Physician care

DOs and MDs: What are the true differences?

A recent study found that there is no pronounced difference between DOs and MDs when it comes down to the care provided and the costs of that care.

Brian Loveless, DO

Brian Loveless, DO, is the chief medical officer of WesternU Health.

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My most recent two-part conversation on the osteopathic medical profession (Part 1, Part 2) sparked a lot of discussion in The DO’s comments section. I was most taken with the comments regarding DO distinctiveness. It is clear that many physicians out there feel that their practices are distinctive.

These practices include the use of osteopathic manipulative treatment (OMT) with their patients and the often-subconscious use of osteopathic principles defined in the four tenets. These observations were contrasted last month with an article published in the Annals of Internal Medicine titled “Comparison of Hospital Outcomes for Patients Treated by Allopathic Versus Osteopathic Hospitalists.” I want to talk a bit about the article, and then share some comments of my own.

Level of care and DO availability

The article looks to determine if the “quality and costs of care differ between hospitalized Medicare patients treated by allopathic or osteopathic physicians.” It is a retrospective observational study, but because they used a random sampling of Medicare beneficiaries hospitalized during a specific time period, and because admissions are assigned at random to hospitalists on call, there is a type of randomization taking place. This might be better called a natural experiment.

The authors do a significant amount of adjustment and analysis, and the supplemental material is full of even more statistical analysis. Not being a statistician, I am not going to comment on the appropriateness of the analysis done. I can say, however, that in looking at the results, there are no differences between the care provided and the costs to the system.

There are a few differences identified, including the fact that DO hospitalists tended to be younger and more likely to be female, tended to practice in the Northeast and Midwest (where there are a lot of osteopathic medical schools) and in minor teaching or non-teaching hospitals. Interestingly there were no differences in the proportions of specialties.

One notable observation was that 37% of hospitals had zero osteopathic hospitalists, and 6% of hospitals had only osteopathic hospitalists. More on that later. In reviewing the supplemental material, the only analyses where the confidence interval did not contain zero (generally meaning no difference between the two groups analyzed) were adjusted length of stay for arrhythmia, gastrointestinal bleeding and spending on imaging. All of these measures favored osteopathic hospitalists, but the differences are so small as to be negligible and likely confounded.

DOs vs. MDs: What are the true differences?

In their discussion, the authors (all MDs) list several reasons why there might be no difference in the care provided, including standardization of medical education despite two different accrediting bodies and common residencies under the ACGME (though the article did attempt to use residency training as a variable and found no differences).

One reason noted was the lack of use of OMT by osteopathic physicians. This has been noted for a long time and was most recently quantified in a study published in the Journal of Osteopathic Medicine in 2021. Healy, et al., surveyed 10,000 osteopathic physicians via an online survey. Of the 1,683 that responded, 78% used OMT on less than 5% of their patients, and 57% never used it at all. The identified barriers included lack of time, lack of reimbursement, lack of support and lack of confidence.

Overall, I think this is a quality study showing that DOs are non-inferior to MDs in the hospital setting in several quality areas. But are we better than that? In a previous column, I described my take on recent osteopathic history, noting that for a significant portion of the 20th century we were primarily focused on demonstrating our equality with our allopathic colleagues. I believe now is the time to move past equality and demonstrate our distinctiveness. Yes, this includes OMT. And yes, it is difficult to quantify the “soft” skills such as empathy that mark our distinctive practice. But we as a profession need to continue to study, demonstrate and, most of all, exemplify that DO distinction.

More in common than meets the eye

The accompanying editorial written by Charlie M. Wray, DO, and J. Bryan Carmody, MD, makes several points. They state that, “Although often described as two distinct philosophies, modern osteopathic and allopathic medicine have more commonalities than differences.” While there is no such thing as a foundational allopathic philosophy of medicine, such as we have in osteopathic medicine (the four tenets, five models, et cetera), it is true that there are many commonalities between the two professions.

Later they state, “Although osteopathic training focuses on providing holistic, patient-centered care, osteopathic medicine can hardly claim a monopoly on these terms and ideas as they now permeate the modern health care milieu.”

I have said something similar in a past column, but I believe that what these authors are describing is the movement of allopathic medicine towards the practice that we have ascribed to osteopathic physicians for more than 100 years. It continues to be the responsibility of the osteopathic profession to demonstrate the value of this type of care, and to work with anyone in the health care space who wants to do the same.

Finally, I want to call attention to the final statement of the editorial. Discussing the importance of equal opportunities in residency applications, they state “one might hope that the letters after an applicant’s name become just as inconsequential as the differences in the care that they provide.”

I recognize that I am in danger of slipping into a “no true Scotsman” fallacy here, but I don’t think that the distinctive care provided by osteopathic physicians, as I have defined it through all of my columns, particularly one from June 2022, is inconsequential. And I challenge the osteopathic profession to continue to prove it.

Related reading:

Brand identity: Highlighting the osteopathic physician’s distinctiveness

The state of DO-MD relations: This emergency medicine physician has a unique take

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9 comments

  1. Julieanne P. Sees, DO, MBA, FAOAO, FAOA, FAAOS

    Magnificent! Thank you always, Dr. Loveless! Great article, challenge on, love it and live for it!

    Reply

  2. Steven Kamajian

    Excellent article! The comparison article in question is a hospital based comparison review. The reality of hospital work is that every clinician uses the same EHR-EMR. The drop down menu is the same for everyone. The treatment options are the same for everyone. The documentation requirements are the same for everyone. The utilization review committee, the department committees , and the ever present chief medical officer complaints, the discharge coordinator notes are the SAME for everyone. It is the equivalent of looking at a photocopy of a page from a book and trying to guess which brand of manufacture
    made the machine that it was copied from. There is no distinctiveness in processes ENGINEERED TO REMOVE DISTINCTIVENESS.
    The sad part is how the EMR is a measure of care no matter what.
    Ask a patient: this is what is documented in your chart by a doctor…were any of these four pages of questions ever asked of you? Were any of these physical exam components ever done to you? More than likely, the answer (ESPECIALLY if the patient was a doctor) will be no. But it sure is documented. Our students, and our hospitalist are rewarded by the completion of their documentation. Our hospital CEO, CFO, CMO have bonus compensations tied to “metrics” that are standardized by the EHR-EMR. I expect us all to measure the same if the mechanics of care are always tied to a pre established documentation protocol.

    Reply

  3. MICHAEL KOLINSKI DO

    Very well written Dr. Loveless. Thank you for the read which was a good “pick-me-up” to start my day. Bravo

    Reply

  4. Steven Kamajian,D.O.

    Excellent Article!Again, we have to look to how EHR-EMR’s and drop down menus are uniform no matter who is utilizing them.We have to understand from a management point, medical care can’t be an art it must be a uniform homogenized product.The drop down menu does not discriminate as to who is operating the computer…everyone has the same options and choices.If you look at a page of paper that has been photocopied from a book, the engineers goal is to have the copy look the same as the original. No one can tell which photocopy machine the photocopy was made upon. CEO’s, CMO’s , Chief Nursing officers, utilization review, department reviews, discharge coordinator’s reviews are all designed to have the same exact outcomes to meet national metrics and to make sure the management team meets IT’S metrics for management bonuses at the end of each quarter.
    It thus comes as no surprise when a hospital based study of of
    all things hospitalists shows uniform outcome.That is the precise goal of employment of physicians…each physician can be replaced by someone else without anyone noticing any difference in “quality metrics”.The art of medicine is antithetical to an
    EHR-EMR.Nowhere in an EHR are drop down options for an osteopathic structural exam or differential diagnosis. CMO’s
    rage against “laundry lists of diagnosis on the chart”.Their reviews are “focus on the admission diagnosis and get the patient out as soon as possible”.Thus the uniform test results.You can’t be different

    Reply

  5. Lonely osteopthicnoediatrician

    Perhaps we could accept, that many (perhaps most?) of our osteopathic students are actually NOT osteopathic trained after their 2nd year in medical school. Many (perhaps most) never perform OMT on a patient (ever?) while on a rotation in 3rd and 4th year unless they specifically sign up for a rotation in NMM. I still do OMT on 20% of my primary care patients after 20 years- but I also know that the students who follow me say I’m the exception, not the rule, on their rotations. Then, they move from
    No osteopathic training in rotations to no osteopathic training or preceptors in an ACGME residency. OR programs? Not in my specialty ( or perhaps 5 residents trained per year across the country). Twenty years ago, medical school told us we were distinct. Fifteen years ago, the osteopathic profession moved to the mantra that we could be osteopathic and not do OMT. Now we don’t do OMT, we don’t train separately and we expect to still be distinct? It will be the future (perhaps sooner than anyone wants) that we won’t be osteopathically certified either. It will be a short time until we are just the exact same except a few and OMT training will become optional. Are we pretending it was taught, on actual human patients- for most learners during the pandemic? Tele-OMT training didn’t work. I wish the profession the best of luck.

    Reply

  6. Rebecca J Bowers. Do

    It is unfortunate that there has been a trend of too many DOs settling for “just as good as” an MD. Thank you for encouraging US physician DOs to embrace Osteopathy. People need Osteopathy, and if physcian DOs aren’t practicing it, more and more non-physician DOs will. Non-physician DOs can help people a great deal, but it’s not the same as someone with physician-level knowledge practicing it. It’s such a shame that Osteopathy is not also being used much by many physician DOs. Think of all the good it would do our patients if more DOs actually practiced osteopathic medicine instead of just getting a degree in it.

    Reply

  7. vincent granowicz, D O

    This refers to hospital docs only. Office practices are/can be very different. All phases of medicine are practiced in the office. As an FP, I tried to keep m patients out of the Hosp. for 62 years. OMT was an important part of that.

    Reply

  8. P Brooks

    MD and DO are definitely distinct entities when applying to competitive surgical specialties. DO applicants have a significant disadvantage especially in this upcoming era when Step 1 is pass fail, courses are pass fail, and there is no class rank. It will be interesting to see the match rate of DOs into traditionally allopathic surgical programs this upcoming cycle. I anticipate it being almost impossible as programs now emphasize research, the prestige of the school, letter of recommendation in the academic community, etc. This is very unfortunate as the quality of residency training impacts you more as a physician than the medical school you attended. If the DO community is willing to accept its distinctions as comprised of only primary care physicians in the coming years, then continue as is and emphasize a degree based on OMT. If future DOs will only be able to pursue primary care specialties, considering shortening medical education to 3 years would provide a more useful distinction and advantage. It would also accommodate for the lower earning potential of primary care and lower the the medical education debt burden.

    Reply

  9. Leon J Yoder, DO,FACP

    Very good comments re: our 2 professions. I am 83 and still working at a small community hospital in rural Oklahoma. I am certified by both ABIM and Osteopathic boards in internal medicine and gastroenterology. I was one of the first DOs to get ABIM certification. I became program director for a GI fellowship through Oklahoma State University College of Osteopathic Medicine. I am proud of both professions since both have advantages that you so well outlined. The main factor I see is the confusion the public sees in knowing what a DO stands for and thereby unable to discern if a DO has the same credentials and training of that as his counterpart. At some point I personally feel we should all unite with one universal degree and avoid confusion. The schools can continue as they have. We need to continue supplying our country with the best physicians. Each medical school has its own unique philosophy, skills, research but in the end the outcome is the same. That is producing a well trained, competent, and compassionate physicians. Leon J Yoder, DO, FACP

    Reply

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