The 4th wave of osteopathic medicine: Re-establishing osteopathic distinctiveness

As the profession celebrates National Doctors Day on March 30 and will soon celebrate National Osteopathic Medicine (NOM) Week from April 15-21, it is a good time to reflect on the current state of the profession and where it is headed. To that end, I would like to share a summary of my recent keynote presentation given to the Osteopathic Physicians and Surgeons of California (OPSC) on the distinctive practice of osteopathic medicine.

‘The banner of osteopathy’

I started with a brief overview of how we got to this point in our profession’s history (of course, this overview is my opinion, and I would welcome other viewpoints). On June 22, 1874, A.T. Still, DO, MD, wrote in his autobiography, “I flung the banner of osteopathy to the breeze,” by which he began to apply his methods of healing illness and disease. Almost 20 years later, he opened a school in Kirksville, Missouri, the charter of which states, in part, that “the object of this corporation is to establish a college of osteopathy, the design of which is to improve the present system of surgery, obstetrics and treatment of disease generally, and place the same on a more rational and scientific basis …”

The rest of his banner quote from Dr. Still’s autobiography says, “For twenty-three years it [the banner of osteopathy] has withstood the storms, cyclones and blizzards of opposition. Her thread are [sic] stronger to-day than when the banner was first woven. Her colors have grown so bright that millions now begin to see and admire and seek shelter under her protecting folds from disease and death. Mothers and fathers come by legions and ask why this flag was not thrown to the breeze before.”

We’ll come back to that quote in a few minutes, but I believe we are in the fourth wave of osteopathic history at this time. The first wave was from the establishment of the American School of Osteopathy until the Flexner report. The second wave began in the 1940s and built on the scientific foundations of osteopathic medicine. The third wave, starting in the 1960s, was primarily focused on obtaining respect for the profession and equality for DOs. And the fourth wave, I contend, is the re-establishment of osteopathic distinctiveness.

By the numbers

According to the AOA, there are 148,829 osteopathic physicians and 38,042 osteopathic medical students in the U.S. In 2023, we saw a 99.5% residency placement rate for DO seniors seeking GME. Many of them went into primary care specialties. In the last three decades, the total number of DOs and osteopathic medical students has more than quadrupled. This is all wonderful for the profession.

And yet, we still have our problems. There are 41 colleges of osteopathic medicine with 66 locations across the country, each tasked by the AOA’s Commission on Osteopathic College Accreditation (COCA) with providing osteopathic education.

However, there are only 26 osteopathic neuromusculoskeletal medicine residency programs, meaning we are not producing doctors with the requisite training to teach osteopathic principles and practices (OPP). There are only 252 ACGME-accredited residency programs—just 1.9% of all the ACGME’s programs—with osteopathic recognition, which means young physicians are not getting enough distinctive osteopathic training in residency.

The future of osteopathic medicine

Next, I want to look at where we might be headed. A 2021 article in the Journal of Osteopathic Medicine (JOM) looked at osteopathic manipulative treatment (OMT) use among osteopathic physicians in the U.S. The study showed that 78% of nearly 1,700 DO survey respondents used OMT on less than 5% of their patients, and 57% never used it. This demonstrated a worsening of the situation compared to just 20 years ago. A 2001 Academic Medicine study reported that 54% of physicians used OMT on less than 5% of their patients.

The barriers to OMT use have remained constant, with lack of time, lack of support and lack of confidence being the top three roadblocks. In a previous column, I reviewed an Annals of Internal Medicine article that showed no difference in the care provided by allopathic or osteopathic hospitalists, and I gave my opinion that this represented a lost opportunity by the profession in that it showed that the osteopathic hospitalists were not practicing distinctively.

The situation goes deeper than that, though. The distinctive elements of osteopathic medicine—patient-centered, health-focused and focused on mind, body, spirit and the body’s self-healing capabilities—are being taken up by many other clinicians. A simple search of the internet for the four tenets of osteopathic medicine will bring up thousands of research articles on topics like the biopsychosocial model of illness (including a mind-body medicine course offered at Harvard Medical School) as well as articles on structure and function as a model for modern health care written by nurse practitioners,  chiropractors writing articles on how the body heals itself and much more.

As I have noted in other columns, a subset of the profession feels that the letters behind our name are inconsequential because we practice the “same medicine.” However, osteopathic medicine was originally proposed to improve the practice of medicine, not become the same as the status quo. Those ideas that Dr. Still was able to combine into a coherent medical system will not go away, but other professions will repackage and claim them if we do not continue to fly the “banner of osteopathy.”

Think back to the quote from earlier: “For twenty-three years it has withstood the storms, cyclones and blizzards of opposition. Her thread are [sic] stronger to-day than when the banner was first woven. Her colors have grown so bright that millions now begin to see and admire and seek shelter under her protecting folds from disease and death. Mothers and fathers come by legions and ask why this flag was not thrown to the breeze before.” I still regularly have patients asking why they have never heard of osteopathic medicine. Nearly 150 years after Dr. Still introduced his ideas to the world, it is disappointing that osteopathic medicine is not more well-known.

Uplifting the profession

So how do we move the profession forward in a positive direction? I do not want this to be a downer of an article! Empathy is one key element of osteopathic medicine that should be discussed more. In 2020, a group of researchers at the American Association of Colleges of Osteopathic Medicine (AACOM) published an article showing that, while empathy among all medical students declines as they get further along in their training, there was less decline among osteopathic students than allopathic students.

A recent JOM study showed that in patients receiving osteopathic vs. allopathic care for low back pain, the strongest treatment effect was not the use of OMT (less than 25% of patients in the osteopathic group received OMT) but physician empathy. The distinctive practice of osteopathic medicine begins in medical school, and our patient-centered care continues to enhance our patients’ self-healing capabilities.

Osteopathic medicine needs all of us to get involved. This might look like teaching at your local osteopathically recognized residency program. It might be engaging in AOA-sponsored or state activities to promote distinctive osteopathic practice (the Osteopathic Physicians & Surgeons of California passed a joint resolution with the Montana Osteopathic Medical Association at the AOA’s 2023 House of Delegates, allowing the AOA to promote osteopathic medicine, including OMT, as representing high-value care within the triple aim of care). It might mean demonstrating to medical students how you practice as a distinctive osteopathic physician, regardless of your specialty. And it certainly means to get back to using your hands in your practice. I know you were all just waiting for me to say that, right?

Looking at the barriers to using OMT identified in the research, the AOA and the American Academy of Osteopathy (AAO) have many resources to help you break through obstacles. Courses (including short refresher videos) to get you more confident in your skills. Help navigating organizational problems like privileges, supervision, etc. Help figuring out how to get paid in a fee-for-service model or demonstrating the value of your care in a capitated model. The solutions are out there; we need to be willing to look for them and engage.

I want to leave you with another quote from Dr. Still. In his autobiography, he encouraged all future DOs to “let your light so shine before man that the world knows you are an osteopath pure and simple and that no prouder title can follow a human name.”

Related reading:

DO placements in 2024 NRMP Match reach all-time high

How to develop more clerkships for osteopathic medical students