The distinction between allopathic medicine (M.D.s) and osteopathic medicine (D.O.s) has long historical roots.  The first osteopathic medical school was founded in 1892, by Dr. Andrew Taylor Still, as an effort to reform the highly variable medical education of the time.  The medical establishment was not thrilled with the new movement, but it took until 1910 for the Flexner Report to similarly try to reform allopathic medical education (and, by the way, to recommend elimination of osteopathic medical schools). 

For decades, D.O.s were a small and disadvantaged minority.  It wasn’t until 1969 that D.O.s could join the AM.A.  It wasn’t until 1973 that D.O.s were eligible for licensure in all 50 states and the District of Columbia.  It wasn’t until 2014 that allopathic and osteopathic medicine agreed to a single accreditation system for graduate medical education.  Today, the general consensus is that training is “virtually identical,” and even the distinction of an “osteopathic hospital” has, for the most part, been lost.   There are, though, still some 38 osteopathic medical schools.   

Advocates of osteopathic medicine sometimes assert that it is more holistic and more “hands-on,” but it is getting harder and harder to argue such distinctions. 

Credit: AOA

It is interesting to note that U.S. trained D.O.s have full practice rights in 45 other countries, and restricted rights in several others, but in most other countries, osteopaths are not physicians.  They can get Bachelors, Masters, or Ph.D.s in osteopathy, but these are considered non-medical degrees.  Osteopaths in those countries focus more on physical manipulation techniques that were part of the original osteopathic training (and which, in theory, D.O.s still are taught).

The U.S. is the outlier in considering D.O.s physicians. 

Again, I’m not saying the U.S. has it wrong.  I’m not saying D.O.s are not fully equivalent to M.D.s.  What I’m saying is: who does it serve to have both M.D.s and D.O.s? 

It’s hard for patients to find good physicians.  We usually rely on proximity, who is in our network, maybe some word of mouth from friends and family.  If we’re diligent, we might look at where a physician we are considering went to medical school, did their residency, had their fellowship, and got their board-certification in.  But it’s one thing to try to evaluate the importance of going to, say, Harvard Medical school versus a Caribbean medical school, but how is a patient to evaluate osteopathic versus allopathic training and licensure? 

When you’re picking a lawyer, you might care about what law school he/she went to, but at least you don’t have to think about what kind of law school it was.  That’s not true with physicians.  That doesn’t make sense, and it doesn’t help patients get the right physician and/or the best care.

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I started thinking about this issue a few years ago, when I was thinking about how we should train “A.I. physicians” (be they fully independent ones, or a additional resources for human physicians).  We’d want to give them the best data, the latest research, and the most up-to-date training.  So, would that be allopathic or osteopathic? 

If we can’t answer that question, and I don’t think we currently can, then we should be very cautious about training A.I. in medical care at all.  If we don’t understand what the biases, shortcomings, or advantages that come with each type of training, we’re imposing needless human handicaps on future A.I. capabilities.  

As I wrote in my earlier piece:

…if we don’t want our AIs to be either “M.D.” or “D.O.,” but rather a combination of the best of both, then why don’t we want the same of our human doctors? Why do we still have both? 

House, MD versus AI, What?

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Separation of D.O.s and M.D.s is a historical artifact.  The separation predates what we even think of modern medicine; prior to the Flexner Report, medical education was neither rigorous nor consistent.  Both allopathic and osteopathic medical education have changed greatly over the years, and, not coincidently, have grown more similar.  But, still, the separation remains. 

We still have those distinct medical schools, each with its own oversight organization (AACOM and AAMC).  We still have separate licensing (COMPLEX and USMLE), each overseen by its own board (NBOME and NBME).    We still have separate professional organizations (AOA and AMA).  This is no way to run a railroad, as the saying goes – much less a healthcare system.

As I often lament, it’s 2022.  We’re almost a quarter of the way through the 21^st century.  We need to figure out the best way to educate, train, license, and oversee physicians.  Maintaining a split that dates from the 19^th century is not just foolish, but downright dangerous. 

The question we should always be asking is: what is best for patients?  Not “how have we always done it?”

So, no, until I see a concerted effort to take the best from the osteopathic and allopathic schools in order to develop a 21^st approach to what a physician should be, I’m not going to take any purported healthcare reform seriously.