IT IS TIME TO END D.O. DISCRIMINATION

IT IS TIME TO END D.O. DISCRIMINATION

In light of recent events, I want to talk about D.O. discrimination. Anti-D.O. bias is real, and I believe it is a serious issue that is worth addressing and worth fixing. Most osteopathic physicians are incredibly smart and talented doctors who have a lot to contribute to advancing medical science and helping to care for patients. Hindering the chance for osteopathic physicians to contribute to these goals can slow progress and reduce the proper medical access of millions of patients. Just imagine what would happen if all the D.O.’s in America instantly disappeared. Most importantly, millions of patients would be left without proper medical care. Further, consider what the fight against scope-creep would look like if all D.O.’s were caring for patients. This phenomenon is driven, in large part, by arguments about a lack of medical access. Removing D.O.’s from the American system would leave an even more significant gap and exacerbate this problem. I firmly believe that there is no substitute for a properly trained physician in today's increasingly complicated medical care, but scope-creep is not the topic of this essay. This essay is about D.O. discrimination.

As physicians and scientists, we (hopefully) understand that pointing out a problem is only step zero in solving it. What matters is a proper understanding of the mechanism causing the problem. When most people talk about D.O. discrimination, they don’t even attempt to describe the causal factors. In the few who do, I have seen a common theme where people like to attribute a “perceived reduction in quality” as the mechanism behind the discrimination. Some people point to differences in research experience or selection quality as the basis. This hypothesis seems like a dramatic oversimplification and far from the parsimonious idea of Occam's razor. For starters, I would guess that the range in quality between graduates of any single school is far greater than the difference between any random D.O. and M.D. school. Obviously, this depends on what metrics you are using to describe the “quality” of a physician and what specific two schools you are comparing. Still, we have all met mediocre physicians from great schools and great physicians from mediocre schools. More importantly, though, the “lack of research” or the “selection bias” mechanisms ignore the most glaringly obvious difference between the education of an M.D. and a D.O. in favor of minor differences. 

I actually remember the first time I ever witnessed D.O. discrimination. I was a naïve undergraduate who only recently learned that D.O. wasn’t just short for “D.O.”ctor. I had applied to all the schools in my home state I filled out the primary application, and then the secondary applications started coming in. Like most of us, I had a general template of responses that I tailored to each school. This worked well until I got to a question that asked: “why do you want to be a D.O.?” I looked up the difference and found some minor details online about “musculoskeletal techniques” and “holistic medicine.” I ended up writing something about how I thought it was a good idea to look at all aspects of a patient during diagnosis and treatment. This seemed a little self-evident, but I didn’t give it much thought.

My first experience with anti-DO bias was shortly after I received acceptance at an osteopathic medical school. I excitedly told a P.I. in the department I was researching in. This individual was one of the most intelligent people I had ever met, and I respected them greatly. Their response to my news was that I would get a proper medical education, but “I needed to be careful.” They told me that some of the material they taught at these schools was little more than pseudoscience. This comment worried me, so I immediately went to my computer. I started vigorously researching what exactly had prompted this comment. I found surprisingly little information on the negative side. A few people on Student Doctor Network and Reddit mentioned that it was easier to get into D.O. school and that it was less prestigious and more things of this nature. I found a few comments about the lack of evidence on a couple of websites, but these were rare, and I didn’t find much more than this. On the positive side, I found the Journal of the American Osteopathic Association, which seemed legitimate. I also saw that the number of D.O.’s practicing in the U.S. was substantial, and legally there was no difference. Prestige wasn’t that important to me, and given the lack of critical material, I felt that it couldn’t be that bad. I thought to myself that there is no way hundreds of thousands of people had gone through D.O. school for a hundred years if they were teaching material that wasn’t evidence-based. I was very wrong.

This essay is about ending D.O. discrimination, but the way we need to do this is not by focusing all of our attention at the level of the discriminator. We need to stop the actual reasons causing the discrimination. The truth is that M.D.'s’ have a very legitimate reason to be skeptical of us osteopathic physicians. This reason is the main difference between an M.D. and D.O. school, a collection of techniques called OMM. It, as a whole, has almost no believable evidence. On the more reasonable side, there are similar techniques to those practiced by Physical Therapists: stretching, massages, etc. On the other side, there are concepts like Chapman’s Point’s, Cranial, and many more that are… well, you know. Eventually, we will have to compile our notes on flawed OMM research and write an article about it, but we consider that low yield because anyone who has gone to D.O. school knows the research is bad. Our OMM professors give us the absolute best data they have, and if you read even a few of the papers used to justify these techniques, you already know most of it is nonsense. The vast majority of the studies either show no difference between placebo, only have a laughably small sample size, or look at a bunch of dependent variables and pick the one that shows a slight improvement. Most of the justification is based on anatomical relationships, but just because something sounds theoretically possible doesn’t mean it is inherently correct. That is the whole reason we use controlled scientific experiments to tell facts from things that “sound good.” 

The teaching of osteopathic manipulative medicine is even set up in such a manipulative way that traps you into propagating the system. It begins with the more plausible techniques and the history during the first year. Then it slowly transitions to the crazier stuff during the second year. Much like the frog in the boiling water, by the time you realize what is going on, it is too late. You have given a significant sum of someone else’s money to help propagate a system that teaches conjecture alongside legitimate experimentally based modern medicine. Then you graduate, move on to residency, and put it all behind you. This is the problem. This is the reason behind the discrimination. All D.O.’s have gone to a school that teaches things as facts that have no basis in reality beyond a hypothesis, and so far, it hasn’t changed. It makes perfect sense that M.D.'s’ are skeptical of us. The most significant advancement in medicine was not the invention and manufacturing of penicillin or the first transplant. It was when our ancestors decided to question their beliefs and stop teaching things that didn’t have evidence. If you are unfamiliar with it, Google the humoral theory of medicine. The summary is that for over 2000 years, doctors believed something without rigorous evidence. They didn’t question it, didn’t try and disprove it, and the net-effect was useless medical care that never improved until we started only believing things that we had evidence for. Physicians are busy people and don’t have time to spend reading every new paper about OMM. They know its well-deserved reputation that elements of it are pseudoscience, and they have every right to be concerned about us. If we want to end D.O. discrimination, we need to stop teaching this material at our schools. 

The primary motivation I had for writing this is because I see so much misguided anger at D.O. discrimination on social media and from my peers. The truth is most of us do not buy into OMM. Most of us do not deserve to be discriminated against just because we were forced to learn this material. And let’s be honest, the unfortunate reality of our world is that there are too many examples of baseless discrimination. The tendency is to think that all discrimination is wrong, but that is not inherently true. Would you not be skeptical of a fellow physician who was propagating anti-vaccination material? What about a fellow resident who wasn’t giving the standard of care because of some ridiculous reason? Of course, you would. That is what is happening here. You have doctors responding to a legitimate concern about the potential of candidates who do not understand the value of evidence-based medicine. To be clear, I am a D.O. resident, and I obviously do not think every D.O. is a lousy doctor. I don’t even think a significant percentage of D.O.’s are lousy doctors. A small minority of deeply confused OMM doctors have set up a system of medical education that propagates falsehoods, and all of us osteopathic physicians are paying the price.

In conclusion, I want to reiterate that I am not trying to say that residency programs, rotations, etc., should have barriers to limit D.O. access. I am saying that I understand the genuine causal factors that are driving policies like these. And more importantly, I know that these driving factors can be fixed. If we want to end D.O. discrimination, it is up to us osteopathic physicians to get rid of material from our curriculum that does not have legitimate, reasonable, and rigorous evidence. The generations of osteopathic physicians that came before us failed. They moved on with their lives and never looked back. But enough is enough. We are a new generation of osteopathic physicians, and I, for one, will not bend the truth with statements like “some of it is crazy, but it gave me more tools for my toolbox” or “some if it is crazy, but it really helped reinforce the anatomy.” I will be honest. Most of it is not based on any evidence, and it is time for a change. 

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Thanks for taking the time to read this essay! Purging our curriculum of this material is going to be a long battle. But it is a battle that is worth fighting. If you believe that the OMM curriculum needs to be fixed, please consider filling out this form to show your support. It is anonymous and only asks for your school, your expected or past graduation date, and there is a space for your thoughts. There is also space for you to indicate if you would like a member of our team to reach out to your school. We will happily send the director of your OMM program an email detailing some of our concerns with this material being included in our medical education.

Thanks again and stay rational,

-TRO