On the Oft-Debated Question of What It Means to Be an Osteopathic Physician

To the Editor:

I am an emergency physician in active practice. I graduated from Des Moines College of Osteopathic Medicine and Surgery (now Des Moines University College of Osteopathic Medicine) in 1983. I have been a preceptor for osteopathic medical students for many years. I have heard their laments and complaints. They work with me at all of the odd hours, including the wee morning ones when everyone else is sleeping. They learn that the emergency department is a safe place to ask uncomfortable questions. So they ask and I echo their existential question: DO? So what?

They ask me what it really means to be an osteopathic physician. I would like to re-ask that question, providing them cover. So let's start with heresy.

Being a DO is not about skeletal manipulation. I will repeat myself, taking the coward's cover of opinion: osteopathic manipulative medicine (OMM) is not primary.

There, I have said it and am a heretic. And I am certain I will have a lot of company.

Let's visit the negative aspects first; that is easiest. If we are all about manipulation as a primary identity, then we are osteopath-chiropractors. If manipulation is our primary identity, then we are not “physicians trained in the osteopathic philosophy,” and we give our patients less than they deserve.

Let's review some admittedly revisionist history to understand where we are. Andrew Taylor Still, MD, DO, the founder of our profession, had some problems with then-conventional medicine.^1,2 After the Civil War, he sought the cause of the death he witnessed and determined it to be “the ignorance of our ‘Schools of Medicine.’”^2(p92) He taught his students his own philosophy of medicine and, recognizing that his system was “different and better that the traditional practice of medicine,” selected the DO degree.^1(p7) This branding—DO instead of MD—served at the time as a beacon for medical care that, by current standards, might not help, but at least it would not harm!

In this setting, with an oath to do no harm, providing patients comfort was the least the DO could do. And here the development of OMM made perfect sense: we may not always cure but we can always provide care and comfort.

A good half century later, Abraham Flexner rightly castigated virtually all medical education.³ Osteopathic and allopathic schools had to change, and although most did, some died. The central tenets of osteopathic medicine kept an occasionally anemic flame alight; today it glows strong.

And that brings us to the positive aspects. The concept of a holistic approach, long a central osteopathic but controversial allopathic concept, has clearly come to fore. A wariness of drugs, likely the fulcrum of Still's revolution, is now de rigueur. Viewing the patient within the framework of his or her family and environment rather than as an isolated diseased organ is so accepted as to beggar discussion. Within my memory, these were not well-accepted allopathic concepts, yet they were ever accepted osteopathically.

And so, today we face a new challenge: managing success and assuring our students that they have a unique, valuable identity and contribution. And here is where I submit that osteopathic philosophy is the winner of our identity. We must figure out how to leverage our philosophy, especially for our students, who are our professional future.

As I close my third decade as a DO, I would like to see a wider conversation on what it takes to be a DO in the modern world. I submit the following, not nearly exhaustive, not nearly rank prioritized list:

• excellence in patient care

  • primacy of the patient-physician relationship

• excellence in medicine

  • always an awareness of the patient's wishes and life philosophy

• excellence in the use of diagnostics, always having a relevant question before ordering an answer (ie, test)

  • respect for borders—personal, professional, and societal

• excellence in anatomy and physiology, keeping in mind the inherent healing ability of the body

  • awareness that the patient cures himself or herself and that physicians just help

• excellence in the use of chemicals, making no excuses for sloppiness and avoiding nocebos

  • constant advocacy for our patients, speaking ever truth to power

• excellence in choosing therapeutic modalities, including the use of OMM when indicated

  • ensuring that modalities chosen, including medications, are appropriate for this patient at this period of his or her life

• excellence in caring—always

If there appears to be a theme—that of excellence—that perception is correct.

The 1 consistent lament I hear from the students I have been privileged to precept these many years is despair at poor diagnostic skills and impoverished logic they witness in training in the therapeutic selections made by preceptors, whether DOs or MDs. I think we can do better; we owe this much to our future. I was the beneficiary of such teaching early on.

The primacy of good science and patient care was and is and should be the central guiding principle of medicine, especially osteopathic medicine.