Even as a small minority of osteopathic physicians today regularly use osteopathic manipulative treatment on their patients, MDs continue to show interest in learning OMT, according to a number of DOs.
Several members of the osteopathic medical profession believe that instructing MDs in OMT builds awareness of osteopathic manipulative medicine and leads to more referrals, gives MDs the confidence to supervise DO students and residents who are doing OMT, and provides MDs with new skills to improve patient care.
As an osteopathic medical student, Sarah J. James, DO, remembers feeling “proud and territorial” about her OMM training. “When I heard about MDs who wanted to learn OMT, I thought, ‘Shame on them for not going to osteopathic medical school in the first place,’ ” recalls Dr. James, who graduated from the Des Moines (Iowa) University College of Osteopathic Medicine in 2008.
But her attitude changed when she trained alongside MDs in the dually accredited family medicine residency at Columbia St. Mary’s in Milwaukee. “There was a significant amount of DO envy on the part of MD residents because we had skills they didn’t have,” Dr. James says. She began to show some of her MD peers how to do basic OMT techniques for alleviating tension headaches and low back pain.
“I changed my perspective mainly because of the clear benefit to patients when MDs who are interested learn OMT techniques properly,” Dr. James says.
Before she started instructing her MD colleagues, a few of them had tried to learn OMT on their own and were misapplying a high-velocity, low-amplitude rib technique on patients. “So I thought, ‘If they are going to do OMT anyway, at least I can give them some skills that are safe for them to use,’ ” Dr. James says.
After finishing her family medicine residency, Dr. James completed a one-year residency in neuromusculoskeletal medicine and OMM at the University of North Texas Health Science Center Texas College of Osteopathic Medicine in Fort Worth. Today, she serves on the faculty of the dually accredited multisite family medicine residency program at the University of Wisconsin (UW) School of Medicine and Public Health in Madison. Several MDs in this program are learning OMT.
Dr. James instructs interested MDs in how to do soft-tissue, muscle energy and myofascial techniques. “I am giving the MDs basic skills—techniques that a first-year osteopathic medical student can do,” she says. “I also talk to them about A.T. Still and osteopathic philosophy.”
One allopathic physician who does a significant amount of OMT is Samantha N. Sharp, MD, a fellow in integrative medicine at the University of Wisconsin.
“The reason I’m interested in OMT is that I think DOs in general get a much better education in the musculoskeletal system than I did in my allopathic training,” says Dr. Sharp. “DOs have a comfort with the body and musculature that I am still working to achieve.”
“So I thought, ‘If they are going to do OMT anyway, at least I can give them some skills that are safe for them to use.’ ”
During her residency and fellowship, Dr. Sharp has used OMT on patients with upper respiratory infections or sinusitis, patients with headaches, pregnant women with low back pain, and children with sleep problems and attention-deficit/hyperactivity disorder.
“For example, for patients with upper respiratory infections, which are most commonly viral, OMT is a way to offer treatment and relief without writing a prescription for something they don’t really need,” Dr. Sharp says.
The director of osteopathic medical education for the UW’s family medicine residency, Hollis H. King, DO, PhD, has encouraged Dr. Sharp and other MDs to attend the school’s quarterly day-long OMT workshops.
“Working with all of the DO residents who are honing their manipulation skills has been a huge part of my learning,” Dr. Sharp says.
Growing but not new phenomenon
Instructing MDs in OMT is not a new phenomenon. Since 2004, the Harvard Medical School Department of Continuing Education has conducted an intense three-day “Introduction to Osteopathic Manipulative Medicine” course in Boston roughly every other year. The CME course has drawn MDs from a variety of specialties, including physical medicine and rehabilitation, pain management, orthopedic surgery, neurology, obstetrics-gynecology, sports medicine and pediatrics.
“A growing number of MDs look at OMT as an extra skill set they would love to develop,” says course director Darren C. Rosenberg, DO, an assistant professor of physical medicine and rehabilitation at Harvard. “We decided to offer the course because there was enough interest among MDs who wanted not only the ability to treat patients with OMT but also an understanding of palpatory diagnosis, which is just as important.”
Course participants learn about the history and philosophy of OMM and begin to learn how to use manipulative techniques in diagnosing and treating patients for musculoskeletal disorders. In addition, the attendees are taught the contraindications for OMT and how to code and bill accurately for it.
“I don’t expect people to take a three-day course with us and become proficient in doing OMT,” Dr. Rosenberg says. “What I do is expose them to manipulation. Our course serves as a gateway to more-advanced CME courses in OMT that MDs can take, whether at the University of New England College of Osteopathic Medicine or elsewhere.”
Those who take the Harvard OMT course but don’t incorporate manipulation into their practices still improve their physical examination skills and gain a better understanding of when to refer patients for OMM, says Dr. Rosenberg, who has received many referrals from Boston MDs who have completed his program.
“MDs are excited about OMT because it isn’t something they are normally introduced to,” says Douglas J. Jorgensen, DO, a frequent instructor at the Harvard CME course. “Teaching MDs what OMM is enhances their understanding that what we do is different from what physical therapists or chiropractors do.”
More than three decades before the Harvard OMT course’s inception, the Michigan State University College of Osteopathic Medicine (MSUCOM) in East Lansing began offering manual medicine CME courses that MDs and physical therapists, as well as DOs, could take. In addition to basic OMT, MDs can take courses on function, myofascial release, cranial manipulation, muscle energy techniques, and other OMM topics.
For some 20 years, Edward G. Stiles, DO, taught MDs in this CME program. “If our goal is to help people get better health care—and manipulation helps people with back pain and other musculoskeletal problems—I don’t have any qualms about teaching MDs who want to learn OMT,” says Dr. Stiles, who directs the one-year neuromusculoskeletal medicine and OMM residency at Pikeville (Ky.) Medical Center.
Many osteopathic medical students and young DOs do not yet recognize the usefulness of OMT, Dr. Stiles observes. “In contrast, physicians who have been out in practice awhile—MDs as well as DOs—realize that many patients have musculoskeletal problems and a lot of symptoms are mechanically related,” he says. “Because DO students don’t have that experience yet, many are inclined to blow off OMT.”
Building confidence in MD faculty
Another reason given for the waning use of OMT among new DOs is that they don’t have enough opportunities to hone their skills during their third and fourth years of medical school and during their residencies.
Osteopathic medical students often have MD preceptors for their clinical rotations and work under MD faculty members during their residencies and fellowships. Even MDs who see the benefits of manipulation typically lack the knowledge and confidence to supervise DO trainees who are performing OMT and are hesitant to sign off on these procedures, as attendings must, Dr. King notes.
At UW, Dr. King and Dr. James are developing a program to train the family medicine residency’s MD faculty members in basic OMT skills. Dr. King previously helped create a similar program to educate MD preceptors supervising students from the A.T. Still University-School of Osteopathic Medicine in Arizona in Mesa. He envisions that MDs who complete the largely video-delivered program will receive a certificate of completion attesting to their training in the supervision of basic OMT skills.
“I’m happy to share what I’ve done, so people don’t have to reinvent the wheel,” says Dr. King, noting that a handful of comparable programs are under development at other institutions, including MSUCOM and the Midwestern University/Arizona College of Osteopathic Medicine in Glendale. “This is an idea whose time has come.”
Levels of competency
Dr. King believes that in the future, competency tiers may be established for MDs who are interested in OMT. At one level would be MDs qualified to supervise DOs who do OMT but not to perform it themselves. Above that would be MDs who have completed enough coursework and demonstrated enough skills to be given some sort of certification of competency. And there might be a top level of qualification for MDs motivated to attain the highest degree of proficiency.
If the AOA, the American Association of Colleges of Osteopathic Medicine and the Accreditation Council for Graduate Medical Education agree to adopt a unified system of accreditation, MDs might be allowed into AOA-approved residencies. If that comes to pass, a pathway should be developed to allow MDs with equivalent OMM training to enter residencies in neuromusculoskeletal medicine and OMM, Dr. King says.
“In my opinion, if we expect MDs to allow us into their residency programs, we should allow them into ours,” says Dr. Jorgensen, who serves on the American Academy of Osteopathy’s Board of Governors. The challenge, he says, is to develop a preparatory pathway for MDs, who lack the two years of training in osteopathic principles and practice completed by all graduates of DO schools.
“I have at least as many MD students as DO students who are interested in learning OMT,” says Dr. Jorgensen, an OMM specialist in Manchester, Maine. “What’s more, some MDs practice more osteopathically than some DOs do. This proves that there is inherent value in what we’re doing—people want to learn OMM.”
Dr. Jorgensen worries that opposition by some DOs to MDs learning OMT could hurt the osteopathic medical profession in the long run.
“My concern is that if we don’t take the reins in preparing OMT educational modules for MDs, some other entity will and our profession will lose control over the process,” Dr. Jorgensen says. “There is a vocal minority who believes we shouldn’t be teaching OMT to anyone but other DOs.
“But my personal belief is that this is the reformation that A.T. Still envisioned when he began osteopathic medicine. If we hold the flame too tightly to our chest, we run the risk of snuffing it out.”