Potential Harms of the Status Quo

Introduction

I want to begin my series of essays by discussing the problem of OMM and the disadvantages of having two systems for medical education in the US. The main point of this essay is why the current system needs to be analyzed and fixed. I will focus on three categories of harms that I have placed in an order that I consider least to most debatable. First, the harms of wasting resources; second, the problem of variably applying foundational scientific principles; third, the ethical dilemma of practicing OMM.

Wasted Resources

The most self-evident harms of OMM and having two pathways to becoming a physician fall under the category of wasted resources. This category includes many examples, but I will spell out a few. An appalling example is all of the wasted student time. A quick estimate of student time spent studying OMM follows. If you assume ~10,000 1st and 2nd year DO students in the US, each spending ~100 hours a year learning OMM, this totals 1,000,000 hours a year studying OMM by first and second years. This amount of time is incredible, but it is only part of the story. The rest of the story is the well-established fact that only a tiny percentage of DO’s use OMM in any form in their practice. Even if you assume that 50% of DO’s use OMT, this totals to 500,000 hours a year wasted by first- and second-year students. I know that at my alma mater, at least, that 100 hours a year hardly covers the time spent in OMM lab and excludes all sorts of things like studying/prep-work and time spent during rotations. This number is unacceptable in the context of the ever-expanding amount of medical knowledge and increasing physician burnout. 

The second example I will give of wasted resources is the unnecessary redundancy of having two pathways to becoming a physician. Think for a minute about the resources required to create an exam like COMLEX. The time physicians, PhDs, businesspeople, editors, administrators, etc., spend preparing these exams is not insignificant. This is time being wasted by valuable and intelligent human beings whose talents could be used for other, more pressing projects. Further, think about the time spent on everything from making the AOA website and promotional pamphlets to running the Student American Academy of Osteopathy. These and many other examples are pointless redundancies that make no sense outside of our current system of two primarily identical pathways to becoming a physician. There are many historical reasons and perverted incentives that keep these systems separate, and I hope to write a future article looking at these.

A third example of waste I have seen at my school is the OMM department. One aspect of this example is the disproportionate number of OMM faculty. The OMM department at my school was conspicuously large. On the one hand, this indicates to me that it might be a situation where teaching is more profitable than practice. The net effect is to incentivize the continued teaching of OMM, regardless of the evidence. On the other hand, these are qualified physicians who are spending their time teaching us OMM that could be serving in a system with a shortage of doctors. Another aspect of this example is the wasted money spent on the OMM lab, the OMM tables, etc., and all the individual staff to facilitate OMM teaching.

Variable Standard of Evidence-Based Medicine

The second category of harms stems from having a variable standard for the term “evidence-based medicine.” I know this paragraph is where I am most likely to lose the OMM purist, so I want to start by assuring those readers that this argument only requires the minimalist position concerning what evidence exists for OMM. Given that OMM is not a single entity but rather a collection of techniques, this section only requires that a single concept currently being taught does not meet the modern criteria for evidence-based medicine. I am not going to name any particular technique; I just ask that hesitant readers take a moment and consider the gamut of OMT. You should be able to find a single OMM concept that does not have multiple randomized-controlled trials demonstrating its efficacy beyond a reasonable doubt.

Given this minimal position, teaching techniques that do not meet the standard-of-evidence for other modern therapeutics has many potential issues. Most apparent, it socializes medical students to the idea that you do not need the highest quality evidence for therapy. This socialization is harmful for many reasons. Un-verified treatments, in general, have a much higher chance of causing harm or, at best, doing nothing and wasting physician time and patient resources. More broadly, medical doctors are supposed to make up the societal bedrock of scientific thinkers and be above reproach with our beliefs. We live in a society plagued by harmful ideas based on conjecture: the anti-vaccination movement, essential oils, and more pseudo-science ideas that will inevitably come and go as they have since the beginning of humankind. Our place in society mandates that we fight these harmful ideas and that we do everything in our power to train the next generation of physicians to fight these ideas.

Admittedly, the concept of a “variable definition for evidence-based-medicine” is a little abstract, and when I bring it up, I hear a common objection. The objection comes in the form of an argument along the lines of: 

“There are many other therapeutics with unknown mechanisms or therapies with minimal evidence outside of OMM that are recommended to patients every day, and OMM is just another one of these.”  

This argument has many problems. The first part of this argument ignores that the few therapies with unknown mechanisms have demonstrated efficacy beyond a reasonable doubt, and their mechanisms will eventually be understood. Within the OMM literature, very few techniques have believable data demonstrating efficacy or a mechanism. The second part of this is how a lot of Osteopaths frame OMM, i.e., as a last resort or some kind of supplemental therapy that “can’t hurt.” This justification sounds reasonable but ignores the enormous number of resources and the very particular way the techniques are taught. For example, it is theoretically possible that muscle energy on the ribs is a way to increase the depth of respiration. Still, if a five-second massage of the ribs accomplishes the same thing, it is ridiculous to learn complicated jargon and techniques to diagnose rib somatic dysfunction.

I also believe that there are not just a few isolated cases of poorly researched techniques within the umbrella of OMM. Instead, OMM is characterized by many techniques without evidence. This observation that OMM is made up of many techniques without evidence indicates a more significant problem: a poor and variable definition of the term “evidence-based medicine.”

The Ethical Dilemma of OMM

The final harm of OMM that I want to discuss is an ethical dilemma I see with practicing OMM, especially full-time OMM practitioners. Assume for a second a worst-case scenario that every single OMM technique is nothing more than a placebo. In this scenario, doctors who practice OMM full-time are essentially scamming patients and taking advantage of the hard-earned trust that the public has in medical doctors. I do not want to claim that empirically every single technique is nothing but placebo because that is a claim that can only be answered experimentally. I think it is helpful to view the whole of OMM as falling on a spectrum, from everything being correct to nothing being correct. Where precisely the field falls on this spectrum is open to debate, but I feel confident saying it is unacceptably less than 100% correct. The ramification of misusing patient trust could have potential long-term effects in the form of reduced patient trust that would make practicing evidence-based medicine more difficult. The immediate results are wasting financial resources and physician time that could be better spent addressing our country's health disparities. 

Conclusion

For the sake of brevity, I haven’t spelled everything out in this essay concerning each category or listed every other possible harm I have considered. My goal for this is to increase awareness about these issues and provide justification for the rest of my essays. I believe that just the harms listed here are more than enough reason to continue this conversation to reach a better status quo for us physicians and those that follow.